American

Journal of
Psychotherapy Official Journal ofAAP Founded in 1939

Volume 54 Number 3 Summer 2000

Highlights:

ON T H E MILLENNIUM: Part 2
Thoughts on the Year 2000 and beyond
by Editorial Board Members

PSYCHOTHERAPY WITH OLDER ADULTS

Gary J . Kennedy, M.D., and Stacey Tanenbaum, M.D.

Dedicated to the Transtheoretical Practice of Psychotherapy

American Journal of Psychotherapy
Official Journal of the Association for the Advancement of Psychotherapy
Founded in 1939

EDITOR-IN-CHIEF
T. B Y R A M K A R A S U

ASSOCIATE EDITORS
E D I T H K. F R I E D L A N D E R
B E T T Y C. M E L T Z E R

EDITORIAL BOARD

E . JAMES ANTHONY W. W A L T E R MENNINGER

AARON T. B E C K ROBERT MICHELS
JAMES F. T. B U G E N T A L JOHN C. NEMIAH
ANN W. BURGESS ANNA 0 R N S T E I N
RICHARD D. C H E S S I C K F R E D PINE
BERTRAM J. COHLER JUDITH L . R A P 0 P 0 R T
ROBERT COLES C A R O L Y N SAARI
HABIB DAVANLOO G. J. SARWER-FONER
P A U L A. D E W A L D T H E O D O R E SHAPIRO
MORRIS E A G L E P E T E R E . SIFNE0S
JEROME FRANK WADE H. S I L V E R M A N
G L E N 0. G A B B A R D R O B E R T D. STOLOROW
W I L L I A M N. G O L D S T E I N HANS H. STRUPP
LOUIS A. G O T T S C H A L K G E O R G E E . VAILLANT
JAMES S. GROTSTEIN PAUL L . W A C H T E L
JAY H A L E Y S T A N L E Y L . WITKIN
SEYMOUR H A L L E C K IRVIN Y A L 0 M
L E S T 0 N HAVENS
OTTO K E R N B E R G
Book Review Editor
PAULINA F. K E R N B E R G
SOPHIE F R E U D
P E T E R D. K R A M E R
R O B E R T LANGS
ARNOLD LAZARUS Legal Consultant
LESTER LUBORSKY WENDY J . L U F T I G
ARNOLD M. L U D W I G
JUDD MARMOR Publication Manager
JAMES F. MASTERSON TINA M. BONANNO
 RICHARD D. CHESSICK
Associate Editor
International Editorial Board

HANS GEORG GADAMER

Honorary Member
International Editorial Board

INTERNATIONAL EDITORIAL BOARD MEMBERS

JERZY ALEKSANDROWICZ ANDRE HAYNAL JOHANNES MYYRA

Poland Switzerland Finland

RAYMOND BATTEGAY ROBERT HINSHELWOOD M . ORHAN OZTURK

Switzerland England Turkey
C. S. IERODIAKONOU M A R I O PIGAZZINI
ISIDORO BERENSTEIN
Argentina Greece Italy
J O S E A. INFANTE
EMANUEL BERMAN MALCOLM PINES
Chile England
Israel
U T E INSELMANN
WOLFGANG BLANKENBURG DONGSHICK R H E E
Germany
Germany Korea
H A N A JUNOVA
ELZBIETA BOHOMOLEC ANDREW SAMUELS
Czech Republic
Poland England
SUDHIR KAKAR
HOWARD BOOK India JACQUES SCHOTTE
Canada Belgium
S U K - H U N KANG
PRAMOTE CHAOWASILP Korea ANTONIO ALBERTO S E M I
Thailand Italy
O S A M U KITAYAMA
CARLOS L. CORNAGLIA Japan CHANNAPATNA SHAMASUNDAR
Argentina India
MAURICIO KNOBEL

DlDIER CREMNITER Brazil JAROSLAV SKALA

France ALFRED KRAUS Czech Republic
Germany
JANOS CSORBA ROSS SKELTON
Hungary HERMANN LANG Ireland
Germany
RODOLFO D. FAHRER VLADAN STARCEVIC
Argentina ALFRIED LANGLE Yugoslavia
Austria
PIERRE FEDIDA RUTH STEIN
France D. BACHTIAR LUBIS Israel
Indonesia
STEPHEN FREIBERG JOAN SYMINGTON
PEDRO LUZES
Australia Australia
Portugal
SEBASTIAN GIUDICELLI IMRE SZECSODY
FINN MAGNUSSEN
France Sweden
Norway
ROBERT GORDON LASZLO TRINGER
O L G A MARLIN
Australia Czech Republic Hungary

LEON GRINBERG PERE FOLCH MATEU M A X J . VAN TROMMEL

Spain Spain Holland

SVEIN HAUGSGJERD CHRISTOPH M Ü N D T WALDEMAR ZUSMAN

Norway Germany Brazil
 Table of Contents

"On the Millenium": Part 2

Psychoanalysis at the Millennium 277
Richard D. Chessick, M.D., Ph.D.
Cognitive Therapy of Schizophrenia: A New Therapy for the
New Millennium 291
Aaron T. Beck, M.D., and Neil A. Rector, Ph.D.
Preserving the"Psychosocial" in an Era of Biological Psychiatry 301
Paul A. Dewald, M.D.
The Application of Computerized Content Analysis of Natural
Language in Psychotherapy Research Now and in the Future 305
Louis A. Gottschalk, M.D., Ph.D.
New Trends for a New Millennium 312
Wade H. Silverman, Ph.D.
Object Relations and Intersubjectivity in Depression 317
Heinz Weiss, M.D., and Hermann Lang, M.D., Ph.D.
Neurological Dysfunction, Psychic Conflict, and Psychotherapy 329
MareikeWolf,Ph.D.
Presentness: An Intersubjective Dimension of the Therapeutic Act 340
Rina Lazar, Ph.D.
The Birth of Reality: Psychoanalytic Developmental
Considerations 355
Ryan LaMothe, Ph.D.
C A S E STUDY
Second Generation to Holocaust Survivors: Enhanced
Differentiation of Trauma Transmission 372
Micha Weiss, M.A., and Sima Weiss, M.S.W.
FROM THE LITERATURE
Psychotherapy with Older Adults 386
Gary J. Kennedy, M.D., and Stacey Tanenbaum, M.D.
REFLECTIONS
Transpersonal Psychotherapy 408
Seymour Boorstein, M.D.
Letter to the Editor 424
Book Reviews 426

A M E R I C A N JOURNAL OF PSYCHOTHERAPY, Vol. 54, No. 3, Summer 2000

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Copyright 2000 by the Association

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P a r t 2
 Psychoanalysis at the Millennium*

R I C H A R D D. C H E S S I C K , M.D., Ph.D.**

This article explains and discusses the immense complexity of the psychoana-
lytic process as it is becoming increasingly understood at the millennium, and
offers the possibility that it can be viewed from at least five channels of
psychoanalytic listening. The careful ongoing examination of the transference
countertransference interactions or enactments, and their "analytic third" (32
location in the transitional space is extremely important in psychoanalytic
practice. We must be careful in our interpretations of the clinical data not to
stray any farther from the fundamental concepts of Freud than is necessary,
lest we end up with a set of conflicting speculative metaphysical systems and
become a marginalized esoteric cult. Freud's work remains our basic
paradigm, the core of psychoanalysis, even though his papers on technique and
his emphasis on the curative power of interpretation are from a one-person
psychology standpoint and his view of psychoanalysis as just another empirical
19th-century science requires proper understanding and emendation in the
light of accumulated clinical experience since his time.

I ask you what sense do these old quarrels make for us? The profound
resentment of unbending partisans has kept the wounds of our congrega-
tions open for far too long, wounds whose deadened flesh has become
insensate, so we feel no need for the doctor.
St. Augustine
The above quotation is from a letter written by St. Augustine (1, p. 77)
about 395 A.D. in his effort to reach some kind of reconciliation with the
Donatists. Both the Donatists and the Catholics shared a great many basic
principles at the time but the Donatists, named after Donatus, a martyred
hero of the resistance to any compromise, were known as stubbornly
refusing to negotiate or yield even on the smallest details of their theologi-
cal doctrines. As a result, Augustine's efforts failed and he ended up
resorting to traditional Christian solutions—violence, restriction of civil

"Presented at the 2000 annual meeting of the American Academy of Psychoanalysis, Chicago, I L .
**Professor of Psychiatry and Behavioral Sciences, Northwestern University; Senior Attending
Psychiatrist, Evanston Hospital; Fellow, American Academy of Psychoanalysis; Training and Supervis-
ing Analyst, Center for Psychoanalytic Study in Chicago. Mailing address: 9400 Drake Ave., Evanston,
I L . 60203-1106.
A M E R I C A N JOURNAL OF PSYCHOTHERAPY, Vol. 54, No. 3, Summer 2000

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liberties, and deportation—in an effort to stamp out this heresy (which

nevertheless lasted until the 7th century A.D.).
So it is that plus ça change, plus cest la même chose, the more things
change, the more they remain the same: When I was a resident in psychiatry
we had a series of seminars by one of my most influential and revered
teachers, Franz Alexander, who could be counted on to discover in each
and every case presentation, regardless of the material or diagnosis, that the
nucleus of the disorder was an Oedipus complex.
With all this high-powered psychoanalytic training, information, and
experience gathered in my residency, after spending two years doing
military service in the United States Public Health Service working with
drug addicts in a federal prison, I entered into the full time private practice
of psychoanalytic psychotherapy in 1960. At this point, I encountered a
fascinating schizophrenic patient who was not so schizophrenic that I could
not stand her, and who, after several years of intensive psychotherapy, made
a very noticeable recovery and adaptation that enabled her to live a
reasonably decent life in our lunatic culture. Bursting with pride near the
end of the treatment as I had watched this woman evolve from a dilapi-
dated human wreck into a very presentable and now married young lady, I
could not refrain from asking her, near the end of the treatment, which of
my interpretations had had the most significant impact on her improve-
ment and development. Her response was, "You have kind eyes."
This took me down a considerable distance and set me thinking about
what it is that actually brings about a cure in psychoanalytic treatment and
about what sort of theoretical orientation is most suitable for what I (2)
believe to be first and foremost a clinical medical discipline. I gradually
began to think of my patients and their narratives as sort of Rorschach
cards on which a variety of theories may be imposed. Kohut (3) tried to
distinguish between experience-distant and experience-near theories, but
this proved to be simply more narcissism on the part of psychoanalysts,
because now we know that all theories are experience-distant, and it is in
the area of theories that there is the most argument. So the philosopher
Epictetus, in his classic treatise Encheiridion ("Manual," 100 A.D.), gave us
an aphorism that Laurence Sterne thought was so worthwhile that he used
it as a motto in his famous novel Tristram Shandy, published around 1760:
Tarassei tous Anthropous ou ta Pragmata, Alla ta peri ton Pragmaton
Dogmata, which I roughly translate as meaning "people are not disturbed
by things, they are disturbed by theories about things."

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FIVE C H A N N E L S O F P S Y C H O A N A L Y T I C LISTENING

Over a period of 25 years, from about the 1970s to the present, I gradually
evolved what I have called the five-channel theory of psychoanalytic
listening. I have published a book (4) and a number of papers (5, 6) on this
topic and so I will only very briefly review here the five standpoints or
channels or models or perspectives or frameworks from which I suggest we
tune in to the transmission from the patient. The first was presented by
Freud. It involves the Oedipus complex and the emergence in a properly
conducted psychoanalysis of the pressure for drive gratification in the
transference. This enables us to study the patient's conflict in terms of
defenses against the instinctual drives and the resulting compromise forma-
tions produced by the ego in dealing with its three harsh masters—the
superego, the id, and external reality. Freud 's structural theory, placing the
Oedipus complex at the focus of all psychoneuroses, was developed in
order to best depict this one-person standpoint; the analyst is thought to be
simply the observer of it all.
The second channel utilizes the perspective of object relations theory
for its model. It is based on the work of Klein and her analysand Bion, and
focuses on the earliest projective and introjective fantasies of the patient as
they appear in the object relatedness manifest in the transference, and on
the process of projective identification, which is defined differently by
every author. Understanding of these processes through a conceptualiza-
tion of the patient's earliest internalized object relations yields data about
how the patient as an infant organized these relations into self and object
representations and then projected and reintrojected various aspects of
these images. This helps to clarify the patient's relationships in the present,
because all such current relationships are perceived and reacted to through
the spectacles of these early organized self and object representations.
A third channel, focusing on the patient's being-in-the-world, is the
phenomenologic point of view. Here, an attempt is made to grasp the facts
of the patient's life phenomenologically, without other theoretical precon-
ceptions to organize the data. A corollary to this approach is that society
shapes the individual, and we can only understand the individual if we
understand the society or culture or world in which he or she must
continuously live and interact. So to understand an individual, we must
understand that lived state of being-in-the-world which is unique for the
situation of each person.
The fourth approach is from Kohut's self psychology, which focuses on
the state of the patient's sense of self as it is empathically grasped by the

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analyst. Important predecessors of this approach were Fairbairn and

Winnicott. The latter introduced the notion of the true and the false self
that was taken up in detail by R. D. Laing (7) in his brilliant exposition of
the phenomenology of schizoid and schizophrenic conditions.
The final approach to organizing the transmission from the patient
might be loosely termed the interactive, focusing on the countertransfer-
ence of the therapist or, more generally, on the here-and-now factors in the
treatment with emphasis on both the patient's and the analyst's participa-
tion, from what is designated as the two-person standpoint. This is the
domain of intersubjectivity and postmodernism, popular as we go into the
21st century. Many of the numerous and conflicting points of view under
this rubric have been developed as a response to our increasing understand-
ing, especially in pre-oedipally damaged patients, of the patient s need for
an experience and not just for an explanation in the treatment, as Frieda
Fromm-Reichmann (8) put it.
Hans Loewald, for example, although he was a pioneer in developing
the traditional psychoanalytic approach, was also a student of the philoso-
pher Heidegger. Loewald (9) insisted that the patient's experience of the
analyst was a major factor in the curative process. Hence, the patient's
metaphor, "kind eyes" begins to make some sense. This is especially true in
patients who present us with archaic transferences that actually force us to
make immediate decisions about what to do, for example, having to decide
whether to try to put a stop to a patient's suddenly developing promiscuous
behavior in the age of AIDS.
Anyone who was a patient of Sigmund Freud had quite an experience of
the personality of his analyst. Freud was anything but neutral and opaque,
and certainly Freud in his actual practice often, in my opinion quite
sensibly, violated some of his own admonitions published in his papers on
technique. It is likely that Freud's papers on technique were basically aimed
at preventing massive acting out by incompletely analyzed or even unana-
lyzed therapists with their patients, as was certainly common in the early
days of psychoanalysis and remains all too common with much less
justification today. But Freud's admonitions tended in the middle of the
20th century in the United States to become codified into a rigid set of rules
that sometimes produced iatrogenic narcissistic manifestations in patients
and led to either an impasse in the treatment or a surrender of autonomy by
patients, accompanied by a massive identification with the "aggressor"
analyst.
I am very aware that in my approach five theoretical orientations or
models are being utilized that directly conflict with each other and cannot
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be thought of as complementary because the basic premises that underlie

them, both their epistemological foundations as well as their basic assump-
tions about human nature and its motivations, directly collide. This forces a
radical discontinuity as we shift from channel to channel of listening in our
receiving instrument, rather than, as we would all prefer to do, sliding back
and forth between theoretically consistent or at least complementary
positions. But the worst mistake a beginner can make at this point in the
development of psychoanalytic theory is to assume that in some fashion
these five various standpoints can be blended or melded into some
supraordinate theory that can generate all of them. This problem in the
human sciences in general is profound, and some thinkers such as Michel
Foucault (10) have claimed that in principle no agreement can ever be
reached on a single theoretical model for scientific understanding of all
human mentation and behavior.

DIVARICATION OF CONTEMPORARY PSYCHOANALYTIC THEORIES

My approach at the beginning of the 21st century requires tolerance and

flexibility on the part of the analyst as well as a certain maturity, for it is well
known that sometimes the unfortunate result of a personal psychoanalysis
is that the individual becomes a strong and rigid adherent of the particular
theoretical orientation and style of one's analyst. Since there are no data
available at present that convincingly and decisively prove that any of these
theoretical orientations are the one and only best one, uncritical adherence
to any one of them must be viewed with suspicion as unresolved counter-
transference from ones personal analysis. And these five channels are only
my choices, the ones I have found most clinically useful; there are viable
others.
Our beleaguered discipline is in the process of correcting itself, al-
though I doubt this will reduce the vehemence and multiplicity of the
attacks on it, which have continued since its inception. One might argue
that the tyranny of mismanaged care along with the revolutionary findings
of biological psychiatry have substantially reduced the incomes of most
psychoanalysts and in so doing may have introduced an important initiating
factor toward the revision of schismatic tendencies and the improved
reality testing regarding outcomes in our field, as well as an increasing
tolerance of each others disagreements about theoretical matters. As
Benjamin Franklin said to the first Continental Congress in 1776, "We must
all hang together or surely we will all hang separately."
Wallerstein (11) emphasized the transition of psychoanalysis into world-
wide theoretical diversity and the dependence of theoretical orientations on
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local social and cultural factors, a fact that I have repeatedly referred to in
my publications (2, 12) calling for a Nietzschean style genealogical study of
what is considered "truth" and of factors influencing choice of theories
among psychoanalysts in various countries. The eminent British psychoana-
lyst Steiner (13) also insisted, "Despite the universality of the process of the
unconscious, psychoanalysis is considerably influenced by the historical,
cultural, and social context in which it is developing" (p. 233). This does
not mean that these overarching theoretical perspectives have equal status
however, since they are not equal in ultimate explanatory power. We hope
that eventually there will be greater correspondences between the con-
structs of the theory and the relationships between the observables in our
consulting room, for psychoanalysis, as stated above, is first and foremost a
medical clinical discipline (2).
Gedo (14) in a recent volume argued that the evolution of psychoanaly-
sis can either be conceived of as the story of a discipline breaking up into
irreconcilable fragments, or as the emergence of a new paradigm that
transcends the disputed theories of an earlier time. This new paradigm, he
repeatedly insists, is a biological or natural-science view of psychoanalysis
in which all descriptions and discussions of mental functions must take into
account the somatic substrate and what is known about it. As Freud said,
the ego is first and foremost a body ego. Otherwise one is forced into what
Gedo calls a rationalist or a mentalist view, in which various theories
conflict and are not capable of being tested and being weighed. He often
calls this latter stance the hermeneutic viewpoint, based on philosophical
positions and with no agreed-upon standards of validation.
CURATIVE FACTORS
The fundamental techniques of psychoanalysis include free association,
frequency, regularity, recumbency, the analyst's general passivity, relative
neutrality, abstinence, and confinement to interpretation, according to the
classical view as proclaimed, for example, by Gill (15) in his earlier work.
But the trouble with this formulation is that it is too simplistic; we have
achieved an increasing recognition of the extreme complexity of the
psychoanalytic process. Ferenczi's elevation of the analytic relationship as a
central vehicle of therapeutic change to an equal importance alongside
Freud's focus on interpretation has gained increasing acceptance in our
time. The debate remains unresolved over whether the therapeutic power
of psychoanalysis should be attributed to the verbal-interpretive function
of the analyst or to the emotionally involved and responsive analyst
asserting his analytic powers through all aspects of his or her affectively
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intense relationship to the patient. We are only now beginning to under-

stand the powerful effect of the real person of the analyst, of the intensity of
his or her emotional involvement with the patient over many years, of the
special qualities that inevitably evolve in each individuals analytic situation,
and of the use, wittingly or unwittingly, of noninterpretive interventions.
This requires the reassessment of our conceptions of analytic abstinence,
anonymity, and neutrality. There is a gradually developing consensus that
the sicker patient, who suffers from developmental pathology, requires the
provision of support, the role of new experience, and, as Gedo (16) puts it,
the correcting of "apraxias," defects in basic social habits of living. This
sicker group is characterized by unreliability of object contact or object
constancy; failure to tame drives or to develop stable defenses; deficiencies
in self-esteem, in frustration tolerance, and in affect modulation; and a
blurring of self and object boundaries.
In psychoanalysis the replay of old scenarios, dyadic and triadic,
including strong negative transferences, is given the greatest opportunity to
be manifested and to be successfully interpreted and worked through in the
here-and-now. One way to look at it has been presented by Arlow and
Brenner (17), who describe the psychoanalytic process as one in which
interpretations destabilize the equilibrium of forces that are in conflict in
the patient's psyche, which leads to a growing awareness and understand-
ing of these conflicts, working through, and new conflict resolution
through more adaptive and less self-defeating compromise formations.
Yet, every good psychoanalytic clinician knows that our insights into
patients do not occur either by accident or by necessarily incisive rational
thought. The process is often more similar to what the famous contempo-
rary artist Francis Bacon (18) tells us about how he gets an idea for a
painting:
What I call accident has nothing to do with some kind of inspiration with
which we have credited artists for so long. It is something which comes from
the work itself and which suddenly appears out of the blue. In the end, painting
is the result of the interaction of those accidents and the will of the artist or, if
you prefer, the interaction of the unconscious and the conscious. But you know,
things seem clear enough when you talk about them, but that's not at all what
it's like when you're at the canvas. There you don't know where you are or
where you're going, or above all, what's going to happen. You are in a fog. (pp.
86-87)
POSTMODERNISM AND INTERSUBJECTIVITY
This leads the discussion to postmodernism, a concept that can easily be
used as an excuse for wild analysis or relativism. But what also follows from
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the postmodernist argument is that whenever a narrative appears unified,

clear, and complete, something must have been suppressed in order to
sustain the appearance of unity! This is extremely important for psychoana-
lytic clinicians to understand, because the suppressed within the story does
not lose its power, it continues to affect the character of the whole. Here lies
the value of deconstruction, which explores again and again the limits of
the narrative in order to reveal the many unresolvable antimonies in a given
narrative. This implies that any interpretation of clinical material must
suppress some aspect of the material and that other interpretations are
always possible. It is this situation that makes our work so extremely
difficult.
From the postmodernist point of view, psychoanalysts need to listen
attentively to the patient's speech for multiple voices, not as a unified choir
but to tease out singular voices that have been drowned out through years
of oppression, demands for conformity and submission, and painful psycho-
logical or even physical punishment. As R. D. Laing (19) put it in his
discussion of the "politics of the family," the individual who dares to
challenge the demand for conformity and submission to the family system is
labeled as either bad or mad. It was Lacan's signal contribution to call our
attention once more to the patient's speech, returning to the approach
demonstrated in the early publications of Freud.
In deprivileging the analyst as the oracle of truth, postmodernism stands
in contrast to the positivist interpretation of experience. It moves psycho-
analysis away from the place of a scientist uncovering facts and toward the
direction of a collaboration in developing personal narratives that assume
the interpretive nature of all clinical understanding. The attempt to justify
our interpretations as some sort of 19th-century scientific procedure
actually leads to a loss of respectability, for this demeans and neglects our
hermeneutic skills and real clinical therapeutic power. The presentation of
psychoanalysis as a traditional 19th-century science may have been neces-
sary for Freud to legitimate a new, highly revolutionary and brilliant
discourse, but today we are in a new context, a new focus on a two-person
psychology in the consulting room that creates spaces, as Winnicott (20)
said, whereby two subjectivities are legitimized, each with its own history,
script, and cast of characters. We are interested in the influence of one on
the other, for there is no way to avoid the fact that the patient and the
analyst continuously and mutually influence one another.
Furthermore, we cannot simply assume that the actual behavior of the
analyst is correctly perceived by the patient, whether or not the interven-
tion of the analyst is an accurate interpretation introduced in an empathic
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and timely manner or an inadvertent error. We can only infer what any
behavior or intervention by the analyst means to the patient through a
disciplined study of the patients behavior, associations, dreams, and
actions inside and outside the sessions (21). There is general agreement that
the psychoanalytic treatment situation is vastly more complex than was
realized by the early generations of psychoanalysts.
I have already mentioned what Gedo has called apraxias, i.e., defects in
psychological ability to modulate ordinary emotional responses to the
vicissitudes of everyday life. The patient brings to the analysis a certain set
of maladaptive internalized practices that represent internalized identifica-
tion with significant parents and/or compromise formations formed by the
early ego in dealing with its three harsh masters. The patient presents these
mechanisms from the very first moment of contact with the analyst, even on
the telephone making the first appointment; it is sometimes possible even
while setting the initial appointment to recognize patients who are para-
noid, anxious, obsessive-compulsive, depressed, and so on. This is hardly
totally attributable to the vicissitudes of the psychoanalyst's input, although
such input may have a triggering affect from time to time.
Our theories and our personalities always have distorting consequences
on whatever appears in the analytic situation, and this is what produces the
exceedingly frustrating paradox that all great conflicting theorists in our
field have found clinical material in their patients that they believe validates
their theories. But there are certain essential patterns that are built into the
fabric of the self or, looking at it from a differing channel or theoretical
viewpoint, that constitute primary ego mechanisms or defense transfer-
ences, that will be revealed sooner or later in any well-conducted analysis.
However, there is no doubt that patients gain an enormous amount of
knowledge about us as time passes and that it is impossible to maintain
strict neutrality. At the same time, surely, it is throwing out the baby with
the bath water to claim that the whole of the material of any psychoanalytic
procedure is intersubjective and that the patient's basic contribution to this
material cannot be sorted out in order to stand by itself and give us at least a
reliable adumbration of the patient's psychic structures (22).

WHAT IS P S Y C H O A N A L Y S I S ?

In my (23) opinion psychoanalysis can be conceived of as a shared

communal belief system subject to constant revision through clinical
experience, a revision that each of us ought to be doing all of the time as a
consequence of our individual clinical practice and our communications
with our colleagues. We need to understand a lot more about the choice of
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theoretical systems in psychoanalysis. Our basic paradigm still is the

Standard Edition of the Works ofSigmund Freud. But what determines our
choices of models? How do they affect the "data" gathered in the psycho-
analytic treatment? How do they affect the psychoanalytic treatment
process itself? How does one go about using more than one model in the
most efficient and effective manner in our psychoanalytic work? These are
questions that should be going through the mind of every analyst as he or
she works with every patient.
Careful consideration of these matters leads to, at present, unresolved
philosophical issues, because every theoretical orientation in turn rests on
epistemological and ontological premises that conflict with each other.
Here, I believe Hegel gets great credit because he left to posterity the
sentiment that there is something either fundamentally wrong or at least
unsublatably one-sided with our traditional ways of attaining a correct
conception of reality or of finding out what things really are. This is the
reason we need to take Hegel's philosophical projects seriously, as well as
for the important psychological insights that are contained in his master-
work Phenomenology of Spirit. Here, Hegel (24) already recognizes that the
self is a shifting and changing set of mental attitudes which has a develop-
mental line of its own. His discussion of the relationship between the
master and the slave is one of the best early depictions of the dynamics of
the sadomasochistic interaction and is worthy of careful attention even
today by clinicians. One does not have to accept Hegel's total metaphysical
system in order to benefit from a study of Hegel, and for that reason in my
recent book Emotional Illness and Creativity, (25) I have referred repeat-
edly to Hegel's concepts involving the function and meaning of artistic
creativity and the destruction of that creativity by emotional illness.
There is a case vignette in one of Kohut's (26) books where a young male
patient comes in breathlessly, stating that he drove at an incredible speed
because he was late for his analytic session. Kohut simply tells him that he is
crazy to do that. I might have done the same thing with this patient, simply
spontaneously telling him that this was crazy behavior and he should cut it
out. When one firmly tries to get the patient to stop uncontrolled and
self-destructive behavior, the patient recognizes at some level that the
therapist actually cares about him or her in a human way, not as a specimen
being observed through a magnifying glass. I believe that this has an
enormous effect on propelling therapy forward.
If a patient becomes suddenly promiscuous or begins engaging in other
uncontrolled and self-destructive behavior during a psychoanalytic pro-

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cess, the analyst has a certain responsibility to explore this and intervene if
necessary to protect the patient. This is what I believe to be the physicianly
vocation of the psychoanalyst. At least in my practice, if my patients are
really doing crazy things that are dangerous and self-destructive, I inter-
vene; from my point of view the lack of intervention represents a serious
negative countertransference, as does the failure or refusal to prescribe
psychopharmacologic agents during periods of acute emotional suffering
that sometimes occur during psychoanalysis.
A significant number of psychoanalytic cases in the middle of the 20th
century were ruined by the development of iatrogenic narcissistic phenom-
ena because the analysts were trying so hard to be rigidly blank, neutral,
and opaque. I have been told that there was one lady analyst who not only
sat behind the patient, but put a screen between herself and the couch.
These are very loud messages to patients about the personality and the
problems of the analyst and they are bound to produce strong reactions,
but such reactions are not necessarily transference.
Sometimes as a result of showing enough care to try to stop the patient
from being flagrantly self-destructive, the patient pulls himself or herself
together, shapes up, experiences an increased cohesion of the self, and
achieves the kind of cure we often see in adolescents or young adults who
have used the therapist as a temporary selfobject to shore up a self which is
crumbling. Once they have done that, they do not need the therapist any
more, and there is no particular reason for them to ever contact the
therapist again. The only question is, can we call this a psychoanalytic cure
or a nonpsychoanalytic cure? This, of course, depends on one's theoretical
orientation and beliefs as to what is and is not psychoanalysis!
Over the years I have seen a number of adolescent or young adult
patients who used me in this manner, pulled themselves together, straight-
ened out their lives, and went on to a more or less ordinary existence. They
were not able to explain why this happened, and I am convinced it had
more to do with the capacity of the adolescent or the young adult to utilize
the therapist for whatever he or she needs at that stage of development,
regardless of the theoretical orientations or interpretations that the thera-
pist has to offer; that is to say, it is the genuineness and the personality of the
therapist, as Nacht (27) says, "what the analyst is rather than what he says"
(p. 106), that makes the difference [see also Nacht's (28) discussion of this].
Switching now to the object relations channel, Summers (29) points out
the great importance of Winnicott's concept of the analytic process occur-

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ring in transitional space. Summers characterizes the analytic relationship

as having a
"formlessness," the purpose of which is to provide the therapeutic space for the
patient to create a new object relationship . . . the task for the patient is to find a
way to use the analyst to create the needed object. The analytic object is neither
the patient nor analyst but what the patient creates from what the analyst
offers, an "analytic' third" (p. 116).
The question of whether pregenital impulses can be analyzed and if so,
how to do it, is also still debated at this turn of the century time. Anna
Freud did not believe it could be done, and she opposed the so-called
"widening scope" of analysis. I think the reason for this was that Anna
Freud was thinking of psychoanalysis as consisting solely of interpretation,
but pregenital impulses usually present themselves in archaic transferences
which force the analyst to make immediate practical decisions and some-
times even to take action! I maintain that we need not be afraid of these
pressured decisions if we are well analyzed and really have the patient s best
interests at heart with no secret agenda. None of us is perfect in that
respect, but I do not believe that patients require perfection, in fact, thank
God, they are very tolerant of our many various weaknesses and personal
foibles. But basically we must have a physicianly vocation, and if we do not
have it, no matter how brilliant we are, there is going to be big trouble in
the analysis, or to put it in another way, we must have kind eyes. This is true
even if the patient is unable to perceive those kind eyes for a long, long time
because of the transference.
Why is it that in pre-oedipally damaged patients memories appear in
archaic transferences and enactments rather than in dreams and verbal
reports? We now know (30) there are two kinds of memories, probably
stored in different parts of the brain. The important experiences that form
our basic internalized object relations occur before the development of
language has progressed very far, and are stored as procedural memories
rather than autobiographical or declarative memories. Procedural memo-
ries involve sequences of actions and are recovered via the interpersonal
situation or enactments that the patient creates in the transference -
countertransference situation with the analyst. Pressures are brought on
the analyst, feelings are aroused in us, conflicts disturb us internally as we
work with the patient. Procedural memories antedate declarative memories
and involve a network of unconscious expectations and interpersonal
models. Through enactments and the exploration of fantasies, these are
recovered and curative events are allowed to take place, consisting of a

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modification of these expectations and interpersonal models or apraxias,

sometimes via interpretation and sometimes via an inadvertent corrective
experience or new object relationship formed with the analyst that neither
the patient nor the analyst may necessarily know is taking place.
We can no longer adhere to a theory based on an extreme and rigid
interpretation of Freud's papers on technique, which Freud himself had
sense enough to ignore when the patient's well-being was at stake. That is
why the rat-man got a sandwich from Freud's kitchen. Can you imagine
Freud as a candidate telling he did that to a mid-20th century psychoana-
lytic institute supervisor? John Rosen, the father of so-called "Direct
Analysis" (31) used to tell this story: One day he was extremely upset at the
end of an analytic session and when he got up from the analyst 's couch, the
analyst beckoned to him to come into the other room in the office. There,
the analyst opened a file cabinet and took out a bottle of scotch. He poured
a stiff drink for each of them. After they clinked glasses and downed the
whiskey, his analyst said, "Now don't you tell anybody about this!"

REFERENCES

1. Wills G (1999). Saint Augustine. New York: Penguin.

2. Chessick R (2000). What is psychoanalysis? Journal of the American Academy of Psychoanalysis, 28,
1-23.
3. Kohut H (1971). The analysis of the self New York: International Universities Press.
4. Chessick R (1992). The technique and practice of listening in intensive psychotherapy. Northvale, NJ:
Jason Aronson.
5. Chessick R (1985). Psychoanalytic listening II. American Journal of Psychotherapy, 39, 30-48.
6. Chessick R (1990). Psychoanalytic listening III. Psychoanalysis and Psychotherapy, 8, 119-136.
7. Laing R (1969). The divided self. New York: Pantheon.
8. Fromm-Reichmann F (1950). Principles of intensive psychotherapy. Chicago, I L : University of
Chicago Press.
9. Loewald H (1960). On the therapeutic action of psychoanalysis. International Journal of Psycho-
Analysis, 41, 16-33.
10. Foucault M (1973). The order of things. New York: Vintage.
11. Wallerstein R (1999). Psychoanalysis: Clinical and Theoretical. Madison, CT: International Universi-
ties Press.
12. Chessick R (1992). What constitutes the patient in psychotherapy? Northvale, NJ: Jason Aronson.
13. Steiner R (1984). Review of Psychoanalysis in France, Serge Lebovici and Daniel Widlocher (Eds.).
International Journal of Psycho-Analysis, 65, 232-233.
14. Gedo J (1999). The evolution of psychoanalysis: Contemporary theory and practice. New York: Other
Press.
15. Gill M (1984). Psychoanalysis and psychotherapy: A revision. International Review of Psychoanaly-
sis, 11, 141-179.
16. Gedo J (1979). Beyond interpretation: Toward a revised theory for psychoanalysis. New York:
International Universities Press.
17. Arlow J & Brenner C (1988). The future of psychoanalysis. Psychoanalytic Quarterly, 57, 1-14.
18. Bacon F (1993). In Conversation with M. Archimbaud. London: Phaidon Press.
19. Laing R (1972). The politics of the family. New York: Vintage Press.
20. Winnicott D (1971). Playing and Reality. New York: Basic Books.

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21. Chessick R (1996). Dialogue concerning contemporary psychodynamic therapy. Northvale, NJ: Jason
Aronson.
22. Chessick R (1996). The application of postmodern thought to the clinical practice of psychoanalytic
psychotherapy. Journal of the American Academy of Psychoanalysis, 24, 385-407.
23. Chessick R (2000). Psychoanalytic clinical practice. London: Free Association Books.
24. Hegel G (1807). Phenomenology of spirit. Trans. A. Miller Oxford: Clarendon Press, 1977.
25. Chessick R (1999). Emotional illness and creativity. Madison, CT: International Universities Press.
26. Kohut H (1984). How does analysis cure? Chicago, I L : University of Chicago Press.
27. Nacht S (1988). Symposium on the essentials of psychoanalytic cure. M. Osman and N . Tabach-
nick, reporters. Psychoanalytic Review, 75, 185-215.
28. Nacht S (1962). The curative factors in psychoanalysis. International Journal of Psycho-Analysis, 43,
206-211.
29. Summers F (1999). An object relations model of psychoanalytic therapy. Hillsdale, NJ: The Analytic
Press.
30. Fonagy P (1999). Memory and therapeutic action. International Journal of Psycho-Analysis, 80,
215-223.
31. Rosen J (1953). Direct analysis. New York: Grune & Stratton.

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 Cognitive Therapy of Schizophrenia:
A New Therapy for the New Millennium

AARON T. BECK, M.D.*

NEIL A. R E C T O R , Ph.D.**

Over the past decade, major advances have he en made in extending the
principles and therapeutic strategies of cognitive therapy to the treatment of
schizophrenia. In a number of large-scale outcome studies with cognitive
therapy for schizophrenia, cognitive therapy has been shown to offer
significant gains for those patients who have not been wholly helped with
medications. It may even serve to prevent the consolidation of the illness if
delivered with those in the early stage of the illness. We first outline the
state-of-the-art" conceptualization and strategies employed by cognitive
()

therapists to treat positive and negative symptoms and then review the clinical
trials.

As we enter the New Millennium, a promising new approach to schizophre-

nia is emerging. Accumulating empirical evidence indicates that cognitive
therapy combined with standard treatments provides significant improve-
ment of drug resistant and residual symptoms. In addition, the new
approach offers a more humanistic understanding of the patient with this
devastating disorder. In contrast to the more mechanistic framing of
schizophrenia in terms of abnormal brain scans and deficient responses to
tests of attention, memory and cognitive performance, the cognitive ap-
proach views the patient as a whole person with many troubling, apparently
baffling problems but also with the resources for testing and modifying his
or her more esoteric beliefs.
Specifically, the cognitive therapist views the phenomena, such as
persecutorial delusions and distressing hallucinations as a highly convo-
luted expression of the kind of reaction experienced by anyone who has felt
mistreated, depressed or fearful. When these more bizarre elaborations are
explored, the therapist can discern the more familiar psychological prob-
lems characteristic of depression, social phobia, anxiety disorder, obses-

*Professor of Psychiatry, Dept. of Psychiatry, University of Pennsylvania; Director, The Beck

Institute of Cognitive Therapy. Mailing address: Room 754, Science Center, 3600 Market Street,
Philadelphia, PA 19104-2648.
**Clarke Institute of Psychiatry, 250 College Street, Toronto, Canada.

A M E R I C A N JOURNAL OF PSYCHOTHERAPY, V o l . 5 4 , N o . 3 , S u m m e r 2000

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sional disorder, and posttraumatic stress disorder and can draw on the
kinds of strategies used in the cognitive therapy of these conditions.
The patients' neuro-developmental vulnerability makes them exquis-
itely sensitive to the kind of life stresses we all encounter, but with fewer
psychological resources to deal with them. Additionally, more unique
stressors, including enforced hospitalization, imposed behavioral controls,
and stigmatization, added to the demoralization produced by a chronic
relapsing disorder, pose therapeutic issues that the cognitive approach aims
to address.

COGNITIVE F O C U S IN SCHIZOPHRENIA

Nearly fifty years ago, Beck (1) described the cognitive treatment of a man
with a seven-year, treatment-resistant delusional system. The patient was a
28-year-old WWII veteran, who, upon returning home from the war, had
come to believe that former members of his military unit were now working
on behalf of the FBI to monitor his activities. The patient also was
experiencing extreme anxiety and dissociative states as a response to the
erroneous beliefs. He was treated for 30 sessions over eight months. The
focus of treatment was on the identification of the antecedents of the
patient's delusional system and the implementation of reality-testing strate-
gies to modify the beliefs; that is ways of questioning and testing alternative
ways of understanding events. By the end of treatment, the patient was able
to stand back, and reason himself out of the erroneous beliefs when he
became suspicious of being watched. Two decades later, this case report
was followed with a report of a cognitive investigation of eight patients with
ongoing delusions (2). Through careful questioning of the evidence that
these patients held in support of the delusions, they began to see their
delusions as hypotheses about the meaning of events rather than as
absolute, rigid "truths." Other clinical researchers began to report similar
benefits using the same cognitive focus (3).
More recent laboratory experiments testing cognitive processes in
persons diagnosed with schizophrenia have extended our understanding of
the biases that may serve to maintain erroneous beliefs and aberrant
perceptions. Studies have shown that paranoid schizophrenics, for ex-
ample, have a selective perceptual bias for threat-related stimuli (4).
Further, they are far more prone than other patients to attribute distressing
occurrences to other people rather than to themselves or the situation (5).
Moreover, despite this compensatory strategy of blaming others for mis-
haps, they show low self-esteem on covert assessments (5). Studies of
hallucinations have shown a similar perceptual bias (6-8). People who hear
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voices are more likely than controls to recall printed words as voices or
misidentify garbled sounds as true words (4,9).
The application of cognitive therapy is based on several observations
about the patient. A psychotic patient is not pervasively irrational but has a
psychosis-free zone that can be utilized in therapy. Contrary to popular
belief, the hallucinations and delusions are not impermeable to psychologi-
cal interventions. Further, these symptoms can be triggered or ameliorated
by environmental factors. Finally, it is possible to make sense of the seeming
bizarreness of the content of the delusions, hallucinations, and thinking
disorder, and these symptoms can be placed in a meaningful context.
The focus of cognitive theory is on the patient as a unique individual
whose psychosis developed in a specific setting. Throughout treatment, a
trusting, collaborative relationship between patient and therapist is crucial.
It often takes much longer and requires more effort to establish rapport,
trust, and collaboration than with other psychiatric patients. The therapist
uses the same kind of gentle questioning, collaboration, and empirical
testing of beliefs intrinsic to the cognitive therapy of depression.
While for the sake of convenience it is useful to discuss the approaches
to hallucinations, delusions, and negative symptoms separately, in actual
practice, these approaches are synchronized (9-12).

VOICES
Careful questioning about the nature of the auditory hallucinations can
provide a number of clues for therapeutic intervention. The therapist
inquires about the frequency, duration, intensity, and variability of the
voices. What circumstances tend to bring them on, and what circumstances
tend to terminate or attenuate them? What events occurred prior to their
initial onset? What agents (God, the devil, dead relatives, etc.) are suppos-
edly talking to the patient? What are or have been the patient's reactions to
the voices: at first, surprised, puzzled, uncertain; then, scared, angry, sad (in
unusual cases, happy or indifferent)?
In most cases, the patients react to the voices as they would to other
people talking to them; that is, they establish an interpersonal relationship
with the voices. The patient may believe that because of their imperative
tone and content, the voices are omnipotent, omniscient, or uncontrollable.
Consequently, the patient often feels helpless, vulnerable, hopeless, or
desperate. These beliefs can be alleviated by a number of strategies. The
uncontrollable belief can be addressed by demonstrating to the patients
that they can initiate, diminish, or stop the voices. Initiating voices is
accomplished by selecting and reproducing a stimulus known to excite
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them; e.g., recalling or imagining a scene, discussing a sensitive event, or

focusing on others' voices or sounds in the next room. Diminishing or
obliterating voices is accomplished by listening to music with a radio
headset, shadowing (repeating what the voice says), or engaging in conver-
sation.
The omnipotence and omniscience are addressed by setting up experi-
ments that will prove that the patients can ignore the commands or "mind
reading" without dire consequences. The devastating threat-filled meaning
of the voices (for example, tortured for eternity) can be alleviated by
demonstrating to the patients that the voices are generated not by a
malevolent entity but by the brain. Socratic questioning is useful: Can
others hear the voices? Why not? The ability to turn them on and off
provides further evidence that they are generated internally. Explanations
regarding how the brain functions to produce thoughts that are vocalized
often helps. Finally, demonstrating that the voices reflect the patients' past
or present thoughts can suggest that the voices simply represent their own
attitudes about themselves or those they think other people have about
them.

DELUSIONS

Delusions, although often bizarre, may be approached in much the same

way that we address beliefs, hypotheses and distortions in nonpsychotic
patients. The major difference is that cognitive distortions are more readily
discounted by nonpsychotic individuals if they do not hold up under
reasoning or reality testing. Patients with psychoses take hypotheses as
facts, imaginings as reality.
The content of psychotic delusions reflects everyday concerns regarding
interpersonal relationships: being attacked, influenced, manipulated, con-
trolled, demeaned. A significant feature of delusions is the "centrality" of
the patients' interpretations. They perceive themselves as the focal point of
a global drama and relate all events to themselves. Once formed, the
delusions shape the interpretation of events and explanations for adversi-
ties.
The therapeutic approach is directed at undermining the tenacity and
centrality of the delusions. By gently questioning the patient about the
nature, origin, and basis of the delusions, it is possible to move the patient
into a questioning mode. The therapist initially deals with the kinds of
interpretations and explanations that are peripheral to the more flagrant
and highly charged beliefs. The therapist, for example, selects one or more
of a series of questions to help the patient to evaluate his or her conclusions.
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Consider a patient who decides the following events are attributable to

the deliberate harassment by a conspiratorial group: his laundry arrived
late, loud noises from a truck woke him up during a nap, and he could not
find his notebook. The questions could take the following form: 1. Does it
follow that this inconvenience is due to a deliberate manipulation rather
than a random event? 2. What is the evidence that it is caused by a group?
3. What alternative explanations are there? The patient may also be
questioned regarding the mechanisms by which he reads other people s
minds. By questioning the inferences, the therapist can help to undermine
the underlying belief structures.
"Focusing" is another therapeutic intervention. The therapist encour-
ages the patient to concentrate on the visible characteristics of the sup-
posed persecutors and formulate criteria by which a trusted outsider (such
as the therapist) could apply these criteria. Generally, the more the patient
concentrates on observing the unique features of the presumed persecutor,
the less they fit the profile and the more likely they are to be discarded.
Using a variety of approaches such as these enables the therapist to break
the deadlock the delusions have on the processing of information.

NEGATIVE SYMPTOMS
The negative symptoms revolve around affective and behavioral defini-
tions: flattening of affect, paucity of speech, anhedonia, withdrawal, apathy,
and abnormality of thinking. Many, but not all, of the negative symptoms
may be attributed to depression (which may be alleviated using standard
cognitive strategies and techniques). Symptoms not responding to antide-
pressant approaches may be attributed to the positive symptoms: hallucina-
tions and delusions. Patients may fold into themselves under the powerful
pressures of the hallucinations and delusions.
The alleviation of delusions and hallucinations may have a favorable
impact on other "deficit" symptoms. The residual symptoms may then be
approached by engaging the patients in real-life tasks: depending on their
level of functioning, the therapist may try to arouse the patients' interest in
various projects, improve his socialization, and reinforce vocational skills.
Even the thinking disorder manifested by highly symbolic, mixed-up
ideas may be alleviated. The therapist attempts to pick out the theme that
appears to be represented in these verbalizations. By translating the
chopped-up and highly symbolic language into the patient s everyday
concerns, the therapist can switch the patient to a higher cognitive level and
begin to focus on the patient's perceived interpersonal problems.
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SESSION-BY-SESSION STRUCTURE
In terms of the delivery of cognitive therapy, sessions are active and
structured: the therapist and patient are working collaboratively toward
mutually agreed-upon goals. Individual sessions follow pretty much the
same format as cognitive therapy for other psychiatric disorders: a struc-
tured agenda is set at the beginning of each session; the therapist and
patient work toward prioritized goals; homework is set at the end of each
session and may include: the monitoring of situational triggers that activate
delusional beliefs and/or hallucinatory activity; the monitoring of mood
states and the important link between negative automatic thoughts and
negative moods with dysfunctional thought records (DTR); the completion
of activity schedules to reinforce participation in pleasurable and task-
based activities; and homework assignments that involve behavioral experi-
ments to test erroneous beliefs and/or control over hallucinations. Sessions
typically run between 15-45 minutes, include frequent breaks, and offer
flexibility in terms of the session-to-session goals. The manual-based
cognitive-therapy interventions were developed for delivery in individual
format, although recent clinical developments have shown the safety and
effectiveness of cognitive therapy in group modality. For instance, Wykes
and colleagues (13) have described a very effective group cognitive therapy
for auditory hallucinations, consisting of six group-sessions.
RESEARCH FINDINGS

Programmatic research testing the effectiveness of cognitive therapy for

schizophrenia has largely taken place in England (14-23) although a more
recent study has been completed in Italy (21). While there are some minor
differences between the cognitive-therapy interventions delivered in these
studies, they all share a common emphasis on the use of cognitive and
behavioral techniques to 1. target and reduce the frequency, severity, and
distress associated with the experience of positive and/or negative symp-
toms, 2. enhance coping skills to better manage both positive and negative
symptoms, and 3. reduce the personal stigma associated with the illness.
I s COGNITIVE THERAPY EFFECTIVE IN COMBINATION WITH MEDICATIONS FOR
MEDICATION-RESISTANT SCHIZOPHRENIA?
Garety and colleagues (14) conducted a nonrandom-allocation controlled
trial pilot study. Patients were assigned to receive either standard care (i.e.,
pharmacotherapy plus case management) or cognitive therapy plus stan-
dard care. Cognitive therapy was delivered weekly or biweekly over a
six-month period for a maximum of 22 sessions. Patients receiving cogni-
tive therapy showed global improvement on psychiatric symptomatology as
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well as lower levels of preoccupation, conviction, and acting on delusional

beliefs. There were modest differences between the two treatment groups
on indices of dysfunctional self-perception, such as self-esteem and depres-
sion.
A more recent, randomized controlled trial by Kuipers and colleagues
(15) has been completed. Patients were randomly allocated to either
cognitive therapy and standard care (n = 28) or standard care only (n = 32).
Following nine months of weekly or biweekly individual therapy, clinical
improvement, as assessed by a general measure of symptomatic distur-
bance, was significant only for patients who received cognitive therapy.
This study also demonstrated that patients have a low drop-out rate (11%)
and express high levels of satisfaction with the CBT intervention (80%). A
subsequent paper on the predictors of outcome in this study showed that
the key predictor of response to cognitive therapy was "a response indicat-
ing cognitive flexibility concerning delusions" whereas this cognitive vari-
able was unrelated to outcome in the control group (16).

Is COGNITIVE THERAPY MORE EFFECTIVE THAN SUPPORTIVE THERAPIES?

Sensky and colleagues (17) conducted a randomized controlled study with
90 patients with medication-resistant schizophrenia. Patients were random-
ized to receive either 20 weeks of cognitive therapy plus standard care or 20
weeks of "befriending" therapy plus standard care. Befriending therapy
was conducted by the same therapist who delivered the cognitive-therapy
intervention and the total amount of time spent in individual face-to-face
therapy was equivalent in both treatment groups. Befriending therapy
encouraged patients to talk about neutral, nonthreatening topics (e.g.,
current events, hobbies, holidays, etc.). Both groups showed significant
improvement on the schizophrenia change scale score at the end of
treatment. However, patients who received cognitive therapy showed more
clinical improvement at nine-month follow-up, whereas the clinical gains
made by the befriending group deteriorated to pretreatment, baseline
levels. Significant gains were also reported in the reduction of depression
severity in this study.
Tarrier and colleagues (18-20) conducted two trial studies on their
comprehensive cognitive-behavioral program termed 'Coping Strategy En-
hancement' (CSE) that resulted in similar findings. The first study assessed
the efficacy of a 10-session CBT intervention compared to a problem-
solving treatment condition, and a control condition. This study pointed to
superior benefits of CSE compared to both the problem-solving, and the
control condition. Differences were most apparent on measures of the
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frequency and severity of delusions and this improvement was still appar-
ent at six-month follow-up.
In a more recent study, Tarrier (19) randomly allocated chronic schizo-
phrenic patients suffering from persistent positive symptoms to: 1. cogni-
tive therapy plus standard care, 2. supportive counselling plus standard
care, or 3. standard care only. Both psychotherapy conditions consisted of
20 sessions within a ten-week period followed by four booster sessions at
monthly intervals. Cognitive therapy was superior on all measures of
clinical outcome: delusions, hallucinations, and general psychopathology.
The routine-care group, moreover, experienced more relapses and spent
more days in hospital. Further, patients who received cognitive therapy
continue to maintain their clinical benefits and have significantly fewer
positive symptoms than patients in the other two groups, at twelve-month
follow-up (20).
Is COGNITIVE THERAPY MORE EFFECTIVE IN COMBINATION WITH ATYPICAL
ANTIPSYCHOTICS?
Pinto and colleagues (21) in Italy completed a randomized controlled study
comparing cognitive therapy (n = 19) versus supportive therapy (n = 18)
in medication-resistant inpatients and outpatients, started on an effective
dose of clozapine. Both treatments were shown to produce statistically
significant improvement on overall psychotic symptoms, positive symp-
toms, and negative symptoms. However, patients receiving cognitive therapy
showed greater reductions on measures of overall psychotic symptoms and
positive symptoms than did patients receiving combination supportive
therapy. An unpublished study at six-month follow-up showed that pa-
tients who received cognitive therapy in combination with clozapine
continued to have significantly better outcomes on measures of total-
symptom and positive-symptom but also on negative-symptom ratings,
compared with patients who received adjunctive supportive therapy. While
the beneficial effects of cognitive therapy were not due to differences in
medication use as daily clozapine use was equivalent between the groups
during the active phase of treatment, the overall effect-size scores in this
study were extremely large and greater than in any other study conducted
to date. These results may point to the superior effects when cognitive
therapy is combined with the novel antipsychotics.
Is COGNITIVE THERAPY EFFECTIVE IN THE ACUTE STAGE OF THE ILLNESS?
Drury and colleagues (22, 23) have tested the effectiveness of cognitive
therapy in acute psychosis. Forty patients were randomized to either a
cognitive therapy or to a control group consisting of structured recreational
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activities and informal support. An equal number of hours were devoted to

each group. At posttreatment, patients in the cognitive therapy group
showed significantly greater reduction in delusional beliefs than did pa-
tients in the control group. The improvement in delusional thinking was
first noticeable at seven weeks. At nine-month follow-up, 95% of the
patients receiving cognitive therapy showed no, or only minor hallucina-
tions or delusions, as compared to 44% of the control group. Depending
on the definition of recovery from the acute phase of the illness, cognitive
therapy was associated with a 25-50% reduction in recovery time. The time
from admission to discharge from the hospital was 49 days on average for
patients receiving cognitive therapy and 108 days on average for patients in
the control group.

CONCLUSION

There is increasing evidence to suggest that patients with psychosis can

benefit from cognitive techniques that identify, reality-test, and correct
distorted conceptualizations underlying the experience of delusions and
hallucinations. There is also evidence to suggest that CBT can help patients
to become more motivated and engaged with social and vocational
events—in this way, reducing some of the negative, deficit features of the
illness. Neuroleptic medications continue to offer tremendous benefit to
patients with psychosis but they appear to be only part of the answer. The
studies reviewed point to clinically significant gains (25-50%) offered by
CBT above and beyond that of medications. These positive gains appear
also to be maintained over time—leading to lower relapse rates, less time
hospitalized, and reduced costs to the health care system. Finally, the
finding that outcomes of cognitive therapy are superior to supportive
therapy suggests that cognitive, and not general therapeutic factors, are the
active ingredients of change.
There are grounds for optimism that cognitive therapy is a safe, feasible,
and effective psychosocial intervention in combination with medication-
based treatments for schizophrenia. Increasing attention is being given to
determine whether early intervention with cognitive therapy can change the
long-term trajectory of the disorder. More attention to clinical refinements
and therapist training in the U.S. and Canada is needed.

REFERENCES

1. Beck AT (1952). Successful outpatient psychotherapy of a chronic schizophrenic with a delusion

based on borrowed guilt. Psychiatry, 15, 305-312.
2. Hole RW, Rush AJ, & Beck AT (1979). A cognitive investigation of schizophrenic delusions.
Psychiatry, 42, 312-319.

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3. Watts F N , Powell G E , & Austin SV (1973). The modification of abnormal beliefs. British Journal of
Medical Psychology, 46, 359-363.
4. Kaney S, Wolfenden M, Dewey M E , & Bentall RP (1991). Persecutory delusions and recall of
threatening and non-threatening propositions. British Journal of Clinical Psychology, 31, 85-87.
5. Bentall RP, Kinderman P, & Kaney S (1994). The self, attribution processes and abnormal beliefs:
Towards a model of persecutory delusions. Behavior Research and Therapy, 32, 331-341.
6. Bentall RP (1990). The illusion of reality: A review and integration of psychological research on
hallucinations. Psychological Bulletin, 107, 82-95.
7. Chadwick P D & Birchwood MJ (1994). Challenging the omnipotence of voices: A cognitive
approach to auditory hallucinations. British Journal of Psychiatry, 164, 190-201.
8. Birchwood M & Chadwick PDJ (1997). The omnipotence of voices: Testing the validity of a
cognitive model. Psychological Medicine, 27, 1345-1353.
9. Kingdon D , & Turkington D (1994). Cognitive behavioral therapy of schizophrenia. New York:
Guilford.
10. Fowler D , Garety P, & Kuipers E (1995). Cognitive behaviour therapy for psychosis: Theory and
practice. New York: Wiley.
11. Chadwick PDJ, Birchwood M, & Trower P (1996). Cognitive therapy for delusions, voices, and
paranoia. New York: Wiley.
12. Tarrier N (1992). Psychological treatment of schizophrenic symptoms. In D Kavanagh (Ed.).
Schizophrenia: An overview and practical handbook. London: Chapman &Hall.
13. Wykes T, Parr A, & Landau S (1999). Group treatment of auditory hallucinations. British Journal of
Psychiatry, 175, 180-185.
14. Garety PA, Kuipers L , Fowler D , et al. (1994). Cognitive behavioural therapy for drug-resistant
psychosis. British Journal of Medical Psychology, 67, 259-271.
15. Kuipers E , Garety P, Fowler D , et al. (1997). London-East Anglia randomized controlled trial of
cognitive-behavioural therapy for psychosis. I: Effects of the treatment phase. British Journal of
Psychiatry, 171,319-327.
16. Garety P, Fowler D, Kuipers E , et al. (1997). London-East Anglia randomized controlled trial of
cognitive-behavioural therapy for psychosis: I I . Predictors of Outcome. British Journal of
Psychiatry, 171,319-327.
17. Sensky T, Turkington D , Kingdon D , et al. (2000). A randomized controlled trial of cognitive-
behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Archives of
General Psychiatry, 57, 165-112.
18. Tarrier N , Beckett R, Harwood S, et al. (1993). A trial of two cognitive-behavioural methods of
treating drug-resistant residual psychotic symptoms in schizophrenic patients: I. Outcome.
British Journal of Psychiatry, 162, 524-532.
19. Tarrier N , Yusupoff L , Kinney C, et al. (1998). Randomised controlled trial of intensive cognitive
behaviour therapy for patients with chronic schizophrenia. British Medical Journal, 317,
303-307.
20. Tarrier N , Wittkowski A, Kinney C, et al. (1999). Durability of the effects of cognitive-behavioural
therapy in the treatment of chronic schizophrenia: 12-month follow-up. British Journal of
Psychiatry, 174, 500-504.
21. Pinto A, L a Pia S, Mannella R, et al. (1999). Cognitive behavioral therapy and clozapine for clients
with treatment-refractory schizophrenia. Psychiatric Services, 50, 901-904.
22. Drury V, Birchwood M, Cochrane R, & MacMillan F (1996). Cognitive therapy and recovery from
acute psychosis: A controlled trial I. Impact on psychotic symptoms. British Journal of
Psychiatry, 169, 593-601.
23. Drury V, Birchwood M, Cochrane R, & MacMillan F (1996). Cognitive therapy and recovery from
acute psychosis: A controlled trial II: Impact on recovery time. British Journal of Psychiatry, 169,
602-607.

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of Biological Psychiatry

P A U L A. D E W A L D , M . D . *

For psychodynamic thinking and understanding to feel relevant to psychiatric

residents in current training programs, it must focus on the clinical problems
they encounter with patients. It must be presented in everyday language and
in a form applicable to their own clinical experience. Abstract theory or
a
deep" formulation may alienate rather than attract interest.

At the start of the 21 century, there is a commonly agreed-upon recogni-

st

tion that the psychosocial components of Engel's (1) biopsychosocial model

of illness have been significantly reduced and/or eliminated in most
psychiatric training programs. The rapid expansion of genetics, neurobiol-
ogy, and the application to psychiatric illness of impressive advances in
psychopharmacology have focused attention of psychiatric educators away
from the emotional, psychological, and social forces impinging on individu-
als and have stimulated a reductionistic mode of thinking about human
behavior that is almost exclusively neurochemical and biological.
In nonmedical training programs, the focus on the influence of psycho-
logical and social forces on the individual to create disruptive or difficult
behavior and personality patterns has been retained (partly due to the fact
that psychopharmacologic treatment approaches are not prescribed by this
group of therapists), and a variety of different psychotherapies have been
developed. The emphasis in many, if not most, psychiatric training pro-
grams has been on the psychiatrist as a medical diagnostician and medica-
tion manager. If psychosocial issues are significant, they are assigned to less
arduously trained psychologists, social workers, or counselors. In other
words, the relevance of the psychodynamic component of professional
understanding of mental disturbances and character formations has in most
psychiatric training programs been downplayed in favor of a more descrip-
tive behavioral, nonmotivational orientation to the problems presenting in
patients.

*Clinical Professor of Psychiatry, St. Louis University School of Medicine; Training and Supervising
Analyst (Emeritus), St. Louis Psychoanalytic Institute. Mailing address: 4524 Forest Park Blvd., St.
Louis, M O 63108.

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Attempting to maintain a focus and interest on psychodynamic forces

and factors in this current context can seem like a lonely and difficult
proposition for those dynamically trained psychiatrists who continue to
teach in medical school and psychiatric residency programs. For the most
part, trainees in such programs are no longer interested in depth psychol-
ogy, nor in infantile neuroses or deep psychodynamic formulations in
regard to patients' difficulties. Formulating cases and the understanding of
psychopathology in those terms (the "bread and butter" of psychoanalysts)
results in glassy-eyed nonacceptance or indifference among psychiatric
trainees in today's programs. The problem of maintaining the important
contributions developed in the last one hundred years by psychoanalysis
and psychodynamic psychiatry then becomes an issue of psychodynami-
cally oriented teachers adapting and adopting our understanding to the
needs and motivations of today s group of psychiatric residents and medical
students.
Psychodynamic thinking to be meaningful to today s trainees must, in
one way or another, be applicable to some of the clinical problems and
therapeutic stalemates that such trainees encounter in their everyday
interactions with patients. This requires us to distinguish in simple terms
the chief distinctions of a psychodynamic approach to understanding
behavior and the therapeutic process, as compared with the other models
of human behavior currently being presented in these programs.
In my own experience it is possible to frame the following elements of
the dynamic approach in simple and everyday terms:
1. That behavior evolves out of antecedent behavior and that the experi-
ences, memories, traumata, relationships, and developmental processes of
childhood interact with constitutional, genetic, and sociocultural factors to
serve the development of a unique template for each individual. This
template forms a background through which subsequent life experiences,
relationships, and the subjective sense of one's self and one's functioning
are developed. Recent neurobiological research demonstrates that the
template and the many stimuli and experiences that have contributed to it
have a direct effect on the growth and neural network connections of the
brain itself, resulting in intensified synaptic readiness as well as the pruning
of unused or unstimulated neural components.
2. Evolving from the concept of the early and progressive development
of the template, with its neurobiological as well as its psychological
elements, is the evidence for the existence of unconscious mental processes,
which (though not consciously recognized by the individual) may exert a
significant and modifying impact upon the feelings, motivations and
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patterns of the individuals behavior. Some of these unconscious mental

processes have meanings that are reflections of early "forgotten" experi-
ences and relationships (the past unconscious). Other effects of the tem-
plate are more appropriately focused on current factors, forces, and
relationships that are temporarily blocked from awareness (the present
unconscious) and reflect motivational and emotionally affective patterns
not fully recognized by the individual in question. Psychodynamic thinking
helps understand these seemingly unexplainable behavior patterns, symp-
toms or thought processes that turn out to have identifiable motivational
meanings.
3. The third major distinction recognized by psychodynamic thinking is
the central role of the relationship and interactions between the patient and
the caregiver in understanding the nature of the patient s difficulties. This
relationship also serves an important function for conducting the therapeu-
tic process itself. Both patient and therapist respond to each other, partly
on the basis of their own internal template (transference and countertrans-
ference), and these interactions illustrate characteristic and repetitive
problems and patterns of behavior.
By emphasizing these factors in common, everyday language and illus-
trating them by the clinical problems that today's psychiatric residents face,
one can begin to interest them in including this perspective. Issues, such as
self-defeating behavior, experiences of unconscious guilt, noncompliance
with therapeutic recommendations, noncompliance with medication man-
agement, cancellations of therapeutic sessions, suicidal thoughts, erotic or
hostile transference feeling states, are only a few of the issues that otherwise
baffle and puzzle residents seeking to work with patients.
The psychiatric teacher who can help the student understand and better
manage some of these otherwise discouraging behavior patterns begins to
pique the interest of the trainee who previously was not considering some
of the dynamics of the situation. Resident trainees begin to question or
wonder about some of the behaviors they previously tried to argue the
patient out of, or confront with "common sense" interventions. When the
dynamic understanding adds to the success of therapeutic interactions, it
initiates a pattern of grudging appreciation which may subsequently in-
crease to a beginning identification with the dynamic perspective that is
clinically applicable to all patients.
In the supervisory situation, a resident is frequently apologetic or feels
that the supervisor has nothing to offer since " I don't have a psychotherapy
case." By this is meant therapeutic work with someone who comes regularly
for expressive and insight-directed psychotherapy. But when the supervisor
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is able to demonstrate to the trainee the importance of the dynamic

understanding of the "medication management patient"; or the hospital-
ized patient whose behavior is disruptive to the routines of the unit; or the
patient who is making excessive demands of the therapist's attention and
time; or the repetitive patterns of a person's behavior; or the repetition of
behavior patterns with the resident, the trainee is thereby helped to observe
that psychodynamic thinking runs across the entire spectrum of psychopa-
thology and human behavior. The idea of applying psychodynamic thinking
to help direct one's therapeutic measures in "supportive" psychotherapy is
frequently new and surprising to the trainees (2-4).
The impact of health-care financing and the limitations imposed by the
managed care system make the model of classical psychoanalysis even more
inappropriate for today's psychiatric derivative training programs. How-
ever, application of psychodynamic concepts to the problems faced by
psychiatrists will enhance their effectiveness with patients in spite of those
restrictions.
In summary, gearing the level and applications of psychodynamic
thinking to the commonly occurring behavioral and symptom difficulties
that psychiatric residents encounter and demonstrating that the dynamic
understanding and approach to these issues allows for a more comfortable
and effective management of the patient involved is frequently the first
inducement for today's psychiatric resident to acknowledge that psychody-
namic thinking may have a place in psychiatry after all.
REFERENCES

1. Engel G L (1981). The clinical applications of the biopsychosocial model. American Journal of
Psychiatry, 137, 535-544.
2. Dewald PA (1994). The supportive and active psychotherapies: A dynamic approach. Northvale, NJ:
Jason Aronson.
3. Rockland R L (1989). Supportive therapy: A psychodynamic approach. New York: Basic Books.
4. Werman DS (1984). The practice of supportive psychotherapy. New York: Brunner-Mazel.

304
 The Application of Computerized Content Analysis of
Natural Language in Psychotherapy Research Now and in
the Future

LOUIS A. G O T T S C H A L K , M.D., Ph.D.*

For many years the author and his colleagues have been involved in studying
the roots and processes of the conveyance of semantic messages via spoken
language and verbal texts. After establishing that reliable and valid measure-
ments of highly relevant neuropsychiatric categories, such as anxiety, depres
sion, and cognitive impairment, can be made by identifying and counting the
occurrence per grammatical clause of language content and form categories
typifying specific content-analysis scales, the research focus has turned
towards computerizing this process of content analysis. This report summa-
rizes the achievements and applications of the current empirical status of this
method of computerized content analysis of natural language to psycho-
therapy research, and it speculates on possible future applications in the
millennium.
INTRODUCTION

For the millennium, what are the prospects for application of computerized
content analysis of natural language in psychotherapy for the future? The
amazing progress during the late 1990s in technology and, especially, in
computer software and hardware, promises applications and discoveries
that are very likely to relate constructively to the subjectivity characterizing
the processes and procedures of psychotherapy.
For the benefit of the many individuals who have not been able to keep
informed up to the present time of the advances and applications of
computerized content analysis of verbal behavior, a review of the scientific
status of computerized content analysis of language would be appropriate.
REVIEW OF RESEARCH INVOLVING THE CONTENT ANALYSIS OF VERBAL BEHAVIOR,
INCLUDING ITS COMPUTERIZATION

The development of an objective and reliable method of measuring the

magnitude of various psychological dimensions from natural language was
motivated by the recognition that diagnosticians and therapists use their
*Professor of Psychiatry, Department of Psychiatry and Human Behavior, College of Medicine,
University of California, Irvine, C A 92697-1675.

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patients' speech as the major source of information for their diagnostic

formulations and therapeutic interventions. In doing so, they assess how
and what is said in an impressionistic manner that may allow for a relatively
high likelihood of distortion and/or error from potentially incorrect em-
pathie responses and inferences during the process of evaluating the
meanings and significance of their patients' talk. How to minimize such
error and how to maximize the uniformity and consistency of the inferential
evaluations concerning a speaker s subjective experience and the relative
magnitude of these psychobiological states and traits became a major aim in
our development of a computerized method of measuring these dimensions
from natural language.
In the process of our probing the immediate emotional reactions of
individuals from speech, an effort was made in the elicitation of speech to
minimize a speaker s reactions of guarding or covering up. In initial studies,
the instructions to elicit speech from patients or other subjects were
purposely relatively ambiguous and nonstructured—simulating a request
to free-associate—so as to avoid guiding the speaker to talk about any
specific topics. This approach was used to establish norms for the neuropsy-
chiatrie dimensions to be measured for medically and neuropsychiatrically
healthy individuals, as well as to compare any individuals in a standard
context so that demographic and personality variables could be explored
and investigated while holding relatively constant the influence of such
variables as the instructions for eliciting speech, the nature and personality
of the interviewer, the context, and the situation. The effects of varying
these noninterviewee variables were subsequently investigated, one by one,
after reliable and valid content-analysis scales were developed. The develop-
ment of the Gottschalk-Gleser method of content analysis, which is the
focus of this report, involved a long series of steps. 1. The lexical cues per
grammatical clause (the smallest unit of verbal communication) were
carefully pinpointed by which a receiver of any verbal messages infers the
occurrence of any of these psychobiological states in the speaker. 2.
Differential weights were assigned to semantic and linguistic cues convey-
ing the magnitude of a speakers subjective experience whenever appropri-
ate. 3. A group of construct-validation studies (including such criterion
measures as psychological, physiological, pharmacological, and biochemi-
cal) were carried out to serve as criteria with respect to what each
content-analysis scale measured. 4. On the basis of these construct-
validation studies, changes were made in the content categories and their
assigned weights in each specific content-analysis scale, in the direction of
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maximizing the correlations between the content-analysis scores with all

independent criterion measures (1-5).
The theoretical framework from which this measurement method was
developed was an eclectic one. It included behavioral and conditioning
theory, psychoanalytic clinical theory, and linguistic theory (1,5,6).
The Gottschalk-Gleser Content Analysis Method for measuring the
magnitude of psychobiological states and traits from the content analysis of
verbal behavior was successfully applied to many different neuropsychiat-
ric dimensions. Extensive empirical research established the validity and
reliability of scales measuring a variety of emotional and psychobiological
states, including Anxiety (Death, Mutilation, Separation, Guilt, Shame, and
Diffuse Anxiety subscales), Hostility Outward (including Overt Hostility,
Covert Hostility, and Total Hostility Outward subscales), Hostility Inward,
Ambivalent Hostility (hostility originating externally and directed towards
the self), Social Alienation-Personal Disorganization, Cognitive Impair-
ment, Depression (including 7 subscales), Health-Sickness, and Hope.
Extensive cross-cultural research has been carried out, which has
validated the Gottschalk-Gleser Content Analysis Scales in Australia (7),
Germany (8-10); Chile (11-13); Italy (14), Poland (15); Norway (16) and
other countries.
It is beyond the scope of this communication to explain to the reader
the details of our activities to computerize the content and form analysis of
our validated content analysis scales and how the computer software works.
For a reader who would like to know the research steps, over 25 years, that
we have taken to achieve this computerization, I will cite, here, our major
publications on this project that can be scanned or reviewed, if desired (15,
17-24).
Briefly, the software system generates four distinct classes of outputs,
the last three of which are optional. The most basic output is a listing of
each clause and the scores assigned to it. This is printed as clause per typed
line, with each clause followed by a line of scores (one or more per
content-analysis scale selected), but more lines may be used if the clause or
scores are lengthy. The second class of outputs is a scoring summary for
each content analysis scale. The summary gives tallies of the number of
occurrences of the various scores/codes, a word count, and it derives a
single number from the score/codes relevant to each scale. The summaries
indicate to what extent the score derived from the verbal sample deviates
from the norms that have been obtained for each scale (in terms of standard
deviations). These norms, available for children and adults, have also been
derived from speech samples elicited by purposely ambiguous instructions
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requesting the speaker to talk for five minutes about interesting or dramatic
personal life experiences. The third class of outputs is an analysis or
interpretation, in textual form, of the scale scores. It is directed to the
clinician making diagnostic use of the scoring output, and it suggests
clinical areas for further examination and areas in which significant devia-
tions from the norms are found. The fourth class of outputs consists of
possible neuropsychiatric diagnoses which the clinician might consider in
evaluating the patient. The diagnoses suggested for consideration are taken
from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV),
Fourth Edition (25).
SOME PAST APPLICATIONS OF THIS CONTENT ANALYSIS METHODOLOGY TO
PSYCHOTHERAPY THEORY, PRACTICE, AND RESEARCH
This content analysis methodology has already been applied to psycho-
therapy theory, clinical practice, and research in a number of ways. It has
been tested or applied
• as a predictor of psychotherapy outcome (5,26-28);
• to research on defense mechanisms in psychotherapy (1,6,29);
• as an aid in dream analysis (29, 30);
• to understanding and discerning the course of psychotherapy (31, 32)
• in appraising the relationship of symptoms, such as petit mal epileptic
episodes (33) or touching the mouth (34, 35), to the occurrence of
psychodynamic conflicts.
It has been involved in psychosomatic research and the comparative
effectiveness of different psychotherapeutic methods (9,15,36,37); and for
neuropsychiatric diagnostic assessment (5, 9, 26, 38,39).
It has been proven to be a rapid and objective method of assessing the
mental effects of psychoactive drugs, a procedure of considerable interest
today in determining and distinguishing the effects of psychoactive pharma-
cological agents in comparison to the effects of psychotherapy or a
combination of psychotherapy and pharmacotherapy (40).
And it has been demonstrated to be a reliable method of measuring
certain neuropsychiatric dimensions of individuals from the content analy-
sis of their extemporaneous speech (41, 42) or the computerized content
analysis of their writings (43).
THE APPLICATIONS OF COMPUTERIZED CONTENT ANALYSIS OF VERBAL BEHAVIOR TO
PSYCHOTHERAPY IN THE FUTURE
Now we can finally return to answering the question asked in the beginning
of this paper. What are the prospects for the application of computerized
content analysis of natural language to psychotherapy in the millenium?
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Readers will easily recognize that I am a champion and devotee of the

technology of this computer age. Some may even worry that I might believe
that computerized methodology may replace the psychotherapist. Cross off
that idea immediately, for I do not believe that the computer can ever
replace the human as a psychotherapist! Although I am aware that there
has been some experimentation along this line, I find it unimpressive and
deficient. However, the scientific and sophisticated writings of Ray Kurz¬
weil, such as The Age of Intelligent Machines (44) and The Age of Spiritual
Machines (45), do make one wonder whether computerized psychotherapy
might replace humans doing psychotherapy.
I do believe that there are now good uses and that there will be
improved applications of computerized programs capable of objectively
analyzing the meanings of speech and verbal texts and of measuring the
magnitude of many highly relevant neuropsychiatric dimensions.
This computerized methodology will be useful in rapidly screening
large samples of people for neuropsychiatric and general medical disorders
or vulnerabilities. It will be useful in following over time the mental
functioning of patients receiving psychotherapy or any medical treatment.
Requiring only small samples of a speaker's speech, it will prove useful in
assessing the emotional and cognitive status of individuals who are in some
remote location, for example, astronauts on extended space travel whose
speech can be transmitted to a properly equipped computer station on the
planet Earth.
At the present time, the computerized content-analysis process of verbal
behavior first requires recording the speech and transcribing it on a
computer diskette in a form that clearly indicates to the computer the
grammatical clauses in a speech sample, either by a punctuation mark (a
period, question mark or exclamation mark) or in the case of compound
sentences inserting a slash V" at the appropriate location in a sentence.
Gottschalk and Bechtel (24) are now being funded by a National Institute
of Health research grant to develop computer software that is capable of
automatically clausing speech or verbal texts and, furthermore, to achieve
voice-recognition capacity for the application of their computerized content-
analysis software that will enable them to directly analyze verbal behavior
without being required, first, to have it transcribed onto a computer
diskette. Though there are recognized problems yet to solve, it is definite
that our technology has developed to such a level that it will soon be
possible to carry out direct voice-recognizable computerized content analy-
sis of speech.
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2. Gottschalk L A , Winget C N , & Gleser G C (1969). Manual of instructions for using the Gottschalk-
Gleser Content Analysis Scales: Anxiety, hostility, social alienation-personal disorganization.
Berkeley, Los Angeles, CA: University of California Press.
3. Gottschalk L A (Ed.) (1979). The content analysis of verbal behavior. Further studies. New York:
Spectrum Publications.
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Significance in clinical medicine and psychiatry, Heidelberg, Germany: Springer- Verlag.
5. Gottschalk L A (1995). Content analysis of verbal behavior. New findings and clinical applications.
Hillsdale, NJ: Lawrence Erlbaum Associates, Publishers.
6. Gottschalk L A , Fronczek J , & Abel L (1993). Emotions, defenses, coping mechanisms, and
symptoms. Psychoanalytic Psychology, 10,237-260.
7. Viney L L , & Mantón M (1973). Sampling verbal behavior in Australia. The Gottschalk-Gleser
Content Analysis Scales. Australia journal of Psychology, 25,45-55.
8. Schofer G , Koch U , & Balck F (1979). Test criteria of the Gottschalk-Gleser content analysis of
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9. Koch U , & Schofer G (1986). Sprachinhaltsanalyse in der psychosomatischen und psychiatrischen
Forschung. Grundlagen und Anwendungsstudien mit den Affektskalen von Gottschalk und
Gleser. Weinheim und Munchen: Psycholgie Verlags Union.
10. Suslow T (1993). Die sprachinhaltsanalytischen Angst und Aggresivitatsskalen nach Gottschalk und
Gleser. Frankfurt: Lang.
11. Lolas F, & Gottschalk L A (1978). E l método de análisis de contenido de Gottschalk y Gleser en la
investigación psyquiatria. Acta Psichiatrica Psicológica Americana Latina. 24,241-256.
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Chile: Editorial Universitaria.
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magnitude of psychological dimensions: Its application in transcultural research. Transcultural
Psychiatric Research Review, 26,83-111.
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Content Analysis Scales: A step towards concurrent validation. European Journal of Psychologi-
cal Assessment, 12,43-52.
15. Heszen-Nejodek I, Gottschalk L A , & Januszek M (1999). Anxiety and hope during the course of
three different somatic illnesses. A longitudinal study. Psychotherapy and Psychosomatics,
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Institute on Drug Abuse.
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28. Gottschalk L A (1974). The application of a method of content analysis to psychotherapy research.
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29. Gottschalk L A , & Fronczek J (1993). Defense mechanisms and hope as protective factors in
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33. Luborsky L> Docherty JP, Gottschalk L A , et al. (1997). The context for absence epilepsy episodes
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34. Gottschalk L A (1974). The psychoanalytic study of hand-mouth approximations. In L . Gold-
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35. Gottschalk L A (1997): The context of touching the mouth area during psychoanalytic sessions. In
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 New Trends for a New Millennium

WADE H . SILVERMAN, Ph.D.*

Six new trends leading us into the new millennium are described. They
include psychotherapy integration, specialization, managing care, the expan
ing scope of practice, cultural diversity, and psychotherapy without walls. We
are entering an age of greater public access to psychotherapeutic interventions,
and more control of our professional field. Changes will be revolutionary.

Elsewhere in my thoughts about the new millennium (1), I identified six

trends regarding the future of psychology that will lead us into the 21 st

century. These include psychotherapy integration, specialization, managing

psychotherapy, expansion of the scope of practice, cultural diversity, and
psychotherapy without walls.
Psychotherapy integration is the movement toward a comprehensive
knowledge of psychotherapy practice through transtheoretical research.
The research is beginning to inform us about the exciting possibilities of
building a body of knowledge that applies more widely to daily practice.
More simply, this research is designed to inform us how and under what
conditions psychotherapy works.
There is much to be learned about what are the active ingredients to
psychotherapy. Studying specific techniques as they relate to symptom
reduction fails to take into account the participants—therapist and client.
Psychotherapy integration focuses on core ingredients, such as the therapeu-
tic alliance and client expectancies (2). It also uses more sophisticated
matching studies to formulate conceptions of the right therapist for the
right client in the right context as opposed to the right technique for the
right problem.
The trend toward specialization addresses the reality that the field of
psychotherapy is highly competitive in a market of decreased governmental
and insurance dollars as well as a geometrically increasing number of
service providers. Specialization, an adaptation to the overpopulated and
underfunded psychotherapy market, will occur both in training and in the
practice of psychotherapy.

*Private Practice. Mailing address: 1390 South Dixie Highway, Suite 2222, Coral Gables, F L
33146-2946.

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In the training arena, there is a proliferation of specialty programs at the

predoctoral and postdoctoral levels. The American Psychological Associa-
tion (APA) has responded to the trend toward specialization by forming the
Commission for the Recognition of Specialties and Proficiencies in Profes-
sional Psychology (CRSPPP), established in 1995 to review petitions
requesting APA recognition for a specialty or proficiency. A specialty is
defined as a field that requires comprehensive training, e.g., clinical
psychology, health psychology, whereas a proficiency is defined as a more
concrete skill, such as biofeedback and hypnosis.
Debates about the need for specialization in psychotherapy will con-
tinue. Specialization has its dangers; one of them is the potential exclusion
of generalists in major shares of the psychotherapy market.
There is also the potential danger of specialization in the training arena.
With growing competition among professional training programs for stu-
dents, more will begin to offer either specialty tracks or simply define
themselves as a specialty program. We must be careful not to sacrifice
sound, comprehensive general training curricula forflashy"faddish" special-
ization tracks.
Managing psychotherapy is a major trend in mental-health-service
delivery. Many psychotherapists are losing their autonomy in clinical
decision-making and economic stability with the expansion of managed
care. Despite the many shortcomings of the system, managed care is the
dominant economic force in health care delivery and will continue to be so
for many years. It is widely accepted by the public and by mental-health-
service providers. Approximately 125 million Americans are enrolled in
managed care programs. In a recent survey by Norcross, Orlinsky and
Beutler, 60% of a sample of the Division of Psychotherapy members of the
APA were accepting managed care patients for more than a year.
Some of the more egregious sins of managed care will be rectified not
only because of public clamor, but because it is cost effective to the
corporate entities. Since there is a dramatic drop-off in the number of
clients continuing treatment after just a few sessions, it is cost effective to
reduce drastically the amount of paper work presently required for the
intake of managed care clients. Similarly, the authorization process will also
be streamlined to reduce management costs, while more emphasis will be
placed on utilization review.
Though managed care has been widely accepted by the public, certain
aspects of it are not acceptable. Patients are demanding the right to due
process of their grievances and the right to sue for mismanagement,
negligence, and fraud. They also want the right to better access to
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specialists and the right to choose their own practitioner. These changes
will occur.
The future of the independent practice of psychotherapy will rely upon
a variety of arrangements, including practitioners working for, or contract-
ing with, managed care entities, models of independent practice, such as
those described by Pipal (3), Kovacs (4), and privately owned and operated
professional groups.
Competition for mental health dollars will also expand the scope of
practice. One dramatic example is the movement of psychologists to obtain
prescription privileges.
In 1996, the APA Council of Representatives formally endorsed model
legislation and curriculum for prescriptive authority (5). Legislation has
been introduced for prescriptive authority by several state associations and
curricula are being implemented in several universities.
Another "hot" new addition to traditional psychological services is
psychological coaching. It combines aspects of the psychotherapeutic
relationship with organizational techniques, such as skill development and
performance enhancement, to assist clients with everyday work and family
problems.
The realities of a changing population will force the field of psycho-
therapy to address the issue of cultural diversity. Approximately one third
of our population consists of cultural minorities (6). Psychotherapy cannot
survive without addressing the needs of a diverse population as well as the
development of relevant and accessible services.
Addressing cultural diversity requires focused effort on delineating the
needs of ethnic minorities. There are four primary reference groups: Native
Americans, African Americans, Asian Americans, and Hispanic Americans-
Latinos (7).
Currently, there is a rich variety of resources already available to
enhance training in cultural diversity (8-10) that will help to foster
culturally sensitive clinicians.
However, psychotherapy research lags far behind training in addressing
cultural diversity. As an example, in a recent article (11) I vigorously
criticized a Division 12 task-force report on effective psychotherapies,
a.k.a. empirically validated therapies, as "espousing empirically validated
treatments for White people" (p. 214). Its insensitivity to the issues of
cultural diversity in the formation of generalities as to whom to deliver what
services was astounding.
Watts (10) notes four perspectives that can contribute to a psychology
of human diversity: a) population-specific psychologies, such as the psychol-
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ogy of women or Asian-Americans; b) sociopolitical perspectives that

expunge historical, economic, and system analysis; c) crosscultural psychol-
ogy; and d) ecological psychology. He identifies how each of these perspec-
tives facilitate theory and action.
While research in diversity is in the embryonic stage, Yutrzenka (7) does
report that new cultural-inclusive theoretical models are being developed
as well as more culturally sensitive and culturally inclusive research designs
and methodologies.
The field of psychotherapy is breaking free from the confined spaces of
private offices with waiting rooms and white-noise appliances and entering
the computer and telecommunication age. We are now in the age of
technology and world-wide communication networks. Applied psychology
is now practicing telehealth "the use of telecommunications and informa-
tion technology to provide access to health assessment, diagnosis, interven-
tion, consultation, supervision, education, and information across dis-
tance" (12, p. 527). We use telephones, electronic mail, and video
teleconferencing equipment (13).
Interactions between service provider and client can be in either
"real-time" or "virtual." In real-time the client accesses the provider live
through a telecommunication link-up, most often in a hub-and-spoke
system designed to include a broad geographical area (12). Virtual interven-
tions are comprised of "canned" or playback interventions stored and
administered by technology. Psychologists have already used this technol-
ogy in learning how to do psychotherapy (see Master Therapist series) and
to diagnose through software-designed decision trees available from testing
services.
More research and considerably more thought must be put into the
design and implementation of telehealth services. However, many of you
will be accessing psychotherapy clients and coaching mentees in the
not-too-distant future.
At the more personal level, there is now a second-generation Silverman
psychologist entered in graduate school. I hope that she will enjoy a lifetime
journey as fulfilling as I have had in studying and practicing psychotherapy.
In the early 1970s, I was deeply involved in the community mental health
movement. We professionals helped to bring psychotherapy to the streets,
training paraprofessionals, seeking out impoverished and underserved
populations, and training advisory board members in the concepts of
quality and comprehensive services. To paraphrase George Albee, this was
mental health s second revolution.
Now, at the turn of the century we are entering another revolution—
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public access. Psychotherapy will be going on-line, both real and virtual, to
a new population of clients. We will serve new demographics incorporating
knowledge of a more culturally diverse client population.
Psychotherapists will own and operate their own service systems, or
unionize to acquire more control of their financial status. Techniques of
psychotherapy and coaching will begin to merge so as to emphasize quality
of life and life enhancement instead of addressing only conflicts and
psychopathology.
Psychotherapy will be integrated into a broader program of physical
health and peak-performance strategies. Our misguided obsessions with
methodology will be deemphasized in favor of a greater focus on problem
resolution and a more thorough understanding of context or environment.
As we enter the new millennium, I am both hopeful and optimistic
about the professional future of the next generation.
REFERENCES

1. Silverman W H (2000). Psychotherapy in the new millennium. Psychotherapy: Theory/Research/

Practice/Training, 37, 1-9.
2. Silverman W H , & Beech R (1979). Are dropouts, dropouts? Journal of Community Psychology, 7,
236-242.
3. Pipal J E (1996). Without apology or fear: Reflections on Hoyt and Budman (1996) and managed
mental health care. Psychotherapy: Theory/Research/Practice/Training, 33, 124-128.
4. Kovacs A L (1991). The uncertain future of professional psychology. Psychotherapy in Private
Practice, 8, 39-60.
5. Cullen E A , & Newman R (1997). In pursuit of prescription privileges. Professional Psychology:
Research and Practice, 28, 101-106.
6. Highlen PS (1994). Racial/ethnic diversity in doctoral programs of psychology: Challenges for the
twenty-first century. Applied & Preventive Psychology, 3, 91-108.
7. Yutrzenka BA (1995). Making a case for training in ethnic and cultural diversity in increasing
treatment efficacy. Journal of Consulting and Clinical Psychology, 63, 197-206.
8. Strieker G , Davis-Russell E , Bourg E , et al. (Eds.) (1990). Toward ethnic diversification in
psychology education and training. Washington, D C : APA.
9. Sue D W (1991). A model for cultural diversity training. Journal of Counseling and Development, 70,
99-105.
10. Watts RJ (1992). Elements of a psychology of human diversity. Journal of Community Psychology,
20, 116-131.
11. Silverman W H (1996). Cookbooks, manuals, and paint-by-numbers: Psychotherapy in the 90s.
Psychotherapy: Theory/Research/Practice/Training, 33, 207-215.
12. Nickelson D W (1998). Telehealth and the evolving health care system: Strategic opportunities for
professional psychology. Professional Psychology: Research and Practice, 29, 527-535.
13. Stamm B H (1998). Clinical applications of telehealth in mental health care. Professional Psychology:
Research and Practice, 29, 536-542.

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 Object Relations and Intersubjectivity in Depression*

HEINZ WEISS, M.D**

H E R M A N N LANG, M.D., Ph.D.***

Starting with a clinical vignette the authors discuss Freud's thesis from
"Mourning and Melancholia" (1917) that depression is a defense against the
experience of loss: Whilst a part of the self remains identified with the lost
object another part directs all the aggression against it that originally had been
directed against the object. As a result the relationship between self and object
becomes replaced by a pathological relationship between parts of the self. As
psychoanalytical and phenomenological-hermeneutical approaches congru
ently show, one reason why mourning cannot proceed and feelings of guilt
cannot be worked through lies in the fact that depressive patients need a
symbiotic, idealizing type of identification with their objects in order to
stabilize their identity. Because of their narcissistic vulnerability changes,
personal failures, and disappointment by their objects, which may provoke
unconscious aggression and fear of loss, can easily threaten their psychic
equilibrium. This gives rise to considerable difficulties within the transference-
countertransference relationship. The authors argue that to establish a feeling
of autonomy in depressive patients, a secure framework within therapy has to
be offered and at the same time the negative transference must thoroughly be
worked through.
CASE STUDY

K., a 25-year-old social worker, came to our outpatient clinic, complaining

that her life appeared mechanical and pointless. Ever since her two-year-
old daughter s death from a brain tumor two months previously, K. had not
been able to feel sad or happy, and everything seemed to pass her by as if
she were just an uninvolved and inert spectator. She could not sleep at night
and she suffered from dizziness and headaches. At such times she would
then take some of her daughter s remaining medication, go into her child's
room, lie down on the empty bed and fall asleep there. Sometimes K. felt
*Paper presented at the 41 Meeting of the American Academy of Psychoanalysis, San Diego, CA,
st

1997.
* "Professor of Psychotherapy, Head, Department of Psychosomatic Medicine, Robert-Bosch -
Krankenhaus, Stuttgart. Mailing address: Robert-Bosch Krankenhaus, Auerbachstrasse 110, 70376,
Stuttgart.
***Professor of Psychotherapy, Head, Department of Psychotherapy and Medical Psychology,
University of Wiirzburg.

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the same symptoms that her daughter had suffered from in the last weeks of
her life: She was tired, confused, and nauseous, and felt that she was losing
her balance. She often would wake up from nightmares, in which her
daughter Melanie was still alive and she would be trying in a panic to save
her and divert the impending catastrophe. In one of these nightmares,
Melanie ran out onto the street and K. rushed frantically after her, trying to
keep her from being run over by a car.
K. tried hard to lead a normal life and even completed a course and
became a nurse in a children's hospital after passing her professional exams.
She felt that her partner, Melanie's father, fully supported her in this
endeavor. Nonetheless, she felt cut off from her feelings and empty, as
though a part of her had died. She often brooded over what had happened
without coming to any new train of thought, and she was afraid of
burdening others with her condition. It was clear from the time the
diagnosis was made that her little daughter, who had just learned to talk,
would live only a few more months. Due to the tumor spreading over a
large section of the brain stem, it was deemed inoperable and the prognosis
thereby terminal. After consulting with the doctors, K. had decided against
any aggressive therapies. Even though Melanie did not suffer from pain,
she felt that something was not quite right with her. Sometimes K. would
try with a few simple words to explain the situation to Melanie, and tell her
what a brave girl she was. It was touching how Melanie would repeat these
words and how clever and wise she sounded. They would once in a while
fall asleep together and Melanie would lay her hand on her mother's face, as
if she wanted to console her. At other times the situation became too much
for K., especially when Melanie cried.
Once K. totally lost her temper and started throwing Melanie's toys
around and screaming out of frustration and desperation. When finally
Melanie 's father arrived and relieved her of Melanie, she felt very guilty.
An additional burden was her parents'—especially her mother's—
condemning attitude. Her mother consulted with various doctors both in
the country and abroad and blamed K. for not exploring all medical
possibilities and not going through with the operation. Her mother totally
denied her grandchild's impending death; a few days before the child's
death she bought her a new bed. When Melanie died at home in K's. arms,
she could not talk about it with her parents. Even though her mother's
accusations were completely unfounded—an operation was determined as
being hopeless from the start—she still brooded about it. With Melanies
death her life lost its meaning and purpose. She also hoped that through
Melanie she would get over the abortion she had had over a year ago when
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she was in a complicated relationship, and that somehow Melanie would

give the first baby a way to live. It now appeared to her that she was being
punished for her former decision. It was extremely heartbreaking for her to
clear away Melanie's clothes and changing table and to visit her grave.
Melanie's death is still incomprehensible to her.
Sometimes K. imagines that Melanie is still alive, such as recently when
she looked out at the stars on a clear night and in her thoughts spoke to her.
At that moment she felt happy, yet by the next day, the dullness and
deadness came back, and she felt numb and empty when performing her
tasks.

DISCUSSION OF THE CLINICAL MATERIAL

When considering K.'s description, we recognize the characteristics of a
depressive state of mind: emptiness; a feeling of meaninglessness over-
coming her; sleeping disorders and various other physical symptoms; doubt
and self-blame; and especially a feeling of rigidity, woodenness, and being
cut off from life. As K. says, everything seems to her to be lifeless and
mechanical, and she is not able to feel either happy or sad. Her life appears
to pass her by, with no context of time, as though she were an uninvolved
spectator. We can understand her condition as the loss of a small child is
almost impossible to bear. K.'s description awakens feelings of empathy,
pity, and sadness in us, feelings that she herself cannot yet feel. Let us,
therefore, try to understand what she is experiencing through her own
description.
Especially notable is her remark that she feels as though a part of her had
died. By dying or "dying with" she remains identified with her daugh-
ter—an identification that we find throughout her description: She feels the
same symptoms as her child did, she lies in her daughter's bedroom when
she is not able to sleep at night, and she takes her daughter's remaining
medicine. This all seems to be a very concrete attempt to be close to her
dead daughter, so close that instead of being able to mourn, our patient's
emotions seemed to have died with her child, where as another part of her,
as she says, continues to live, but only "mechanically" and as an "unin-
volved spectator." Therefore, what is being dealt with here is a double
movement: The recognition of the loss of her daughter, along with such a
complete and concrete experiencing of it, that there is no room left for any
sensation of mourning. The result is that the loss is being experienced on
the own self. Sigmund Freud (1) saw an important difference between a
melancholies reaction and a normal mourning process. In his famous essay
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"Mourning and Melancholia" he states: "In mourning it is the world which

has become poor and empty; in melancholia it is the ego itself" (p.246).
Freud characterized the melancholies relationship with reality as one
where the ego remains identified with the lost other, thus staying in its
proximity. This proximity was felt very concretely by our patient—through
bodily complaints, such as headaches, sleeplessness, and dizziness. Such a
physical proximity depicts the closeness in the relation to the lost Other (2),
insofar as the patient remains identified with her daughter in a very
concrete way.
K's report gives, however, another indication that in her feelings she
cannot yet acknowledge the loss of her daughter: She tells us that in her
dreams, Melanie is still alive although she faces some catastrophic danger,
from which she could possibly be saved.
It seems as though K. were trying to avert the catastrophe of loss and her
fear of loss is a first step towards facing it. Loss has to be experienced at first
through anxiety before it can be dealt with and acknowledged through the
process of mourning (3). Mourning is touched on for a brief moment in K. s
dialogue with her daughter underneath the stars. But it cannot proceed and
be worked through, as the farewell is filled with too much pain and guilt.
Let us now come to another important point in K.'s description. She
says that her mothers accusations, although objectively unjustified, con-
tinue to haunt her. Had it been perhaps after all possible to save Melanie?
Was she in the end responsible for her daughter s death through which she
wanted to protect her from further suffering? As much as she believes that
the facts do not justify these thoughts, they nonetheless continue to torment
her; these thoughts are in fact not an external, but are indeed an internal,
mental reality! Here the theme of loss gains another important aspect. For
the situation of loss does not only demand the acceptance of reality, but also
the working through of possible guilt, with the admission that all attempts
to preserve and repair her objects have failed. In this regard we are affected
by K.'s thoughts, that she could be punished for the abortion of her first
child by the loss of Melanie.
DEPRESSION AND THE EXPERIENCE OF Loss
It is easy to imagine that in a different clinical condition such a thought
could be dealt with in a delusional way, that instead of a feeling of guilt, a
delusional certainty of guilt appears, that instead of physical symptoms, a
delusional hypochondriacal fixation takes place. In such a case we would
not be dealing with a reactive depressive mood, but rather with a psychotic
depression.
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Is it possible to determine similar modifications in neurotic, psychotic,

and reactive depression in the relationship of the subject with the Other?
Or are such comparisons not possible, due to completely different etiologi-
cal and structural conditions? Sigmund Freud, in his previously mentioned
work (1), made the following introductory statement: "Melancholia, whose
definition fluctuates even in descriptive psychiatry, takes on various clinical
forms the grouping together of which into a single unity does not seem to
be established with certainty; and some of these forms suggest somatic
rather than psychogenic affections" (p.243). Modern psychiatric classifica-
tion systems, such as the DSM IV (4) or the ICD-10 (5) take this
heterogeneity into account, as they, ignoring any etiological considerations,
speak only of "major depressive disorder" (as episodical or recurring) or of
"dysthymic disorder," the latter being the equivalent of chronic depressive
neurosis. They are differentiated from each other mainly by "severity,
chronicity, and persistence" (4, p.343). Furthermore, they are both distin-
guished from adjustment disorders and bereavement. Yet there seems to be
no clear differentiation between normal and pathological mourning.
In contrast to this, psychoanalysis especially considers the phenomenol-
ogy of the mourning process in connection with the genesis of depressive
states. The melancholic, according to Freud, denies the loss and identifies
himself with the object that he has lost. This identification is carried out
almost completely and realm psychotic depression, such as, for example, in
the nihilistic delusion. It is continually and fantastically anticipated in
neurotic depression, and it constitutes a pre-stage of the mourning process
in the depressive reaction.
The loss experienced is not by any means always of a person. It can also
be represented by the loss of the closeness to the Other, by a disappoint-
ment, an insult, or a partial rejection, for example, in the shape of
not-materialized gratitude, or even merely by a change in the image that the
subject had of the Other and his relation to him. Furthermore this Other
can also be represented abstractly, for example, by the loss of the work-
place, health, environment, or a social role, as has been documented to be
frequently the case at the onset of manic-depressive psychosis (6). More
generally speaking, the loss concerns an object or a value, which has been
deprived of its identity- and security-providing function. This loss must not
always be a conscious one. It can happen that the patient, to use Freud's
words, "knows whom he has lost but not what he has lost in him" (1, p.245).
In addition, the "what" of this loss appears to entail a certain closeness
to the ego, a certain affinity to the identity of the subject. In order to react
to a loss with depression, the internal prerequisite seems to be that the
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subject was identified to the Other whom he has lost in a special way—be it
a loved person, a social role or an ideal. Psychoanalytical views as to the
psychodynamic of depressive disorders, from earlier works (7) to newer
concepts (8), can be summarized to the effect that the loss leaves a
narcissistic void behind and the patients therefore find it difficult to mourn
what they have lost and to reestablish their relationship to the world. The
considerable narcissistic vulnerability of depressive patients, their tendency
to idealize the Other and their attempt to keep their feelings free of any
ambivalence in the hope that through identification with such an idealized
object they will be protected from any disappointment and anguish, all
tend to support this view.

INTERSUBJECTIVITY IN DEPRESSION
When comparing the triggering situation of a depressive crisis with those of
other mental disorders, it becomes clear that it is not so much the triggering
event but rather the response to the pathogenic situation that is typical for
the depressive reaction. Thus, in 101 outpatients of the Institute for
Psychotherapy and Medical Psychology, University of Wiirzburg, Ger-
many, with the diagnosis of a nonpsychotic depression (ICD 10 F.32
depressive episode n = 39, ICD 10 F.33 recurring depressive disorder n =
9, ICD 10 F. 34.1 dysthymia n = 53), "object-loss" and "new situations,
separation and role-change" ranked the highest in the triggering situation
preceding the onset of depressive symptoms.
Yet, these patients do not differ significantly in this aspect from patients
with other mental disorders. Only in regard to the trigger-situation "con-
flict in the partnership" was there a slight difference (x -test, p=0.067) to
2

be found, which can be understood as an indication of the high vulnerabil-

ity of depressive patients towards stress in a sustaining relationship.
Phenomenological psychiatry and psychoanalysis both largely agree
with the view that the depressively structured person perpetuates a pattern
of sympathetic-symbiotic relationship (9, pp. 77-79). This was described
with the term "Inkludenz" (10), i.e., overinclusiveness, as the tendency of a
depressive personality to "surround himself with people and things of
closeness." In psychoanalytic treatment, patients transfer this sympathetic,
symbiotic relationship pattern onto the therapist. They idealize and cling to
the therapist, expect him/her to reestablish the relationship to the lost
"good object" or to take its place. They also try to keep this relationship
harmonious and free of ambivalence, and to avoid any disappointment or
experience of separateness. In order to work through this idealized transfer-
ence and to achieve an emancipation from the therapist, the depressively
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structured person must also develop a negative (aggressive) transference

and must be able to "argue" with the therapist (11).
The German word for "to argue with"—"auseinandersetzen"—means
literally "to sit apart, to separate." Yet this is precisely what the depressed
person is not able to do. The experience of psychoanalytic treatment
supports even more so that this "arguing with the therapist" is associated
with a massive unconscious fear of loss and that the experience of loss in
turn is accompanied by self-accusations and guilt which depressive patients
turn against themselves so that the "pointer of guilt," to use a phrase from
the psychopathologist Scheid, is always directed against them. The daily
clinical experience also shows that depressive patients have enormous
difficulties in dealing with their aggressions. For this reason they are often
considered to be conforming in their social relations, clinging to authority
and looking for support in structures that they passively succumb to in the
hope that thereby they can attain stability and recognition. The "Typus
Melancholicus," as investigated in Tellenbach's phenomenological studies,
is particularly characterized by these patients' tendencies to identify them-
selves with preexisting structures, environment and role-expectations.
They are more than others committed to achieving expected goals and
correctly performing their duties. In this way they become the "champion
du comme ilfaut" fixated on concrete structures, and are "over-identified"
with them (6). Orderliness, high expectations, and conscientiousness char-
acterize the "Typus Melancholicus" in their social relations, as also Ameri-
can (12) and Japanese research groups have demonstrated. Due to their low
flexibility and "hypernomic social behavior" (6), however, they prove
themselves to be especially vulnerable when it comes to mastering situa-
tions that are too demanding or contradict with normative expectations.
For this reason, diminishing physical strength due to age, or even a simple
illness can set off a pathological decompensation, provided that the
expectations that define their existence can no longer be fulfilled. Using the
term "remanence," Tellenbach (13) worked out this falling behind oneself's
and others' expectations as a particularly serious moment that brings about
melancholia. The pathological situation arises when depressed persons,
due to their exacting orderliness, cannot keep up with their qualitatively
high standards because the level to be accomplished has increased, and
they fall short of their ideal or superego.
IMPLICATIONS FOR PSYCHOANALYTIC TREATMENT AND THE UNDERSTANDING OF THE
TRANSFERENCE SITUATION
Let us now return for a moment to the themes of loss and guilt in neurotic
depression. As we have said, instead of mourning, which is experienced as
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being too painful and which would require the acceptance of the experi-
ence of loss, a part of the self remains identified to the lost other, and—to
use the famous phrase of Freud's (1)—the "shadow of the object" falls on
this part of the ego. Depressive patients are tormented by self-accusations
and self-blame. In the course of psychoanalytic treatment, one often gains
the impression that the patients' accusations that are currently directed
against their own selves were at some point directed against others. "Their
complaints," as Freud formulated (1, p. 248) "are really 'plaints' [accusa-
tions] in the old sense of the word. They are not ashamed and do not hide
themselves, since everything derogatory that they say about themselves is at
the bottom said about someone else." These accusations cannot, however,
be openly directed against the Other, because they would then be uncon-
sciously associated with fear of loss or revenge. Here, a situation is
encountered, where the relationship to the Other is completely transferred
into the own self, and is, to an extent, replaced by a pathological relation-
ship between parts of the self (14)—in such a way that one part of the self
remains identified with the lost object and another part directs the hatred,
which originally was aimed against the object, now against this part of the
self. Consequently, the relationship to the idealized Other is outwardly kept
up, while the "bad" and frustrating aspects of the object are taken into the
self where they are representatively attacked. Analogous to this, in psycho-
therapeutic treatment the idealized relationship to the therapist is at first
maintained, and patients tend to blame themselves for all disappointments,
persistent symptoms and the absence of change. This is reflected in the
therapist's countertransference: In patients that we studied with a nonpsy-
chotic depression, the foremost countertransference feelings before start-
ing with treatment were "sympathy," "helpfulness," and "pity." Further-
more, according to the therapists, depressive patients tend to assume
internal mental causes for their symptoms (Tab. I) and to establish what is
initially considered to be a good working alliance (2.04 for depressive, 1.89
for nondepressive patients, t-test, p=0.0447; assessment by therapists).
In the course of a long-term therapy, however, aspects of the repressed
negative transference begin to appear. In the patients' persisting com-
plaints, suicidal fantasies, or negative therapeutic reactions, that begin just
when internal changes could occur, the therapist gets a taste how these
complaints themselves become something tormenting and how he is being
punished for the failure of the idealized object. I f he loses his balance,
reacts impatiently or annoyed, or if he lets himself be made to react
rejectfully or reproachfully, then a difficult clinical situation may result.
This can increase the level of depression or lead to a transference situation
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 Object Relations and Intersubjectivity in Depression

Table I . SUBJECTIVE ETIOLOGIES IN PSYCHOTHERAPEUTIC OUTPATIENTS

(n = 286)

Depressive Non-depressive
Subjective etiologies (n = 101) (n = 185) X-Test , p
2

intrapsychic causes 66.3% 4.9% .001

interactional causes 50.5% 44.3% n.s.
physical/somatic causes 12.9% 27.0% .006
social causes 9.9% 17.3% .092

in which patients experience masochistic gratification, or, in the case of a

more psychotic depression, react with massive feelings of persecution. Such
constellations can lead to impasses or psychic retreats (3, 15), in which the
therapist becomes so involved in the pathological object-relationship, that a
temporary stagnation results. Yet, if patients are helped to express their
anger or disappointment more directly—and a disappointment cannot be
avoided due to the preceding idealization—then a perceptible progress can
be achieved. Patients can gain the experience that they may show pleasant
and unpleasant feelings to the object without destroying or losing it, just as
the other can reciprocally show pleasant and unpleasant feelings, and that
in this process they can also accept feelings of separateness, reparation, and
guilt (16). In this way they will be placed into the position to "forgive" the
failure of the idealized Other, just as, the other way around, they will
experience how their disappointments can be assuaged and their anger can
be forgiven (3). As particularly Melanie Klein and her followers have
pointed out, this is essential for the experiencing of genuine gratitude and
the tolerating of separateness (17). These experiences are in turn fundamen-
tal to internalizing the relationship with the Other; in other words, to create
an internal situation, in which the relationship continues to exist, even
when the real Other is no longer actually present.

INTERNALIZATION AND SYMBOL FORMATION

One of life's paradoxes is that becoming a subject and becoming indepen-

dent are very closely linked to the ability to endure experiences of
separation and loss. It is precisely this acceptance of separateness that
enables one to enter into a relationship with the Other as an independent
person who is not too much distorted by the subject's projections. This
ongoing process of internalization requires symbol formation, in which the
Other, for example the mother, even though not physically present, is still
accessible as an "internal object." Only by these means is it possible to
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experience presence in the absence and, the other way around, to endure
absence in the presence (18).
Jacques Lacan's structuralistic interpretation of psychoanalysis (19),
which is closely connected to existential philosophy and structural linguis-
tics, points out that the evolution of subjectivity and temporality are
basically linked to a fundamental symbolic process, in which the relation-
ship to the Other is transformed into a symbolic one (20). As we have
previously discussed (21), in the moment that the primary Other can be
symbolized—be it by a word or through a symbolic object, such as
'transitional objects' (22)—the possibility to distance oneself arises and
thereby the beginnings of a space where an own identity can be developed.
As soon as the relation to the Other and the world is transformed into this
level of symbolic representation, people are enabled to establish a reflected,
"playful acting" relationship with the Other, with the world and its norms,
and finally with themselves. This representational symbolizing clearly
remains deficient for those suffering from depression (23). For this reason,
as we have previously shown, they remain dependent on the concrete and
real presence of the Other, in a structure of a narcissistic-fusing primary
relationship. They need this narcissistic-fusing type of relationship, in order
to sustain a feeling of identity. This also explains their existential depen-
dency on the real presence of the "dominating object," their stubborn and
finally desperate attempt to maintain this self-stabilizing relationship at all
costs. If they lose the idealized object deep disturbances in their feeling of
identity up to distortions of reality (24) may occur. When we try to
understand these difficulties in relation to biography, then this dependency
could be understood at least partially as resulting from earlier experiences
of loss. So, among our outpatients, depressive patients showed a tendency
of increased separation experiences in their early years as compared to
other diagnostic groups (x -Test, p=0.067).
2

CONCLUSION

To summarize, depressive persons present considerable difficulties in

tolerating the fundamental dialectics of their existence and relationships as
they are inextricably linked with the symbolic relation to the Other. At least
outside a state of depressive stupor, they do not totally withdraw from the
world and there is no schizophrenic fragmentation. Yet they remain
attached to objects that embody an either-or quality and they are not able to
truly tolerate contradictions and transitoriness (25). Anthropological-
phenomenologically orientated researchers (6, 10, 13) emphasize this
"intolerance of ambiguity" as a main characteristic of the depressive
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 Object Relations and Intersubjectivity in Depression

persons. Consequently they reveal significant difficulties to accept the

contradictions of life, be it their own, the other's, or the inevitable
contradictions and conflicts inherent to certain situations. This also holds
true for depressive neurotics, if less absolutely, as it is extremely difficult for
them, as we have seen, to tolerate ambivalence in a close relationship. Yet,
when the contradictions of life are not really acknowledged and dealt with,
no true feeling of transitoriness can develop. A possible explanation of this,
aside from biological factors, can be seen in the depressed patients'
significant alterations in the experiencing of time, as described by anthropo-
logical psychiatrists (26-30). What these researchers have referred to as
"Werdensstillstand"—a stagnation of development—the loss of the "experi-
enced time," as compared to the "objective time" as it is projected into the
dimension of space, in which depressed patients feel agonizingly trapped,
could be explained as an expression of the rejection of transitoriness, which
in mourning must be genuinely acknowledged and worked through.
The time, the experienced time, is seen by the philosopher Levinas (31)
as "the closeness of the absent." The patient, whom we had mentioned in
the beginning of this paper, also had reported these phenomena of timeless-
ness and described a mechanical handling of life's tasks, even though she
was mainly reactively depressed. In the course of a crisis intervention,
followed by a short-term psychotherapy, this patient became able to mourn
the loss of her daughter. Only when she was capable to mourn, it finally
became possible for her to say farewell to her daughter and to enter—
through feelings and memories—into a new, symbolic relationship, as it
was already touched upon in her dialogue underneath the stars. She had
detached herself from death and decided that it is better to stay alive.

REFERENCES

1. Freud S (1917). Mourning and melancholia. Standard Edition, Vol 14, pp. 237-258.
2. Lang H (1989). Psychosomatik und depression. Daseinsanalyse,6, 68-81.
3. Steiner J (1993). Psychic retreats. Pathological organizations in psychotic, neurotic and borderline
patients. London: Routledge.
4. American Psychiatric Association (APA) (1994), Diagnostic and statistical manual of mental
disorders, 4th edition. Washington, D C : APA.
5. World Health Organization (WHO) (1991), International classification of mental disorders, ICD-10,
Chapter V (F). Geneva: W H O
6. Kraus A (1977). Sozialverhalten und Psychose Manisch-Depressiver. Stuttgart: Enke.
7. Abraham K (1912). Ansätze zur psychoanalytischen Erforschung und Behandlung des manisch-
depressiven Irreseins und verwandter Zustände. Zentralblatt der Psychoanalyse, 3, 302.
8. Kohut H (1971). The analysis of the self A systematic approach to the psychoanalytic treatment of
narcissistic personality disorders. New York: International Universities Press.
9. Chessick R D (1993). A dictionary for psychotherapists. Dynamic concepts in psychotherapy. Northvale,
NJ; London: Jason Aronson.
10. Tellenbach H (1975). Pathogenetische und therapeutische Aspekte der Melancholie als endokosmo-
gener Psychose. Nervenarzt, 46,525-531.

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11. Lang H (1990). Wirkfaktoren bei der Psychotherapie depressiver Erkrankungen. In H Lang (Ed.),
Wirkfaktoren der Psychotherapie. Berlin, Heidelberg, New York: Springer, pp. 309-325
12. Becker J , Spielberger C D , & Parker J (1963). Value achievement and authoritarian attitudes in
psychiatric patients, journal of Clinical Psychology 10,51-Gl.
13. Teilenbach H (1961). Melancholie, 4 ed. Berlin, Heidelberg, New York, Tokyo: Springer.
th

14. Steiner J (1987). The interplay between pathological organizations and the paranoid-schizoid and
depressive positions. International Journal of Psycho-Analysis, 68, 69-80.
15. Rosenfeld H (1987). Impasse and interpretation. London: Tavistock.
16. Klein M, & Rivière J (1937). Love, hate and reparation. London: Hogarth.
17. Klein M (1957). Envy and gratitude. London: Tavistock.
18. Weiss H , & Pagel G (1995). Sprache, Gefühl und Denken oder: Wie psychische Bedeutungen
entstehen. Eine Auseinandersetzung mit den Theorien W R . Bions und J . Lacans. Jahrbuch der
Psychoanalyse,^ 34, 142-178
19. Lacan J (1966). Berits. Paris: Seuil.
20. Lang H (1973). Language and the unconscious : Jacques Lacans hermeneutics of psychoanalysis.
Atlantic Highlands, NJ : Humanities Press 1997.
21. Lang H (1985). Struktural-analytische Überlegungen zur Psychotherapie Schizophrener. Nerve-
narzt, 56,472-478.
22. Winnicott D W (1953). Transitional objects and transitional phenomena. International Journal of
Psycho-Analysis, 34, 89-97.
23. Jacobson E (1971). Depression. New York: International Universities Press.
24. Loch W (1972). Psychoanalytische Aspekte zur Pathogenese und Struktur depressiv-psychotischer
Zustandsbilder. In (Ed.) Loch W . Zur Theorie, Technik und Therapie der Psychoanalyse.
Frankfurt a.M.: S. Fischer.
25. Bion W R (1962). Learningfrom experience. London: Heinemann.
26. Gebsattel V E Frhr v (1928). Zeitbezogenes Zwangsdenken in der Melancholie. Versuch einer
konstruktiv-genetischen Betrachtung der Melancholiesymptome, Nervenarzt, 5, 275-287.
27. Straus E (1928). Das Zeiterlebnis in der endogenen Depression und in psychopathischen Verstim-
mung. Monatsschrift für Psychiatrie und Neurologie, 68, 640-656.
28. Straus E (1930). Geschehnis und Erlebnis—zugleich eine historiologische Deutung des psychischen
Traumas und der Renten-Neurose. Berlin, Heidelberg, New York: Springer.
29. Minkowski E (1933). Die gelebte Zeit, Vols. 1 &2. Salzburg: Müller 1971,1972.
30. Weiß H (1984). Zeitlichkeit bei Bergson und Minkowski. Daseinsanalyse, 1,203-215.
31. Lévinas E (1979). L e temps et l'autre. Montpellier: fata morgana.

328
 Neurological Dysfunction, Psychic Conflict,
and Psychotherapy

MAREIKE WOLF, Ph.D.*

Clinical experience of psychotherapists is getting more and more circum-

scribed by the boundaries of theoretical references. The Freudian "psychic
treatment" for neurosis got its impetus from the friendship between Sigmund
Freud and Ludwig Binswanger, the phenomenological psychiatrist. This
relationship laid the foundation for the references of psychoanalytic psycho-
therapy in Europe. Then, the Freudian conception of actual neurosis led to a
psychosomatic approach. Later, the study of narcissistic neurosis opened up
borderline patients. Today, scientific and medical progress greatly influenc
psych op athological research and the way we look at our patients and their
requests. These changes come from the patients' sayings and their expectanc
of well-being. At the same time psychotherapists have to take a new look at
their theoretical references. On the one hand, a dynamic concept for
psychotherapy is necessary for integrating the phénoménologie approach into
psychoanalysis, and providing the understanding of situations emerging in
neurological dysfunction. On the other hand, psychotherapists pay more
attention to the different actors contributing to a pathology (Who is suffering?
What about the life-partner or the relatives?). These changes lead to a new
look into the processes of identification as well as the notion of identity. This
article discusses these influences on psychotherapy and clinical research
showing how clinical situations get ahead of theoretical references.
CLINICAL SITUATIONS

At present, scientific and medical progress provide a new look at psychopa-

thology. At the same time, the work of psychotherapy could become more
precise, as, for instance the ability to interpret various conditions, such as
heart troubles, sleep disturbances or memory lapses. The approach will
depend on whether these disorders are caused by emotional stress, a
side-effect of a drug, a genetic predisposition or a neurologic disease. The
dichotomy that recognizes either psychic or neurologic causes is outmoded.
Some patients may have neurologic dysfunctions and psychic conflicts that
"Psychoanalyst, Clinical and Psychopathological Psychology, Department of Psychology, Caen
University, France. Mailing address: e-mail: M14Wolf@[Link]; Université Paris 7-Denis Diderot,
Laboratoire de Psychopathologie Fondamentale et Psychanalyse, 2 place Jussieu, Tour 53, 2 étage,
è m e

Rotonde, Case 7065, 75251 Paris Cedex 05.

A M E R I C A N JOURNAL OF PSYCHOTHERAPY, V o l . 5 4 , N o . 3 , S u m m e r 2000

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are very likely to interact. So far, this relationship has not been studied
thoroughly enough. Even if we cannot find a causal relationship explaining
the etiology of the symptom, we may assume that a treatment dealing
simultaneously with neurologic aspects will be more successful uncovering
life events, the psychic world, and the unconscious of the patient than any
treatment ignoring these factors. Rothstein alerted us to the relationship
between neuropsychologic dysfunction and psychologic conflict (1). It is
important to emphasize this relationship and to develop the implications of
this specific situation in the framework of psychoanalytical psychotherapy.
Today, a certain degree of well-being is expected by most people,
including the elderly, in the industrial countries. There is a new demand for
physical as well as emotional well-being by all, even those who have to live
with a handicap caused by an accident or a genetic disease, for example.
Physical impairment does not preclude expectation of well-being in every-
day life. On the contrary! Patients with neurological troubles often say that
they forget their symptoms when they are "psychically relaxed."
Up to now, the opinion has prevailed that there is an incompatibility
between very productive mental functioning—overproductive even, such
as psychosis—and somatic disease. This way of thinking comes from
French psychosomatic approaches of the past twenty years (2,3). Such
training may lead to surprises in clinical situations. Recently I described my
perplexity (4) when my paranoid patient dropped out, after over a year of
psychotherapy: he had an ulcer. He got this ulcer when he was a teenager,
some twenty years before. As far as he was concerned, the ulcer was a part
of him. He did not see the reason for communicating its existence to me.
After all, it was up to me, his psychotherapist, to know everything about
him. I was supposed to know him much better than he knew himself. The
ulcer seemed of little importance to him compared with his other problems.
But I was upset to come to know so late about his physical ailment.
Furthermore, this fact did not match the theories I was trained with.
From the viewpoint of a psychosomatic orientation this was a very
embarrassing episode. The Psychosomatic School of Paris says that the
correlation of psychosis and psychosomatic disease is negative. So there
was no doubt about the psychotic evolution of my patient and the existence
of his ulcer. When his ulcer was healed, after two years of psychotherapy, he
said: "This is the only proof that there is something right about psychoanaly-
sis." Furthermore, to complete the confusion of theoretical references, he
was diagnosed with a malignant tumor in his chest. What was the meaning
of the emergence of this cancer in relation to the breast feeding by his
mother? This situation was already symbolized by the ulcer that had been
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cured. When healing from his psychotic expression of anguish, the domina-
tion of the projective mechanism, his regression to a homosexual and
autoerotic expression was another way to designate the same feeding
problem: a man's breast. It was astonishing that he was not at all afraid of
the possible seriousness of the medical situation. Before, he was a suspi-
cious, paranoid person. Now, he had a good reason to be suspicious, but he
was confident! I think the treatment situation (on the one hand, he had his
woman-psychotherapist as a mother figure, on the other, the surgeon as a
father figure): an ideal transference situation. He healed completely after
his surgery. This case is one of a series of clinical experiences that show the
importance of a theoretical frame on the study of specific cases (5).

PSYCHIC CONFLICT

What about this patient, deeply depressed, because her mother, suffering
from Alzheimer's disease, does not recognize her any more? What about
the trauma? Would she have suffered a depression anyway, even later?
People who have a parent suffering from Alzheimer s will not get depressed
in general. But, they are only rarely questioned on what the disease is doing
to them.
The diagnosis of a fatal disease may be so traumatic that it brings about
in other family members the emergence of manifest symptoms that could
have stayed latent for the rest of their lives. A change in the image of a
relative also alters the interaction of identification processes. The serious-
ness of a disease can be experienced as a kind of depersonalization.
At present, we know that there is a vulnerability for a child to develop a
neurosis, when a sibling is suffering from a neurological or genetic disorder.
It is important for the sexual identity and the resolution of the Oedipus
complex to know how the child will interpret the fact that the afflicted
brother or sister is the same sex or not, and whether he or she is older or
not. Indeed, we see that a psychic disease does not exist only in one person.
A psychic conflict involves at least two people who suffer in their own way.
The well-being of one of them is much more a question of defense
mechanisms. One of them is able to muster defense mechanisms to
function properly; the other, lacking them or employing different kinds of
defense mechanisms, may create conflict between two persons.
The clinical situation shows that a person might not be aware of the
suffering of the person he is living with. The real problem is that the patient
takes a long time before realizing that a beloved person is ill. Once, the fact
is accepted, the patient experiences life in a different way. The analysis of
the transference to the psychotherapist helps the patient understand that
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aspect of transference that may play a part in a love affair or the relationship
with parents. Transference ignores illness. Children with ill parents take a
long time (in the latency period) before realizing how their parents are
considered by others. The importance for children is to have their parents
just in the way they are. This kind of relationship characterizes also the
transference content. In a way, the demand to consider illness leads to
frustration and it is the opposite of idealization as it takes place within the
transference process.

THEORETICAL FRAME

These examples show that psychotherapists have to decide whether the

disease needs medical or psychiatric treatment. They also have to pay
attention to the oscillations of psychic experiencing. When psychotherapy
is an accompaniment of a medical or psychiatric treatment, it actually
attends to the psychic consequences of an ailment. Nevertheless, a refer-
ence to a neurosis theory is helpful. But we must make sure of being aware
that, though a diagnosis of neurosis is correct from a theoretical viewpoint,
it is not the same problem if somebody has doubts about himself all the
time, because he has an obsessional neurosis or if somebody has doubts
about himself because he has Parkinson's disease and cannot manage the
secondary effects of his drugs. The same consideration applies to patients
with delusions who take neuroleptics. They will not turn into neurotic
patients all of a sudden. But the drug will change the psychotherapist's
representation. Why should he work with psychosis theory when the
reference to neurotic processes is possible? He just has to be aware that this
neurotic representation may fail at times. Generally, this kind of practice
shows that representations change quickly for the therapist. They are of
weak solidity in time. Maybe, it is essential for the approach to this kind of
patient, that the psychotherapist avail himself of his own capacity to change
representations quickly. This clearly is not an indication of errors, but it is
part of this kind of work.
Imhof, Altman and Katz (6) described the practical considerations in
transference and countertransference that are relevant in the relationship
between the psychotherapist and the prescribing psychiatrist. Referring to
Bond 's and Langs's writings they point to the complication resulting from
the introduction of a third party. It is a deviation from the "therapeutic
frame" which requires the therapist to "pay special attention by monitoring
the patients adaptation to such a deviation." The authors observed an
emotional instability in the transference reactions. The patient may feel
precariously balanced between the doctors and compensate for this situa-
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tion with a strong emotional reaction culminating in a temporary "flight

into health."
Widlocher (7) makes clear that there is no equivalent for psychoanalyti-
cal concepts in the nervous system. Therefore "it is necessary to introduce a
new language that is adapted to neurobiology and can be translated into
terms intelligible to the observer." Even when using the same terms they
may carry a different or even opposite implication when transferred from
one field to another. Hence, these terms will not be of any use for further
scientific investigation. That is the reason for his proposition to choose a
third language based on a cognitive approach.
Another viewpoint serving our purpose is presented by Chessick in the
special section of "The Application of Phenomenology to Psychiatry and
Psychotherapy" (8). In explaining European and especially German philo-
sophical tradition, he states: "A certain effort will be required from the
psychotherapist to wrench himself or herself from routine thinking and to
concentrate in a different manner. Remember that the aim of phenomeno-
logical study is to rediscover the whole living person and how being in the
world is experienced by that person and those around that person" (pp.
161-162).

PHENOMENOLOGICAL VIEWPOINT

The phenomenological approach proved to be important at the beginning

of the twentieth century for psychosis and neurological disorders. It
preserved its importance for the psychotherapy of psychosis (9). The Swiss
psychiatrist, Roland Kuhn, discovered the antidepressant Anafranil with
the help of a phenomenological approach (10). But the use of a phenomeno-
logical approach for neurologic disorders was forgotten. The progress of
neurobiology laid stress on the physiology of the brain. But it is time to
remember the work of European psychiatrists about seventy years ago,
when there was no other material than the vocabulary of observers and
patients communicating their perceptual distortion. Nissim-Sabat (11)
describes the concept of empathy in discussing the importance of phenom-
enology for psychopathology. Mishara (12) and Lang (13) explain the
psychotherapeutical work with the phenomenological approach.
In recent books, I showed (14,15) that the efficiency of the phenomeno-
logical approaches depends a lot on a personal interpretation and the kind
of use we can make of it. I referred to the confession of Binswanger, who
founded existential analysis {Daseinsanalyse), admitting that he interpreted
the ideas of the German philosopher Heidegger in a very personal way.
After all, ideas should serve practice. And it is just this practice that led him
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to his own approach. I also showed that phenomenology cannot persist as a

unconnected technique, but needs to be associated with another practice,
which explains that phenomenology is very helpful in psychoanalytical
psychotherapy of psychosis. Chessick referred to phenomenology when
examining the interaction of psychosis and open heart surgery (16).

PATIENTS A N D THEIR FAMILIES

At this point, I would like to propose a wider understanding of the

possibilities of the application of phenomenology in considering special
cases in psychotherapy. Things get more complex when we identify the
trouble of a patient's relative (husband, wife, brother, sister, or all other
members living with them). Daily contact with the pathology of a life-
partner influences one's own way of living. We know that every psychic
conflict has to do with intersubjectivity, and that the morbidity of each
symptom will cause harm. So far, we may wonder what can be achieved by
identifying the pathology of a life-partner? After all, such is the rule of
psychotherapy: we can only be responsible for our patient. Even if we were
willing to listen to his whole family, we cannot treat them in the same way.
The positive result of a successful psychotherapy is the patient's psychic
capacity to handle every kind of situation.
So, let us put the question differently. We know that a lot of problems fit
well together. Freud discovered psychoanalysis when studying hysteria and
at the same time he observed that we are rarely confronted by a simple
psychopathological form. Hysteria, for example, can be associated with a
lot of other pathologies. Nosology is just a guide. The existence of
nosological categories does not mean that an affliction is immutable.
Changes may occur in the same way as "changing our mind/' Freud showed
that mainly we have to deal with "mixed neurosis." The reason for this
mixture is that a psychic affliction is changing by adopting several defense
mechanisms (17) over a lifetime or during the treatment. On the one hand,
there is the patient who is likely to develop several symptoms. On the other
hand, this patient will continue this way by looking for a life-partner whose
symptoms fit his own. When people realize that they are always looking for
partners who will make them unhappy, this repetition-pattern is a potent
reason for seeking therapy. They probably behave in a way that provokes
their partners to retort angrily. But there are also couples who function in a
sado-masochistic way and they are happy in this situation.
What about "altered consciousness"? For example, we know from
research concerning couples with one psychotic partner that these couples
may interact as any couple would. Even, when investigating each of the
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 Neurological Dysfunction, Psychic Conflict, and Psychotherapy

partners in isolation, our students found it difficult to say who was really
the psychotic one. The nature of the strong counterreaction based on the
defense mechanisms of the nonpsychotic life-partner may appear to a
student a much more foolish behavior because of its rigidity. Students
sometimes find it hard to distinguish psychosis from neurosis, because they
imagine psychosis as a chronical confusion and neurosis as a better-
controlled suffering state.
Recent research on incest shows how difficult it is to change a situation
that is dangerous for the psychic and intellectual development. Ferenczi
(18) already showed that children have the capacity of empathy to under-
stand and shield their aggressor by splitting their superego. This capacity
will also come to the fore later in adulthood and create a special way of life.
The problem is that some functioning will only become manifest with time.
This conflict creates a kind of fragility of the psyche that leads to vulnerabil-
ity to develop pathological affliction (19). Here the special psychic situation
experienced in incest may be compared with other states of altered
consciousness.
Some pathologies develop only with time, as, for example, depression or
schizophrenia. The life-partner does not see how he could have lived with
somebody exhibiting this pathology all the time. The explanation offered
from a psychogenetic viewpoint helps to understand. Even if the loved
person follows a logic {patho-logics) where the patient cannot get any
insight, he will act in favor of empathy. Nevertheless, the emergence of a
pathology causes the feeling of annihilation and powerlessness.
Neurological dysfunction may also come unexpectedly. But, in fact, the
really painful awareness results from the realization that there were earlier
telltale signs. No Parkinson s or Alzheimers disease, for example, appears
suddenly. It is hard to admit that there were signs in the interaction with the
member of the family that were wrongly interpreted by judging them to be
intentional though they were the simple expression of disease, i.e., a neurologi-
cal display. The problem is to identify what is real for the partner and what
he really feels. Patients faced by neurological dysfunctions are likely to have
doubts about their significance for the other. They wonder if the partner
notices their individual reactions or if they just take place as a kind of
stimuli in human interaction. Which are the statements of the ill person
they can trust as a real appreciation of themselves? Are they confronted by
a real interaction between two people or is it just the secondary effect of a
symptom that cannot be managed by the partner? These questions lead to
existential problems and may result in a depressive attitude wondering
about the meaning of people living together.
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The ill partner is not aware of his expressions and tired of this kind of
self-awareness that does not seem profitable for him. When somebody
suffers, we cannot ask him to give a commentary on his suffering for a
better understanding. He might even not know that he is suffering because
he is completely absorbed by his experiencing of this state. Intimacy of
family life or of a couple threatens to be swallowed up by the problems
organizing the lives of all members.
In the case of somatic symptoms, the visibility of the symptom helps the
comprehension. But, in a case of dislocation of the bridge between
speaking and acting, characterizing neurological dysfunctioning, the part-
ner is confronted by a double-bind situation. In a way neurological
symptoms may introduce a kind of depersonalization in the life-partner.
But the consequences of this depersonalization are temporary and do not
lead to psychosis. It seems to me that the life-partner comes in touch with a
kind of defense in order to master the danger of splitting and the anguish of
death. The patient is mainly interested in "strange objects." Generally,
persons suffering from neurological disorders suddenly investigate certain
activities that seem to become very important to them. This causes a
problem for their environment. Instead of enjoying themselves calmly they
become agitated. We certainly have to consider this way of acting as a kind
of compensation and a defense against psychic splitting. It seems that
action has a regenerative effect for the patients' ego. But this can be very
exhausting for the people sharing their daily lives.
Psychotherapy with these kinds of pathologies aims to help the patient
separate the psychic worlds of two interacting partners. Transference
analysis illustrates this purpose very well. The very special clinical situation
in psychotherapy dominated by neurological troubles emphasizes the truth
met in any psychotherapy: being willing to accept the differences between
two people. A parallel situation arises when the patient understands the
existence of the unconscious. It is important to realize that there is a basic
theoretical difference between the unconscious and neurological dysfunc-
tion. This awareness opens up to imagery functions instead of freezing
them in representations of anguish.

REFERENCES T O P S Y C H O P A T H O L O G Y

Clinical experience of psychotherapists is more and more constricted to the

boundaries of theoretical references. The Freudian "psychic treatment" for
neurosis got its first impetus from the friendship between Sigmund Freud
and Ludwig Binswanger, the phenomenological psychiatrist who created
the concept of "empathy" (from the German term Einfühlung) in working
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 Neurological Dysfunction, Psychic Conflict, and Psychotherapy

with psychotic patients. Ludwig Binswanger, son and grandson of psychia-

trists, made his first observations of psychosis as a little boy. The correspon-
dence between Freud and Binswanger shows that they did not only
exchange ideas but patients as well. Freud sent the psychotic ones to
Binswanger, and Binswanger sent Freud patients who had become more
structured (as those suffering from perversion) after the psychotic episode.
Eventually, Felix Deutsch and Franz Alexander, picking up the Freud-
ian concept of actual neurosis and transference neurosis, developed the
psychosomatic approach. They adapted the neurosis concept to physiology
and created certain metaphors of the body.
Later, the study of narcissistic neurosis was expanded to borderline
patients by Kernberg (20), Langs (21), and Sandler (22). This new nosologi-
cal category helped organize differently psychosomatic disease and addic-
tion pathologies (anorexia/bulimia, drugs, risk-taking, alcoholism). On the
one hand, there is still the classic understanding of borderline patients as an
offshoot of the Freudian narcissistic neurosis. On the other hand, the
representation of borderline patients puts a new light on all sorts of
ego-problems.
Today, scientific and medical progress reveal important incidences of
psychopathological research. This influence alters the way we look at our
patients and their requests. Medical research progresses quickly. Nearly
every year additional data offer a new look at some pathologies, the
function of drugs and the brain function.
This change leads us to renew a hundred-year-old discussion. The
interaction of somatic and psychic factors characterizes the time before
progress was made in medicine. Once the words of the patient were leading
to a medical hypothesis, but today we are able to measure the importance of
the two aspects of well-being: the physical and psychic aspects. Besides,
humans are social beings, and psychic life cannot be isolated. Psychic
health means a satisfactory interaction with your surroundings and people.
Let us remember too that over a hundred years ago Freud discovered the
unconscious. He made this discovery despite the idea of the splitting of
consciousness like Bleuler s schizophrenia concept. Freud used the vocabu-
lary of paraphrenia or paranoia in order to speak of schizophrenia, meaning
that he chose to investigate the vocabulary of psychic functions. He left his
studies of neurophysiology far behind.
Nevertheless, Freud's writings teach some ideas about mental function-
ing. First, the plasticity of psychic life is important for the success of
psychoanalysis, which suggests an age limit. Freud, however, never indi-
cated an exact age. He said that the functioning of senile people is like a
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regression to infancy. In a way, the development concept of the child

becomes a regression concept for old people. Recently, the French child
psychoanalyst Serge Lebovici said that "probably people growing older
have to make the same effort as babies developing." This aspect is
important if we consider that psychotherapy is more and more required for
children, teenagers, and older persons. Another important aspect of Freud s
choice of vocabulary is when referring to "motility" (the faculty to move) of
associations. The lacking of this motility is responsible for the strength of
the symptom. These considerations improve the understanding of the
relationship between psychic conflict and neurological disturbances. Neu-
rological disturbances may hinder the motility of associations and, conse-
quently, contribute to a psychic symptom.
Psychotherapists are confronted with these new perspectives and have
to think about the way to verbalize them (to their patients or their
colleagues). Is there a need for a new nosological category and a new
technical approach? This paper does not pretend to solve all these ques-
tions. It simply means to continue the opening up of questions that were
already asked by previous authors whose well-known works we quoted all
along, and to place them in the framework of psychotherapy.

REFERENCES

1. Rothstein A (1998). Neuropsychological dysfunction and psychological conflict. The Psychoanalytic

Quarterly, 47, 2, 218-239.
2. Marty P, De M'Uzan M, & David C (1963). L'investigation psychosomatique. Paris: P U E
3. Sami-Ali M (1987). Penser le somatique: Imaginaire et pathologie, Paris: Dunod.
4. Wolf M (1996). Psychosomatique et processus paranoïaque. In Champ psychosomatique. Paris: E d .
L a Pensée Sauvage, 7, 103-113.
5. Fédida P, & Villa F (dir.) (1999). Le cas en controverse. Monographie de psychopathologie, Paris:
PUF.
6. Imhof J E , Altman R, & Katz J L (1998). The relationship between psychotherapist and prescribing
psychiatrist: Some considerations. A merican Journal of Psychotherapy, 52, 3, 261-272.
7. Widlôcher D (1990). Neurobiologie et psychanalyse. Revue internationale de Psychopathologie, 2,
335-356.
8. Chessick R D (1995). The application of phenomenology to psychiatry and psychotherapy. Ameri-
can Journal of Psychotherapy, 49, 159-162.
9. Binswanger L (1971). De la psychothérapie. In Introduction à l'analyse existentielle. Paris: Minuit.
10. Kuhn R (1990). Psychopharmacologie et analyse existentielle. Revue Internationale de Psychopatholo-
gie, 1, 43-67.
11. Nissim-Sabat M (1995). Towards a phenomenology of empathy. American Journal of Psychotherapy,
49, 163-170.
12. Mishara A L (1995). Narrative and psychotherapy: The phenomenology of healing. American
Journal of Psychotherapy, 49, 180-195.
13. Lang H (1995). Hermeneutics and psychoanalytically oriented psychotherapy. American Journal of
Psychotherapy, 49, 215-224.
14. Wolf M (1995). Théorie de l'action psychothérapique. Paris: PUF.
15. Wolf M (1998). La psychopathologie et ses méthodes, coll. Que sais-je? n° 3298, Paris: PUF.
16. Chessick R D (1995). Psychosis after open heart surgery: A phenomenological study. American
Journal of Psychotherapy, 49, 171-179.

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17. Freud S (1895). Uber die Berechtigung von der Neurasthenie einen bestimmten Symptomkomplex
als "Angstneurose" abzutrennen. Studienausgabe. VI, Frankfurt/M.: Fischer, 1982.
18. Ferenczi S (1932). Sprachverwirrungen zwischen den Erwachsenen und dem Kind. Die Sprache
der Zärtlichkeit und der Leidenschaft (Die Leidenschaft der Erwachsenen und deren Einfluss
auf Charakter- und Sexualentwicklung der Kinder). Internationale Zeitschrift für Psychoanalyse,
20, 1934.
19. Ferenzci S (1934). Réflexions sur le traumatisme. In Psychanalyse IV: OEuvres complètes, 4,
1927-1933, Paris: Payot, 1982.
20. Kernberg O (1975). Borderline conditions and pathological narcissism. New York: Jason Aronson.
21. Langs R (1976). The bipersonal field. New York: Jason Aronson.
22. Sandler J (Ed.). (1988) Projection, identification, projective identification, London: Karnac Books.

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 Presentness:
An Intersubjective Dimension of the Therapeutic Act

RINA LAZAR, Ph.D.*

In this article, the author discusses a mode of the therapist's presence as an

important dimension within the intersubjective framework. She seeks to
introduce the term presentness to denote dimensions of the therapist's
explicit usage of her implicit knowledge and the role of her unformulated
experiences within the therapeutic situation. The emphasis is on the power of
these shared states of mutual reverie and moments of spontaneous responsive-
ness on the part of the therapist. The author wants to emphasize again that
this term describes an important, though not exclusive, dimension of the
therapeutic interaction. It does not replace such psychic functions as observa-
tion, distancing, empathy, or such modes of object-relating as transferenc
countertransference or projective identification. The term presentness illumi-
nates the symmetrical dimension of the therapeutic interaction, and its
contribution to the construction of "meaningfulness" for both patient and
therapist.
To know is to insert something into what is real, and hence to distort
reality . . . so that the more the world becomes distorted before his eyes,
the more the author's self becomes involved in the process and is itself
distorted and confused.
Italo Calvino, Six Memos for the Next Millennium (1988, p. 108).
The longer we engage in psychotherapy, the more varied our understand-
1

ing and conceptualization of the therapeutic act becomes. However, there

is no end to this process, no one single understanding remains satisfactory
for very long. The enigma constantly reemerges, following any newly found
solution. What is the therapeutic act, what is its secret? Are we speaking of
an understanding that basically accommodates and pacifies the patients'
concerns and disturbances, or are we dealing with a subversive type of
understanding? The answer may lie in the manner of our presence with the
patients, our facing them, satisfying an existing need, or, alternately,
enabling a previously undiscerned need to come to the surface. A related

*Supervisor and a faculty member at the Program of Psychotherapy, Sackler School of Medicine, Tel
Aviv University. Mailing address: 9 Ramot Naftali, Tel Aviv 69278, Israel, e-mail: rlazar@[Link]
throughout this article the terms psychotherapy or therapy relate to psychoanalytic psychotherapy.

A M E R I C A N JOURNAL OF PSYCHOTHERAPY, V o l . 5 4 , N o . 3 , S u m m e r 2000

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question is: are understanding and doing, being-present and interpreting,

two different and distinctly defined orders of existence? And, in the light of
this, what is the place of behavior, of enactment, of interaction in acquaint-
ing us, patient and therapist, with our and others' psychic mentation?
Moreover, what will constitute a preferred therapeutic presence, what is its
decisive element, is it our ability to observe the other, to see him/her in a
sharper focus through his/her words and gestures, or is it rather our
immersion in the world as he/she experiences it? Might it be perhaps an
altogether different process, a kind of responsiveness to what is enacted
through us and its exposure (by choice) and our (inevitable) exposure
through it—in order to arrive at a shared understanding?
We can discuss the therapeutic situation, or interaction, in terms of
transference, countertransference, projective identification, counterprojec-
tive identification, etc. All these are hypothesized psychological mecha-
nisms, which are proposed as explanations for the various phenomena that
occur during the therapeutic session. My emphasis, however, is on unfurl-
ing the therapeutic phenomenon itself. It is an attempt to describe the
experience of using ourselves as therapists and the ways we acquaint
ourselves with our patients through various ideas, emotions, and even
behavior, which are not necessarily clear-cut and separate. I shall delineate
and try to illuminate singular therapeutic moments in this explication,
rather than present the therapeutic creation in its entirety.
Trying to understand the way we use ourselves as therapists for the
benefit of our patients, we can borrow Matte Blanco s conceptions of
symmetrical-asymmetrical modes of being. Rucker & Lombardi (1) write:
Asymmetry is roughly guided by Aristotelian logic, wherein difference and
multiplicity prevail; symmetry is guided by such qualities of the unconscious
elaborated by Freud as timelessness, spacelessness, a lack of mutual contradic-
tion, and absence of negation wherein sameness and union prevail. . . . When
stated in object relational terms, these two fundamental modes of being
correspond to poles of fusion or dedifferentiation (representing unconscious
symmetrical relationships) and separateness or differentiation (representing
asymmetrical relationships), (pp. 13,15)
In the psychoanalytic tradition, the asymmetrical dimension has been
favored over the symmetrical one. The emphasis was on abstinence,
anonymity, and neutrality of the analyst in the therapeutic situation, and on
the observing ego and the reflective function of the patient. Nowadays
there is a shift; most modern psychoanalytic theories of self-development
assume that the reflective function itself is dependent upon a shared
experiential (symmetrical) dimension (2-5). It is suggested that there is a
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dialectical relation between both these dimensions—between being within

a shared unconscious relational experience and reflecting on it.
I have chosen to use the term presentness to denote dimensions of the
therapists' explicit use (and sharing) of their implicit knowledge and the
role of their unformulated experiences of the therapeutic situation, as
significant materials in the treatment process. The emphasis is on the power
of these shared states of mutual reverie and moments of spontaneous
responsiveness on the part of the therapist. This term is not originally a
psychoanalytic one. It is used in literary criticism to refer to the author s
active part as an ongoing commentator on the unfolding text. Buber (6)
uses this concept to relate to the dynamics of the "I-Thou" relationship, the
relation of subject to subject. When the object ceases being It and becomes
Thou for the one who is with it; where his/her exclusiveness and singularity
seizes the other involuntarily. The mutuality to which Buber refers in the
I-Thou relationship is not that of therapy in general, but rather an
existential mutuality, which entails total exposure. I want to throw light on
a slightly different situation, which is more confused, even though no less
exposed, an oscillating subject-object and subject-subject relation.
As I understand this concept, presentness is a way of being and a way of
knowing on the part of the therapist that is not based on objective
observation, nor is it empathic immersion or lending of one's presence as a
self-object to the patient. Rather, it is understood that the therapist's
subjectivity, whether in attitude or in action, cocreates the patient's experi-
ence and the total interaction with the therapist. Emphasis is placed on the
ultimate unknowability and ambiguity of experience and psychic truth,
with an accompanying attitude, on the part of the therapist, of uncertainty
and open-endedness toward the therapist's associations and interpreta-
tions. It is a mode of being that allows the presence of the patient to
resonate within the analyst and to impact on each other. Presentness
implies furthermore the possibility that our experience and our relatedness
with our patients contain a mystery that cannot simply he interpreted into the
clear light, but must sometimes be accepted and used without the analyst's
explicit understanding. This dimension of uncertainty and not-knowing
could be shared with the patient with a therapeutic aim in mind.
I believe the concept of presentness to be pertinent to the intersubjective
conception of the therapeutic situation, where the latter is conceived as a
situation that is constantly constructed by the psychology of two persons, of
which they have no complete knowledge. Hence, both patient and thera-
pist need the perceptiveness of the other in order to understand their own
reactions and to put them to good use, to enable the patient, who has come
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for help, to change and grow. The therapeutic interaction is described as a

"mutually constructed, intersubjective playground of transitional potentiali-
ties where meaning can be constructed only in the throws of recognition,
destruction, and perpetual interaction between two actively engaged partici-
pants" (7, p. 168).
There is an interesting literary context where cognate notions of
presentness are found. They refer to an author presenting him/herself as a
narrator who enters the story and broaches his/her uncertainties about the
written material and the way it is written. Therapists may act in a similar
way in their interpretations, through which their uncertainties about their
patients, the therapy, and the quality of their role in the constructed psychic
constellation are revealed. Hoffman (8) suggests that supervisees may
report that they are struggling in their work with patients because, on the
one hand, they would like to tell the patient X but they are afraid of Y. At
these moments, Hoffman often suggests to supervisees that they tell the
patient just that, i.e., " I want to tell you X but I am afraid of Y" (8, p. 299).
He argues that "discussing such dilemmas and conflicts with patients often
helps to engage them in a collaborative exploration of the various patterns
of relating (rooted in various kinds of internal object relations) that are
either being enacted or that are potential at any given time" (8, p. 300).
Renik (9) advocates the need to establish self-disclosure as a legitimate
analytic intervention. He claims that "an analyst should try to articulate and
communicate everything that, in the analyst's view, will help the patient
understand where the analyst thinks he or she is coming from and trying to
go with the patient" (9, p. 485).
Aron (10) speaks of the patients conflictual need to recognize the
therapist as a separate center of subjective experience, and the therapist s
role in illuminating this need as legitimate and essential for psychic change.
Aron aims at expanding the patient s observations of his unspoken percep-
tions in addition to the patient's fantastic and transferential speculations.
The emphasis is not only on the analyst 's self-disclosure, but on the
exploration of the patient's fantasies and perceptions in relation to the
analyst. For example, Aron tells about a supervisory session where the
therapist described a period of five weeks in which the main topic was
the patient's reactions and associations to his therapist's coming lecture,
and the patient's endless hesitations whether to attend this meeting. Aron
suggested to his supervisee that "in the next session, when the patient
discussed his thoughts and feelings about this topic once again, he might
find a suitable moment to ask the patient the following question, or
something like it, in his own words and style: 'What do you imagine that it
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would be like for me to have you come hear the paper? Picture me up at the
podium about to read the paper, I look out into the audience and I notice
you are there. What do you imagine I feel at that moment?"' Aron
continues and tells us that "Indeed, the analyst had asked the question as I
recommended. He was not prepared for what happened next, not to the
patient, but to himself. For the first time the patient stopped finding it so
easy to free associate. . .; now the patient felt blocked, uncomfortable, and
intensely anxious. The analyst too began to feel anxious, but now his
thoughts were racing concerning the upcoming talk. . . . He was able to
work with the patient and show him that his difficulty associating now had
to do with his fears of making the analyst more anxious by talking about
him in a way that was much more personal. The analyst had gone from
being the patient s object to being a separate subject, and this change
happened not because of a developmental step on the patient's part, but
because the analyst had shifted his stance and opened himself up to his own
subjectivity" (10, p. 90).
Bollas (11) also proposes the exposure of subjective materials that are
not clear to the therapist, in order to facilitate the articulation of heretofore-
inarticulate elements of psychic life of the patient. He argues that

there are certain patients with whom one cannot do classical work and at the
same time feel real; indeed it becomes necessary first to restore one's sense of
personal reality in work with such patients before a more classical analysis can
be initiated. The occasional direct use of one's countertransference as the
object of the patient [in which he tells the patient how it felt to be one of the
objects in her environment] may be what is needed to initiate analysis proper,
(p. 229)
I would like to emphasize the rather confused and potentially confusing
dimension of our presence in the therapeutic situation, a combination of
the symmetrical dimension and the individuals struggle for separateness
and self-articulation. In the present context, the reference is not to an
action that is transparent to the person enacting it, to the therapists
self-disclosure as a form of interpretation or clarification, but to affecting in
both senses of the word (being acted upon and moving the feelings), to
communication of our inarticulate experiences of ourselves and the patient.
In contrast to the concept of self-disclosure, the concept of presentness
stresses the relatively uncontrolled, strange, rather vague and nonseparate
dimension of the therapeutic process. It is being acted upon and acting; it is
responsivity and initiative; it is making ourselves strange to ourselves
through being exposed to, embedded in, and exposing states of "unthink-
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ing familiarity" (12). Self-disclosure is an act, a product, while presentness

is a mode of being, a relational position. Yet, it is important for me to stress
again and again that presentness and interpretation are inseparable ele-
ments of the same therapeutic action. Meaning can emerge from "reflection-
in-action" as well as from restrained contemplation.
I have chosen the term of presentness because of its multidimensionality
or even equivocality: it refers both to the category of time, the present, or
present continuous, and the substantive, spatial form, the present presence
of one person in front of the other. It is a kind of concretization of the
vaguest dimensions of the therapeutic situation, the subtle processes of
psychic interaction. In an attempt to understand what presentness is and
what is unique about it, I will try to bring into sharper focus the concepts
referring to the mutative factors in our therapeutic work.

MUTATIVE FACTORS IN THERAPEUTIC WORK

In any discussion of the factors in the therapeutic process that make change
possible, the stress of the drive model has been on valorizing restraint,
free-floating attention, observation, and interpretation on the part of the
analyst, and transference and insight on the part of the patient (13). In the
language of self psychology stress is put on mobilizing self needs or,
differently put, establishing self-selfobjeet relations and on reflexive aware-
ness of these relations, observing from a stance that is close to the
experience of the observed, in which the observed becomes its own
explanation (14). Despite the disparate theoretical languages, the therapeu-
tic assumptions are similar, and converge toward what Spence (15) calls the
"singular solution model." This model, according to Spence, assumes the
existence of a blameless, innocent analyst, who uses free-floating attention
(16), or empathy (17,18) as the direct means of understanding the meaning
found in the material itself. The emphasis in this approach is on a
therapeutic position of attentiveness, aiming at absorbing the patients'
contents and allowing them to be worked through and communicated back
to them through a different formulation.
Spence s (15) alternative model, which he calls the "multiple solution
model," proposes "constructive listening" as a therapeutic tool. It involves
the work of understanding in a process of making assumptions in order to
create some meaning, then refuting them, and beginning all over. This is an
active, inductive, and heterogeneous process. Interpretations here are
regarded, as it were, as alternative ways of viewing what is taking place,
rather than the discovery or exposure of hidden content. In place of a
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model of the analyst's passive presence in the therapeutic session, which

pays quasi-aesthetic attentiveness to the patients' instinctual-affective con-
tents that are addressed to them and their subsequent interpretation,
Spence proposes a therapeutic model that focuses instead on the therapist's
creating-inquiring activity. Concepts, such as distancing or disassociation
(19), the work of understanding (15), the act of freedom (20), the dialectic
of autocentric-allocentric attitudes toward our experience of the patient
(12), or the concept of defamilarization (21), underline a basically more
active aspect. It is assumed here that the ability to move from a common
plane to a separate plane, from one view to another, is what enables change,
the ability of making strange the shared world of interaction and not only
empathy towards the psychic reality of the other. One example is the
emergence from a familiar, nearly automatic, emotional set in relation to the
patient, an "act of freedom," such as Symington's (20) question in relation
to his patient's "Why can't Miss M. pay the same as my other patients?" that
enabled him to extricate himself from the patient's self-perception, and to
facilitate changes in her diminishing attitude to her place.
However, in applying the function of defamiliarization or the work of
understanding, the major tool for change is essentially interpretative. The
emphasis is on the dimension of observation-insight as what gives reason
and meaning to the psychic text. The mutual experience is secondary to it.
The basic assumption is of a clear separation between patients and
therapists, and of the therapists' potential transparency to themselves. In
other words, the therapists can use themselves directly (without any
mediation or assistance from another consciousness) as a tool for absorbing
mental contents, working through and understanding, as a means for
relatively detached or uncontaminated observation of the other (8).
Alongside the act of observing, whether in maximal relaxation like a
mirror, or in the act of defamiliarization, suspending the familiar for a time
to make possible a different reading of the situation, we can suggest two
disparate modes of our presence as therapists tuned to the experiential
dimension. One is empathic immersion in the patient's experience (22), or
lending the therapist's self as a selfobject to the selfhood of the patient (23),
and the other is the subjective presentness of the therapist as an essential
component of the therapeutic interaction. In one mode we try to reach the
patients' subjectivity by way of holding our subjectivity and attunement to
theirs, emphasizing affinity and similarity, whereas in the other, by way of
exposure to otherness in the patients, in the therapist, and in between
(attunement to the unformulated experience).
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The intersubjective position in psychoanalytic theory, as conceptualized

by Hoffman (8), is a social-constructivist view of the psychoanalytic
2

situation, into which I am inserting the concept of presentness. This position

takes the obscureness of experience as fundamental, ubiquitous variable of
the therapeutic interaction. Hoffman emphasizes two main dimensions in
its conception of the therapeutic act and the way it is understood: (a) A
view of reality in general, and therapeutic reality in particular, as a
constructed reality, not as a given outside of the interaction and as exposed
through it. (b) The negation of the possibility of detached observation. The
therapists' subjectivity is unavoidably bound up in their modes of observa-
tion and their understanding, and it is impossible to completely transcend it
in any manner. There is no knowledge that is transparent to itself, and there
is no one correct framework of reference or therapeutic stance. Hoffman
(24) refers to the dialectic between spontaneous personal responsiveness
and the maintenance of a formal therapeutic setting. The very attempt to
adhere to any schema seems to him as the functioning of a bad object,
owing to the fact that it conforms to a technical position with no deviation
or deflection (24, pp.191-92). Hoffman views the dialectical relationship
between maintaining the analytic setting and mutual personal responsivity
to (and constructing of) the given interaction as the functioning of a good
object. For example, his playful responsiveness to his patient's unrelenting
demand for a tranquilizer and their reflection on it after the event served as
a way to extricate both of them from a power struggle of enforcing one's
rules on the other. An uncritical commitment to one side of the dialectic at
the expense of the other, either a meticulous adherence to the formal
setting and authority, or absolute responsivity to the personal dimension,
constitutes a disruption of the therapeutic action.
However, in referring to a personal deviation, what is involved, in my
view, is not only a conscious and controlled self-exposure, mainly of the
therapist's ethical attitude toward the patient's life situation, or some
personal act in response to the patient's demand or request, as Hoffman
(25) suggests, but rather exposure through action, through the unformu-
lated intersubjective relations. By bringing forth a strange part from within
ourselves as a powerfully sensed or realized emotional response, perceived as a
deviation from and as a breach of the rules (as acting in), we suddenly become
more completely present to ourselves and our patients, even if this experi-
enced as uncanny or even queer. This therapeutic attitude (of presentness) is

2
Recently Hoffman (25) suggested another concept—dialectical constructivism—that encompasses
both the discovered and the constructed in psychoanalysis.

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fundamentally a dynamic one. It relates to the question of the therapeutic

text, not as something introduced from without into the therapeutic setting
itself and displayed, reported or illustrated in it, but rather as a dialogic,
intra-therapeutic occurrence. It is not explicit and overt, but a mode of
experiencing that is revealed through us without deliberation.
Vignette
R. is a successful professional woman in her thirties working in the field of
psychotherapy. She maintains intensive relationships with women friends,
but only sporadic ties with men. After having decided to end the therapy
(this was twice-weekly psychoanalytic psychotherapy that lasted eight
years), she changed her mind close to the date she had fixed. On continu-
ing, it became clear to us that she was entering into a new territory. In order
to experience her physicality she invested much time in diving lessons,
under the close guidance of an instructor. After having found a very
sensitive and understanding dentist, she dared to begin dental treatment,
which until then had been traumatic for her. Through observation of what
was happening to her now, she recalls her early experiences when as a baby
she had a splint on her legs and pelvis to correct her posture, yet, her
functioning had not been impaired—"doing everything without any restric-
tion." Another memory is a burn at the age of two, which resulted in a
temporary loss of speech. She became aware of a need to be constantly
close to someone, to experience a cuddling contact at a slow pace, "eye to
eye." This need interfered with her ability to make new acquaintances
through "blind dates." Listening to her speaking about a frustrating date,
she had evoked in me an association with a dream she had had at an earlier
stage in the therapy. In the dream she is swimming to the shore with a friend
whose femininity is very striking, and on the beach near a water tap, she
sees another girl, T , whose flirtatiousness arouses R s envy, standing talking
to a young man. I share my association (the dream) with her and interpret it
as indicating R's conflict between the need for a slow and gentle touch (to
hold her hand and dive with her) and a flirtatious, histrionic, seemingly
protective relatedness.
At the following session, R. opens with a question about what it was that
brought T s name to my mind, how had I linked up to the dream from her
therapeutic past. She tells me that the young man whom she had dated and
had found desirable (a feeling that was not reciprocated) had previously
been T's boyfriend, and had disappeared from T's life as well. I note that
every subject that she raises touches on something that is familiar (to me or
to her) but is meant to remain hidden or concealed; e.g., something she
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knows about relationships through her patients she is not supposed to

report on or, what I know about some of the people she talks about during
the session, but not through her. The feeling during the whole session is one
of "noise on the line," a sort of crossover of two communication networks,
the overt and the covert, that no one can do anything with. It is a feeling of
excessive involvement that hinders a spontaneous psychic movement, that
would be made possible could attention be given to what is happening to
her. The atmosphere is discomfiting, laden with suspicion. I speak about the
feeling of knowledge beyond what is said, which binds what is stated directly
in the session into a strange mold.
She opens the next session with my last sentence in the previous session.
She feels that she has no space of her own in the net that is woven around
her in the therapy and in the interactions outside of it with people to whom
she is supposed to provide help. She speaks hesitantly, with a lot of
difficulty and a sense of shame about the quality of her work with a patient
who as an infant would choke every time she ate or cried, a problem that
continued until the age of three, for no clear organic reason. During the
session, I experience her difficulty, the breaks in her speech. I see the fact
that she brings up her therapeutic work in the present context as an
expression of her recent self-exposure to her physicality through a new
activity and the memories that have stayed with her since infancy. I recall
old dreams of hers that dealt with physical matters (both violent, a shot
fired straight to the stomach of a feminine figure in a pool, and strangers
invading her house while she is cleaning the bathroom). My associations in
relation to them are of a hard, blocked stomach, and the connection with the
kind and tender sport-instructor and the doctor who held her hand as places of
relaxation new to her. I shared them with her. R. reacts with surprise, since
these are precisely the contents that her patient raises, namely, of blocked
intestines, of emotional arrest. There is a feeling of going together, at a slow
pace, to places that are regressive in their (corporal) contents, as well as in
their quality and the manner of their communication, through almost
bewitched dreams and memories.
The entire interaction in this and the previous session is one of an
intermingling between the two of us, although not in a manner that can be
disclosed on the level of shared information. In my associations I also
became aware of segments of experiences that she does not speak about.
We can think of this mode of communication as mutually regulating
(regressive) states of consciousness between patient and therapist (10),
while the therapist serves a maternal function that processes contents of the
unconscious for the patient and makes them manageable as if she were a
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sucking infant. I constitute for her the presentness of a significant and split
infantile part of herself (one that is known and not known by her), and in
order to know it she remained beyond the date she had fixed for the end of
the therapy. The fact that she could not terminate the therapy indicates that
there was a dimension of noise on the line and a lack of separation.
However, the confusion, or noise, is communicative and not only an
obstacle; it informs her and me of different overt and covert levels,
emerging and seductive physicality, that arise in the therapeutic interaction
through the exposure of my associations . 3

The kind of therapeutic position I have delineated seems plausible in

light of Spezzano's (26) controversial statement that "there is no such thing
as a one person consciousness"; rather consciousness is intersubjective by
its very nature. It can be conceptualized only as a creation of minds in
interaction:
No one of us will ever come to hold in our consciousness the fullest available
account of our unconscious psychology. That fullest available account at any
moment in time will always exist in multiple minds, each holding pieces of the
account. Others will always know aspects of us and will know us in ways that
we do not know ourselves. . . . In fact, their ability to do that depends precisely
on our having made it knowable to them. (26, p. 40)
The unconscious, in his view, is communicative, and in most cases we learn
about unconscious acts and representations not through ourselves directly
but through what is raised by the person facing us. Placing the therapist's
consciousness at the patients' disposal rather than being seen as an
impediment, a barrier between the patients' conscious and unconscious
psychic processes, is regarded as an intermediary and facilitator between
them. The patients know themselves only through the therapist who is
present to them (5, p. 612). I would add another aspect to this view of
Spezzano s: the therapist as being exposed to the totality of his presence
through the patienfs contents which also reflect her, the therapist. One is
made present through the other, and at the same time makes the other
present. This is an interpersonal view of the mind which posits that
subjectivity arises along with intersubjectivity and is not prior to it.
Philosopher Marcia Cavell (2) elaborates this view. She traces a line
from Wittgenstein to Davidson, that holds: "'Internal' or 'subjective' states
are more public than we may think." Whereas Descartes and the Cartesians

3
I am aware that my language of describing the therapeutic situation is conventional. I try to unfurl
an experience of mutual reverberation in an ordered manner (asymmetrically). It may however be that
my limitation is for the better; for it exemplifies the dialectic interplay of the symmetrical and the
asymmetrical dimensions of the therapeutic intervention.

350
 Presentness

believe that first there is thought or intentionality, "mental discourse," and

only then, as a matter of convenience, speech. Cavell assumes that we
cannot divorce the activity of thinking and speaking, that they are synchro-
nous and coterminous. As language is public, anchored in a shared external
world, so, in a way, are the thoughts that it expresses. We have to look to the
process of interpretation to tell us not only how we know the minds of
others but also how we are able "to mean" ourselves (2, pp. 20-21). That is
to say, the articulation of subjectivity is always performed through someone
else. The process of interpretation informs us not only of the ways in which
we know the other s mind, but also of the ways in which we can have
meaning for ourselves. It follows that empathy, for example, is not depen-
dent on our departing from our viewpoint and entering that of the other,
but on revealing and broadening the common basis, exercising our imagina-
tion in relation to the other's beliefs and desires, on the basis of which
his/her behavior appears reasonable. In order to understand the other
there must be a common basis of beliefs or desires; their founding is
achieved through an interpretive process that is necessarily prolonged and
open-ended.
In this clinical vignette, I tried to illustrate the use I make of the way I
experience my presence during therapy, my internal attitude and my mode
of work with it, a sort of experience-near self-articulation. This stance of
presentness lies somewhere between an internal attitude and self-
articulation. We can say that while any act of interpretation involves the
therapist's self-regulated psychic activity in relation to what occurs during
the session, an act of emergence from a given psychic set, presentness is
psychic activity that is regulated by the therapeutic dyad without any sharp
separation between patient and therapist; it is self-other regulated. Present-
ness constitutes a kind of a lent space for those held in it (the therapist and
patient), although asymmetrically regarding the purpose for which they are
meeting, and in their functions and responsibilities. One can hypothesize
that this experience is mediated by mechanisms of projective identification
and counterprojective identification. In my opinion it is a shared product of
minds in interaction, and not one that our patients projected onto us and
identified with. The emphasis here is on decentering as being acted on and
not as an action. The experience is more vague and not under full control.
However, this concept does not exclude other uses of ourselves as thera-
pists, but explicitly emphasizes one aspect: our being intertwined with the
patient in an unconscious shared space, of which our clarifications, by
working through (introspection and reflection) or exposure (and shared
working through), enable the symbolization of an inner world that until
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then was present as a fact-without-words and not as an articulated experi-

ence; our being part of an unconscious, active, but absent, text that has to
be made present both in the sense of the present time and of the existence
of an interlocutor. We may think of the present continuous and the
undifferentiation of the psyche-in-interaction as the defining dimensions of
any unconscious mentation.

CONCLUDING COMMENTS

A linear model of the human psyche and of the therapeutic act assumes the
existence of two separate entities, one lending itself to the other, available
for use. A nonlinear model runs counter to the concept of the subject as
possessing unity and distinct boundaries; it refers to states of the self, of
dissociation, in which both participants in the therapeutic relation inevita-
bly find themselves.
The concept of presentness joins the concepts proposed by Baranger
(27), namely, "the unconscious fantasy of the field," and that of Ogden (28),
"the analytic third," as unconscious shared therapeutic realities that acti-
vate and are activated by the therapeutic dialogue. Yet, Ogden and
Baranger remain in a position that assumes the potential transparency of
the therapist s experience to herself, and utilize it as an indication of what is
happening to the patient, as material for creating a meaning that can be
communicated to the patient without explicitly disclosing the experience
itself. The concept of presentness goes beyond that, it involves the thera-
pist s presentation of an unconscious or unformulated psychic cocreation,
which will never know itself fully and clearly, not through the other, and
only partially. The interpretation is through a ceaseless investigation of
what is expressed without being known. "Presentness" has affinity to
Bollas s (12) "direct use of countertransference." It differs in emphasizing a
mode of being and not only a specific therapeutic act, and on its being
based on mutuality.
Introducing the term of presentness, in order to express the subjectivity
of the therapist in the context of the therapeutic encounter, draws on a
nonlinear rather than a linear perspective of the analytic process. The
assumption is that unconscious communication blurs the boundary be-
tween the therapist's and the patient's subjectivity in such a way that each
contributes to the construction of the other's perception of self in relation
to another. It extends the image of iterative regulation of each other's
perceptions/constructions of meaning to argue that self-other clear-cut
differentiation, as the mutative dimension of the therapeutic act, is a
scientific (positivist) myth.
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 Presentness

I want to emphasize again that this term describes an important, though

not exclusive, dimension of the therapeutic interaction. It does not replace
such psychic functions as observation, distancing, empathy, or such modes
of object relating as transference, countertransference or projective identi-
fication. The term presentness illuminates the symmetrical dimension of
the therapeutic interaction, and its contribution to the construction of
"meaningfulness" for both therapist and patient.

REFERENCES

1. Rucker N G & Lombardi K L (1998). Subject relations: Unconscious experience and relational
psychoanalysis. New York: Roudedge.
2. Cavell M (1993). The psychoanalytic mind. From Freud to philosophy. Cambridge, MA: Harvard
University Press.
3. Fonagy P & Target M (1998). Mentalization and the changing aims of child psychoanalysis.
Psychoanalytic Dialogues, #,87-114.
4. Mitchell SA. (1993). Hope and dread in psychoanalysis. New York: Basic Books, pp. 613-626.
5. Spezzano C (1996). The three faces of two-person psychology: Development, ontology and
epistemology. Psychoanalytic Dialogues, 6,599-622.
6. Buber M (1923). I and Thou. (W. Kaufman trans.) New York: Charles Scribner's Sons, 1970.
7. Davies J M (1994). Love in the afternoon: A relational reconsideration of desire and dread in the
countertransference. Psychoanalytic Dialogues, 4, 153-170.
8. Hoffman I (1992). Some practical implications of a social constructivist view of the psychoanalytic
situation. Psychoanalytic Dialogues, 2,287-304.
9. Renik O (1995). The ideal of the anonymous analyst and the problem of self-disclosure. Psychoana-
lytic Quarterly, 64,466-495.
10. Aron L (1996). A meeting of minds. Mutuality in psychoanalysis. Hillsdale, NJ: The Analytic Press.
11. Bollas C (1987). The shadow of the object. London: Free Association Press.
12. Stern D B (1997). Unformulated experience: From dissociation to imagination in psychoanalysis.
Hillsdale, NJ: The Analytic Press.
13. Strachey J (1934). The nature of the therapeutic action of psychoanalysis. International journal of
Psycho-analysis, 15, 127-159.
14. Kulka, R. (1991). Reflections on the future of self psychology and its role in the evolution of
psychoanalysis. In [Link] (Ed), The evolution of self psychology: Progress in self psychology,
Vol. 7, pp.175-183. Hillsdale, NJ: The Analytic Press.
15. Spence D P (1984). Perils and pitfalls of free floating attention. Contemporary Psychoanalysis, 20,
37-59.
16. Freud S (1912). Recommendations to physicians practicing psychoanalysis. Standard Edition, Vol.
12, pp. 111-120. London: Hogarth Press, 1958.
17. Kohut H (1984). How does analysis cure? A. Goldberg & P. Stepansky (Eds.). Chicago, I L :
Chicago University Press.
18. Kohut H (1959). Introspection, empathy and psychoanalysis. An examination of the relationship
between mode of observation and theory. Journal of the American Psychoanalytic Association, 7,
459-483.
19. Sterba R (1934). The fate of the ego in analytic therapy. International Journal of Psycho-analysis, 15,
117-126.
20. Symington N (1983). The analyst's act of freedom as agent of therapeutic change. In G . Kohon
(Ed.), The British School of Psychoanalysis. London: Free Association Books, 1986.
21. Lazar R (1995). The familiar and the strange: The dynamics of change. Israel Journal of Psychiatry,
32,157-166.
22. Schwaber E A (1995). The psychoanalyst's mind: From listening to interpretation—a clinical report.
International Journal of Psycho-analysis, 76,271-281.
23. Kulka R (1995). The psychoanalyst's mind from listening to interpretation: Will psychoanalysis
evolve from individuality to subjectivity? Sihot-Dialogue, 9,191-197.

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24. Hoffman I (1994). Dialectical thinking and therapeutic action in the psychoanalytic process.
Psychoanalytic Quarterly•, 63, 187-218.
25. Hoffman I (1998). Rituals and spontaneity in the psychoanalytic process: A dialectical-constructivist
View. Hillsdale, NJ: The Analytic Press.
26. Spezzano C (1995). "Classical" versus "contemporary" theory. The differences that matter clinically.
Contemporary Psychoanalysis, 31,20-46.
27. Baranger M (1993). The mind of the analyst: From listening to interpretation. International Journal
of Psycho-analysis, 74,15-24.
28. Ogden T H (1994). The analytic third: Working with intersubjective clinical facts. International
Journal of Psycho-analysis, 75,3-20.

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 The Birth of Reality:
Psychoanalytic Developmental Considerations

RYAN LAMOTHE, Ph.D.*

In this article, utilizing an emended version of Winnicott's notion of

transitional objects and recent parent-infant research, the author offers a
perspective on the development of individuals' experience of being alive and
real in relation to objects and persons. Primary transitional objects, which
represent parent-infant interactions, facilitate the infant's transition from
early undifferentiated, bodily, and global experiences of being real and alive to
the infant's yoking and extending these subjective organizations to recognized
not-me objects. Secondary transitional objects make their appearance whe
the child begins to acquire the capacities for self-reflexivity, symbolization,
and language. These objects provide the child with opportunities to gain
confidence and courage in extending, yoking, and making use of his/her
subjective experiences of being alive and real in relation to cultural symbols
and rituals. More importantly, secondary transitional objects are paths toward
mutual recognition, acceptance, and sharing experiences of being alive and
real.
I have become increasingly aware over the past several years that the sense of
aliveness and deadness of the transference-countertransference is, for me,
perhaps the single most important measure of the moment-to-moment status of
the analytic process. (1, p. 23)
It is tempting for those of us interested in clinical work and theoretical
aspects of psychoanalysis and philosophy to become enamored with, if not
lost among, questions regarding what is true or false, real or fantasy. Is what
the patient is saying a transference distortion or is it true? Are the patient s
memories accurate portrayals of what really happened? Is the patient s
story one relatively distorted version among many stories? Are the patient's
beliefs about God illusory, mere endopsychic representations? Are his/her
religious beliefs socially constructed illusions, omnipotent fantasies, or
delusions? On occasion these questions result in vicious circles of seem-
ingly endless and unresolvable debates (2-4). This perspective of "reality,"
which emerges from questions concerning objectivity and truth, tends to

"Assistant Professor of Pastoral Counseling, Saint Meinrad School of Theology. Mailing address: 1
Hill Dr. St. Meinrad, I N 47577.

A M E R I C A N JOURNAL OF PSYCHOTHERAPY, V o l . 5 4 , N o . 3 , S u m m e r 2000

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eclipse the patient's experience of being and feeling alive and real in
relation to objects and persons. Winnicott (5), perhaps recognizing the
power of objectivists, remarked that
Somehow the word people tend to claim sanity, and those who see visions do
not know how to defend their position when accused of insanity. Logical
argument really belongs to the verbalisers. Feeling or a feeling of certainty or
truth or "real" belongs to the others, (p. 155)
Perhaps, we need to begin with different questions, queries that change,
as Wittgenstein (6) put it, "the method of answering [them]" (p. 36). I
believe two questions, manifested in recent psychoanalytic literature (1,7,
8), shift our attention from fact vs. fantasy, objectivity vs. subjectivity, and
true vs. false, without necessarily denying the importance of these appar-
ently dichotomous issues. In relation to what and whom does the patient
achieve an experience of being and feeling alive and real? What contributes
to or obstructs the patient's (and therapist's) capacity to be and feel vital
and real in this moment?
Reality and truth, as used in this article, are understood as representing
and presenting subjective and intersubjective organizations of feeling alive
and real, which are clearly developmental achievements that are contingent
upon the person's constitutional capacities and parent-child interactions.
These organizations, which ideally become more diverse and differentiated
with maturity, include persons' reflective and nonreflective sense of agency,
purpose, meaning, competence, and self-esteem as well as a sense of
spontaneity and freedom. This means, then, that the social context and
developmental position determine the shape and content of individuals'
experiences of being alive as well as their understandings of truth. Reality
and truth, then, have more to do with richness and diversity of experiences
of vitality than with fact or independent objects.
While this idea of reality resists quantitative and empirical research
designs, it can be clinically and theoretically useful in trying to understand
and respond to patients who communicate, using meaning-laden meta-
phors, such as feeling like stone, empty, dead, useless, false, lifeless, numb,
or barren. In other words, most patients are less interested in their
therapists educating them to objective reality or correcting their putative
misconstructions than in achieving a reality that involves experiences of
being alive and real in relation to objects and persons. As Mitchell (8)
exclaims,
What the patient needs is not a rational reworking of unconscious infantile
fantasies; what the patient needs is a revitalization and expansion of his own
capacity to generate experiences that feel real, meaningful, and valuable, (p. 24)
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 The Birth of Reality

In this article, I shall use an emended version of Winnicott's work and

recent parent-infant research, a developmental perspective that describes
the process and characteristics of experiencing being alive and real in
relation to objects and persons. This abridged presentation addresses the
questions above and provides a framework for understanding and appreci-
ating patients' use of diverse cultural beliefs and practices (e.g., religion) in
constructing and maintaining a sense of vitality. I would add that this
perspective raises questions regarding the complex ways therapists' and
patients' subjectivities shape and create moments of vitality (as well as
deadness).
ORGANIZATIONS O F REALITY IN H U M A N DEVELOPMENT

I propose to offer a perspective on the development of reality and truth in

human life, relying, in part, on recent psychological research on infant
development (9-13) and a redacted version of Winnicott's theory of
psychosocial development. There are three reasons for utilizing a Winnicot-
tian framework and concepts in proposing a theory of the subjective and
intersubjective achievement of being and feeling alive. First, Winnicott s
idea of "the use of an object," as a developmental and, indeed, lifelong task,
is crucial for understanding organizations of experiences of being alive and
real in relation to objects and persons. This includes the idea that experi-
ences of vitality are contingent upon significant persons. Second, while
Winnicott's notion of transitional phenomena has been criticized (14-17),
it continues to be useful in portraying the movement from one developmen-
tal organization of reality to another. Third, while Winnicott did not
entirely abandon Freud's notion of the reality principle, his developmental
theory, notion of "true self," and belief in the importance of the caregiver's
own sense of vitality for the infant's psychological development demon-
strate his clinical interest in, and concern about, patients' experiences of
feeling alive.
EARLY INFANCY
During the last half of this century, developmental researchers and theorists
have generally agreed that the infant is socially and cognitively active at
birth (18-20). More recent infant research clearly demonstrates that the
infant seeks sensory stimulation, invariant patterns, and possesses the
cognitive ability to discriminate between preferred objects, touch, and
sounds (12). Experiments with infants and caregivers, however, do not
reveal, with any certainty, how infants perceive objects or what they
experience in relation to objects. For example, the experiments, which
demonstrate that infants in the first few months of life can discriminate
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between sounds and objects, lead some theorists (11) to reject long-held
hypotheses of the infant s illusion of psychological merger with the mother
or part mother (5, 21), normal autism (22), normal symbiosis (23), and
autistic-contiguity (24). These hypotheses, often based on adult experi-
ences of dissolution, desires for merger, and separation anxiety or panic
(23, p. 5), posit that the presymbolic infant is poorly differentiated,
experiencing boundarylessness and union with the maternal object.
The position held here is that in the first few months of life the infant,
while able to discriminate between objects, "appears to experience a world
of perceptual unity" (12, p. 51). This unity includes perceptions and
experiences of objects as me-objects (21). An infants preferred affective-
sensory-laden and dynamic object (e.g., breast), in other words, is "me" and
organized into a rudimentary self-structure.
There are four interrelated characteristics regarding these early organi-
zations that are necessary for a sense of being alive. The first is the close
connection between the infant's body and his/her perceptual, experiential,
and organizational capacities. Freud, for example, suggested that the "ego
is derived from bodily sensations, chiefly from those springing from the
surface of the body" (25, p. 27): hence, "the ego is first and foremost a
bodily ego" (25, p. 26). More recently, Stern posited that the infants
emergent self-organization "concerns the body: its coherence, its actions,
its inner feeling states, and the memory of all these" (12, p. 46). Thus, one
aspect of the infant's earliest representations is that they are organized, in
part, as mind-body units that are undifferentiated (26).
A second and related aspect of these early, sensorimotor schemata is the
presence of the parent. These presymbolic schemata include the other and
what is initially represented is not an object, but an object relation: self-in -
relation-to-object. These presymbolic representations of self and object are
simultaneously constructed, and are constructed in relation to each other.
What is represented is an emergent dyadic phenomenon that cannot be
described on the basis of the partner alone. . . . What will be represented, at the
presymbolic level, is the dynamic interactive process itself. (11, pp. 172-3, 175)
The nursing dyads interactions and concomitant representations do not
preclude the idea that the mother or part mother is perceived by the infant
as a me-object. In other words, a me-object represents the infant-mother
interactive attachment. Hence the infant s early schemata are inchoate with
regard to persons and objects, though representing interactions with the
mother (26, pp. 22-29).
A third aspect is the interrelation between the infant's constitutional
structures and parental responses. The infants early organizations and
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experiences are dependent on his/her emerging constitutional capacities

and the mother's "good enough" responses. It may also be said that the
infant's actualization of his/her constitutional capacities are contingent
upon appropriate and timely maternal responses to the infant's needs and
"expectancies" (11). Negatively speaking, severe early deprivation or im-
pingement shatters the infant's global or basic trust (27, p. 249) and
consequently obstructs the infant's constitutional capacities that organize
body-me-caregiver representations into a relatively coherent self-structure
(28). Deprivation strikes at the infant's ability to experience, rely on, and
establish rudimentary organizations of perceptual unity, contributing to a
global or pervasive loss of vitality. This early deprivation may be manifested
later in experiences of profound disconnection with one's body and other
people (29), dissolution, fugue states, as well as annihilation or engulfment
anxiety.
Finally, the infant's sense of being alive is contingent, in part, on his/her
experiences of, and belief in, personal omnipotence, which are dependent
on the mother providing the infant with near one hundred adaptation to
her infant's needs (21, p. 10). The infant, in other words, creates the breast
at the point of need, and it is the mother who facilitates this "illusion" by
anticipating the infant's needs. That is, the caregiver promotes the infant's
emerging sense of agency and control and concomitantly his/her experi-
ence of global vitality.
Given this view, what would it mean for the infant to have experiences
of being alive and real? In general, reality for the infant is bodily, sensory-
based, global, and creatively dynamic—omnipotently connected to mother-
infant interactions, providing a rudimentary and perceptually unified,
nonreflective sense of agency and control. These early experiences of reality
are not yet differentiated in terms of me and not-me objects or differenti-
ated, for example, in terms of feeding and being-put-to-bed interactions.
For instance, "the baby does see the mother's smiling face, but this, which is
in reality her response to his smile, reflects back to him his own aliveness"
(3Q, p. 12). An infant's embodied agency and embodied sense of vitality, in
other words, "can only arise out of a state of eager aliveness in two people;
the infant with the potential for life and the mother alive inside herself and
tuning to the emerging infant" (31, p. 102). Finally, embodied and undiffer-
entiated organizations of vitality become the "barely perceptible back-
ground of sensory boundedness of all subsequent subjective states" (24,
p. 50).
Practically and clinically this makes sense. Consider an adult who loses a
hand or breast. Experientially adults yoke self-organizations to their bodies
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and experience a sense of undifferentiated unity and at the same time they
discriminate between this or that part of their body. It is my hand. My hand
is part of me. Yet, the loss of my hand, which may evoke tremendous
emotional pain, does not result in the loss of me. The pain of this loss is not
simply change in self-perception; it also strikes at the undifferentiated and
cohesive bodily schemata that have their roots in, but are not limited to,
early infancy. Of course, one does not have to stop at the body. Adults can
join, nonreflectively, objects and persons, in part, to me-organizations. For
example, Primo Levis (32) poignant description of the forcible removal of
psychologically necessary objects points to the close connection between
psychological structures and objects (and actions such as rituals).
But consider what value, what meaning is enclosed even in the smallest of daily
habits, in the hundred possessions which even the poorest beggar owns: a
handkerchief, an old letter, the photo of a cherished person. These things are
part of us, almost like limbs of our body; nor is it conceivable that we can be
deprived of them in our world, for we immediately find others to substitute the
old ones, other objects which are ours in their personification and evocation of
our memories. Imagine now a man who is deprived of everyone he loves, and at
the same time of his house, his habits, his clothes, in short everything he
possesses: he will be a hollow man, reduced to suffering and needs, forgetful of
his dignity and restraint, for he who loses all often easily loses himself, (p. 27)
This early (and lifelong) ability to yoke me-schemas to ones body and the
capacity to extend this to objects and interactions, which are not necessarily
regressive or pathological in adulthood, are crucial for a sense of being alive
and real.
VIGNETTE 1

From a clinical perspective, patients may report feeling disconnected from

their bodies and from people. They may also report not feeling alive in their
bodies. Janet, an intelligent thirty-five-year-old mother, had a history of
being physically and emotionally attacked by her mother and sexually
abused by her much older brother. While possessing no conscious memo-
ries of her first two years of life, Janet had numerous memories of her
sadistic mother, who frequently and unexpectedly beat Janet. Not surpris-
ingly, Janet often reported feeling nothing or feeling numb, which occurred
alongside experiences of feeling disconnected from her body and from
others. During the first year of her therapy, when Janet struggled with
intense, intrusive, and seemingly overwhelming thoughts and feelings from
her past, she would lie down at home and become totally still, as if she were
"dead or stone."
Janet s experiences illustrate, in part, a collapse of the basic trust needed
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to establish a cohesive and unitary self-organization that yokes body and

other objects into global and undifferentiated experiences and organiza-
tions of being real and alive. Dead and stone, in other words, are metaphors
for the collapse of undifferentiated sensory and dynamic experiences of
being alive and real in relation to one's body and to all objects. Moreover,
Janet's behavior and metaphors may point to her childhood experiences; of
an infant, lying still and shutting down expression of expectations because
she despairs of being met (33, p. 9).

P R I M A R Y T R A N S I T I O N A L O B J E C T S (PTOS) A N D O R G A N I Z A T I O N S O F REALITY

Early infancy's undifferentiated, sensory-based, and dynamic organizations

of feeling real, soon give way to a growing ability to differentiate between
me and not-me objects and hence the need to organize these into new
schemas. It is during this preverbal period that primary transitional objects
make their appearance. The concept of primary transitional objects pro-
vides an answer to the question: How does the infant move from global,
bodily experiences of feeling alive and real to more differentiated experi-
ences of being in relation to recognized not-me objects?
Let me pause here momentarily and indicate why and how I am using
the concept of primary transitional objects (PTO), leaving the explanation
of secondary transitional objects (STO) for later. Busch et al. (15) correctly
noted significant differences between the objects of early infancy (e.g.,
blanket) and those in later childhood (e.g., dolls). Furthermore, they
argued that the numerous developmental changes and achievements that
take place between the first months of life and age two necessitate
additional study in the use and functions of objects. Without providing
much detail they coined the terms primary and secondary transitional
objects in order to distinguish between the functions and characteristics of
early and later objects. I use PTOs in two ways. First, PTOs refer to
Winnicott's notion of the first transition, when the infant makes use of the
object to transition from perceptually unified and embodied organizations
of experience to more differentiated organizations. In short, the PTO
represents the period between merger and the appearance of the capacity
for symbolization. Second, PTOs are linked to those organizations of
experience that are nonverbal and nonreflective. PTOs, in other words,
present (versus re-presents) persons' experiences.
PTOs make their appearance in human development during the time
the infant is beginning to perceive objects as independent of him/her and
hence outside his/her omnipotent control (21). This recognition evokes
anxiety because of the changes in relation to the loss of perceptual unity,
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loss of personal omnipotence, realization of dependence on the mother for

recognition, realization of limitations, and changes in infant-parent interac-
tions. These changes in infant-parent interactions result from the infant's
growing cognitive and motor capacities and declining maternal preoccupa-
tion. One of the functions of PTOs is to soothe and comfort the infant
during these periods of change and anxiety (21). The PTO soothes the
infant because it "stands for the breast or the object of the first relation-
ship" (21, p. 9). In other words, the PTO presents the mother's early
"technique of mothering" (21) or idiom of care (34) and is therefore linked
to the infant's earlier undifferentiated experiences and organizations of
feeling alive and real. It would be more accurate to suggest that the infant's
early sensory, global, and dynamic schemata formed in relation to the
parent become yoked to the PTO. Here is where we acknowledge and
accept the paradox. The PTO is recognized as independent of the infant,
yet yoked to the infant's global and undifferentiated experiences of being
alive and real. It is the first object, recognized as a not-me object, that the
infant uses to regulate and transform his/her affective life, contributing to a
sense of agency in relation to an independent object. Put differently, one
could say the PTO transforms earlier organizations and is used to provide a
subjective sense of being alive.
PTOs function in another way. The infant's earlier experience of
omnipotence is now transferred onto a discrete object, which remains
within the infant's area of omnipotent control. This provides the infant with
the space to create and destroy the transitional object, giving him/her a
sense of control and agency in relation to an object that is yoked to the
infant's experiences of being alive and real. In this process of playfully
creating and destroying the transitional object, the infant gains a sense of
trust and confidence in relying upon an object for a sense of being real and
concomitantly yoking his earlier organizations of being alive and real onto
an object.
Of course, this is all contingent upon the good-enough parental re-
sponses. That is, parents must not challenge or force the infant away from
his/her idiosyncratic selection and use of a transitional object. Positively,
the good-enough parent continues to recognize, mirror, and meet the
infant's needs, thus continuing to facilitate a space of trust and hope in
order for the infant to begin to yoke early schemata of being real to other
objects in the presence of others. That is, when the maternal object is alive
and real and good enough a potential space is created (21, p. 9), which
enables the infant to learn to make use of objects, in terms of his/her being
alive and real. Hence, the infant's "internal object depends for its qualities
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on the existence and aliveness and behavior of the external object" (21,
p. 9).
This process and potential space includes the parent's implicit and
explicit recognition, affirmation, and support of the infant's use of transi-
tional objects, his/her emerging differentiated agentic activities, and the
infants spontaneous and playful expressions. Put differently, parental
attunement is crucial for the emergence and consolidation of personality
structure and for the child's experiences of feeling alive. The person's
emerging personality structure (35) and experiences of feeling real are
always in relation to an independent object, in this case the caregiver. The
parents' recognition and appropriate responses to the child's selfobject
needs, for example, contribute to vitalizing self-experiences (36, p. 149)
and these vitalizing self-organizations emerge, in part, in relation to an
object that is an independent reality.
Conversely, in situations of parental impingement, deprivation or the
absence of parental attunement, the object world becomes dangerous and
frightening to the infant. The infant does not have the confidence or trust to
yoke his/her global experiences of being real to an independent object, yet
the infant's capacity for differentiation is not obliterated and his/her need
for affective regulation and agency remains important. In situations of
significant parental failure "the baby survives by means of the mind . . . this
thinking becomes a substitute for maternal care and adaptation" (5, p. 156).
Put another way, "The baby compensates for who is not there by enclosing
himself in a mental relationship with himself. . . . (T)he baby holds himself
together as if in a mental self-embrace so as not to disintegrate" (37, p. 218).

VIGNETTE 2
Tom, a patient who painfully struggled to deal with a global sense of
anxiety, illustrates, in part, the points above. When Tom was around one
year old, his mother became incapacitated due to a severe illness. Shortly
after, Tom's father abandoned the family, leaving his two sons and daughter
in the care of his wife's older sister. Tom's aunt and her alcoholic husband
were less than welcoming of these three additions to their household. Tom
recalls his aunt's rage and hatred whenever his father tried to contact him
and his siblings. Tom's aunt frequently reminded them that if it were not for
her, they would be on the streets. Not surprisingly the overwhelming loss of
both parents, accompanied by an emotionally distant and severe aunt,
made it difficult for Tom to view the world or people as trustworthy. When
Tom began therapy he reported feeling anxious all the time, though the
anxiety was more intense when he was around people, including his wife
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and nine-year-old child. He gained some relief by dreaming about anxiety-

free situations, such as loving his wife, working confidently at his job, and
playing with his child. In addition, every evening Tom would surrepti-
tiously take one pain pill. These pills, and the idea of the pills, provided
relief from the anxiety of living. Tom zealously guarded this medication,
seeing it as his only hope for refuge and comfort. In addition, once the pill
began to work, Tom would feel more alive, more confident, yet this change
was internal and not manifested in his behavior toward his wife or child. In
other words, he kept this experience of feeling alive and real hidden,
fearing that even this might be stolen from him.
Clearly in Tom's life there was little trust of other people and hence an
eclipse of spontaneity and playfulness in his interactions with others. One
could say that he was surviving in a world bereft of trustworthy, safe, and
dependable objects. More specifically, Tom's use of medication to alleviate
anxiety represents a failed primary transitional object in two ways. First,
Tom's early separation from his mother and father and his subsequent
fragile attachment to his aunt made the world of objects too dangerous to
risk yoking his experiences of feeling alive and real or sharing those
experiences in the presence of those who would recognize, affirm, and
support them. Thus, the pill represents an absolutely safe object to contain
his anxiety, yet this object and any experiences are internalized. The pill
contains his anxiety, serves as an idea of soothing during the day, and
provides him with some internal, secret, global, and bodily sense of feeling
alive and real. I would add here that the pill points to more preverbal
organizations because of the poverty of symbolic meaning associated with
them. There was an absence of symbolism when Tom discussed using these
pills.
Second, Tom's early undifferentiated organizations remained frozen
and untransformed inasmuch as Tom was unable to gain enough confi-
dence to yoke these experiences to objects not within his area of omnipo-
tent control. This PTO, in other words, did not serve to move him toward
expanding his use of other objects and persons for a sense of comfort,
agency, and being alive. Part of Tom's torment and conflict, I believe, was
precisely that a residual spark of early undifferentiated experiences of being
alive in relation to his mother remained; an "unthought known," perhaps.
At some level he knew and hoped for the possibility of experiencing being
real and alive in relation to other people, but was terrified to take the risk.
In summary, PTOs represent the partial transformation of the infant's
global, sensory-based, dynamic schemata of being alive and real to prever-
bal, more differentiated experiences and organizations of being alive and
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real in relation to recognized not-me objects. These earlier undifferentiated

schemata do not disappear and even in their transformation, continue to be
intertwined with more differentiated schemata of being alive and real. At
the same time this transformation includes a movement from an undifferen-
tiated and embodied sense of agency and affective regulation to one that is
more differentiated. Now there is a recognized me that moves my legs,
grabs that blanket, and feels real.

S E C O N D A R Y T R A N S I T I O N A L O B J E C T S (STOS) A N D O R G A N I Z A T I O N S O F
REALITY

STOs make their appearance when a child begins to achieve and consoli-
date his/her capacities for symbolization, language, and self-reflexivity.
These objects represent a transition from preverbal experiences of being
alive to more complex and diverse shared experiences of vitality. Put
another way, STOs serve as a bridge that facilitates the child's use of more
complex symbolic objects and activities and, more importantly, provide a
space to learn how and when to yoke experiences of being alive and real to
symbols and not-I objects, sharing these with others. Toward this end STOs
have several interrelated functions that point to developmental tasks
required for the child and his/her parents. I briefly address two of these
functions.
First, STOs provide an object and relationship that the child uses in
symbolic play and this includes his/her use of language in relation to the
object (12, pp. 166-169). On the one hand, this symbolic play is idiosyn-
cratic and not shared, though the child plays in the presence of his/her
parents (38). On the other hand, this play is shared in that the child is
beginning to make use of and internalize complex familial and cultural
meanings, expectations, beliefs, and signs (39, 40). Put another way, the
child utilizes secondary transitional objects in symbolic play in order to
assimilate and accommodate, to use Piaget's terms, more complex socially
shared contexts of trust and distrust and more complex forms of communi-
cation. The child's symbolic play, then, serves as opportunities for the child
to reconstruct, omnipotently, a symbolic world, which provides an experi-
ence of agency in relation to symbolic objects. Finally, this idiosyncratic
symbolic play provides the space for the child to yoke and hence partially
transform earlier preverbal schemata of being alive to symbols and lan-
guage (12, pp. 172-174). That is, in the process of symbolic play the child
extends his/her experiences of being alive and real to symbols, symbolic
objects, rituals, and language. Most of us have no conscious memory of the
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experience of this transformation, but it is poignantly portrayed in Helen

Keller's description:
We walked down the path to the well-house, attracted by fragrance of the
honeysuckle with which it was covered. Someone was drawing water and my
teacher placed my hand under the spout. As the cool stream gushed over my
hand she spelled into the other the word water, first slowly, then rapidly. I stood
still, my whole attention fixed upon the motion of her fingers. Suddenly I felt a
misty consciousness as of something forgotten—a thrill of returning thought;
and somehow the mystery of language was revealed to me. I knew then that
w-a-t-e-r meant the wonderful cool something flowing over my hand. That
living word awakened my soul... (41, pp. 23-24; italics mine).
The child's symbolic play, then, is the space where he/she gains the
confidence and learns to risk extending, and in the process partially
transforms and re-organizes experiences of vitality in relation to more
complex symbolic objects and activities.
This idea of symbolic play does not preclude the notion that the child's
play operates in the "pretend" mode—["ideas (that) are felt (believed) to be
representational but their correspondence to reality is not examined" (42,
p. 219,43)]—but places these concerns in the background. In other words,
while correspondence and coherence theories of reality/truth are impor-
tant, they tend to minimize or overlook the experiences and objects that are
real to the person or child. For example, are the patient's prayers to God
illusory or "pretend modes" of play? Returning to the child's use of play,
when asked by an adult, "Do you believe that the refrigerator box is a
castle," the child is sure to say no. I am arguing for a space that considers a
person's communications in terms of his/her experiences of being alive and
not strictly whether his/her experiences are logical or socially "factual,"
"real," or "truthful." At the same time I am not suggesting that symbolic
play is not, in part, illusory, pretend, or fantasy. It is the child's (and adult's)
experience of feeling alive, being real, and full of vitality that are in the
foreground and of most importance. This is Winnicott's point, I believe,
when he opts for the importance of play and his idea of potential space. In
those intense moments of feeling alive one rarely asks, "Is this experience a
fact? Is it an illusion?"
A second aspect of STOs is related to the child's recognition of not-I
objects as well as his/her recognition of his/her own I-ness. The recognition
of not-I objects evokes anxiety in the child, in part, because it points to the
recognition of limits and his/her dependence on significant not-I objects
for his/her sense of I-ness (44, pp. 33-35: 45, p. 863). STOs not only soothe
and comfort the child during times of discontinuity, absence, and change
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they also act as reciprocal "pretend" contexts of " I " recognition. The child,
in other words, recognizes the STO as a not-I (and an I) and in return
believes the object to recognize him/herself as an I . This belief and
experience of recognition is linked to the parents' recognition and accep-
tance of the child's emerging agentic expressions of being an I . Thus the
parent-child attachment of mutual recognition is carried over to this area of
symbolic play. STOs, then, represent, in part, the child-parent interactions
of recognition, which includes experiences of trust and support as well as
concomitant cultural symbols, language, and rituals. For example, Sally, a
four-year-old, quietly plays alone with two of her dolls. With great poise she
speaks to, or more accurately converses with, each doll as she pours tea and
places cookies on a tray. In her symbolic play Sally recognizes and is
recognized as an " I " and it is this that eventually paves the way for her to
risk being an agentic " I " in relation to others within the wider cultural
milieu.
The parents' role in this transition is to refrain from questioning,
forcing, or impinging upon the child's selection of a STO or his/her playing
with the object. Moreover, the parents' continued recognition of the child
and meeting the child's needs provides the background of trust and safety
that are requisite for the confidence and courage to risk yoking and
extending his/her subjective and symbolic experiences of being alive and
real onto not-I objects within his/her area of omnipotent control. Identity
and agency in relation to not-I objects are, in other words, contingent upon
the parents' timely and dependable recognitions of the child's identity and
agency as well as meeting his/her needs (45). Good-enough parents, then,
provide the background presence of trust that is experienced in terms of
recognition of the child's sense of I-ness and agency, increasing the child's
courage to risk extending and yoking internal experiences of vitality onto
not-I, symbolic, and linguistic objects. This joining and extension trans-
forms earlier less differentiated organizations of being alive and real to
more symbolic and differentiated schemata, eventually moving the child
toward a mutual intersubjective sharing of experiences of feeling and being
alive and real.
Many analysts (46-49) argue that parental recognition during this phase
provides the child with a self-reflective capacity and sense of having a mind.
Both are important in possessing a sense of being alive. I would add,
however, that good-enough parental recognition includes the child's recog-
nition of his/her parents' sense of aliveness in seeing and being with the
child. Mom and dad manifest some interest and excitement in engaging
their child. " I am alive in the eyes of the other," which means " I am"
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important and worthwhile. Parental recognition of this type facilitates the

child's sense of being alive. It is to be hoped that we never lose the
experience of being valued and significant in our engagement with others. I
believe patients often search to see if their therapists' recognitions contain a
sense of vitality in hopes of gaining importance and value.
Finally, good-enough parents are able to handle the anger and hurt the
child expresses as a result of inevitable disappointments and disillusion-
ments as he/she tries to learn and integrate complex symbols, rituals, and
language. This handling of disappointments provides the child with experi-
ences of trust and a sense of the parents loyalty and offers opportunities for
repairing relational disruptions. This in turn gives him/her increasing
confidence to risk extending subjective experiences of being alive and real
to objects, which is a necessary step toward moments of shared experiences
of feeling alive.
Parental impingement and deprivation, which includes the absence of
parental recognition, reduces the child's capacity to make use of symbols
and language. This means that the child will have difficulty yoking his/her
experiences of being alive to symbols, language, and rituals because of a
lack of trust and confidence (21, p. 102). More importantly, trauma freezes
this type of symbolic play, leaving the child and adult in a world of people
too dangerous to share mutual objects, activities, and experiences of being
alive and real (47, 50). These children and adults retreat into a symbolic
play that is isolated and rigid. Language and symbols are not used to share a
sense of aliveness. Instead they are used to protect a solitary subjective
sense of being real and defend against, in part, social situations of shared
experiences of vitality. We observe aspects of this in married couples who
say that their marriages are dead. Certainly these couples communicate, but
they do not commune. They are so angry, hurt, and disappointed in their
spouses they no longer have a shared sense of being alive. Neither one has
the necessary confidence and courage needed to take the risk of yoking and
sharing his/her experience of being alive with the other. We can discern
threads of this when listening to a patient's narrative that comes across as
boring and deadening. The symbols are present in the communication, yet
there is little or no connection with the patient's experience of being alive. It
is too risky even to connect an experience of being alive to personal
narrative, possibly fearing that this too will fail and will fail to be recognized.

VIGNETTE 2 (CONT'D)

The work with Tom, described above, illustrates several claims. Tom, a
bright and articulate man, was adept at describing his experiences when he
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began therapy. I was puzzled for several months by my experience of Tom.

On the one hand, Tom told a good story, providing me a view of his present
and early experiences. On the other hand, I frequently felt disconnected or
distant from him and at times wondered whether anyone or any object
could take my place. Certainly my countertransference has a narcissistic
aspect, yet there is also a human desire to create and share moments of
vitality. The absence of these moments is diagnostically significant.
At one point, an image of Tom being on stage and me sitting in the
audience suddenly came to mind. Tom performed a ritual and narrative
(51, pp. 129-145) that kept at bay the possibility of intersubjective aliveness
and at the same time evoked a sense of deadness. At what I believed was an
appropriate time, I wondered aloud about this image and my sense that
Tom both desired and feared sharing his life with me. Tom's response was
relief that someone recognized how much fear and work went into trying to
connect as well as sadness that this vital connection eluded him. Tom also
began to be aware of his experiences of depersonalization in relation to his
aunt and uncle. In my view Tom used language and rituals of acting as a
type of secondary transitional phenomena. He was stuck in the area of
transition, in the midst of solipsistic symbolic "play." Language and sym-
bols were not used to share in experiences of being alive and real with
others, and for good reason. Tom had suffered at the hands of his aunt and
uncle. At best, their recognition and affirmation were highly conditional
and at worst, they communicated their indifference with regard to Tom and
his desires. This left Tom deeply afraid to risk yoking his sense of being
alive with anyone not within his area of omnipotent control. The only
option open to Tom, he believed, was to remain in this isolated and safe
world of solipsistic symbolic play.
In sum, STOs emerge as the child begins to acquire the capacities for
symbolization and language. The child makes use of secondary transitional
phenomena in complex solitary and idiosyncratic symbolic play. This play
enables the child: a) to accommodate and assimilate more complex,
diverse, differentiated, and symbolic communication and activity (e.g.,
ritual); b) to risk yoking and extending his/her earlier less differentiated
organizations of being alive and real onto other symbols and language; and
c) to experience a sense of agency in terms of " I " and learning to recognize
and be recognized by an " I . " Parental recognition, support, and affirmation
provide the background of trust, confidence, and courage for the child to
risk experiences of being alive and real in relation to not-I objects. STOs
are transitional in the sense that they serve as a bridge to shared or
intersubjective objects and activities of being alive and real.
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CONCLUSION

Logical and empirical criteria for discerning truth and reality claims, while
important, frequently miss the more significant aspect of human existence:
the experience of truth and reality. In this article, I offered a developmental
perspective that addresses the question how human beings establish and
organize subjective and intersubjective experience of being alive and real.
Certainly this is a cursory view, but its heuristic value is its shift in clinical
focus. The patient's use of objects and rituals is not interpreted in terms of
reality vs. illusion, true vs. false. Rather, the concern is: a) the patient's
capacity to yoke and extend his/her experiences of being alive and real to
objects that are shared; b) his/her capacity to share his/her experiences of
being alive and real with other significant persons; and c) the patient 's ability
to recognize these experiences in others. The potential space of therapy,
then, is for the sake of creating, through empathic inquiry and containment,
an environment that "confirms the patient's existence as a- live, feeling
other" (52, p. 199) and provides the patient with the confidence and
courage to risk being alive and real with others. Put another way, the
potential space in therapy may be viewed as creating (often spontaneously)
moments of subjective and intersubjective vitality, which must be ap-
proached obliquely yet with intention. Thus, in psychoanalytically informed
therapy, a goal is not conformity or acceptance of an external and indepen-
dent reality. Rather, it is facilitating the patient's experiences of being real in
relation to and with independent objects. In Winnicott's words "we all hope
that our patients will finish with us and forget us, and that they will find
living itself to be the therapy that makes sense" (21, p. 87).

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 CASE STUDY (GROUP)

Second Generation to Holocaust Survivors:

Enhanced Differentiation of Trauma Transmission

MICHA WEISS, M.A.*

SIMA WEISS, M.S.W.**

"Second generation to Holocaust Survivors" is a description of a segment of

society, as well as an attempt at characterizing these individuals. It is common
to speak of mechanisms of transmission of trauma as characterizing the
dynamics of the second generation. This paper intends to advance differentia-
tion between two kinds of transmission of trauma: direct transmission (also
called transposition) and indirect transmission. There seems to be some
confusion in this realm, since there is some discrepancy between clinical and
the experimental publications: Whereas the first usually presents evidence of
direct transmission of trauma in the second generation, the second mostly
demonstrates indirect transmission. We shall present a clinical account of
group therapy demonstrating indirect transmission, proposing a distinction
between second-generation individuals owing to the relative dominance of
each of the mechanisms in their mental structuring. This distinction has
significant clinical consequences.
"The Holocaust has touched us all, making us all its survivors, but the offspring
of those who were there have intimate knowledge of the meaning of being
victims and triumphant at one." Professor Dasberg, psychiatrist and survivor
(in Memorial Candles [1]).
The essence of this intimate knowledge of the second generation as
survivors is under considerable controversy. On the one hand, Kestenberg
(2), and recently Kogan (3), identify the second generation as being
immersed in their parents' trauma, as a result of a process of transposition
of trauma. This means a process by which the members of the second
generation live aspects of their parents' trauma as if they were their own.
"Clinical Psychologist, Supervisor, 'AMCHA' Tel-Aviv; Tel-Aviv Community Health Center. Mail-
ing address: Harav-Fridman Rd. 20, Tel-Aviv 62303, Israel.
**Director of ' A M C H A Tel-Aviv.
' A M C H A National Israeli Center for Psychosocial Support of Survivors of the Holocaust and the
Second Generation.

A M E R I C A N JOURNAL OF PSYCHOTHERAPY, V o l . 5 4 , N o . 3 , S u m m e r 2000

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On the other hand, Hazan (4) claims that relating to someone according to
his/her generational belonging amounts to stereotyping, which is the result
of the difficulty in grasping the complexity of the human situation.
Between these two, there is a sense among the second generation, and
among the professionals dealing with their difficulties, that members of the
second generation, though having various things in common, are far from
being homogeneous.
Already in Wardi's (1) influential book in Israel, though not stressed,
there is a differentiation between two kinds of the second generation: The
"memorial candles," that carry their parents' Holocaust trauma within
themselves, and their siblings who are not identified as "memorial candles."
Wardi does refer to differences among the second generation and their
emotional well-being, stating that it is connected to several variables, such
as age of the parents during the Holocaust, their background, the type of
traumas they endured, and the emotional disposition and assets of the
second generation.
Nevertheless, while referring to intergenerational transmission of the
trauma and its effects, these differences get blurred, and the mechanism of
transmission becomes homogeneous. Danieli (5) proposed a nomenclature
of members of the second generation, according to their parents' kind of
Holocaust experience. This effort of differentiating within the second
generation shows that children of partisan survivors differ from children of
camp survivors who, in turn, differ still from those whose parents had been
in hiding.
Schwartz et al. (6), in their study of transmission of psychiatric symptom-
atology from Holocaust survivors to their offspring, attempt to distinguish
between two kinds of nongenetic transmission: Direct specific transmission
and indirect general transmission.

DIRECT SPECIFIC TRANSMISSION

The children learn to think and behave in disturbed ways, similar to their
parents. Their world of associations is that of the Holocaust, and at times
one gets the impression as if they themselves had been there. This is the
kind of transmission that Kestenberg (2), Kogan (3), and to a considerable
extent Wardi (1) describe.

INDIRECT GENERAL TRANSMISSION

Here, what is transmitted is not the trauma itself, but that, as a result of
having being traumatized, the first generations' parenting abilities were
diminished. These parental weaknesses affected their children.
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Felsen (7), in an overview of the state of knowledge on the subject of

transmission of trauma among Holocaust survivors, states that this differen-
tiation between direct and indirect transmission seems to be valuable not
only for the understanding of the transmission of psychiatric symptoms,
but also as a conceptualization that enhances our understanding of transmis-
sion in all its varieties.
Davidson (8), attempting to track the way in which direct transmission
occurs, points to the mechanism of projective identification as one of the
ways in which the survivor parents try to rid themselves of the terrible
memories and the feelings associated with them. In effect, through the
mechanism of projective identification, experiences of their parents can
become mental properties of the son or daughter. Davidson notes that there
were members of the second generation that arrived for treatment and
looked as though they themselves had endured the Holocaust.
Kogan (3), following Kestenberg (2), demonstrates in her case presenta-
tions how members of the second generation unconsciously live their
parents' Holocaust trauma in their own lives.
An example could be a patient named Gabrielle (3, pp. 6-28), who lived
out in her life the trauma of being abandoned, and of abandoning (her
child, and for a while also her therapy), feeling depression and guilt, as a
result of her mother's ridding herself unconsciously of her depression and
guilt. This is an example of direct transmission, or "transposition of
trauma" in Kestenberg's terms.
Concerning indirect transmission, Felsen (7) concludes that research
has made possible the mapping of characteristics of parenthood that had
been affected as a result of the Holocaust trauma, as, for example,
difficulties in allowing the unfolding of the process of separation-
individuation. This kind of research of indirect transmission is illustrated in
the studies of Boszormenyi-Nagi et al. (9), followed by Shafat (10). Their
thesis is that as a result of the many losses of the survivors, and their
inability to mourn them, their children were burdened by unconscious
expectations to compensate for these extremely painful losses. These
expectations put the children in the situation of being unable to fulfill
"loyal obligations" to the survivor parents. This failure might be perceived
by the children as reflecting their own failure rather than the parents'
unresolved mourning, and has been found to influence self-esteem, capac-
ity for intimacy, and even sexual life in the second generation.
It seems, then, that conceptualization of distinctions between different
kinds of members of the second generation in the professional literature
concerning trauma transmission is not well consolidated. Felsen (7) adds a
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further complication. She points out a discrepancy between research

findings and clinical presentations in the professional literature: whereas
the first usually find evidence of indirect transmission, most of the clinical
reports describe instances of direct transmission.
The reason for this discrepancy seems to be the fact that it is hard to
trace experimental evidence of direct transmission, because it is more in the
intrapsychic mode of "being" (11), and is frequently unconscious. Experi-
mental tools trace instances of indirect transmission, which tend to be more
easily revealed through these tools. Clinical reports, however, are usually
presented by psychoanalysts, and demonstrate more often manifestations
of direct transmission that correlate with classic psychoanalytic thinking.
This somewhat confusing inconsistency, added to the overwhelming
character of the Holocaust trauma, and the emotional weight that it places
on the researchers and the clinicians themselves, creates difficulties in the
effort of reaching differential conceptualizations among the second genera-
tion. It resembles the difficulty of differentiating between the survivors
themselves concerning the type and the magnitude of the trauma they had
endured.
We would like to demonstrate, through clinical material that was
obtained in group work with therapists at the AMCHA Tel-Aviv branch,
the existence mainly of indirect transmission. We shall discuss the findings
in an effort of enhancing differentiation among the second generation.
THE G R O U P STORY

The group was planned as a dynamic group for therapists who are
themselves members of the second generation. The treatment objective was
to expand their understanding of the meaning of their being members of
the second generation.
The group met once every two weeks throughout one calendar year, for
meetings lasting two and a half hours. The group started with nine and
stabilized around six members. Most of the members had families, and
were between 40-52 years of age.
Beginning
From the first meeting through Danny's exposure of his complex relation-
ship with his parents, the main theme of the group became crystallized: The
compound meaning of being the offspring of the Holocaust survivors.
Danny was flooded by his exposition, and decided not to proceed with
the group, while the others hesitantly began to share their wish to get in
touch with their "fragile interior." Doubts were raised—are we able to get
in touch with ourselves? Do we really want to? Danny's departure, added to
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unstable attendance at the first meetings, heightened the anxiety of being

abandoned. Members of the group began to check whether it was a safe
place, were the others committed, would it be possible to entrust the group
with ones fragile mental possessions.
There was a premature effort to feel together and connected to one
another. When this process was interpreted, the anxieties were released,
among them the question if the group leaders will be more present, safe,
and emotionally available than the parents had been.
These themes: the present-absent parents, the anger, the disappointment,
the pain, and the feelings of guilt, gradually became the main themes that
thread through the life and the story of the group.
The process of the psychological birth of the group into one entity took
time, and during quite a few meetings there was much caution, the
atmosphere remained tense, with the members addressing the leaders for
direction and demanding clear tasks.
Gradually, members began to cautiously open up. Gali shared her pain
and grief following the death of a beloved uncle, triggering related issues in
the others. The dominant theme that reverberated was the joint journey
with the parents to the sites of the Holocaust, e.g., the camps, and the
parents' birthplace, (maybe symbolically representing an analogy to the
concept of the "primal scene" in classical psychoanalytic theory [12]). At
this point, the underlying meaning could be understood as a metaphor of
the group's journey to the realms of the Holocaust from within. Yet, the
members' choice was to explore their harsh childhood experiences. Gali
told of the death of her father when she was two, and thereafter moving
between foster homes, due to her mother's inability to provide for her. Gali
attacks her mother, who has been unable to confront the hard questions
Gali posed about her childhood, with the mother demanding exclusiveness
of suffering. The expression of rage towards the mother raised divided
reactions in the group, between those who identified with Gali's pain, and
those whose concern was for the well-being of the mother who had
survived the Holocaust. The leaders interpreted these two reactions as
being two parts of a hard and inhibiting conflict within each of the group
members, a conflict so commonly found among the second generation.
At this point, halfway into the group process, Sima, the coleader, was
unexpectedly absent for one session before and another after the summer
holiday. At first, the group ignored her absence, but reacted with tension
that became replaced by a lot of anger directed towards Anney. The group
accused her of being unpredictable, uncommitted, and disappointing after
her being absent for one session. When the leader interpreted the anger as
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being related to her absence, she opened in the group a path of exploring
various emotional reactions among the participants. It began with a naive
question by Hava about the possibility of receiving fiscal compensation for
the absence of one of the leaders, otherwise it would be unjust. It continued
with feelings expressed by Rachel who confronted the leader and asked her
if she cared at all about the group. This related to Rachels life story, whose
father, a child survivor himself, had deserted the family when Rachel was
three years old. She had to take care of herself because her mother had to
go to work to provide for the family.
These feelings of connecting to the experience of a disappointing or
absent parent arose in a powerful and direct fashion, and enabled the
members to touch upon this wound that exists in different formations
within themselves. Touching this wound, this absent place, as if it opened a
stream of memories and emotions, led to what will occupy the following
sessions, the fantasy of compensation. It began with Hava s question about
fiscal compensation due to the leader's absence, and proceeded to a fantasy
of demanding payments as second generation from the Germans.
This fantasy led on to a fascinating story by Hava. Her son, who traveled
the east for a year, met a charming local orphan his age, fell in love, and a
few days before the session Hava had heard that he was bringing her back
with him. Hava, who has two sons, and all her life longed for a daughter,
was flooded with uncontrollable emotions, actually a "mania" according to
her, about a "ready-made daughter." All her efforts to calm herself were
unsuccessful. The dramatic story excited us all, filling us with the expecta-
tion and the craving incorporated in the fantasy of compensation. This
provided energy, a sense of aliveness, and cohesiveness to the members of
the group.
The fantasy of compensation is also central to Anney, who expressed the
wish that the group itself will develop into a sort of a benefitting family,
headed by the leaders. This "family" will be better, warmer, and more
containing than the real family. Anney is the only member in the group that
has not yet built her own family. When she felt that her wishes were not
fulfilled, her reaction became aggressive and demanding. She found it
difficult to proceed with the group in the process of relinquishing fantasies,
and decided to end her participation in the group.
As expected, Hava came to the meeting after the eagerly expected
event, and shared her disappointment that rather than a "ready-made
daughter," just her son's girlfriend, who is a stranger to her, had arrived.
This made a shattering impact on the group and the atmosphere became
tense and "depressive." The story raised in the leaders an association to the
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"Bureau for the search for relatives" in the 1950s, when the survivors were
glued to the radio in the futile search for their lost relatives. The yearning to
find lost relatives was combined with a fantasy of undoing the losses. The
association was offered to the group, but no use was made of it.
The oppressive atmosphere, following the shattering of the fantasy,
brought about a deeper sharing among the participants, with the group
having a better tolerance to contain these strong emotions.
Tali spoke about the struggle between her and her mother-in-law, a
Holocaust survivor, concerning her ten-year-old daughter. The grand-
mother, who is consumed by anxiety and dread, draws her granddaughter
into her horrified world, with Tali helplessly watching her daughter being
immersed in fears, and stuffed with food. The account was presented as a
story of sacrificing a daughter to a demanding Holocaust survivor, and
raised intense reactions in the group.
Following Tali's story, Gali shared a painful confrontation she had had
that week with her mother. During a conversation about her childhood
with her mother, Gali, who had moved between various foster homes after
her father's death, tried to attain her mother's recognition that her child-
hood was harsh, that she too has her pains. The mother's reaction, " I had
better not stayed alive. . . (after the Holocaust)," left Gali feeling isolated
and empty. Our understanding was that the mother's inability to empathize
with her daughter's pain in the present, as in the past, is the result of the
survivor mothers difficulties in allowing the existence of pain other than
her own, and of avoiding getting in touch with feelings of guilt that are
intolerable.
Hagit reacted, "We are the product of deformed love." This statement
was experienced as precise by the group members, and helped to contain
the difficult experiences that were brought up. The story of the group
continued to unfold, and at this stage allowed an intense experience.
Gali did not manage to drag herself to the following session, out of the
need to "lick her wound" by herself. This echoed in the group and raised in
Hagit a painful memory at the age of five. She was in a huge parking lot
outside her father s workplace, trying, on her mother's insistence, to find his
car, while he tried to avoid her. The description of the helpless little girl in
the huge parking lot touched everybody, and allowed Hagit, who is rather
reserved emotionally, to get in touch with her pain and cry over her
wounds. Hagit's father's extreme emotional detachment from his daughter,
of which we had occasionally heard in the group, is an extreme example of
the lack of ability we meet in some of the child-survivors to identify with
their parental roles.
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The group at this stage was highly cohesive, with its members feeling
they could count on one another. For us, the conductors, these were
exciting sessions, at times deeply touching us. We observed that we had not
experienced such emotional vividness in previous groups, which made us
wonder about the difference. In our processing of the sessions, being
second generation ourselves, personal themes arose, and hopefully got
worked through.
We noticed that each parent s Holocaust story did not receive a central
place in the group, and came up as a supplement to something in the life
story of a group member. We wondered how much it was influenced by our
subjective feelings, being ourselves from families in which the parents'
Holocaust was not spoken about. This fact, the scarce use of the parents'
Holocaust story, is unusual in these kinds of groups, where the assumption
is about the centrality and the importance of the parents' story.
With termination near, the process of differentiation deepened. Follow-
ing the better differentiation between the first and the second generation,
better differentiation was also made between the members themselves. The
group members realized that they are not all the same, and began to define
the individual and the different beyond the shared and the uniting.
The group approached its final meetings. During the last three sessions,
memories and associations, related to stages in separation, were raised. It
began with Tali sharing a difficult experience. A close friend had fallen ill
with cancer, and Tali, in her shock and her emotional paralysis, almost
suffocated the potential life their relationship still held. Tali's voice also
symbolically reflected a voice concerning the group, that of the expected
separation threatening to feel premature and unexpected. It was possible to
discern at that point the resemblance of this emotional paradigm to the
basic experience of the survivors concerning their unexpected losses.
It continued in the next meeting with one of the members sharing, for
the first time in her life, the tragic event of her giving birth, years before, to
a dead baby in the sixth month. The atmosphere in the group was of sorrow
and participation, with an ability to allow space for grief and loss. We
stressed their ability to make place for their personal tragedies, unshad-
owed by those of their parents.
From the vantage point of the group, even with associations concerning
the coming separation being hard and even premature, the group members
allowed themselves the space to digest and process it.
At the end of the group, two voices could be discerned: One, that of
accomplishments, of better differentiation, that had its outlet in expressed
satisfaction, in the refreshments brought in, and in their plans to meet
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independently later on. The other voice was that of the frustration of the
fantasy of compensation, and of the unrequited expectation that their
parents will finally understand their side. This voice found expression
mainly in their inability to express gratitude towards the leaders about the
meaningful journey we had gone through together.

DISCUSSION

The starting point of the discussion was the impression of a deep and
meaningful experience that the group had gone through—members and
leaders alike. We observed that attendance in the group was meaningful for
each one of the participants, even though there were significant variations
as to their focus of concern.
The second point, already mentioned, was the fact that in essence, the
parents' Holocaust experiences were not the focus of the group.
At the beginning, each of the participants told of the parents' Holocaust
experience, and during the group work, the parents' trauma appeared
when relevant to the participant's story. Nevertheless the group's focus
throughout was on the participants' subjective experience concerning their
traumatic childhood experiences!
This is in contrast to the technique usually described in the professional
literature concerning the work with the second generation, where the
starting point is the concept of "transgenerational transposition of trauma."
This concept, first formulated by Kestenberg (2), states that the parents
transferred to their offspring through unconscious communication their
sometimes unspoken of trauma!
Accordingly, the therapeutic work needs to concentrate on identifying
the presence of the parents' trauma in the life of the second generation, in
order to proceed to establishing differentiation between that trauma and
the internal world of the second generation. To attain that, the therapeutic
stance aims at getting to intimately know the parents' trauma, followed by
the search of similar themes in the internal world and its derivatives, in the
life of the second generation.
The group-work technique is to interpret the group process as a kind of
a "journey" through the Holocaust realm, enabling the participants, all
members of the second generation, to see how, through their associations,
they join in creating a group story that demonstrates how their parents'
Holocaust story is embedded in their own mental structure. The aim of this
symbolic journey is to advance the expulsion of their parents' trauma, in
order to assess and redefine their identity as those not directly exposed to
the Holocaust. This theoretical and technical stance is dominant in the
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individual work of Kogan (3), and exists with variations in the group work
of Wardi (1), among others. As we stated before, we did not undertake this
"journey," but, on the contrary, stressed as central the subjective experience
of the second generation vis-a-vis that of the parents. One can notice in
retrospect junctions in the group work and in the leaders' choices that gave
impetus to the direction that the group took. For example, at the beginning
of the group, where the theme was the trip to the parents' Holocaust site, it
might have been possible to promote the theme of the Holocaust within
each of the participants. What happened in effect was an intensive and
productive probing into the members' childhood pains as a result of their
parents' diminished ability to offer a safe and nurturing environment,
because of their traumatization.
Another example, among many possible others, when approaching
termination, was that we could have interpreted the weighty themes that
were brought up, as an expression of the way the second generation live out
in their own lives their parents' horrendous and untimely separations. We
chose to amplify the permission the members gave themselves to mourn
their harsh experiences, unshadowed by their parents' Holocaust traumas.
This stance, which we assume to have been influenced by our subjective
attitudes, being ourselves members of the second generation, and which
was probably affected by the members sharing the same profession with us,
enabled amplification and emphasis of the differential position of the
children of the survivors versus the survivors themselves. This approach
also illuminates the differences between the trauma of the parents, and that
of their offspring, differences that are evident, but tend to get blurred
through theoretical conceptualizations, such as "transposition of trauma"
and the like. This way of working brings out the differentiation between the
generations. Terms, such as "Deformed Love," as a representation of the
second generation's trauma, exemplify this. From this point of view, one
might say that the very word "trauma," to relate both to the Holocaust
survivors' experience, and to the second generation's ordeal, can be
misleading. To our best professional impression, working with this position
and technique enabled differentiation and strengthening.
The basic premise that underlies this approach, unlike that of the
"transposition of trauma," is that the suffering of the second generation is
not necessarily the result of transgenerational transmission of the trauma. It
is the outcome of the tragedy of the second generation being raised by the
survivors, who were swamped with feelings of suffering and bereavement,
that interfered with their parental abilities. This is a fundamentally different
dynamics!
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A question probably comes to one's mind at this point: What then is the
most appropriate way to conceptualize the second generation's situation,
the transposition of trauma approach, or the secondary-transmission ap-
proach? In our view neither is inclusive. Our approach is, that in order to
"capture" the complex reality of trauma transmission, both conceptualiza-
tions are helpful if used appropriately.
From our experience of treating the second generation, it seems that
there are those whose problems can validly be conceptualized as being
mainly the result of "transposition of trauma" (direct transmission). None-
theless, there are also those whose problems are better conceptualized
under the heading of secondary transmission.
This distinction is important because it entails a different therapeutic
attitude: When one is dealing with direct transmission, the therapeutic
stance aims at identifying and encouraging a process of regression in order
to uncover a "near"-identicalness between the inner experience of the
second generation and that of the survivor parents. The objective of this
process is to enhance awareness of the existence of direct transmission in
order to further differentiation. When one is dealing with secondary
transmission, the method, as we demonstrated through our group, is to
amplify and stress differentiation and separateness.
Our position is that in effect, both types of transmission of trauma
appear to be present in the mental structure of the second generation, but it
seems to us that it is possible to differentiate between individuals according
to the relative dominance of one of these mechanisms. One can describe the
two modes of transmission as two circles, an external one and an internal
one. The external one is the circle of the secondary transmission, where the
influence of the "deformed love" occurs. The effects can be dramatic to the
life of the member of the second generation, but from a structural point of
view, one is speaking of the influence of "whole objects" through mecha-
nisms of internalization. This kind of transmission is qualitatively not
different from other kinds of complex parental influences, except for the
specific themes common to this group. An example of common specific
themes is difficulties with separation, problems with the vicissitudes of
aggression, etc. (6).
The internal circle consists of direct transmission. This type of transmis-
sion is a result of the infiltration of mental themes and affects from the
parents' mental structure into that of the second generation. In order for
that to occur, there needed to be a more coercive encounter between less
than "whole objects." The conditions for this arose when the parents'
trauma was not at all confinable, either as a result of the nature of the
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trauma, or as a result of the parents' mental structure. Under these

unconscious coercive conditions, the unfolding of the child's development
towards maturation and differentiation was impaired. From our experi-
ence, the probability is higher to find manifestations of direct transmission
within members of the second generation who were born in the years close
to the war, within those who are only children, and those who are children
of child-survivors, who had absorbed the trauma in their own formative
years. In particular cases, when parents lost a family and children in the
Holocaust, the probability of finding derivatives of direct transmission in
the second generation is higher. Some of these members of the second
generation have not managed to build a family of their own, and often the
intensity of their immersion in their parents' Holocaust is evident, even to
themselves.
Diagnostically, these persons usually suffer from the cluster of personal-
ity disorders, and sometimes more severe pathologies, with weak defense
mechanisms, and differentiation between self and objects not yet fully
established. This mental structure is related, and may have been created, as
suggested by Davidson (8), by parenting that is beset by mechanisms of
externalization, such as projective-identification. Such upbringing inter-
fered with the development of better differentiation and autonomy. Con-
versely, there are those of the second generation who succeeded better in
their individuation process, have managed to build up their separate lives,
but nevertheless suffer the consequences of being affected by "deformed
love," using our group's terminology. This is the result of being raised by
parents who are survivors of horrendous circumstances. In these cases, the
concept of "transposition of trauma" is less helpful to the understanding of
the suffering of this group, which is much better explained through terms
of deficiency and narcissistic wounds.
It seems to us that for the first group, the therapeutic procedure
described in the literature would be the treatment of choice, whereas for
the second group, the technique we described with our group would be the
most appropriate. It might be that this could offer an explanation for
Anney's leaving the group, due to her being identified, in our opinion, with
the first group.
We find it important in our concluding remarks to stress our point of
view that the two kinds of transmission of trauma may, and often do exist,
within the same individuals. Nevertheless, it seems to us that members of
the second generation can he differentiated among themselves through the
relative dominance of either of the two mechanisms of transmission. From
our experience, this differentiation is helpful in assessing the kind of
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treatment that is needed, and may sharpen the clinician's ability to discrimi-
nate between the different modes of transmission, in various stages of the
treatment.
In the assessment phase, decisions can be made concerning the kind of
treatment, its estimated length, and the recommended therapeutic stance,
according to the dominant mode of transmission that is identified. When
that is direct transmission, the treatment of choice would be a longer,
regression-promoting treatment. The therapeutic strategy would aim to
expose the lack of differentiation between patient and the survivor parents,
due to massive direct transmission derivatives, in order to initiate the
process of individuation.
When assessment defines indirect transmission as the main mode of
transmission, usually a shorter treatment modality may be suitable, with a
therapeutic aim of enhancing differentiation. Sharpening the distinction
between these two modes of transmission allows a better attuned attentive-
ness to the transition of the patient between phases of the treatment in
which indirect transmission is apparent, and phases of existing lacunae of
direct transmission derivatives that have a distinct clinical quality.
We hope that in this article, we have been able to open up a professional
avenue of systematic differential thinking concerning the second genera-
tion of the Holocaust survivors, that to our best impression are not
homogenous. We find this avenue to be productive, and believe it may
afford us a better fit between our therapeutic tools and our patients' needs.

Acknowledgment: We are grateful to the members of the group for enabling us this experience and
learning.

REFERENCES

1. Wardi D (1992). Memorial candles: Children of the Holocaust. Tavistock, England: International
Library of Group Psychotherapy.
2. Kestenberg JS (1982). Survivors' parents and their children. In M.S. Bergman & M.E. Jucoby
(Eds.), Generations of the Holocaust (pp. 83-102). New York: Basic Books.
3. Kogan I (1995). The cry of mute children. London: Free Association Books.
4. Hazan Y (1987). Second generation of Holocaust survivors—A concept in doubt. Sihot-Dialogue,
Israel Journal of Psychotherapy, 1, 104-107.
5. Danieli Y (1981). Differing styles in families of survivors of the Nazi Holocaust. Children Today, 10,
6-10.
6. Schwartz S, Dohrenwend. BP, & Levav I (1994). Nongenetic familial transmission of psychiatric
disorders? Evidence from children of Holocaust survivors. Journal of Health and Social
Behaviour, 35, 385-402.
7. Felsen I (1998). Transgenerational transmission of effects of the Holocaust. In Y. Danieli (Ed.),
International handbook of multigenerational legacies of trauma. New York: Plenum Press.
8. Davidson S (1992). Recovery and integration in the life cycle of the individual and the collective. In
I.W. Charny (Ed.) Holding on to humanity—The message of Holocaust survivors: The Shamai
Davidson Papers. New York: New York University Press, pp. 189-206.

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 Differentiation Between Direct and Indirect Transmission

9. Boszormenyi-Nagi I, & Spark G M (1973). Invisible loyalties: Reciprocity in inter generational family
therapy, Hagerstown, MD: Harper & Row.
10. Shafat R (1994). Commitment to parents as unsolvable problem in children of Holocaust survivors,
Sihot-Dialogue, 9, 23-27.
11. Erlich S, & Blatt SJ (1985). Narcissism and object love: The metapsychology of experience.
Psychoanalytic Study of the Child, 40, 57-79.
12. Blum H (1979). On the concept and consequence of the primal scene. Psychoanalytic Quarterly, 48,
27-43.

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 FROM THE LITERATURE

Psychotherapy with Older Adults

GARY J. KENNEDY, M.D.*

STACEY TANENBAUM, M.D.**

The scope of need and possible benefit of psychosocial interventions in late

life far exceeds the scientific evidence of efficacy. Most studies have been
conducted in academic settings with self-selected, relatively independent older
adults for whom measures of benefit were narrowly defined. In reviewing the
existing literature concerning individual, group, and couples therapies in the
geriatric population, we find that with appropriate adaptations for medical
comorbidity, cognitive and sensory impairment, caregiver inclusion, and
realistic modification of treatment goals, psychotherapeutic endeavors with
the senior patient can prove to be highly successful.

INTRODUCTION

All therapies share common themes of establishing a supportive optimistic

relationship, examining distortions, addressing conflict and ambivalence,
repairing interpersonal or intrapsychic deficits, and restructuring defenses.
The goal of each is to change expressed behavior through individualized
treatment (1,2). While advanced age is not in itself an obstacle to therapy,
age-relevant adaptations with special attention given to medical comorbid-
ity, cognitive capacity, and the role of family members and caregivers are
often necessary to make the endeavor effective. In addition, modifications
of the therapeutic goals to include increased self-reliance, reduction in
primary-care-service needs, improved social or family functioning, and
long-term health care planning can further optimize treatment outcomes.
Older adults are particularly receptive to the short-term, focused

"Professor of Psychiatry and Behavioral Science, Albert Einstein College of Medicine, and Director,
Division of Geriatric Psychiatry Medicine Montefiore Medical Center and Bronx Psychiatric Center.
Mailing address: Montefiore Medical Center, 111 East 210 Street, Bronx N Y 10467-2490. e-mail:
th

gkennedy@[Link]
* ''"Resident Physician, Department of Psychiatry and Behavioral Science, Albert Einstein College of
Medicine, Montefiore Medical Center.

A M E R I C A N JOURNAL OF PSYCHOTHERAPY, Vol. 54, No. 3, Summer 2000

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 Psychotherapy with Older Adults

psychotherapies developed in recent years. These therapies have in com-

mon an emphasis upon clinical problems and treatment goals. Following an
initial assessment of the clinical issues, including cognitive abilities, capac-
ity for change, and structure of care giving to name only a few, one may
select the therapeutic modality best suited to the needs of the individual. In
the following paper we will summarize various brief, group, family, and
caregiver therapies, emphasizing adaptations suited to the needs of the
older adult (See table I).
BRIEF PSYCHODYNAMIC THERAPY

Short-term psychodynamic therapy is indicated for older persons with

adjustment disorders, grief reactions, and recent onset of traumatic stress
disorders (3). An essential component of treatment is to help the patient
reestablish a positive sense of self and mastery while avoiding excessive
dependency. Setting a time limit of 15 sessions is often useful. While

Table I . TYPES O F PSYCHOTHERAPY FOR O L D E R ADULTS

Therapy Distinguishing Attributes

Brief Psychodynamic Problem focused, transference not examined
Supportive Meant to maintain present level of function or
symptom control
Cognitive-Behavioral Directive, symptom focused, techniques practiced out-
side of therapy to counter misperceptions and mis-
taken beliefs
Behavioral Educational with focus directed at reducing negative
and increasing positive experiences
Interpersonal Exploratory, focused on interpersonal conflict, role
change and role deficits
Life Review, Recall of personal history to master one's present and
Reminiscence future
Problem Solving Focused on change, narrow and pragmatic
Group Therapy Includes reminiscence, psychodynamic, cognitive-be-
havioral, caregiver support, and persons with
dementia
Family Therapy Focused on the family as caregivers
Marriage or Couples Focused on age and illness related changes in the rela-
Therapy tionship and the individuals
Dementia Caregiver Focused on the caregiver role, combines elements of
Counseling cognitive-behavioral and interpersonal therapy
Bereavement Therapy Restructuring (not restoration) the experience of the
lost loved one

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support is an integral feature of the therapy and is often sought to resolve

problems of survivor guilt, and/or negative attitudes toward the self and
aging, most patients can achieve insight and successfully terminate treat-
ment without requiring long-term, supportive care. However, for those
patients unable to meet these goals, ongoing supportive therapy may be
indicated in order to control symptoms and maintain present levels of
functioning.
Although transference may not be interpreted in short-term psycho-
therapy, an awareness of transference and countertransference is an impor-
tant element in any therapeutic relationship. Transference in late life
evolves out of childhood relationships as well as significant adult ties, and is
often evoked by stress or conflict. Certain transferences arise more fre-
quently in late life as the older adult confronts the loss of goals and ideals,
changes in family and intimate relationships, illness, disability, and mortal-
ity. In reviewing the available literature on transference, Lazarus and
Sadavoy (3) noted that in older patients, transference may appear as an
inability to engage in an alliance with a younger (in their eyes inexperi-
enced) therapist, therefore doubting the therapist s capacity to understand
or help senior citizens. However this "reverse transference" often hides
deeper fears of decline, inferiority, and dependence (4). Retired persons
seeking to adjust to the loss of self-esteem and the rewards and recognition
in the workplace may experience the (successfully employed) therapist as a
domineering, rival sibling. The therapist who is unable to restore the
damaged self-esteem immediately may be seen as a withholding or depriv-
ing parent. Other narcissistic insults, such as loss of physical or verbal
prowess, beauty or stature may provoke an idealized mirror, or magical
transference. The unavailability of a sex partner and the perceived loss of
physical attractiveness in contrast to the intimacy and privacy of the clinical
setting may provoke a frankly erotic transference. Patients may also
develop a spousal transference, particularly following bereavement. Recog-
nition and appreciation of these elements at the outset of treatment will
allow the skilled therapist to utilize the transference as a guide to building a
more reality-based alliance.
Countertransferential issues arising in the treatment of older adults may
involve unresolved conflicts over dependency, illness, or death, as well as
rage or fear surrounding parental rejection. Unconscious avoidance and
distancing may result, truncating empathy and making the relationship safe
but sterile. Alternatively, idealized countertransference may serve as a
defense against latent hostile or sexual feelings toward parents or the threat
of abandonment stemming from the patient's frailty. The practitioner may
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engage in ill-considered power struggles with family, failure to terminate

after treatment goals are clearly attained, or have difficulty limit setting with
visits or phone calls.
GENERAL PRINCIPLES O F COGNITIVE-BEHAVIORAL THERAPY

Cognitive-behavioral therapy (CBT) seeks to enable the individual to

change thoughts, feelings, and action by focusing on erroneous perceptions
and habitual behaviors. It has been tailored to specific disorders, including
depression, anxiety, panic, agoraphobia, obsessive-compulsive, and sleep
disturbances. The approach is educational and structured with active,
problem-oriented sessions and homework assignments aimed at mediating
the effects of thoughts upon feelings and behavior by closely monitoring
those thoughts that accompany emotional, symptomatic episodes. The
therapist plays an active role in helping the patient to examine the validity
and logic of these thoughts in order to identify distortions and misinterpre-
tations, with the ultimate goal of changing dysfunctional patterns of belief
that predispose to distorted experience.
As suggested by Gallagher and Thompson (5), there are several adapta-
tions that can help to maximize the success of cognitive-behavioral therapy
in the older patient. A thorough orientation to the approach and to the
active participation required of the individual often needs to be accompa-
nied by a review of the patient s learning habits and styles in order to
identify those patients who may have greater difficulties in accepting
therapeutic suggestions. Recognition of medical comorbidity and limita-
tions, particularly cognition or sensory impairments, may necessitate a
more active role by the therapist (6). Recorded sessions for playback at
home, written instructions to accompany homework assignments, and a
review of past material prior to progressing to the next assignment may be
useful. For the older person with limited resources and difficult life
circumstances, moderate goals may be more realistic. Longstanding prob-
lems may necessitate extended treatment, and termination may be relative
rather than absolute, allowing for return to therapy should new problems
emerge or old problems recur.
COGNITIVE-BEHAVIORAL THERAPY FOR LATE-LIFE DEPRESSION
Perhaps best developed for depression, cognitive behavioral therapy seeks
to alleviate dysphoria by attacking what Beck (7) referred to as a "Cognitive
Triad" of negativism toward the self, the environment, and the future.
Persistently distorted perceptions and beliefs in which depressed persons
see themselves as deficient, incapable, and unlovable, the present environ-
ment as overwhelming and fraught with failure, and the future as hopeless
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and immutable maintain this triad. In cognitive-behavioral therapy the

therapist helps the patient to examine pointless self-criticism, guilt, loss of
positive motivation, and the tendency to view problems as overwhelming.
The patient is asked to examine behaviors that perpetuate depression,
such as withdrawal from family, friends, religious or community support
institutions, as well as behaviors that foster well-being. Activities leading to
a sense of accomplishment and pleasure are identified and then scheduled
rather than left to the initiative of others or to impulse, encouraging
decisiveness and assertiveness rather than passivity and dependence.
Progress is measured by keeping count and assessing the emotional effects
of the activities. When suicidal thoughts are present the therapist explores
the motives in an effort to reduce hopelessness and to tip the balance
toward survival. Here reasons for living, such as family, faith, future goals
(modest as they may be), and previous demonstrations of resiliency are
made more salient. The effect over time is to alleviate depression through
reinforcing positive, rewarding experience and perception. Again the
approach is adapted to the realities of late-life losses and disability to reach
realistic goals that offer a degree of improvement if not full recovery.

COGNITIVE-BEHAVIORAL THERAPY FOR LATE-LIFE ANXIETY DISORDERS

Cognitive-behavioral therapy has been shown to be a valuable therapeutic
technique in treating patients with panic, agoraphobia, obsessive-compul-
sive disorder, and generalized anxiety by eliciting manifestations of the
disorder under controlled conditions that lead to extinction of the symp-
toms (8). The symptoms of panic and anxiety entail emotional, cognitive,
and somatic components; these elements are generally intertwined by the
time of presentation, such that any single feature is likely to trigger the total
configuration. The goal is to counter the entire configuration of anxiety and
panic, including the anticipatory anxiety, the agoraphobic avoidance of
triggering stimuli, and the despair that accompanies these persistent and
disabling symptoms (8). Older adults suffering from these illnesses may
have isolated themselves for years, often proving resistant to treatment
overtures, especially if supportive services from visiting nurse or "Meals on
Wheels" are in place. Nonetheless, with the help of friends and other
providers offers of treatment should be discussed. It is important to add
that frail persons of advanced age may have realistic fears of being out of
their homes alone.
Although medications may be required to give some patients enough
relief to access psychotherapy, the gradual reduction if not elimination of
anxiolytic agents may be required for CBT to be fully effective. Sanderson
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 Psychotherapy with Older Adults

and Wetzler (9) argue that medications interfere with the treatment of
panic disorder by blunting the experience of symptoms rather than learn-
ing how to extinguish them. Their argument is especially compelling for
older adults in whom the sedative effects of the benzodiazepines may be
associated with impaired cognition or falls. In individuals able to tolerate
their disorder long enough to learn to lessen their symptoms through
psychotherapy, medications may be avoided entirely.
Treatment is initiated with orientation to the methods of teaching,
training of techniques, and lesson plan. Definitions of panic, anxiety, and
agoraphobia should be provided, and physical symptoms addressed. In
order to assure patient and therapist alike, contact with the primary-care
provider and careful review of underlying medical conditions and current
treatments is advised. The physiology and psychology of fear and anxiety
and the physiologic consequences of over-breathing are reviewed. In-
creased aerobic exercise and reduction in stimulant coffee and tea are also
suggested. The patient's avoidance behavior and anticipatory anxiety are
brought out and are shown to be counterproductive and self-defeating. As
the therapy progresses, cognitive restructuring is introduced, using the
clinical history to demonstrate how thoughts can provoke or accentuate
panic and anxiety. The patient is instructed to keep a record of thoughts
that precede or accompany the panic and anxiety, as well as erroneous
conclusions or assumptions of catastrophe that follow it. In conjunction
with this record, the therapist is able to work with the patient to "decatastro-
phize" the episodes by employing various coping techniques that include
respiratory control and the relaxation response. Once the educational
components are complete and the techniques for breathing and eliciting
the relaxation response are mastered, controlled provocation of anxiety
and panic with increasingly challenging stimuli may be approached. The
patient is then asked to purposefully and progressively (from least to most
threatening) seek out the anxiety-provoking situations outside of the
therapy, and to implement the rehearsed coping responses. Once the
prearranged termination goal has been achieved, the patient is inoculated
against future failure with the instruction that recurrence under stress is not
a catastrophe, only an indicator for a booster session or the need to
redouble practice of techniques.

COGNITIVE-BEHAVIORAL THERAPY FOR OBSESSIVE-COMPULSIVE DISORDER

Obsessive-Compulsive Disorder may be difficult to diagnose in the older
adult in part due to decreased occurrence in this population, but also
secondary to the patient's reluctance to share irrational, ego-dystonic
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symptoms with the practitioner. Comorbid depression may also confound

presentation and diagnosis. Although older patients with the disorder are
more likely to have sustained the symptoms without treatment for a longer
time than younger patients, both groups appear to respond equally well to
intervention (10). Following an initial assessment of symptoms, including
obsessions, compulsions, environmental and internal triggers, feared conse-
quences, avoidant behaviors, mood, insight, and overall impairment of
functioning, a treatment plan is formulated outlining targets for interven-
tion as well as treatment goals.
The interventions may include both psychological and pharmacological
elements. Along with educational discussions, it may be helpful to provide
the patient with a self-help bibliography, as well as materials related to
diagnosis, interest groups, and organizations. Treatment goals to break the
linkage between the obsession and resultant thought or anxiety should be
clarified early on. Cognitive restructuring is used to examine distorted
beliefs. For specific fears the patient is asked to practice imaging the trigger
object or thought beginning with the least threatening element or item, and
then follow it with a relaxation exercise rather than the obsession or
compulsion. Self-monitoring is used to reinforce a sense of mastery over the
provoked anxiety and ultimately extinguish the response. Family involve-
ment may be essential in assisting with homework completion and symp-
tom monitoring. Termination should be relative, with the option for
booster sessions should symptoms again become disabling. Transient emer-
gence of symptoms under stress is to be expected and is not an indicator of
recurrence.

BEHAVIORAL THERAPY FOR DEPRESSION

Behavioral therapy for depression emerges from Lewinshons (11) observa-
tions that depressed people both produce and engage in fewer pleasant
activities. Lack of positive reinforcement leads to a downward spiral,
resulting in depressive disorder. A purely behavioral approach to depres-
sion includes educating the patient about the underlying theory of depres-
sion and identifying examples of both pleasant and unpleasant behaviors
and events in everyday experience. A plan or contract specifying which
aversive events can be realistically avoided and which pleasant events can
be increased is agreed upon, including an expectation of frequency of
events, duration of behavior, and maintenance of a performance log.
Graded improvement is expected as the pleasurable events are increased in
time or amount and is monitored by amelioration of mood as assessed by
the patient on depression instruments. Improved mood is not expected
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with the initial phase, only a new set of behaviors. As the patient becomes
accustomed to self-monitoring, the array of pleasant and unpleasant events
may be expanded, the contract advanced, and more complex tasks ap-
proached. Ultimately, the patient should be symptom free, able to continue
habitual positive reinforcement without the use of record keeping or
scheduling. The simplicity of the theory, common-sense quality of the
intervention, and methodical technique lend themselves well to work with
older persons (12).

INTERPERSONAL THERAPY FOR LATE-LIFE DEPRESSION

Interpersonal therapy is a technique developed for the treatment of
depression over 12-20 weekly sessions in which thoughts and feelings that
are beyond one s awareness, yet responsible for distress, may be changed by
examination. The target is behavioral change in present interpersonal
relations rather than resolution of intrapsychic conflict, with a focus on
short-term goals and problem solving rather than open-ended exploration
of thoughts and feelings. This approach has been successfully modified for
use with older adults (13). In particular, the therapist working with the
older adult must be active rather than neutral, targeting issues, and
focusing on pragmatic solutions. As in cognitive-behavioral therapy, educat-
ing the patient about how the treatment works is as important as establish-
ing rapport. Although interpersonal therapy is less directive than cognitive-
behavioral or problem-solving therapy, the therapist working with physically
disabled, medically frail older persons is often used as a resource for advice
and information (14).
Interpersonal therapy is designed to address four typical depression-
related problem areas: grief and bereavement, role transitions, role dis-
putes, such as marital conflict, and interpersonal deficits, such as difficul-
ties making new friends or accepting care. All occur commonly within the
geriatric population, and all may precipitate or worsen social isolation and
loneliness (12). The approach is explicitly time limited and is not designed
to alter personality traits or delusional material. An initial review of the
important personal relations within the patient s life, past and present, will
help to determine current conflicts as well as past influences and anteced-
ents. Specific relationships associated with current and previous episodes
of depression should be identified. Role-play may be used to demonstrate
or practice new interpersonal approaches or responses. Working within the
context of the realities of advanced age, the therapist must address the
patient s dependency needs, limitations due to loss, and life-long psychopa-
thology in a practical and realistic manner. Greater flexibility toward the
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length of the sessions, telephone accessibility, and missed appointments

due to transportation, health, or financial problems is extended to seniors
than would be the case with younger persons in therapy. Goals should be
kept modest, with ample support and frequent reassurance. Because the
older adult may have limited options to develop new relationships or living
situations, the patient is more often encouraged to tolerate rather than
terminate problematic long-term relationships, working with the therapist
towards finding acceptable alternatives.
LIFE REVIEW OR REMINISCENCE THERAPY
Life review or reminiscence therapy has much to offer the older person
struggling with troubling events or the realization of mortality, and may be
the treatment of choice for survivors of the European Holocaust and others
traumatized by overwhelming stress (15). The technique involves a review
of the past in an effort to help the patient find meaning in the present
through partial resolution of conflict within the self or with others. Integral
to the process are homework assignments, including review of memora-
bilia, photos or journals, reunions with friends or family, and autobiographi-
cal writing, all of which may be shared with the therapist. Through these
assignments, patients not only confront and solve old problems, but also
may find an increased tolerance for current conflict, a lessening of guilt and
fears, an acceptance of life circumstances, and a greater sense of giving (16).
Obstacles to treatment are multiple. Survivor guilt, rage, resentment,
cynicism, and distrust are only a few examples of the challenges to
therapeutic engagement and alliance. Patient recollections of betrayal,
desecration, humiliation, and incomprehensible loss threaten to overwhelm
the therapist. In spite of protests by some individuals to keep old wounds
buried, most patients are responding to the unspoken preferences of others
who would rather not be burdened or who trivialize the events. The
therapist s willingness to listen provides a powerful incentive to the patient,
as well as a measure of protection against damaging intrusion. While the
therapist will never fully realize the patients experience, a meaningful
degree of understanding for both parties is possible provided the patient is
willing to recall and communicate. This understanding can be crucial to
coping with life-threatening illness or injury, bereavement, or nursing home
admission that may evoke recollections of catastrophic events.
PROBLEM-SOLVING THERAPY
Problem-Solving Therapy is directive and brief, usually spanning six
sessions. The patient is asked to identify problems ranging from thoughts,
feelings, and interpersonal difficulties, assess the circumstances surround-
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ing each problem, assign those with a lesser probability for change to a
lower priority, and formulate a feasible approach of action. Once a problem
is identified and its determinants are specified, a brief list of potential
solutions is generated by patient and therapist. For each solution a set of
pros and cons is constructed that serves to prioritize the solutions from
most to least difficult to effect. Pessimism ("it hasn't worked before") and
lack of motivation ("I forgot to practice") are addressed within the course
of treatment. However, the focus is kept purposefully narrow on the initial
problem in order to avoid a dilution of effort, and the patient should be
reminded that additional problems might fall beyond the scope of the
present therapy. While it is sometimes necessary to address these additional
problems, the goal of treatment is to keep the patient and therapist focused
on specific, realistic solutions.

GROUP THERAPY WITH OLDER ADULTS

Group therapy serves a variety of patient needs. In the nursing home the
group may be a sounding board used to adjust to the indignities of
institutional living and to advocate for a greater stake in decision making.
In the outpatient setting, it may range from psychodynamic or cognitive
treatment of depression to maintenance of social interaction in cognitively
impaired persons. Regardless of the structure, the therapists positive
regard for each member, and an air of optimism, warmth, and empathy are
fundamental for success (17). Screening and preparation of patients for
group work is also essential. An assessment of the individuals emotional,
interpersonal, and cognitive capacity is critical to any successful group (18).
In each case the therapist will need to orient and educate the patient in
order to demystify the process, reduce anxiety, establish a therapeutic
alliance, and clarify expectations regarding attendance and confidentiality.
The patient should be able to express a willingness to commit sufficient
time and effort to a therapeutic trial. Patients who cannot or will not attend
to the process, who devalue others' participation, who blame others for
their problems, or who are unable to share anything positive about
themselves as a result of suspicion or depression will do poorly. When
group therapy is an adjunct to pharmacotherapy, it is important that both
the therapist and the prescribing provider communicate (19).
Older-adult groups need not be homogenous with regard to age,
gender, income, or marital status. However differences in cognitive impair-
ment, physical disability, hearing loss, and language will often prevent the
development of cohesion and therapeutic success. Persons with these
difficulties will require a more rather than less homogenous setting. While a
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mature, cohesive group can tolerate the addition of a more impaired

member, a newly formed group may be less forgiving. Patients in crisis or
those who are actively suicidal should be excluded until their distress is less
contagious.
Regardless of group composition, positive outcome is correlated with a
structured format (20). The structure will vary according to the problems
addressed or the technique employed. Impaired patients may benefit more
from an activity-oriented group than a more verbal modality. While
language skills in general vary more among older persons than young,
speech discrimination and immediate word recall tend to decline with age,
often resulting in decreased comprehension. Word recognition, however,
remains unchanged, or actually increases, as vocabulary expands. The
therapist must make allowances for failed communication and not hesitate
to repeat or reinforce information, making sure that all group members get
the intended message. Positive reinforcement, initiating, and insuring that
all members actively participate are the major activities of the therapist. By
fostering group cohesion, the therapist also promotes a critical expectation
of benefit and improved self-esteem. (21, 22) In order to lessen the
drop-out rate, mid-morning or early-afternoon groups are better suited for
seniors. Use of a cotherapist insures continuity across episodes of illness,
professional leave, and vacation.
Groups for patients with dementia have characteristics of both activity
groups and conventional psychotherapy. They should include aspects of
reality orientation, resocialization, and remotivation, with support and
positive feedback given for active, creative participation. Psychodynamic,
cognitive-behavioral, goal-directed, or problem-solving formats are less
beneficial, and homework is rarely assigned. Efforts that focus on improved
social skills, cognitive and sensory stimulation, and reduced behavioral
disturbance with resulting alleviation of caregiver burden are more realistic
goals. Reminiscence and maintaining a sense of self-regard promote satisfac-
tion and a sense of well-being. Relaxation exercises, in-chair range of
motion practices, discussion of holidays and recent events are also useful.
However reflection on the future is less beneficial. Some patients will have
difficulty maintaining the flow of conversation due to lack of speech
initiative or word-finding difficulty. Others will be unable to stop speaking
or will perseverate. The therapist should speak loudly and slowly, facilitat-
ing cues to individual openings and closures. Topics of discussion and
related vocabulary should be within the group members' grasp, often with
redundant categories and associations to assist failing memory. While
patient errors should not be challenged, correct information should be
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stated with tact and sensitivity. Transient improvements in verbal or

physical skills may occur but are not likely to persist. Coordination with
family caregivers is essential to arrange for attendance and feedback
(23-25).
Reminiscence or life-review groups assist patients to evaluate and
reintegrate their past within the interpersonal sphere of the "here and now,"
using recollections of past successes and losses in order to illuminate the
future. Increased life satisfaction rather than improved social skill is the
goal. Groups may be conducted with nursing home residents but must be
tailored to the cognitive and sensory capacities of the participants (26, 27).
"Milestoning," the purposeful review of positive life events, may be empha-
sized to foster cohesion and avoid group anxiety or demoralization.
Intervention by the therapist may be needed to redirect the conversation
back to current interpersonal experience should morbid pre-occupation
with the past or self-absorption occur (19).
In cognitive-behavioral group therapy the emphasis is on the achieve-
ment of mastery and a positive outlook. The group need not be diagnosti-
cally homogeneous, and may include patients suffering from panic attacks,
generalized anxiety, and depressive disorders. Although patients with
obsessive-compulsive disorder may be included due to the relative infre-
quency of their condition, they may also require individual sessions.
Treatment is time limited and incorporates behavioral strategies, recogni-
tion and rejection of negative thinking, alternative responses, relaxation
training, and assigned homework. Group learning is achieved through
individual example and the participants' capacity to question distorted
beliefs, self-defeating assumptions, perceived lack of alternatives, and
social isolation. Education regarding symptoms and diagnoses, focus upon
observable behavior rather than motivation, and role-play are key elements
that make the group a learning laboratory (19).
There is an established literature on psychodynamic groups with older
persons (28). The narcissistic injuries of aging are the focus, and the
technique is meant to maintain a sense of self-efficacy and self-esteem in the
face of age-related losses. The work is intrapsychic and interpersonal rather
than behavioral. The key elements revolve around transference to indi-
vidual group members, the group as a whole, or the therapist. The goals of
treatment are increased insight and adjustment, with little emphasis upon
homework or skill. Contact outside the group is discouraged in order to
maximize the examination of individual reactions within the group. Care-
givers of persons with dementia, Parkinson's disease, or stroke may be
better served with a support group.
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Caregiver support groups are often used in parallel with group time for
the patient with dementia. Here the focus is on a supportive relationship,
problem solving, and coping strategies, with the dual goals of reducing
depression and anxiety in the caregiver and delaying nursing home admis-
sion for the family member. Information regarding nursing homes, power
of attorney, coping skills, and behavioral disturbances are shared. Support
groups may be open-ended and sustain the individual beyond the death or
nursing home admission of their family member. Because the group may be
more supportive than insight oriented, contact between individuals outside
the group is not discouraged but is brought back for discussion. Caregivers
with longstanding marital conflict, personality disorder, substance abuse,
or major depression are better served with individual treatment (see section
below on caregiver treatment) (29, 30).

FAMILY THERAPY

The issues faced by the family with a declining senior member are similar to
the challenges of adolescence. The adolescent strives to establish autonomy
within the context of depending on family for security and support. The
older adult seeks to retain autonomy in the face of increased reliance on the
family as caregivers. The therapeutic approach begins with an effort to
understand the family's dilemma; neglect of the family will be at the
patient's expense. Sometimes the family acts as co-therapist, while at other
times the family is more of a "co-patient." Zarit and Zarit (12, 31)
summarize salient features of family caregiving, acknowledging the stress-
ful, stigmatizing affects of long-term illness and disability, the multitude of
stressors, the variety of possible adaptations made in response to these
stressors, the need to prioritize solutions including nursing home place-
ment, and the ongoing struggles between continuity and change.
Bereavement may begin as the transition is made to caregiver, continu-
ing throughout the patient's decline and eventual death. The transition into
the caregiving role involves change by the individual as well as increased
reliance on agencies and institutions by the family. Longstanding family
resentments, rivalries, power struggles, or financial interests can lead to
demoralization and paralysis. Family-systems theories can assist in clarify-
ing boundary issues or communication styles that may prove problematic.
Identification of enmeshed, overly protective or rigid families, or those with
single vs. multiple spokespersons is important (32). Semple (33) suggests
that typical conflicts experienced by families in dementia care include
disagreements and uncertainty concerning diagnosis, treatment, quantity
and quality of care, and division of caregiving responsibility. Psychody-
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namic issues can be central to these conflicts, with unconscious factors

driving the motivation to provide or withhold caregiving. Repressed hopes
of reconciliation, fears of domination, survivor guilt, or identification with
the aggressor may make a family member go to unreasonable lengths to
meet the needs of the care recipient or the preferences of other potential
caregivers.
The family meeting is the major means of allowing expression of
differing views and gaining consensus on potential interventions. As de-
scribed by Zarit and Zarit (12), a single meeting with telephone follow-up is
often sufficient to provide information, orient to the prognosis and care
needs, insure future access to the clinician, and reduce misunderstandings
and conflicts. Working with the patient and primary caregiver, arrange-
ments are made regarding whom to include and where to hold the meeting.
Meetings held in the home may be most effective, promoting a more
relaxed atmosphere and a more approachable clinician. Asking for ques-
tions from the outset will prepare the clinician for a more concise presenta-
tion of diagnostic and treatment issues as well as the transition to future
care needs and the expectations of the family. Once the family is satisfied
that the clinician has addressed the patient s needs, the focus can be shifted
to the caregiver and the family.

MARRIAGE OR COUPLES THERAPY WITH OLDER ADULTS

The bond of marriage and commitment can be particularly important in
coping with the stresses of late life. However, increased burdens of illness
and age-related changes such as retirement may have a negative impact
upon these ties. Beckham and Giordano (34) found that disabling illness or
impairment of one partner often creates new roles within the relationship
with strong implications for both individuals. Depression, especially when
resistant to antidepressant treatment, is a frequent cause of referral for
marital or couples therapy (35).
As conceptualized by Lewis (35), assessment of couples may be viewed
from an interpersonal perspective including issues of attachment, need for
intimacy vs. need for independence, shared beliefs, values and paradigms,
balances of power, and abilities to negotiate crisis. Greenbaum and Rader
(36) emphasized how older couples can experience future life-stage transi-
tions at an earlier time, as when the death of a parent or an in-law
precipitates marital conflict in which the bereaved spouse identifies with
the deceased and clings to or withdraws from the partner. Therapy can
facilitate the bereaved partners mourning, which, if unresolved may
contribute to the breakdown of longstanding marriages (37). Gilewski et al
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(38) discussed treatment extending over nine months to help a couple

establish a better relationship after longstanding marital conflict was
exacerbated by retirement. Wolinsky (39) designed a developmental coun-
seling model to encompass the emotional and psychological strengths and
liabilities of an older population. Stemming from his previous work in this
area (40), the model targeted issues unique to the mature-stage marriage,
marital life review, stress-reduction techniques and improved drug thera-
pies (39, 40). Alternative treatment techniques include conjoint marital
therapy, communication training, and behavioral approaches, such as
"contraction/relaxation exercises." Psychoanalytic therapy has also been
suggested to help patients transform the potential trauma of personal crises
into the progressive developmental experience of transition (41).
Based upon their study of 60 geriatric couples, Greenberg and Kennedy
(42) concluded that though issues of communication, intimacy and individu-
ation were similar among young and old couples, they could not be
approached in the geriatric patients without also addressing concrete
service needs or psychotherapeutic interventions, including medication. As
reported by Jacobson and Addis (43), less than satisfactory outcomes
following behavioral couple therapy were found among the more severely
disturbed couples, those of advanced age, the emotionally disengaged, and
couples with marked gender-role polarization. These findings led them to
conclude that preventive interventions at periods of the life cycle known to
be high risk for couples discord may be more successful than modifications
made after the fact.

TREATMENT OF CAREGIVER BURDEN AND DEPRESSION

Family members remain the mainstay of dementia care in the community.
Their caregiving burden has long been recognized as a major public health
concern. Efforts to contain Medicare and Medicaid expenditures for home
care and nursing facilities threaten to further increase this already substan-
tial burden. Gallagher and associates (44) found that among caregivers,
46% of those seeking help and 18% not seeking help met diagnostic
criteria for depression. There is considerable literature on the importance
of spouses to the well-being of persons with dementia; Caregiver burden is
an independent predictor of institutionalization beyond that which might
be explained by the relatives impairment (45). A number of studies
indicate that with adequate treatment of depression, caregiver burden can
be reduced, affective symptoms in their demented relatives improved, and
nursing home admission delayed (29, 46-47). However, though consider-
able attention has been devoted to the distress associated with caring for
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someone with dementia in the community, less has been directed to

caregivers following nursing home admission, despite the fact that more
than 80% of community caregivers do not relinquish the role once their
relative is admitted (31, 48). Even in those cases in which caregiver
assistance does decline following nursing home admission, there may be no
associated decline in caregiver burden compared to community caregivers
(47, 49). Rather, it appears that neither the severity of impairment nor the
extent of caregiving is directly correlated with the weight of the burden
(45,49-54).
Difficulties with issues of separation-individuation can add to the
burden of care giving and predict caregiver depression, often presenting as
prolonged preoccupation with the demented individual or confusion with
their new role within the family (55). Despite existing studies of therapeutic
interventions regarding separation-individuation, questions remain as to
whether excessive caregiver burden is an indicator of untreated depression,
warranting individual psychiatric treatment rather than support-group
services (29,56). Zarit and Zarit (12) noted that caregivers usually seek help
for their relative rather than themselves, so that initial assessment must
begin with the identified patient before shifting to the caregiver s needs.
Some caregivers are reluctant to make their needs known to other family
members or to accept assistance from a home care agency, often related to
underlying fears of rejection, inadequacy, loss of control, or financial
concerns. The impact of caregiving upon functioning in other areas of the
individuals life should be determined. Serious impairment in job perfor-
mance or other family responsibilities should be identified. Following
assessment of needs, problems, stressors, supports, and proposed interven-
tions may include counseling and education, problem-solving and family
meetings, or support via individual or group formats.
Peer support through dementia-caregiver groups sponsored by local
Alzheimer's associations or nursing homes will lessen the alienation and
sense of inadequacy the caregiver feels. However, support groups are not
available to, nor desired by, all caregivers. A support group in which all the
caregivers have late-stage relatives will shock the person whose spouse or
sibling is in the early stage of illness. Due to the supportive nature of the
task, relationships extending beyond the group are encouraged. However,
as previously mentioned, group support is no substitute for individual
treatment when warranted, especially in cases exhibiting symptoms of
depression, anxiety, substance use, psychosis, or suicidality. Medication,
interpersonal therapy, and cognitive behavioral treatment may all be useful
in these instances. As caregivers experience grief reactions, more likely
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during the initial and final phases of their relative s illness, bereavement
therapy (described below) may be appropriate. The element that differenti-
ates treatment of caregivers is the ongoing and progressive nature of the
stress. While many caregivers will cope with a minimum of support and
information, others will benefit from referral to community agencies and
peer support groups, and a growing minority will require the assistance of a
mental health specialist. As the boundaries between these categories are
fluid rather than fixed, a sophisticated, structured approach to the care-
giver with ongoing assessment and re-assessment of problems and appropri-
ate interventions is necessary.

BEREAVEMENT THERAPY

Bereavement is a predictable life event among older adults. Loss of one s

spouse, friends, siblings, adult children, and even grandchildren is increas-
ingly frequent with advanced age. Although most older patients may not
perceive bereavement to be a problem in need of professional attention,
there are demonstrable impacts upon mortality (57). Compared to younger
individuals suffering similar losses, bereaved older adults are more likely to
develop a major depressive episode within one year of their loss. Spousal
bereavement, more prevalent among older women than men, is accompa-
nied by greater likelihood of disability, solitary living, and nursing home
admission. In light of these factors, it is important to recognize the
complications of bereavement and to assist patients in negotiating the
experience, especially when social isolation, advanced age, or medical
comorbidity are present. The principles of bereavement therapy can apply
to the loss of any family member or intimate friend. The technique is
straightforward, with elements of cognitive-behavioral and psychodynamic
therapy.
Most older patients are not surprised by their feelings of emptiness,
sadness or loneliness, nor by their preoccupation with the deceased.
Hallucinatory phenomena of scent, sight or tactile awareness of the de-
parted spouse are common and often comforting. However, reported
fatigue, irritability, insomnia, anger, and social isolation are less often
anticipated and unwelcome. Ambivalent past relations, unresolved resent-
ments, or histories of abusive behavior by the deceased may lead to
particularly complicated grief reactions. Sudden, unexpected death occurs
with little time for the individual and the supportive relationships to
prepare. Those with weaker social networks may face more difficult
transitions. Individuals without children and older husbands dependent
upon their wives for a social life may find the social isolation difficult to
402
 Psychotherapy with Older Adults

bear. Conversely, the death of a loved one following prolonged dementia or

other chronic illness may be followed by a relatively brief period of
mourning.
At the onset of therapy, the patient is offered an initial session in which
to discuss feelings and coping with the loss. The circumstances of the
spouse's death are elicited in an effort to alleviate the burden of grief as well
as to uncover doubts and ambivalence about what the patient or other
caregivers might have done to prevent the loss. Self-blame or resentment
towards others needs to be explored and the reality of interpretations
tested. Similarly guilt over feeling relief at the passing of a difficult burden
should be uncovered. Anger at the spouse for "going first, leaving me alone
with all this" may not be expressed initially, either out of respect for the
dead or fear of the intensity of the resentment.
When several sessions seem indicated, an interpersonal inventory of the
bereaved might be helpful. Shared and delegated roles and responsibilities
within the relationship should be explored, including management of
financial and social obligations as well as practical adjustments that the
surviving individual may need to make. Reflections of the couples' first
meeting, shared leisure interests, life accomplishments, and reactions to the
births of children serve to balance more negative feelings, reinforcing the
lasting value of the relationship and allowing for expression of less pleasant
recollections. The impact of earlier losses, such as parents, siblings, or
friends will likely affect the patient's response to later bereavement and
should be included in the inventory. Accessibility of children and grandchil-
dren as a realistic source of support should be assessed, as well as any
considerations of relocating nearer to the child. Issues of autonomy vs.
dependence will likely arise. Some patients with a history of marital
conflict, periods of separation, or extramarital affairs may welcome new
freedoms. For others, thoughts of future romance are alien and fraught
with feelings of guilt and betrayal. In many cases a predetermined waiting
period has already been chosen as a boundary.
The patient should be encouraged to reestablish life's routine and social
rhythm, maintaining regular sleep, exercise, and meals, attending church,
synagogue or senior center, and participating in volunteer organizations
and family affairs. While it may be difficult initially to be around others
who serve as a painful reminder of the loss, the patient should be reminded
that it is better to confront these painful memories surrounded by a support
system than to do so alone. When transition back to the regular routine is
significantly impeded by severe, persistent or disabling sleep disturbance,
weight loss, helplessness, or undue suspicion and isolation, intervention
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may be indicated. Extreme withdrawal, persistent refusal to interact with

family or friends, and evidence of frank delusions suggest a paranoid
reaction. In an individual without past history of similar episodes, the
correct diagnosis may be brief psychotic reaction; sleep deprivation can
play a role as precipitant. Treatment with an antipsychotic should be
initiated with planned withdrawal within the coming months. Although
passive wishes for death are not uncommon in bereavement, intrusive
thoughts of suicide or suicidal methods should signal major depression and
indicate a need for more aggressive treatment. Other signals include neglect
of life-saving medications (hypoglycemics, antihypertensives, antiarrhyth-
mics), increased alcohol intake, and misuse of analgesics. While sedatives,
such as Zolpidem or short-acting benzodiazepines, may be of considerable
benefit, in patients with symptoms that approach major depressive criteria
or require treatment with a benzodiazepine for more than 2 weeks, sedative
antidepressants, including nortriptyline, trazodone, nefazodone, or mirtaz-
epine may be a better choice. The ultimate goal of Bereavement Therapy is
to assist the patient in processing the past relationship and current loss in
order to bear the future separation and maximize existing, positive relation-
ships.

CONCLUSION

There is increasing evidence that older patients suffering from a variety of

disorders, including depression, anxiety, caregiver burden, and compli-
cated bereavement, can benefit from psychotherapeutic interventions. For
therapists accustomed to psychotherapy with younger persons, necessary
adjustments may include allowances for sensory and cognitive impair-
ments, greater collaboration with the patients family and other care
providers, and identification of improved function as well as symptom
reduction as worthwhile goals. Facility with couples, families, and group-
therapy techniques will expand the practitioner's options and the patient's
opportunities. In conjunction with current advances in the choices and
benefits of pharmacotherapy, late-life psychotherapy remains a fundamen-
tal component of treatment.

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 REFLECTIONS

Transpersonal Psychotherapy

SEYMOUR BOORSTEIN, M.D.*

The history, theory, and practice of Transpersonal (or Spiritual) Psychotherapy

are presented. The author describes his own evolution from a traditional
psychoanalyst to a psychotherapist who uses the tools and wisdom from
spiritual traditions to enhance traditional psychotherapy while, at the same
time, improving the self system of the therapist. Dangers as well as benefits of
the spiritual approach are outlined.
The creation and holding of a spiritual or transpersonal context is described
and ways to ascertain, in the clinical situation, the appropriateness of such an
approach are explained.
The use of bibliotherapy to help transform and expand the worldview of
the patient is outlined. Prayer and meditational systems also have a healing
role in this approach. To illustrate the uses of Transpersonal Psychotherapy in
practice, four cases are presented: 1) a paranoid schizophrenic man, 2) a
well-functioning borderline person, 3) a very poorly functioning borderline
person, and 4) a high-functioning neurotic man who had been in psychoanaly-
sis.

In this paper, I will start by providing a general overview of what the

transpersonal or spiritual focuses on, and then I will explain how I have
tried to use the transpersonal in clinical ways to help my patients. (The
terms transpersonal and spiritual are used interchangeably.)
To say something significant about psychotherapy in general in a paper
of this length is almost impossible, and to focus on transpersonal psycho-
therapy is even more challenging. Just as there is no meeting of minds as to
what psychotherapy is, I believe there is even less agreement about what
Transpersonal Psychotherapy is in its specifics. (A selection of the abun-

*Associate Clinical Professor of Psychiatry, University of California School of Medicine. Mailing

address. 45 Laurel Grove, Kentfield, C A 94904.
A M E R I C A N JOURNAL OF PSYCHOTHERAPY, Vol. 54, No. 3, Summer 2000

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dant variety of spiritual approaches can be found in my book, Transpersonal

Psychotherapy [1].)

OVERVIEW

In 1992, in an article in the Journal of Transpersonal Psychotherapy, Lajoie

and Shapiro (2) reported on their survey of more than 200 definitions of
transpersonal psychology and concluded that the field is "concerned with
the study of humanity's highest potential, and with the recognition, under-
standing, and realization of intuitive, spiritual, and transcendent states of
consciousness" (p. 91).
Some aspects of a spiritual approach to the healing of emotional
problems have been practiced for thousands of years by shamans and
medicine men. Aside from Jung's work in this area earlier in the twentieth
century, I would date the more "modern" struggles with the transpersonal
to the past thirty to thirty-five years.
It was in the 1960s that research with LSD and other psychedelics
suggested that there were alternate states of consciousness or realities
available to be experienced. Also around that time, many young Americans
went to Asia and brought back to the western world meditative and
spiritual systems they had encountered and practiced there.
It was an era of great experimentation and exploration into altered mind
states and alternate belief systems of what reality is. Throughout the past
three decades or so, there has been an increase in vigorous theorizing,
thinking, and practicing in transpersonal studies, resulting in what to me is
the emergence of the field of transpersonal psychotherapy in its own right. I
want to emphasize however that, because of the difficulties of dealing with
areas of knowledge and experience beyond the usual boundaries of body-
ego and beyond the limitations of space and time, the field is still in its
infancy. To speak of extending ones sense of identity beyond [trans] the
individual [personal) to encompass wider aspects of humanity, thinking,
and the cosmos, is difficult for most people. This is especially true of
therapists who were taught using hard sciences as their model for the
understanding and approach to life's problems.
I believe that a special tribute to Ken Wilber is called for because of his
efforts over the past twenty-three years to clarify the many complexities in
the areas of consciousness, transcendent states, psychology, meditation,
and other spiritual systems.
Historically, the main theoretical approach to transpersonal knowledge
has been based on the Perennial Philosophy model of Aldous Huxley in
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which one believes in and can experience the nonseparateness and intercon-
nectedness (one-ness) of all things.
More recent writers, such as Jorge N. Ferrer, feel that the over-emphasis
on the personal-experience approach to the transpersonal can lead to
spiritual narcissism. I believe that the use of spiritual knowledge for
self-inflation feeds narcissism, and under narcissism's influence, spiritual
leaders, even some who are considered advanced practitioners of respected
spiritual systems, may take advantage of their followers (sexually or finan-
cially). With spiritual narcissism comes the nonintegration of the transper-
sonal into everyday life. "It cannot be repeated too often that, regardless of
the quantity, spiritual experiences do not 'produce a spiritual life" (3).
Ferrer's emphasis is on understanding the transpersonal as something to
participate in rather than own. Thus, the awareness of the sacred can be
present in an individual, a relationship, a community, or even a place (e.g.,
so-called sacred locations, such as Lourdes). ^

VALUE O F TRANSPERSONAL PSYCHOTHERAPY

In the preparatory stages of writing this paper, I asked myself: Of what

value is transpersonal psychotherapy? What does it offer that a more
traditional psychotherapy does not? How might it change the therapist and
the patient in ways that are less likely with traditional psychotherapy? As I
pondered these few questions, I felt that they call for a book-length
endeavor to be explored fully. But let me try to, at least, outline some of the
major points.
To enter into the realm of the transpersonal involves a specific world-
view that then offers certain very hopeful and positive directions. Philoso-
phers and religious and spiritual leaders have struggled for thousands of
years with the question of the purpose of life.
To pursue the spiritual dimensions of life presents an immediate
problem for the scientist. My belief is that these dimensions lie outside of
our space-time dimension or are perhaps intertwined or enfolded within it
in ways that we cannot yet understand. I do not believe that we currently
have instrumentation that can measure or validate these other dimensions.
Are they perhaps the "other dimensions" that the quantum physicists who
are studying the String Theory postulate? (4).
Meditation, psychedelics, and Holotropic Breathing (5) are a few of the
methods by which these other dimensions can be accessed. Can conscious-
ness exist without a body to enclose it? Data on Near-Death Experiences
(6), Remote Viewing and Healing-at-a-Distance (7), Reincarnation (8), and
the Spectrum of Consciousness (9) suggest that it can. Again, we run into
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the problem of "scientific" validation of events that I believe are happening

outside of or beyond our usual understanding of our space-time dimension.
Even the solidity, stability, or dependability of our space-time dimension
is in question with Einstein's relativity theories in which we see that those
things we assume are constant (space and time) are not as constant as we
thought.
Many of the great religious and spiritual systems, along with certain
philosophic stances, suggest that our perception of what we call popular
reality is flawed, that what we see as dual or separate is not really that way,
that on some level all things are interconnected. Another way of saying this
is "God is One" or "Everything is God" or "The manifest world and
Ultimate Source (God, the Divine, Emptiness, etc.) are all one." Since
language itself is dualistic, it is difficult even to talk or write about
transpersonal matters. We are talking about a possibly nondualistic system
with dualistic language, and that presents problems from the start.
The Dalai Lama has taught that it would probably be best if we could
experience both dimensions simultaneously. Most of us usually live in
space-time with occasional moments of awareness of a spiritual dimension.
I feel that therapists can be inspired to have greater empathy and caring
for their patients when they believe in their interconnectedness. This can be
especially helpful with patients who are more challenging to us and toward
whom we have less-than-caring feelings. The spiritual dimension(s) is most
often associated (in its ultimate stages) with positive feelings, such as love.
(This is not to say that there are not "Dark Night of the Soul" periods also.)
Before going on, I need to mention a not uncommon danger of having
this worldview. For people in a lot of psychological and/or physical pain,
these other dimensions can present an enticing escape to avoid doing the
psychological and/or physical work of mastering the problems of existence
in our space-time world.
Early on in the New Age Movement (1960s and 1970s), there was a
common sentiment that the spiritual dimension was primary and therefore
most or all of one's energies should be used in its pursuit. Narcissistic
self-inflation was (and still is) a real dangerous consequence of holding this
view of " I am on the God Squad." There are now spiritual teachers and
theoreticians who feel that the glimpses (or more) of the transcendent
dimensions should be used to help transform this dimension or, to say it
another way, to bring heaven onto earth. This view is an antidote to
narcissistic proclivities and can greatly increase one's healthy engagement
with this dimension of life.
Patients can use as ego-ideal models many of the spiritual teachers
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present and past, especially in how they handle(d) adversity, anger, and
forgiveness. Death for self and loved ones, with all of its surrounding issues,
becomes softer and a bit less frightening.
My current working hypothesis is that the core nature of consciousness
is positive and loving, and that negative mind states arise with the concern
of survival of the body. We are genetically neuronally programmed for
survival, and when this is threatened, in reality or metaphorically, our
fight/flight survival mechanisms kick in and give rise to the usual negative
mind states we see, such as anger, depression, and withdrawal.
Personal Background
At this point in the paper, I need to stop for a brief excursion into how I
came to be involved in this area. Whereas traditional psychotherapy can be
taught to any reasonable student of human psychology, Transpersonal
psychotherapy cannot. The arena of the transpersonal cannot be ap-
proached just intellectually—like love, it has to be believed in and/or
experienced to some extent.
In 1959, I finished a traditional psychiatric training program at the
Menninger School of Psychiatry and subsequently finished my traditional
psychoanalytic training at the San Francisco Psychoanalytic Institute in
1969. Until 1970, I would have described myself as an atheist and dour
realist, i.e., pessimist. In the early 1970s in California, there was the
phenomenon of weekend New Age workshops in which everything was
promised from enlightenment (whatever that vague term meant) to the
development of all kinds of paranormal powers. On a whim, I attended a
meditation course given by a physician for physicians only. The goal of this
course was to develop the power to make diagnoses at a distance, having
only a name and address. I believed that it could not be done. To my
amazement, at the end of the workshop, I made five consecutive correct
diagnoses, including a missing middle finger, cancer of the lower left bowel,
and tuberculosis of the upper lung. My traditional scientific paradigms
were deeply shaken by this experience. I had obtained knowledge outside
any traditional modes of informational transfer, and over the next five years
I explored everything I could to try to make sense out of what I experi-
enced.
In time I realized that the development of paranormal powers was a
secondary phenomenon to the spiritual search for the more ultimate
questions and answers about existence. This is the arena where religion (the
more traditional, organized groups) and spiritual approaches and disci-
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plines have struggled for the ultimate answers to spiritual questions — Why
are we here? Is there a purpose to existence? Where did we come from?
I believe that traditional psychotherapy is basically pessimistic (though
called "realistic") in its outlook. There is the oft-quoted line attributed to
Freud that psychoanalysis attempts to convert "neurotic misery to ordinary
misery." Transpersonal psychotherapy attempts to open awareness to this
and to other psychic realms where joy, love, serenity, and even ecstasy are
present. As I have stated, without a basic belief in and/or experience of
these transpersonal or spiritual realms, I do not think one can be a
transpersonal or spiritual psychotherapist.
My belief in the separateness of the lines of development of our
emotional and spiritual life has led me to a very specific approach that I find
useful. (I must again reemphasize that just as traditional psychotherapy has
many approaches, so many other transpersonal therapists may have ap-
proaches different from mine. I discuss my personal therapeutic approach
in more detail in Clinical Studies in Transpersonal Psychotherapy [10].)
Where applicable, I use the technologies developed by religious and
spiritual traditions to access transpersonal realms to help in the healing of
the more common painful psychological states. In addition, I work within a
certain spiritual context wherein I conceive of every patient as a part of me
in a much larger picture (the "no-boundary interconnectedness" of which
Huxley's Perennial Philosophy speaks). I maintain this contextual stance
whether or not the patient has a religious or spiritual belief system. Should
the patient have such a system, then I will in all likelihood share my belief
system. If the patient does not have such a belief system, I will usually keep
this context quietly to myself. To my surprise, I find that this does not affect
the patient's transference work in any significant way, and it does improve
the working alliance.
Spiritual approaches may be helpful in the healing of traditional
psychological problems. I use the more readily available psychological tools
as my primary methods to approach my patients' conditions. This also
includes the use of medication when appropriate. If there are genetic
and/or biochemical proclivities toward, for example, depression or anxiety,
then meditation or other spiritual practices may have little or no effect on
relieving the conditions. There is now enough data to suggest that although
a spiritual approach may help one live more comfortably with a depression
or anxiety condition, it may take a psychotropic, "biochemical helper" to
eliminate the condition. I believe that life is difficult enough as is, and if
there is any way to lessen the suffering, I think we should do it. I do not see
any virtue in needlessly struggling with relievable pain.
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I personally know of some spiritual teachers and long-term (twenty-five

to thirty years) spiritual aspirants who use the SSRIs (e.g., Prozac or Zoloft)
to lessen their depression and anxiety, which thereby greatly deepens their
spiritual practice. There is still a feeling among some spiritual practitioners
that to use medication means you have failed in overcoming your problems
with spiritual tools. Happily this view is beginning to change.
APPLICATION OF TRANSPERSONAL APPROACH
Having laid some of the background material in place, I can come to the
second part of this paper. Specifically, how do I use the transpersonal
approach to help those who come to me as patients? Let me list my tools
and then go into how and when I use them.
Spiritual Context
Foremost is the spiritual context within which I hold all of my patients. I
have no doubt that this helps me stay in a caring mode—especially with
difficult patients. To convey to a patient that you see him or her as being a
piece of the Divine is incredibly powerful to begin to counter a life-long
view of worthlessness. It can only be done when appropriate for the given
patient, and it will not be effective if the therapist does not actually believe
it in his/her mind and experience it in his/her heart. This approach can also
do wonders in the area of inspiring changes in behavior — especially those
of a narcissistic nature. Another way of conceptualizing this would be in the
development of newer and healthier ego-ideal models. I might ask patients
if what they are doing or want to do is honoring the Divinity within them.
In psychological (self psychology) terms, this can be seen as a type of
mirroring.
Again, where appropriate, I might share with my patients that I pray for
them on a daily basis. There are now three well-researched and formatted
double-blind medical studies (two studies of postoperative healing in
patients recovering from coronary bypass surgery and one study of hospital-
ized AIDS patients) clearly showing that prayer can affect biological
processes, although we do not have a clue as to how it works (11-13). Does
prayer work for me and my patients? I don't know, but most of my patients
do get better. And it helps keep me oriented in a more positive (spiritual)
mind-frame.
Before proceeding, I want to clarify how I determine if adding a
transpersonal or spiritual component will be of value. Somewhere in the
first visit I inquire if the patient is an atheist, theist, or agnostic and if he
currently has a spiritual or religious practice or belief system. Because of
their backgrounds, some patients are antireligious or antispiritual, and in
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those situations I will usually maintain a silent spiritual context of my own.

On occasion, where there is no antipathy, I might suggest that the patient
look at Ken Wilber's first book No Boundary (14), a nonsectarian approach
to the ideas inherent in the Perennial Philosophy. Some patients are bored
or uninterested in the contents, and with those I cease and desist. Other
patients become very excited and interested in knowing more, and with
those individuals adding a spiritual component will usually be very helpful.
Of course, those who already have these belief systems are also helped by
the addition of certain spiritual ideas and practices.

TOOLS OF HEALING
I would like to discuss here in more detail some of the tools I have
borrowed from spiritual or religious traditions to aid in the psychological
healing of patients who come to see me.
In addition to my holding a spiritual or transpersonal context that,
when appropriate, I share with my patients, I use spiritual bibliotherapy,
which is suggesting appropriate books for patients to read. This can help
with certain types of neurotic anxieties and existential angst and gently
invite the reader to contemplate the larger questions of existence. It also
can lead to a more productive engagement with life, both more immediate
and even planetary (e.g., work in worldwide ecological issues as well as
helping the social needs of other human beings). Books describing the lives
of certain advanced spiritual beings can be an inspiration and serve as
ego-ideal models (15).
I divide the use of spiritual bibliotherapy into two general categories:
1. For actual transformation, I found that for many patients reading A
Course in Miracles (16) has been very helpful in opening their thinking
about their lives' dilemmas, how to view them and what they or their own
intimates can do about them. (This book should be read at about a one- to
two-pages-a-day pace and then contemplated.) A Course in Miracles is a
metaphysical text exploring our nondual nature with exercises and medita-
tions that can be used for spiritual changes without the need for a teacher,
eliminating any problems that might stem from difficulty with authority
figures.
2. For expanding ones worldview, I recommend books that attempt to
open readers to a much larger, positive picture concerning their existence,
such as, The Grace in Dying by Singh, on death (17); Lessons from the Light
by Ring, on the existence of consciousness without the need for a living
body (18); Where Reincarnation and Biology Intersect by Stevenson, on the
"movement" of consciousness from one lifetime to another (19); many
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writings of Ken Wilber on the intellectual investigation of consciousness

(20); The Cosmic Game by Grof, on the cosmological implications of LSD
research (21); The Self-Aware Universe by Goswami (22) and Schrodingers
Kittens and the Search for Reality by Gribben (23), on the findings and
theorizing by astrophysicists and quantum mechanic physicists supportive
of the notion of the interconnectedness idea of the Perennial Philosophy.
A major advantage of transpersonal writings is that they tend to bypass
the transference problems inherent in any "teaching" or "instruction." The
patient can close the book at will. The amount of spiritual literature
pouring into the public domain is significant — one need only look at The
New York Times Best Sellers List to get a sense of this. The transpersonal
therapist can help direct the patient to some specific topic or book that
would be helpful.

MEDITATION

I do not consider myself a meditation teacher, so, when I think it appropri-

ate, I will refer a patient to the many meditation centers in my area. There
are basically two types of meditation:
1. Concentration Meditation, in which a word or phrase or breath-
watching is used to block out any other thoughts. Herbert Benson showed
in his work at Harvard (24) that doing Transcendental Meditation ®, a
focused meditation, had many physiological benefits. My experience is that
concentration meditation, as it is also called, can effectively block out more
disturbing thoughts and feelings and thus "splint" the mind for a while
enabling some healing to occur. Words or phrases from a religious or
spiritual tradition can be used or, as expounded by Benson, the use of
secular words can be equally effective (e.g., the word "One").
2. Open Meditation, in which one keeps one's awareness on whatever
changing phenomena arise in the mind. This will frequently lower psycho-
logical defenses to formerly repressed material and enhance the awareness
of one's psychological patterns as they constantly manifest. Especially in the
early stages of meditation the psychological dimension arises very often.
With some grace, luck, and perseverance, one can get glimpses of realities
behind, above, inside, etc., within which our space-time dualistic nature
interacts.
Reading about spirituality can instill a sense of belief, and certain
experiences (e.g., meditation) can give a sense of knowing that these other
dimensions exist.
I also use certain techniques (literature and mantras) to foster forgive-
ness and coping with anger. There are specific forgiveness meditations from
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many of the great religious or spiritual traditions — the Hebrew Bedtime

Shema (25); Christian-based phrases modeled on Jesus' sayings and ac-
tions, e.g., Lords Prayer: "Forgive us our trespasses as we forgive those
who trespass against us," and from the Buddhist meditation teacher Joseph
Goldstein: "If I have offended or harmed anyone knowingly or unknow-
ingly, I ask their forgiveness and if anyone else has offended or harmed me
knowingly or unknowingly, I forgive them." The last three words can be
very difficult to think or to say, but repetition of the prayer can greatly
soften the situation.
Right Speech (from the Buddhist tradition) emphasizes not only telling
the truth, but saying it in such a way that the listener is happy to hear it. If
we all could do this, the world would be transformed very quickly. The
Hebrew tradition also teaches about Lashan Hara (the "evil tongue") and
how to avoid it.
ADDITIONAL TOOLS

Other tools to help with psychological pain and transformation include

Holotropic Breathwork, LSD (where legal), past-life-regression hypnosis,
yoga, visualizations, and psychodrama.
When I first began to experiment thirty years ago with adding a spiritual
component to my standard psychotherapy approach, I subscribed to the
popular misconception that one had to be a fairly well-integrated person to
use these spiritual tools. My experience has led me to feel that this idea is in
error. When used judiciously, with some monitoring for negative side
effects, I believe that these practices can be used for any of the classical
diagnostic categories. Obviously a person in the throes of a crisis situation
or one who is so disorganized as to make communication difficult would be
a poor candidate for a transpersonal approach. In general, patients will try
to use these practices in an integrative way, and monitoring the situation is
always important. These issues were brought home to me in my work with
George.
Vignette 1
I met George, a paranoid schizophrenic, in 1961, when he was forty-three.
(His mother and two siblings were also diagnosed a paranoid schizophren-
ics.) At that time he required hospitalization for paranoia and inability to
function. I worked with George for the next thirty-eight years (he died
recently) on varying schedules from weekly to every third month, depend-
ing on his ability to function.
If he ever stopped taking his antipsychotic medication (Mellaril, 75
mg/day) he would become disorganized and need hospitalization. When he
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retired from work at age sixty-five, I suggested, in a purely experimental

mode, that he "take a look at" A Course in Miracles (16) and see if he found
it helpful. Retrospectively, A Course in Miracles would be considered too
sophisticated and complex a book for someone who was poorly educated
(as George was) and only a few steps away from psychological disorganiza-
tion (George lived a schizoid existence in a trailer park).
To my great surprise, what happened was that his paranoid, psychotic
thinking became more kind. After reading A Course in Miracles (which
speaks often of forgiveness), he told me that he now understood why his
neighbors dog was defecating on the steps to his trailer. He told me it was
because " I wasn't sending enough loving thoughts to my neighbor."
Reading A Course in Miracles apparently helped him organize his psychotic
thinking in a more kindly way.

Vignette 2
Barry, a thirty-two-year-old bus driver, had been fairly well integrated (good
marriage, two children, reasonably normal developmental history) when he
began to have paranoid persecutory ideation and was unable to relate to
coworkers and family. This came about because of the psychological
trauma that aroused great guilt and shame when as a volunteer paramedic
he made a mistake and another person suffered greatly.
Diagnostically, borderline psychotic personality would be closest. Be-
cause he drove a bus, his union contract would not allow him to take any
psychotropic drugs. With medication ruled out, I suggested in an experi-
mental way that he do a mantra meditation from his religious background.
He chose to say the "Glory Be" from the Catholic liturgy: "Glory be to the
Father, the Son, and the Holy Spirit, as it was in the beginning is now and
ever shall be, world without end. Amen." In addition to supportive
psychotherapy, he used A Course in Miracles for concentration meditation
purposes, rather than for contemplation. Thus the persecutory delusional
thoughts were kept at bay and did not overwhelm him as they had before.
In a relatively short time (a few months) the paranoid ideation totally
disappeared, and he was able to resume his work and family life. I felt that
the meditation "splinted" his mind and permitted the other therapeutic
forces of family and therapy to help him mend.
Meditation has now reached mainstream America. It is written about in
Time and Newsweek and is being incorporated into the approaches of
many traditional religious groups. In addition, the work of Jon Kabat-Zinn
has introduced meditation (in this case, a version of Buddhist Mindfulness
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Meditation) into mainstream medicine as an adjunct helping agent for

chronic and/or painful medical conditions (26).
As I mentioned briefly before, there are basically two kinds of medita-
tion—focused (e.g., on one s breath or repetition of a mantra) or open, not
focused (e.g., Buddhist mindfulness or Dzogchen practice). (For greater
detail on meditation, see Daniel Golemans The Meditative Mind [27].)
Some of these meditational systems have been in existence for thousands of
years and evolved to help the practitioners see the dimensions beyond what
we call popular reality. My clinical observations agree with Wilber's theory
that emotional and spiritual lines of development are separate, and I
therefore feel quite comfortable borrowing spiritual tools to help those who
may have emotional distress. In the same vein, I feel it is appropriate to use
psychotherapeutic tools to free up spiritual practitioners from psychologi-
cal problems that are preventing them from putting energy into their
spiritual quest.
Vignette 3
David, age forty-one, was sent to me by a psychoanalyst colleague for
treatment under the Vocational Disability Act. He had murderous and
suicidal ideation along with alcohol and marijuana abuse. The diagnosis
given to him by the Disability Board was "borderline personality" and his
symptoms were precipitated by his supervisor having an affair with David s
ex-wife. Given that I was authorized to see him only once a week, I did not
know where to begin.
Initially bibliotherapy connected us, and a mild tranquilizer helped with
his periods of great rage. He was intrigued by what he read of Buddhist
mindfulness meditation, and I (retrospectively, naively) sent him to a very
reputable teacher for a ten-day retreat. He developed extraordinarily
strong concentration, actually using the nonfocused meditation for focus-
ing purposes. This practice, along with certain forgiveness meditations,
resulted in his becoming symptom-free within a year, and he was able to
return to work alongside his former (nemesis) supervisor. I had an eighteen-
year follow-up (including confirmatory talks with his wife) that indicated
that all gains were maintained, and he was continuing his daily use of
focusing meditation. In fact, recently at his company he was named
Employee of the Year.
Vignette 4
I want to describe in greater detail the case of Bruce, a forty-nine-year-old
engineer in a good marriage with three grown children, who functioned at a
high psychological level. Bruce s case history demonstrates the possible
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interplay of the "personal" and the "transpersonal." What was unique was
that fifteen years earlier Bruce had been in traditional, psychoanalytically
oriented psychotherapy with an excellent psychoanalyst. For many years in
therapy, Bruce had successfully worked out many aspects of his neurotic
anxiety and lack of self-confidence.
He was referred to me by a mutual friend because of my spiritual
interests, hoping that I might have some "new" approach to Bruce s lifelong
problems with melancholia and low level of sadness. His father's recent
death and the approach of his fiftieth birthday raised for him many
questions about his life. Was it meaningful or trivial? Could there be more?
The Catholicism of his early life did not seem to provide enough answers.
Despite his mother 's Catholic orthodoxy, Bruce left the church in early
adulthood. His mother had died a few years before his father and was
remembered by Bruce as being severely hypercritical, angry, and sexually
seductive. With both parents dead, Bruce felt he was next in line, and the
issues surrounding death became very important to him.
I believed that his earlier psychotherapy was very effective, but, as is
usually the case, clearly some areas were not adequately explored. Taking a
careful developmental history revealed that his mother had been very ill
with postpartum complications necessitating that Bruce be kept in the
Catholic Hospitals nursery where care was given along rigid schedules with
little or no time spent on caressing and fondling—just feeding. Because of
his mother's postpartum condition (she nearly died), Bruce spent very little
time with her.
The melancholia and sadness had been minimized by Bruce in his
earlier therapy. I underestimated their significance, although I suspected
they related to this very early deprivational state. His long-term marriage
was described as satisfactory and, because of the description of his earlier
psychotherapy, I erroneously assumed that there were no significant oedi-
pal issues at play.
We started treatment with the idea that existential issues were the
primary concerns of his mid-life distress. I recommended that Bruce read
some of Ken Wilber's books dealing with big-picture issues, such as
pointed to in Aldous Huxley's The Perennial Philosophy (28). Aside from
this spiritual material being offered, most of our interactions were on the
"free association" model, which he was introduced to in his first psycho-
therapy. This included exploring, where necessary, distortions or projec-
tions stemming from the transpersonal material. His associations were
mainly positive in nature and were reflected in a strong working alliance.
Bruce was enthusiastic about my suggesting he read A Course in
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Miracles, which I had felt would be of interest to him because of his

Christian background. This book validated for him his spiritual pursuits
and began to strongly mitigate his criticism of self and others by its
emphasis on forgiveness.
I had suggested that he try vipassana (mindfulness) meditation. Sitting
long weekends gave him a sense of camaraderie along with growing
compassion and empathy for the other sitters, his fellow travelers. Vi-
passana meditation, along with the softening of his hypercritical style,
greatly improved his relationship with his wife and sons and so he decided
to discontinue therapy.
Bruce s mindfulness-meditation practice continued, and he came back
to see me after a ten-day retreat brought up material that had never before
emerged in his therapies. In general, mindfulness meditation tends to lower
or dissolve psychological defenses, resulting in the exposure of what lies
underneath. For the high-functioning person like Bruce, this was a big plus.
(I should mention that sometimes, despite the best efforts of reasonably
sophisticated meditation teachers, students with underlying psychotic pro-
cesses come to a meditation retreat and the ensuing lowering of psychologi-
cal defenses unmasks a full-blown psychotic process. These psychotic
processes usually respond rapidly to antipsychotic medication. In general, I
believe that meditation is unwise for individuals with underlying psychotic
processes.)
Because of being a bit overweight, Bruce had decided to eat less than
usual. After feeling hungry for a few days and having minimal external
stimulation in the silence of the meditation retreat, he began to be flooded
with primitive and ego-driven fantasies and cravings for breasts. He had
occasional bouts of anxiety about his ability to restrain himself when
passing an attractive woman. This craving ended when he had an intense
happy dream of a reunion with a healthy, nurturing mother. There were
many poignant associations to the dream that Bruce and I felt were feeling
memories related to the early nonnurturing nursery experiences during the
first few months of his life.
He attended another ten-day mindfulness-meditation retreat during
which time he again (having done so in his first psychoanalytic psychothera-
pies) repeated his oedipal constellation, but this time with a much more
intense affect. On the retreat he found himself to be attracted to a woman
he had seen on previous retreats (but had never spoken to) and felt she was
involved with a certain fellow meditator. Bruce began having erotic fanta-
sies about her as well as very aggressive fantasies about her supposed male
friend. Simultaneously, he feared the man would attack him while doing
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some kitchen chores (in silence) with his "competitor." Bruce was very
frightened that he would take a large kitchen knife and stab this man.
Earlier psychotherapy and meditation training enabled Bruce to see the
bizarreness of his preoccupation. He was in a happy marriage and knew
absolutely nothing about the "couple" onto whom he had projected his
oedipal conflicts. This conflict was again worked over, but now in the light
of heightened affect. New material came to light regarding his mother s
seductiveness, and resentment he felt toward his father for being weak and
not protecting him. As this new material was worked through, his marriage
became warmer, more affectionate, and spontaneous.
Clearly Buddhist mindfulness meditation did not originate twenty-five
hundred years ago for psychotherapeutic purposes. But assuredly therapeu-
tic effects occur frequently in the retreat setting where, in the silence,
psychological problems bubble up, moral inventories are taken, and con-
flicts are worked out.
Designed to permit the practitioner to gain insights into "reality" and
certain truths about it, meditation can have a wide variety of emotionally
growth-producing effects within what we call popular reality.
In this paper, I have tried to show that psychotherapeutic and spiritual
tools can be used simultaneously to improve and hasten the healing of
patients. It is my hope that this article will invite other psychotherapists to
explore the transpersonal or spiritual realm to see if there might be some
beneficial effects for them and their work with patients.

REFERENCES

1. Boorstein S (Ed.) (1996). Transpersonal psychotherapy. Albany, NY: S U N Y

2. Lajoie D H & Shapiro S Y (1992). Definitions of transpersonal psychology: the first twenty-three
years. Journal of Transpersonal Psychology, 24 (1), 79-98.
3. Ferrer J N (2000). Transpersonal knowledge: A participatory approach to transpersonal phenom-
ena. In T Hart, P Nelson, and K Puhakka (Eds.), Transpersonal knowing: Exploring the horizon
of consciousness. Albany, NY: SUNY.
4. Greene B (1999). The elegant universe. New York: Norton.
5. Grof S (1996). The healing potential of non-ordinary states of consciousness: observations from
psychedelic therapy and holotropic breathwork. In S Boorstein (Ed.), Transpersonal psycho-
therapy. Albany, NY: SUNY.
6. Ring K (1998). Lessons from the light. New York: Plenum Press (Insight Books).
7. Targ R & Kantra J (1998). Miracles of mind. Novato, CA: New World Lib.
8. Stevenson I (1998). Where reincarnation and biology intersect. Westport, CT: Praeger.
9. Wade J (1996). Changes of mind. Albany, NY: SUNY.
10. Boorstein S (1997). Clinical studies in transpersonal psychotherapy. Albany, NY: SUNY.
11. Byrd R C (1988). Positive therapeutic effects of intercessory prayer in a coronary care unit
population. Southern Medical Journal 81, 826-829.
12. Harris WS et al. (1999). A randomized, controlled trial of the effects of remote, intercessory prayer
on outcomes in patients admitted to the coronary care unit. Archives of Internal Medicine 159,
2273-2278.

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13. Sicher F et al. (1998). A randomized double-blind study of the effect of distant healing in a
population with advanced AIDS—report of a small scale study. Western Journal of Medicine 169
(6): 356-363.
14. Wilber K (1981). No boundary. Boulder, C O : Shambhala.
15. Yogananda P (1994). Autobiography of a yogi. Nevada City, CA: Crystal Clarity.
16. A course in miracles (1975). Tiburon, CA: Foundation for Inner Peace.
17. Singh K (1998). The grace in dying. New York: Harper Collins.
18. Ring K (1998). Lessons from the light. New York: Plenum Press.
19. Stevenson I (1998). Where reincarnation and biology intersect. Westport, CT: Praeger.
20. Wilber K (1996). A brief history of everything. Boston and London: Shambhala.
21. Grof S (1998). The cosmic game. Albany, NY: SUNY.
22. Goswami A (1993). The self aware universe. New York: Tarcher/Putnam.
23. Gribbin J (1995). Schrodinger's kittens and the search for reality. Boston: Little Brown.
24. Benson H (1975). The relaxation response. New York: Morrow.
25. Scherman Rabbi N & Zlotowitz Rabbi M (1985).The complete artscroll siddur, sefard edition.
Brooklyn: Mesorah.
26. Kabat-Zinn J (1991). Full catastrophe living: Using the wisdom of your body and mind to face stress,
pain, and illness. New York: Dell.
27. Goleman D (1988). The meditative mind. Albany, NY: Tarcher.
28. Huxley A (1944/1970). The perennial philosophy. New York: Harper & Row.

423
 Letter to the Editor
Dear Editor,

I have read with great interest the article by Jerome S. Gans "Narrative
Lessons for the Psychotherapist: Kafka's The Metamorphosis" (Am J Psy-
chother 1998, 52:352-366). The article discusses Kafka's short story in
which the hero, Gregor Samsa, a young commercial traveler, wakes up one
rainy morning, transformed into a large bug. Dr. Gans elegantly postulates
that the author brings his inner world to the narrator and the interactions of
the main characters in the story. This is similar to the situation in psycho-
therapy and Dr. Gans elaborates on this issue.
Reading the article and the story it is based on, one is struck by the
interesting parallels between some characteristics of the narrator of this
story and the life of Kafka himself. The various characters in this story
constitute in fact "transparent projections" from his inner world. A short
elaboration on these points might be valuable in my opinion to further
understand this issue.
First, the name of the main hero is S^ms^, has certain similarities with
the author's surname (Kafka). Gregor's apartment and living arrangements
are very similar to Kafka's own at the time of writing.
Second, as Kafka's interest was divided between his work as a clerk and
his zest for writing, the hero of this short story is not allowed to follow his
interests, but is forced to take a job to pay his father's debts. Both Kafka
and Gregor accept this situation and try to please their fathers. The
relationship with a distant, but also dominant and demanding father is
common to Kafka and Gregor. It is not a coincidence that Kafka was
influenced by the expressionist current in literature, that had as one of its
motives the conflict between son and father, where the latter represents the
values of bourgeoisie. The metamorphosis might be seen as the result of an
internalization of the object relations with his father or from the repressed
violent feelings towards the father, which are turned inward.
Third, Kafka used to complain that he rarely saw his mother. He wrote
that during his childhood, she used to return from work and comfort him
when he was sick. Moreover, he admitted having wishes to fall sick in order
to regain his mother's attention. Gregor also suffers from such an "ab-
sence," and it might be that the metamorphosis represents a (masochistic)
attempt to regain the primary maternal involvement. Overall, the problem-
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atic relationships between Kafka and his parents (as is his difficulty in
achieving intimate relationships) are symbolized in the environment of
Gregor's home with closed doors and infinite expectations. Gregor's
ambivalence after the metamorphosis, whether to remain in his room and
thus avoid unpleasant scenes for him and his family, or to visit his loved
ones, is a further example of the writer's ambivalence whether to withdraw
or attach.
Fourth, Gregor awakes as a bug. Kafka was horrified by mice and
perhaps even bugs, which represented dark and evil creatures of the night.
Gregor turns into what Kafka is terrified of most. Kafka's feelings of
inadequacy, loneliness, physical weakness and fragility are a further symbol
of the metamorphosis of Gregor into a weak and crushable creature.
Kafka's inner feeling was that his personality had been crushed during
childhood. Thus, relationships might cause the re-experiencing of this
trauma, symbolized by the metamorphosis of Gregor into a bug. Also, the
metamorphosis and the death of Gregor may symbolize the apprehension
held by Kafka, who might have feared a life without fulfillment as a writer.
Bearing these points in mind may help the readership of the Journal to
evaluate on a further and deeper level, the story by Kafka and the article by
Gans.

Dr. Iancu Iulian

Tel Hashomer, Israel

425
 BOOK REVIEWS
RICHARD D. C H E S S I C K : Emotional Illness and Creativity: A Psychoanalytic and
Phenomenologic Study. International Universities Press, New York, 1999, 471
pp., $59.95, ISBN 0-8236-1665-7.
Toward the end of his new book, Richard Chessick tells us that he once assigned a
text by philosopher Martin Heidegger to a group of psychiatric residents and soon
found himself with a "revolution" on his hands. It seems that the students,
"overwhelmed by the struggle of having to learn how to satisfy the bureaucrats of
managed care with enough redundant paperwork to eke out some payment for
their services," were unwilling to put in the time necessary to understand the
abstruse treatise. Nor did the fact that Heidegger valued poetry over science
endear him to Chessick s unwilling medical readers. Giving up on teaching
Heidegger again—"only a fool makes the same mistake twice"—Chessick decided
to assign Henry James's involuted novel, The Ambassadors, to another group of
psychiatry residents to illustrate cultural influences on the formation of the self.
"The result was another revolution," the teacher acknowledges wryly (pp. 403¬
405).
Emotional Illness and Creativity should be of more interest to Dr. Chessick's
students, since its encyclopedic knowledge of philosophy, literature, art, aesthetics,
psychoanalysis, and psychiatry casts light on many subjects. Chessick is uniquely
qualified to write a book on the relationship between illness and creativity, for he is
both a Professor of Psychiatry at Northwestern University and an Adjunct
Professor of Philosophy at Loyola University of Chicago. (He holds both an M.D.
and a Ph.D. in philosophy.) A member of the Editorial Board of this journal, he has
published fifteen books and more than 200 papers. He is one of the country's
preeminent philosophical psychiatrists and has long studied the subject on which
he now writes.
It is difficult to imagine a more daunting subject than the one Chessick
confronts ambitiously here, one that has preoccupied philosophers and artists for
over two thousand years. Plato and Aristotle offered competing theories about the
relationship between illness and art, and Freud entered the foray by postulating
that the artist was close to a neurotic. Many myths surround the subject, including
one with which Chessick strongly disagrees: namely, that psychotherapy removes
or inhibits an artist's creativity.
Emotional Illness and Creativity focuses on two case studies. One is the
"psychotic genius" Ezra Pound, the early twentieth-century American poet who
was one of the leaders of the modernist movement. He also played a key role in
discovering and championing other great writers, including T. S. Eliot, James
Joyce, and Ernest Hemingway. In his mid-thirties he became obsessed with an
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 Book Reviews

economic "social credit" theory that was dismissed by professional economists; he

also became increasingly unstable and virulently anti-Semitic. He traveled to
Europe, sought out Mussolini, whom he idealized, and made several Fascist
broadcasts during World War I I . He was arrested after the war, returned to the
United States, placed on trial for treason, judged insane, and incarcerated for many
years in a psychiatric hospital. Had he not been found insane, Pound almost
certainly would have been found guilty and executed. His flawed masterpiece, the
Cantos, reveals a bewildering mixture of insight and psychopathological murk.
The other case study is "Barry," a personality whose "history" and "writings"
are a composite of Chessick's experiences with several psychoanalytic patients.
Although Barry's life is on the surface successful—he completes his psychiatric and
psychoanalytic training, teaches at a major university, and publishes in professional
journals—his neurotic conflicts severely impair his professional and personal life.
Chessick analyzes Barry's unpublished play and shows how it reveals the writer's
feelings of isolation and fragmentation. Something has gone grievously wrong with
Barry's life, and the physician is unable to heal himself.
Chessick goes back and forth between both case studies, in the process
discussing the fundamentals of the creative process and the functions of artistic
striving. He offers both a psychoanalytic and phenomenologic approach. Devel-
oped by philosophers Husserl and Heidegger and psychoanalysts Boss and
Binswanger, phenomenology emphasizes a person's felt experiences. Chessick
observes that phenomenology poses a challenge to mental health professionals.
"The application of phenomenology to psychotherapy raises the valid question of
whether we as therapists can be sure that we are seeing and hearing our patients as
they really are, rather than as projections of our theories about them" (p. 14).
Throughout Emotional Illness and Creativity, Chessick comes across as a wise,
compassionate, and tolerant thinker whose grasp of the humanities serves as a
model for all scholar/clinicians. He has an empathic understanding of Barry, who
never fulfills his creative potential. Curiously, Barry reflects many of Chessick's
own ideas and values, including the need for relatedness, transcendence, and
rootedness. Barry represents for Chessick a cautionary tale. Barry is unable to
develop and grow. He believes, as does Chessick, that life is ultimately a mystery
and a tragedy, but that art can take us outside of ourselves, exposing us to visions of
truth and beauty. Yet, he cannot find in psychoanalysis, philosophy, or art solutions
to his disabling conflicts.
It is not difficult to disagree with some of the author's observations or
conclusions in a book of this length. I do not share his enthusiasm for Allan Bloom,
whose conservative agenda contradicts Chessick's own progressive ideas espoused
elsewhere in the book. There are a few typographical and spelling errors. He refers
to T. S. Eliot's influential poem as The Wasteland (rather than The Waste Land),
and he misspells the name of Kafka's biographer, F. Karl. There are a few omissions
from the extensive bibliography: he does not mention Kay Redfield Jamison's
groundbreaking work on the relationship between manic depressive illness and
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artistic creativity. More importantly, Chessick does not offer a major new theory
about the age-old relationship between illness and creativity. Nevertheless, readers
will admire the depth and breadth of Emotional Illness and Creativity: its synthesis
of complex ideas, its bold mixture of genres, and its reverence for the irreducible
mystery of artistic creativity. Chessick eloquently reminds us that the need to
resolve psychic conflicts is a major driving force of creativity. Art may sometimes
arise from illness, but art itself is a triumph over illness. Chessick's life and work
demonstrate that the artist and psychotherapist are both involved in parallel quests
toward self-enlightenment.
Schenectady, N. Y. JEFFREY BERMAN, PH.D.

KENNETH A. FRANK: Psychoanalytic Participation: Action, Interaction, and Integra-

tion. The Analytic Press, Hillsdale, NJ, 1999, 304 pp., $47.50, ISBN 0-88163¬
873-2.
Psychoanalytic Participation, Volume 16 of the Relational Perspectives Book Series
edited by Stephen Mitchell and Lewis Aron, is written by an analyst steeped in the
object relations-intersubjectivist-interactionist tradition, which in recent decades
has furnished some of the more interesting and provocative developments in
psychoanalysis. This tradition takes as its starting point the essentially moral idea
that the analyst ought not to represent and conduct himself or herself as a
patriarchal authority but rather as an ordinary helping person equipped with some
special, if provisional, knowledge. Dr. Frank aims to review recent developments
and to extend them in a useful way to some important practical problems, such as
openness and self-disclosure on the part of the analyst, handling of countertransfer-
ence, including erotic countertransference, equality and mutuality.
Dr. Frank's book stands on two legs of very disparate length and strength. The
short critical leg is an extremely truncated and overconfident assessment of
classical psychoanalytic theory, done in a few pages. Frank's central assertion is that
Freudianism theory is a "one-person" (p. 3) psychology, by which he means a
psychology based on a view of people as "separate, self-en closed systems" whose
motives and interactions with the world are to be understood as driven by
"endogenously arising drives" (p. 6). Shifting to the much longer expository leg,
which occupies virtually all of the remaining 268 pages, he argues and seeks to
demonstrate that psychoanalysis is in process of being rescued from this error by
the advent of a "two-person psychology" that acknowledges the importance of
object-seeking as a, or perhaps the, basic developmental motive and which
therefore understands mind in terms of internalized object-relations and intersub¬
jective experience. This, of course, has become the conventional wisdom of a large
segment of psychoanalysis.
Frank knows object-relations theory and its latest refinements in intersubjectiv-
ity and interactional theories. He provides useful discussions of important practical
analytic issues. He is at his best when he comes close to making a case for radical
analytic openness and fearlessness, and for shifting the burden of intellectual
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 Book Reviews

responsibility to where it properly belongs, onto the analyst who claims special
authority for anonymity and inequality.
Frank seems to recognize intuitively that the authority of the Freudian analyst
is bogus, based as it is on an indefensible theory. His problem is that he does not
seem to really understand why the theory is indefensible. Thus he cannot make his
case in a rigorous way or take his arguments far enough.
His critique of Freudianism is actually that of the loyal opposition within
psychoanalysis, which fails to penetrate beneath its rhetoric. What makes Freudian-
ism intellectually slippery and even dangerous is not that it regards the person as a
closed system determined by endogenous instincts or that it is a natural-science
based theory, but that it pretends to do so (and seeks to derive its authority
therefrom) while actually being an extreme socialization-based psychology. This is
a problem of rhetoric versus reality. Freud's instinct and Oedipal theories are no
more based on natural science and biology than is social Darwinism, with which it
has much in common. The Oedipus complex is the psychology of a culturalist
anthropology, and of patriarchy, authoritarian child-rearing, and free-market
statism, all endorsed by Freud. Based on his culture-based construction of human
evolution, he believed, for example, that "a cultural community is perfectly
justified, psychologically, in starting by proscribing manifestations of the sexual life
of children, for there would be no prospect of curbing the sexual lusts of adults if
the ground had not been prepared for it in childhood" (Civilization and Its
Discontents, p. 104). This is a statement from his most mature work, the distillation
of his social philosophy.
When translated into clinical method, the problem of Freudian theory is not
that analysts are noninteractive with patients. They are highly interactive, but in the
particular way prescribed by Freudian theory—i.e., as authoritarian figures,
exactly corresponding to Freud's view of the central importance of patriarchal
authority in the development of individuals and cultures.
Not having a grasp of the real problems of Freudianism—the circularity of its
reasoning, in which cultural conformity determines exaggerated and incorrect
perceptions of one's sexuality and aggression (and one's thinking and judgment, for
that matter), which in turn justify cultural authority—Frank mistakes the rhetoric
for the reality, and opposes it with a theory that seems appealingly humanistic but is
equally problematic. He employs a subjectivist theory of the self with a gross lack
of appreciation for its philosophical underpinnings and its extreme problems.
This type of loose thinking will simply not do as a rigorous alternative to
Freudianism, which remains a serious need. The one-person/two-person di-
chotomy is too superficial. The problem is not interaction vs. noninteraction, but
rather the nature, content, meaning, and purpose of interaction, and which
qualities of the analyst make him or her worth listening to. The idea that emotional
qualities like "authenticity," or willingness to share personal experience, render a
psychoanalyst worth listening to trivializes that problem.
The result is that Frank recommends right methods and approaches for the
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wrong reasons. By that I mean that the appropriate rationale for an egalitarian,
interactionist analytic relationship and process is not an intersubjectivist theory of
mind, which is no more defensible than Freud's pseudo-objectivist theory, but
rather on moral and political-philosophical grounds.
Failing a persuasive argument for the interactionist-intersubjective point of
view, one looks to clinical evidence for demonstrations of greater clinical scope and
efficacy. Here too one is disappointed. The few clinical examples offered to
illustrate the superior workings of an interactionist approach represent quite
ordinary clinical problems and are not persuasive. Notably lacking is any discus-
sion of how such an approach might be applied to more serious clinical problems
from which psychoanalysis has shied away or with which it has had indifferent
success, such as psychosis and psychosomatic disorders, gender disorders, prob-
lems of disadvantaged populations, etc.
In short, Psychoanalytic Participation is nowhere near as ambitious, rigorous, or
radical as it takes itself to be, or as books like this need to be.
Denver, CO J O N A T H A N COHEN, M.D.

JOHN C. PAPAJOHN. The Hyphenated American. The Hidden Injuries of Culture.

Greenwood Press, Westport, CT, London, 1999, 148 pp., $55.00, ISBN
0-313-30930-2.
Our intense current interest in ethnic, racial, and cultural diversity and its
interpersonal consequences in American life has actually been a long-time subject
of theoretical scholarship. Professor John C. Papajohn's small book The Hyphen-
ated American. The Hidden Injuries of Culture looks back at the roots of research
on ethnic identities and the practical applications of its findings to psychotherapy,
having himself participated in the history of this original research.
It is an impressive credit to the cultural-value-orientation framework devised in
the 1950s by Florence Kluckhohn in collaboration with her husband Clyde
Kluckhohn, both cultural anthropologists, that it has stood up over half a century
and become an all-time classic. Florence Kluckhohn postulated that "people in all
cultures and all times" (p. 7) had to make choices regarding their values "to solve
basic issues of living" (p. 7) in such areas as: Activity (Doing versus Being);
Relational areas (Individualism, Collaterality/Interdependence, Lineality/Authori-
tarianism); Time (Future, Present or Past); Man-Nature (Over-Nature, Subjugated
to Nature or Harmony with Nature); Human Nature (Evil but Perfectible, Mixed
or Good).
The author, currently a senior clinician and lecturer in psychology in the
Department of Psychiatry at Harvard Medical School, has devoted his distin-
guished academic career to study the painful conflicts that arose when European
immigrants encountered, and had to deal with, the predominant American value
orientations, as well as the intergenerational conflicts caused by these value
discrepancies in immigrant families. In this book he seeks to demonstrate through
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 Book Reviews

a series of case vignettes the importance of these cultural conflicts in individual

emotional disorders as well as in married couples in which each partner comes
from a different cultural tradition. Indeed, according to Papajohn, these traditions
continue to have often hidden impact even on the third generation, at which point,
sharp conflicts with the requirements of American society may break out.
Papajohn presents case studies of an Irish-American man, an Italian-American
man, a Jewish-American woman, and a Greek-American man, all of them "third-
generation" immigrants. In each case he highlights, with the aid of Kluckhohn's
value framework, the importance that cultural tensions played in the subjects'
emotional disturbances. Papajohn is adept at both cognitive-behavioral and
psychodynamic interventions. He uses both, and therapy usually ends with the
disappearance of symptoms and mostly successful assimilation to American values.
He then introduces three troubled ethnically mixed marriages in which the
partners' eventual understanding that their conflicts originated in the different
ethnic traditions in which they had grown up, leads to increased mutual tolerance
and compromise. All the case stories have highly successful outcomes, perhaps
because the author could select his cases.
In the last third of the book Papajohn discusses cultural changes. In Chapter
10, "Culture Change in American Society" he analyzes the 1960s youth movement
as a rebellion against mainstream American capitalist values. He also briefly
mentions feminist, Afro-American, Mexican-American, and Indian-American move-
ments, again using Kluckhohn's framework, to the neglect of the surely equally
important issues of poverty and discrimination. Papajohn mentions in his introduc-
tion that such a value analysis will facilitate the integration of the current waves of
new immigrants, hoping that the more humanistic values of the new (and old)
hyphenated Americans will permeate and rectify the driven, individualistic competi-
tive thrust of the larger society.
The language of the book is nontechnical and easily accessible. Older readers,
like myself, will be taken back to anthropology and sociology college courses and
literature comparing Irish, Italians, and Jews in such areas as their tolerance of
pain, or their mode of expressing mental illness. In this reviewer's eyes the
boundaries among these white ethnic groups have currently become quite blurred,
perhaps due to the many intermarriages, shifting instead to the newer "color lines."
I also believe that economic injustices above all, rather than value differences
currently divide American society.
The book's bibliography, with a few exceptions refers to readings between 1960
to 1980. The Hyphenated American is thus definitely a journey into history while
claiming current relevance. I notice that the author, a Greek-American, has,
according to this theory, a preferred past time orientation—while the reviewer is
present and future oriented, so that a clash of values may have crept into her
reading and reviewing this book.
Lincoln, MA SOPHIE FREUD, MSW, PH.D.

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AMERICAN JOURNAL O F PSYCHOTHERAPY

THOMAS G . PLANTE (ED.): Bless Me Father for I Have Sinned: Perspectives on

Sexual Abuse Committed by Roman Catholic Priests. Praeger Publishers, West-
port, CT, 1999,200 pp. $59.99 ISBN 0-275-96386-1.
The subject of sexual abuse of male adolescents by priests, particularly Roman
Catholic priests, has attracted wide public attention in the last decade or so. This
edited book summarizes the experience of a group of clinicians who have spent a
large portion of their professional life working in this very specialized area. The
chapters cover theoretical as well as clinical topics. Plante indicates that some naive
individuals believe that priests do not engage in sexual activity. Well, count me
among the naive ones. That is what I thought abstinence meant. As an adolescent
who had Catholic friends, and as a psychoanalyst who treats some Catholic
patients, I continue to be impressed by the guilt expressed by Catholics about any
form of sexuality. Some of the chapters focus on intervention in clergy sexual abuse
and the forensic psychological assessments of both the offender and the victim.
Some neuropsychological findings in members of clergy point to problems with the
right frontal hemisphere, findings that seem to be coming out about all sexual
abusers. There is an excellent chapter on the treatment of molesting priests and a
detailed description of a model program in Washington, D.C. A useful chapter
deals with the treatment of the victims of clergy sexual misconduct. I found the
chapters dealing with psychosocial issues to be more informative than the findings
on the sexual abusers. These latter chapters were a rehashing of information about
sexual offenders in general.
The book could be helpful as a summary of the literature in this field, otherwise
not readily available to most mental health professionals. I was unfamiliar with
most of the journals cited in the book. A lot of secrecy and defensiveness permeates
this area and only a few religious therapists have the opportunity to work with the
abusing priests. I was involved with this subject during two series of assessments,
one dealing with young adults who had been sexually molested by one priest over a
period of a decade. I found the book informative and it confirmed my impression
about the insensitivity of the church to the victims. The cases mentioned above
showed how the denial and the accusatory tone of the church retraumatized the
victims and their families.
There are some interesting findings in the volume, such as the fact that most
victims of sexual abuse are adolescent boys. The authors approach this subject with
compassion and are critical of some feminist approaches that make sexual abuse
the realm of female victims only. Some intriguing discussion as to whether any sexual
contact between a priest and a consenting adult would be considered sexual abuse,
the way any contact between a psychotherapist and a patient is considered abusive.
As all edited books, the quality varies from chapter to chapter, but in general it
is a well-written, informative, and compassionate book. It is useful particularly for
people who may be asked to forensically assist or treat victims of sexual abuse, as
well as a good general introduction to this problem long shrouded in mystery.
Toronto, ONT GEORGE A. AWAD, M . D .

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 Book Reviews

FRANK C. RICHARDSON, BLAINE J. FOWERS, AND CHARLES B. GUIGNON. Re-

Envisioning Psychology: Moral Dimensions of Theory and Practice. Jossey-Bass,
San Francisco, CA, 1999,368 pp., $39.95, ISBN 07879-4384-3.
Do psychological studies and the theories that produce them provide relevant
representations of how people actually live their lives? Pose this question to the
authors—Frank C. Richardson, a Professor, Department of Educational Psychol-
ogy at the University of Texas, Austin, Blaine J. Fowers, an Assistant Professor,
Department of Educational and Psychological Studies at the University of Miami,
and Charles B. Guignon, a Professor, Department of Philosophy at the University
of Vermont. No, the authors claim, not if psychological achievements are judged by
the scientific standards psychology has established as its criteria for evaluation.
In a well-written, abundantly documented, and persuasively argued account,
the authors contend that the great difficulties psychologists have in securing a
genuine empirical theory is because their epistemological attempts to model
psychology as primarily a science appear to be inappropriate. In other words, the
guiding principle of the methodologies used to obtain empirical data is guided to a
far greater extent than is natural science by unrecognized or unacknowledged
systems of values. As the subject of inquiry is embedded in a network of intricate,
interlocking relations, predicated on the personal meanings the subject ascribes to
these relations, the proper system of an analysis of the subject should not be an
experimental design. Rather, it must be an interpretative inquiry that recognizes
and carefully examines the nature and context of the meanings given to the
subject's sundry relations. Crucial in this recognition is the inevitable moral stance
of the investigation, a stance antagonistic to value-neutrality in the natural science
paradigm. For example, "liberal individualism in some form is the disguised
ideology of much modern psychology and psychotherapy" (p. 52). As a second
example, "Freud's view of healing is based on an 'analytic attitude' that explicitly
rejects all objective moral laws (p. 55) (yet) Freud himself strayed significantly from
this narrow path and gave voice to deeply held moral and philosophical preju-
dices" (p. 56).
The authors soundly criticize mainstream psychologists for eschewing an
interpretative approach. They explain, "Much academic psychology has managed
to seal itself off from contemporary debates about the nature of knowledge, its own
historical embeddedness or the extent to which it is socially constructed, and its
entanglement with moral values and political forces. Few psychologists critically
evaluate the metaphysical and moral underpinnings of their methods or theories"
(p. 173).
The solution they recommend for rethinking the unexamined social and
philosophic assumptions contained in psychological theory is ontological herme-
neutics. This is a method of interpretation "which aims to clarify the being of the
entities that interpret and understand, namely, ourselves" (p. 200). It is based on
the notion that psychological science is deeply shaped by various moral stand-
points and that this is a necessary aspect of social science, just as it is with any
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human endeavor . . . by recognizing the inherent moral dimension of psychology,

we can begin to explicitly acknowledge the genuine moral impulses that guide our
inquiry (p. 304).
This is an important book that squarely faces the conceptual assumptions and
social attitudes plaguing psychology and psychotherapy as we enter a new millen-
nium. However, for the clinician reader, this sometimes abstract and overargued
book has a major limitation. For most clinicians the ultimate test of a text is its
ability to elucidate problematic clinical cases. The application of ontological
hermeneutics to one or more clinical vignettes is absent in this fine book.
New York, NY CARL GOLDBERG, PH.D.

FRANK L . SUMMERS: Transcending the Self: An Object Relations Model of Psychoana-

lytic Therapy. The Analytic Press, Hillsdale, NJ, 1999, 268 pp., $45.00, ISBN
0-88163-231-7.
It is widely recognized that two of Sigmund Freud's most notable legacies to the
fields of psychoanalysis and psychotherapy are rather antithetical and contradic-
tory. On the one hand, he bequeathed seminal insights and discoveries about the
human personality that provided empowering hope to those engaged in the
professional practice of ameliorating human suffering. On the other hand, he also
conferred a stultifying, gloomy judgment about the general inefficacy of even deep
psychotherapeutic interventions to produce hoped-for outcomes, dismally suggest-
ing that analysis, at best, can only transform neurotic misery into common
unhappiness.
In this book, Frank Summers, an Associate Professor of Psychiatry and the
Behavioral Sciences at Northwestern University, propounds a psychoanalytic
model that can, he alleges, facilitate a psychological process that ultimately enables
patients to achieve radical personality change as well as genuine and lasting
happiness. Object relations analysis, as described by Summers, begins with several
basic assumptions. First, in contrast to drive theory, the human personality is
viewed as an active agent of its own destiny from the time of its very birth.
Summers decries the tenet of drive theory that tends to view the human personality
as the rather defenseless, immutable prey of tyrannical instinctual drives. Instead,
he posits the more positivistic viewpoint that aggression is not so much an instinct
as it is an innate capacity that holds the potential for growth enhancement.
According to Summers, the hostilities and sadistic tendencies of troubled persons
are not at bottom the perverse workings of destructive drives. Rather, they are the
telltale enactments of frustrated and thwarted quests for self-realization. And the
quest for self-realization, according to this object relations theorist, is a primary
and precious human striving that must be safeguarded and nurtured in order to
help emotionally distressed persons evolve and grow to their fullest potential.
Although friendly and sympathetic to self-psychological theory, Summers parts
ways with this theoretical school when he argues against the Kohutian concept of
early childhood grandiosity. He refers to infant research demonstrating that normal
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infants are not grandiose and do not attempt to gain omnipotent control over
others. As well, Summers sees a risk in a too consistent mirroring of patients' needs
in treatment since this may foster passivity and inertness by not sufficiently
respecting patients' abilities to function as active, constructively aggressive agents
of therapeutic change.
By contrast, Summers has formulated and implemented an analytical treatment
that relies largely upon interpretations richly augmented with "analytic space" that
enables each patient to advance at his or her own inimitable pace and in ways that
are uniquely and safely suited to the patient's needs. To illustrate how he achieves
his therapeutic objectives, the author provides interesting case histories replete
with frank and explicit disclosures of his techniques. Some readers (including this
reviewer) are likely to be discomfited by some of these techniques, such as when
Summers uncritically indulges a patient's search for fusion with him by reading
children's stories to her and eating her homemade desserts during the course of
some of their sessions. Summers argues that these indulgences were necessary and
highly therapeutic in that they allowed for an essential, albeit transient, fusional
bond to take place, but I found these examples to represent something that
Summers himself rejected as a pitfall within self-psychological theory: excessive
mirroring.
What makes this book special and specially useful to clinicians is the author's
visionary stance. He aptly recognizes the importance of helping patients uncover
and realize their buried-self potential and thereby achieve authenticity. Somewhat
poetically and quite convincingly, Summers exhorts therapists to acquire a vision of
the possible, "an image of not just who the patient is but of who the patient may
be." To achieve this goal, the vision of therapists must precede the patient's
conscious experiences. Through this vision and by enabling the patient to form a
new and liberatory object relationship with the therapist, the patient can discover
new possibilities and richer forms of relating. Perhaps, just perhaps, Summers is
right. The transcendence of self, as attained through psychotherapy, can lead to
genuine human happiness.
San Francisco, CA GERALD AMADA, PH.D.

JOHN E . GEDO: The Evolution of Psychoanalysis: Contemporary Theory and Prac-

tice, Other Press, New York, 1999,262 pp., $25.00 (pbk), ISBN 1-892746-27-1.
This interesting and controversial book is in an unusual format. What Dr. Gedo
has done here is to review briefly sixty books that have come out over the past
twenty-three years that he considers "significant," in order to acquaint the reader
with recent developments in psychoanalysis and as a way of supporting his
convictions. In the introduction, he summarizes his own point of view, which
basically maintains that psychoanalysis is a natural science and therefore must be
based on, and consistent with, current findings from the neurosciences. This, he
says, rules out Freud's metapsychology entirely. He works clinically with a hierar-
chical view of mental functions and considers the concept of self-organization
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central. For Gedo, psychoanalytic treatment attempts to correct "dyspraxic pat-

terns of behavior and to fill in apraxic deficits" (p. xi). He believes that we must go
beyond interpretation in psychoanalysis and rests his work heavily on what he
describes as known about the biology of the mind. Gedo has elaborated on all
these themes in his many previous publications, and does not dwell on his own
views in as great a detail here.
Most of the books summarized by Gedo are indeed significant, and I have
reviewed many of them myself in various journals. So, as usual, Gedo is au courant
in the field of psychoanalysis. His book is attractively printed, and I highly
recommend it for anyone interested in current issues in psychoanalytic theory and
practice. The reviews are quite brief and condensed, and the beginner may have
some difficulty in following them, but nothing prevents that beginner from going
back to any original text Gedo is summarizing.
The central issue of the book is stated in one of the two summary chapters at
the end. Gedo argues that the evolution of psychoanalysis can either be conceived
of as the story of a discipline breaking up into irreconcilable fragments, or as the
emergence of a new paradigm that transcends the disputed theories of an earlier
time. This new paradigm, he repeatedly insists, is a biological or natural-science
view of psychoanalysis in which all descriptions and discussions of mental func-
tions must take into account the somatic substrate and what is known about it.
Otherwise, one is forced into what Gedo calls a rationalist or a mentalist view, in
which various theories conflict and are not capable of being tested and weighed.
He often calls this latter stance the hermeneutic viewpoint, and there is consider-
able polemic in the book against it. He concludes, "evidence from the cognate
disciplines has invalidated all previous psychoanalytic hypotheses about early
childhood on the grounds that these have been excessively adultomorphic, and
pathomorphic" (p. 206). So, for Gedo, one either insists psychoanalysis is based on
empirical natural science or it is a hermeneutic discipline filled with a priori
viewpoints based on philosophical positions and with no agreed-upon standards of
validation. In many of the clearly written book reviews that constitute his book, he
makes this either/or distinction repeatedly; one has to be committed to one side or
the other. This makes for a very stimulating and confrontative book.
As always, in the work of John Gedo, there is a sprinkling of his firm and
acerbic opinions, which make the book even more provocative. For example, he
states that Summers work on object relations "has adopted an oversimplified view,
one that has encouraged him to be more indulgent of the reductionism and
incoherence of various object relations theories than is warranted" (p. 75). He
proclaims, " I strongly agree with Freedman's view of the development of a 'self
system' " (p. 89) and "in order to be effective, treatment must go beyond
processing verbalizable mental contents to enhance procedural skills (p. 103).
Reviewing Brenner's well-known The Mind In Conflict, Gedo writes, "it is extraor-
dinary in its complete disregard for the organization of behavior in the first thirty
months of life" (p. 112), and he tells us that "Kohut consistently underemphasized
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 Book Reviews

the consequences of prior structuralization on the regulation of behavior" (p. 123),

adding that "less than twenty years after the death of its founder, self psychology
has splintered into a collection of contending factions" (p. 125). So, the reader will
find much to stimulate agreement or disagreement with Gedos definitive views
and, as usual, Gedo's work makes exciting reading. He tells us that "Klein's
judgment about the difficult nature of infantile development is the most pessimistic
assessment of the human condition ever put forward within psychoanalysis" (p.
140), and, "Lacan's developmental theory is mere science fiction" (p. 149). He
reminds us that "effective analysis is contingent on technical freedom, and that
analytic cure in large measure depends on what kind of a person the analyst is" (p.
151). I was rather puzzled by his undocumented statement that it is "well-known"
that "women who live in the same quarters . . . menstruate in synchrony" (p. 169).
In conclusion, these book reviews, organized in a manner that Gedo has
devised and followed at the end by two brief summary chapters, makes this book
outstanding reading and worthy of attention for anyone interested in psychoana-
lytic matters.
Evanston, IL RICHARD D . CHESSICK, M.D., PH.D.

JOAN ACOCELLA: Creating Hysteria: Women and the Myth of Multiple Personality
Disorder. Jossey-Bass, San Francisco, CA, 1999, 214 pp., $25.00, ISBN
0-78794794-6.
Joan Acocella's expose of the multiple-personality-disorder diagnosis is almost too
convincing. There is no room for half tones or uncertainties: Creating Hysteria is an
argument rather than a discussion, and Acocella argues with wit and elegance,
leaving the battlefield strewn with casualties. Her main targets are the therapists
whose public embrace of the MPD diagnosis during the last twenty years created
an almost cultlike following, extensive media attention as well as a plethora of
publications. Acocella claims that these practitioners knowingly and cynically used
the diagnosis to win riches and fame, in the process sacrificing their patients. She is
especially scathing about Satanic Ritual Abuse (SRA), the spread of which does
defy understanding. (One must be a quick study of acronyms to follow this book.)
Yet, unethical therapists are not the sole casualties of Acocella's battle. This is
war, and she sweeps away all that clutters her path. As most of the women
diagnosed with MPD also reported childhood sexual abuse, Acocella questions the
reality of these reports as well as the good faith and suffering of the survivors, thus
returning full circle to the Freudian assumption that childhood sexual abuse is a
product of female fantasy. The child-protection movement, twelve-step self-help
groups, feminism, insight therapy, new age theory, and social constructionism are
just a few of the other corpses that litter this field.
Acocella also has a disconcerting habit of using one set of beliefs, events or
institutions as evidence, then discarding the same set when the next stage of her
argument requires it. The media, for example, are transformed from hypocritical
traders of truth for ratings in its embrace of MPD to champions of justice when
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they renounce the diagnosis, instead championing FMSF (the False Memory
Syndrome Foundation) (pp. 97-98). Managed care, villainous when it supports the
MSD diagnosis, becomes heroic when it balks at financing long-term treatment of
MPD or indeed any long-time therapy (pp. 113-116). The DSM, as a diagnostic
tool, is alternatively dismissed and used as scientific proof for Acocella's claims.
Acocella's argument also depends heavily on clusters of associations. If we
agree that most reported cases of SRA defy credibility, we must also doubt the
credibility of well-documented cases of disassociative identity disorder (DID) (the
new name for multiple personality disorder) (p. 57). Autobiographical accounts of
cannibalism and baby sacrifice, which abound in the SRA literature, such as Jenny
Walter Harris's Suffer the Child, a ghost-written account of a woman with over four
hundred alters who was accosted by "legions of demons" (p. 57) are associated
with sophisticated novels like Jane Smiley's A Thousand Acres. Ellen Bass and
Laura Davis's The Power to Heal, a work which, though flawed in its failure to
recognize the unreliability of memory, was the first book to validate the pain and
damage of childhood sexual abuse, is dismissed in the same associative sweep,
along with Judith Herman's important Trauma and Recovery.
One of the most troubling aspects of Creating Hysteria is Acocella's attitude
toward women diagnosed with MPD, perhaps a part of her ambivalent relation-
ship with "feminism," which she blames for a multitude of societal wrongs. While
she questions the patriarchal attitude that has historically established hysteria as a
feminine ailment, and even suggests that the MPD diagnosis might have been
"born out of psychiatry's aversion to a certain kind of female patient" (p. 142), her
portrait of women diagnosed with MPD is remarkably lacking in empathy, and
indeed, redolent of the same sort of aversion. These women, including Elizabeth
Carlson, whose case she presents in the first part of the book, are portrayed as
sheeplike followers, meekly accepting their therapists' outlandish suggestions
when not appreciating and using them as a means to obtain the attention they crave
at any cost. Acocella's intention seems to be to defend such women against the
ranks of unscrupulous therapists, but with a friend like this, who needs enemies?
She even questions whether childhood sexual abuse, in fact, "causes any kind of
adult psychopathology" (pp. 77,125).
It is unfortunate that Acocella's need to build aflawlessargument repeatedly
takes her one step too far, as many of her points are so well taken. Her claim that
the concentration on sexual abuse has led to the minimization of physical and
emotional abuse, which can be every bit as traumatizing, is an important one, as is
her assertion that the child's protection movement has tended to ignore the most
critical prédéterminant of all, poverty (p. 39).
As the movement has become increasingly discredited, the diagnosis of MPD is
rapidly disappearing, giving way to the more carefully phrased "dissociative
identity disorder" (p. 103). Creating Hysteria demonstrates without question that
mental health diagnoses are merely societal constructions, subject to the winds of
change and public sentiment, as well as dangerous misuse (p. 57). Acocella herself
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 Book Reviews

rejects any such theory, claiming that "the social construction" of mental illness is a
concept that "can be laid aside" as "foreign to this subject" (p. 28). In fact, a sense
of truth as a relative concept, "the product of shifting cultural assumptions," would
have made Creating Hysteria an even more valuable book (p. 28).
Brooklyn, NY ANDREA FREUD LOEWENSTEIN, PH.D.

RICHARD B. GARDNER: Betrayed as Boys: Psychodynamic Treatment of Sexually

Abused Men. The Guilford Press, New York, 1999, 356 pp., $40.00, ISBN
1-57230-467-7.
This comprehensive, insightful book is about a relatively new clinical area: the
sexual abuse of boys by women and men, the psychological problems they
encounter as adults, the denial by the community and therapists that there was
such a problem, their psychological evaluation, and their psychodynamic treat-
ment. Gardner is trained both as a family therapist and interpersonal psychoana-
lyst. He is a graduate of the William Alanson White Institute of New York, and
Director of the Institute's Center for the Study of Psychological Trauma. This
reviewer is a child and adolescent psychiatrist who does not treat sexually abused
adults. He learned a great deal from this book about an area with which he was
unfamiliar.
The author's primary orientation is elaborated in detail in Chapter 1 "The
Sexual Betrayal of Boys." Sexual Betrayal results from interpersonal experience
that is usually described as sexual abuse, incest or sexual trauma. Betrayal is "the
violation of implicit or explicit trust" (p. 13) in relationship. A boy should have
achieved this during his growing up years. The betrayed boy feels most often as an
adult "jagged, awry, fractured, recklessly hurt" (p. 13), and uses various psychologi-
cal defenses to cope with this. In this chapter, Gardner lists the myths about sexual
victimization, the growing body of professional literature (the references on the
long list date from the middle 1980s and run through the 1990s), and discusses the
prevalence of sexual victimization. He defines the meaning of sexual abuse and
differentiates between contact abuse and noncontact abuse. He provides behav-
ioral descriptions of sexual betrayal for boys and discusses its aftermath. He
summarizes the goals, process, and themes of treatment.
Chapter 2, "Encoding Sexual Abuse as Sexual Initiation," has sections entitled
dramatically: "Are Boys in Charge of Sex with Women," "Can Women Rape
Boys?", "Cinematic Depictions of Sexual Initiation of Boys by Women," "Encod-
ing Female Sexual Behavior with Heterosexual Boys," and "When the Abuser Is
Mother."
The author provides a theoretical, as well as strong clinical, basis for his
psychodynamic formulations and treatment. There are very worthwhile clinical
examples based on the author's own cases that illustrate each chapter, many of
them offering detailed formulations.
Chapters 3-7 deal with key psychological problems related to sexual betrayal.
These chapters are: "Struggles about Masculinity," "Same-Sex Abuse," "Familial
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and Cultural Context of Abuse," "Effect of Chronic Boundary Violations,"

"Dissociation and Multiple Self-States," and "Intimate Relatedness." Chapter 9,
"The Patient-Therapist Dyad," presents transference and countertransference
issues. Chapter 10, "Gender and the Therapeutic Relationship," is coauthored by
Sue A. Shapiro. Chapter 11 is "Group Therapy." There is no summary chapter. A
20-page appendix of references concludes the volume.
Betrayed as Boys is a very informative and insightful book about the sexual
abuse of boys and its aftermath in adulthood. It should be of great interest to all
therapists working in this burgeoning area of clinical practice. The book would
benefit from fewer illustrations in some chapters and a condensation of some of the
overly detailed illustrative clinical cases.
Dallas, TX LAWRENCE CLAMAN, M . D .

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