Wolbergshorttermpsychotherapy PDF

HANDBOOK
OF
SHORT-TERM
PSYCHOTHERAPY
LEWIS R. WOLBERG, M.D.
C o p y rig h t 1980 Louis R Wolberg

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Contents
Preface, vii
1. M o d e l s of S h o r t - te r m T h e r a p y , 1
2. A R a tio n a le for D y n a m ic S h o r t - te r m T h e r a p y , 22
3. C r it e r i a of Selection, 30
4. A G e n e r a l O u tli n e of S h o r t - te r m T h e r a p y , 35
5. T h e Initial Inte rv ie w : A. C o m m o n Q u estio n s, 49
6. T h e In itial In terv ie w : B. C a s e H isto rie s , 61
7. C h o o sin g a n I m m e d ia te F o cus, 90
8. C h o o sin g a
D y n a m ic Focus: A. P r o b i n g into th e P a st, 101
9. C h o o sin g a
D y n a m ic Focus: B. S o m e C o m m o n D y n a m ic T h e m e s , 113
10. C h o o sin g a D y n a m ic Focus: C . P re s e n tin g I n t e rp re t a ti o n s , 125

11. T e c h n iq u e s in S h o r t - te r m T h e r a p y , 135
12. T h e U se of D r e a m s , 170
13. C a ta l y z in g th e T h e r a p e u t i c Process: T h e U se of H y p n o sis , 190
14. C ris is In te rv e n tio n , 208
15. M a k i n g a R e la x in g a n d E g o -B u ild in g T a p e , 223
16. H o m e w o r k A ssig n m e n ts, 235
17. T e r m i n a t i o n of S h o r t - te r m T h e r a p y , 243
R eferences, 25 0
Preface
In 1959, I ch aired a s e m in a r at th e P o s t
g r a d u a t e C e n te r for M e n t a l H e a l t h in N e w
d a te d a n asto n ish in g ly larg e p e rc e n ta g e of th e
Y ork C ity , d u r i n g w h ich a n u m b e r of p a r
re latively recently, h ow e v e r, th a t th e r e has

been a sw in g t o w a r d s h o r t- t e r m t h e r a p y as a
tic ip a n ts p resen ted m a te ria l d e ta ilin g th e ir

th o u g h ts a b o u t an d ex perien ces w ith s h o r t
id eas a n d o b se rv a tio n s of th is s em in ar. It is
p r i m a r y a n d p re f e rre d t r e a t m e n t r a t h e r t h a n
te r m th e r a p y . H e le n A vnet, D ir e c t o r of R e
as a n e x p ed ie n t. E ven n a tio n a l p sy ch o an aly tic
search,
In s u r a n c e C o m p a n y ,
o rg a n iz a tio n s , stro n g h o ld s of lo n g - te rm t r e a t
revealed the res u lts of a p ro ject th a t lasted tw o

a n d o n e -h a lf years, in w h ic h a p a n e l of 1,139
m e n t, have b e g u n to p re a c h its v irtu es and

h a v e o rg a n iz e d c o n ti n u in g - e d u c a tio n courses
psy chiatrists tre a te d p a tie n ts o n a s h o r t-t e rm

basis. O n te r m i n a ti o n , 7 0 p ercen t of the p a
on th e subject. A ho st of articles an d a n u m b e r
of in te re stin g books h ave a p p e a r e d , o u tlin in g
tien ts w ere r a t e d by th e p a n e l as im p ro v e d or
recovered. It w a s concluded th a t a large p o r
te c h n iq u e s th a t th e a u th o r s h av e found v a l u a
t i o n o f th e c o m m u n i t y s p s y c h i a t r i c n e e d s
could be m et by s h o r t-t e rm tre a tm e n ts . J u l e s
ble in th e ir a tt e m p t s to a b b re v ia te tr e a tm e n t.
In th e m a in , sim ilarities of concepts h ave e x
M a s s e r m a n detailed the h isto ric a l-c o m p a ra tiv e
ceeded differences. N ev erth eless, a g re a t n u m

b er of q u e stio n s r e m a in u n a n s w e r e d , an d it is
G ro up
H e a lth
an d e x p e rim e n ta l roots of s h o r t- t e r m th e r a p y ,
tra c in g its o rig in s in th e past. S a n d o r R ad o
p hilo so p h ies, goals, selection p ro c e d u r e s a n d
th e p u r p o s e of th e p re s e n t v o lu m e to c o n tr ib u te
to th e re s o lu tio n of som e of these.
p resen ted m a t e r i a l on m o tiv a tio n a l factors th a t

could prov id e guid elines for tech n iq u e s in
s h o r t-te rm th e r a p y . P a u l H o c h differentiated
O n e of th e m ost critical q u e stio n s is re lated
th e charac teristic s of s h o r t-t e rm versus lo n g

te r m th e r a p y . F r a n z A le x a n d e r d ealt w ith p s y
to th e valu e of d y n a m ic a p p r o a c h e s in s h o r t
te r m th e r a p y . M o s t im p o r t a n tl y , can w e e m p i
rically p ro ve th e effectiveness of a d y n a m ic a lly
based s h o r t- t e r m th e r a p y ? C o n tro lle d e x p e r i
m e n ts h av e been few, a n d even in th ese the dif
cho analytic c o n tr ib u tio n s to s h o r t- t e r m th e r a p y

in facilitating a corrective e m o tio n al e x p e r i
ence. L o t h a r K alin o w sk y lectu re d on th e use of
ficulties th a t s h a d o w o u tc o m e stu dies te n d to
s o m a ti c t r e a t m e n t s
th erap y .
o b scu re results. Yet w ith all o u r skepticism
A le x a n d e r W o lf d ealt w ith s h o r t-t e rm g r o u p
a b o u t q u a n tify in g brief clinical o p e ra t io n s suf
p sy ch o th erap y . M o lly H a r r o w e r described a
ficiently to satisfy th e c rite r ia of objectivity,

validity, a n d relia bility so essential in scientific
studies, d is c rim in a t in g e x p e rie n c e estab lish es
b eyo nd r e a s o n a b le d o u b t th e usefulness of a
d y n a m ic o rie n ta t io n in a n y form of s h o r t-te rm
p sy c h o th e ra p y . T h i s a p p lie s w h e t h e r w e a re
h e lp in g a p e rs o n recognize a n d th e n to com e to
in s h o r t - t e r m
research p roject related to o u tco m e of lo n g

te r m a n d s h o r t-t e rm t h e r a p y . A rle n e W o lb e r g
discussed the in c o r p o ra tio n of ca se -w o rk p ro c e
d u re s in a s h o r t-t e rm p r o g r a m . I gave tw o lec
tu res, o ne on g en era l aspects of te c h n iq u e an d
the o th e r on the e m p lo y m e n t of h y p n o sis as a n
ad ju n ct in s h o r t-te rm t h e r a p y . T h e s e m in a r
w a s pu b lish ed later by G r u n e & S tr a tt o n
u n d e r th e title S h o rt-term P sych o th era p y.
It is in terestin g in review in g th e c u rr e n t
lite r a tu re th a t in d e p e n d e n t studies hav e v a li
vii
te r m s w ith his p ast, as in insig ht th e r a p y , or

e lim in a tin g effects of th e p a st t h r o u g h r e i n
fo rcem ent of a d a p ti v e be hav iors, as in b eh av io r
th e r a p y , o r sq u e e z in g the p a st o ut of m uscles
a n d tissues as in th e n e w body th e r a p i e s , or
viii
HANDBO OK OF SHORT-TERM PSYCHOTHERAPY
g a in in g a perspective on in n e r e m o tio n a l ef
fects of the p a s t th r o u g h sensory a w a re n e s s
search of p a tie n ts w h o h a d been tre a te d in a
techn iq ues, o r co rrec ting h a b itu a l p a st m odes
c o m p a r is o n stu d y w ith tw o fo rm s of b rief psy

c h o th e r a p y (b e h av io r t h e r a p y a n d p sy c h o a n a -
of th in k in g , as in cognitive t h e r a p y . In d eed , a
l y t ic a l ly o r i e n t e d p s y c h o t h e r a p y ) a n d w h o
d y n a m ic a p p r o a c h , in m y o p in io n , is th e best
w e re d is c h a rg e d as im p ro v e d , P a tte rs o n , et al
(1977) found th a t on e y e a r after te r m i n a ti o n ,
design to follow in all form s of p s y c h o th e ra p y ,

h ow ev er b rief th ey m a y be, a n d w h ile it m ay
fully 60 p e rc e n t h a d so u g h t o u t a n d o b ta in e d
not hav e a n im m e d ia te d r a m a ti c influence on
f u r th e r tr e a tm e n t. T h e s e figures a re p ro b a b l y
the p e rs o n a lity stru c tu re , it can catalyze such

c h ang es ev entu ally th r o u g h its c o n tin u in g in
low b ecau se m a n y d is ch arg ed p a tie n ts w h o do
fluence on cognition.
n ot seek fo rm al t h e r a p y u tilize o th e r form s of

h e lp o r self-help to redu ce th e i r tension a n d
In this v o lu m e I h ave a tt e m p t e d to b rin g
b etter th e i r a d ju s tm e n t. Life, after satisfactory
to g eth er co m m o n elem ents in th e chief m odels

of s h o r t-te rm th e r a p y c u rr e n tly in use a n d to
p s y c h o t h e r a p e u t i c t r e a t m e n t , c o n t i n u e s to
p re s e n t a n ev er en d in g series of c hallenges th a t
evolve p rinc iple s th a t can be em p lo yed by in d i
can ta x co p in g capacities of even c u r e d p a
vidual th e r a p ists,
retical biases a n d styles of o p e ra tio n . H o w a

d y n a m ic view p o in t m ay p ractically be in
tients. T h i s is n o t a lto g e th e r bad , for in m e e t

ing th ese cha llen g es th e in d iv idu al h a s a n o p
p o r t u n i t y of s tre n g th e n in g a d a p tiv e p a tt e r n s ,
trodu ced in an y form of p s y c h o th e ra p y is one

of m y goals. T h e s h o r t-t e rm m e th o d th a t I will
of a p r i o r v accination . S h o r t - te r m p s y c h o t h e r
irrespective of th e ir th e o
describe is no t p res e n te d w ith illusion t h a t it is

flawless, infallible, o r u n iv ersally ap plicab le.
m u c h like a boo ster shot can e n h a n c e th e effect

ap y offers th e p a ti e n t a m e a n s by w h ic h o n e s
f u tu re m a y be reg u la te d , p ro v id ed th e th e r a p is t
N o r m a y it p ro ve e q u a lly helpful to all t h e r a
p re p a r e s th e p a ti e n t for a n tic ip a te d events an d
pists o r cu rativ e in every case. It is, n e v e rth e
con tin gen cies a n d te aches a w a y of d e a lin g
less, in m y o p in io n , (and in th e j u d g m e n t of
th e r a p ists w h o have u tilized th e m eth o d ), an
easily learn ed a n d effective te c h n iq u e servicea
w ith these, sh o u ld th ey a p p e a r .
As a h a n d b o o k , th is v o lu m e prov ides a n o u t
ble for the g re a t m a jo rity of p a tie n ts seen in

clinics a n d p riv a te practice. T h e m eth o d also
tak es into co n sid eratio n th e fact th a t th e r e will
be p a tie n ts w h o a re n ot good subjects for
s h o r t-te rm
t r e a tm e n t a n d
line of process in s h o r t- t e r m th e r a p y . S h o u ld
ex tensive d etails of te c h n iq u e be sou gh t, th ey
m a y be found elsew h ere, in clu d in g th e th ird
ed itio n of m y b oo k T h e T ech n iq u e o f P s y
ch o th era p y. It is r e c o m m e n d e d th a t th e re a d e r
w h o will r e q u i r e
if no t a lr e a d y a c q u a i n te d w ith som e tech n iq u e s
o th e r form s of help. U n d e r these c ir c u m

stances, the m e th o d will fun ction as a useful
in itial d iag n ostic p ro c e d u re , e n a b lin g th e t h e r a
pist to select m od alities th a t will serve th e p a
o th e r th a n ind iv idu al p s y c h o th e ra p y e x p e r i
m e n t w ith these to see w h e t h e r they accord
tien t best.
T h e m e th o d also co n ta in s a m ean s of p r o
v id i n g c o n t i n u i n g t h e r a p y for th e p a t i e n t
th r o u g h assigned h o m e w o r k an d th e use of a
casette tape, th e m a k i n g of w h ich will be
described in detail. It h a s a lw a y s confoun ded
me th a t so m a n y th e r a p is ts a ssu m e th a t w h e n
th e last form al t r e a tm e n t session h a s en ded ,
th e p a tie n t can sally fo rth like the fabled
p rin c e a n d princess to live h a p p il y ever after.
T h e facts on the follow -up a r e a g rim d en ial of
this fantasy. F o r e x am p le , in follo w -up r e
w ith o n e s in d iv id u al styles of w o rk in g . In m y
o p in io n , a t h e r a p i s t s usefulness is especially
en h a n c e d by k n o w le d g e of g r o u p th e r a p y (see
T h e T ech n iq u e o f P sy ch o th era p y, 3 rd ed, pp.
7 0 2 - 7 2 9 ) , f a m il y t h e r a p y ( p p . 7 2 9 - 7 3 3 ) ,
m a r it a l (couple) th e r a p y (pp . 7 3 3 - 7 4 0 ) , be
h a v io r t h e r a p y (p p. 6 8 5 - 7 0 1 ) , re la x a tio n p r o
ced ures (pp. 7 6 1 - 7 6 6 ) , a n d so m a tic th e r a p y
(pp. 7 6 7 - 7 8 9 ) . O t h e r te c h n iq u e s m a y p e r i
odically be useful such as h y p n o sis (pp. 791
8 09 ), sex t h e r a p y (pp. 8 0 9 - 8 1 7 ) , a n d biblio th e r a p y (pp. 8 1 7 - 8 3 3 ) . It goes w ith o u t say
in g th a t k n o w le d g e of th e th e r a p e u ti c process
from th e in itial interv iew to te r m i n a ti o n (pp.
PREFACE
ix
3 5 3 - 6 8 4 ; 7 4 3 - 7 5 8 ) an d especially in te rv ie w
W h a t e v e r g a in s m a y accrue from a n y evolving
ing tech niqu es (pp. 3 6 0 - 3 8 2 ) a re in d ispen si-
insights a re n e u tr a liz e d by th e crip p lin g influ
ble.
ence of th e p ro lo n g e d sh elte re d relatio n sh ip .
A final w o rd of cau tio n m a y be indicated.

O n e should not a ssu m e th a t it is alw a y s po ssi
ble to d up lica te or s u r p a s s w ith s h o r t- t e r m a p
pro ach es w h a t can be d o n e w ith a p p ro p r ia te ly
selected p a tie n ts th r o u g h lo n g e r -te rm t r e a t
P la y in g a w a iti n g g a m e in th e h o p e th a t tim e
will even tually dislodge a neu ro sis too fre
q u e n tl y resu lts in p a tie n t p a ra ly sis an d t h e r a
pist fru str a tio n .
m en t. B ut, for the g re a t m a jo rity of pe op le
S u ch disc on certing p h e n o m e n a give im p e tu s

to o u r efforts to s h o rte n th e t h e r a p e u ti c process
seeking help for em o tio n al p ro b le m s, th e tim e
w ith o u t d e v italizin g its effect. T h i s is n ot to
elem ent is no t th e most im p o r t a n t v a ria b le in
d e p reciate e conom ic a n d o th e r practic al r e a
p sy ch oth era py .
is too fr e q u e n tly co n
sons for a b b re v ia tin g s h o r t- t e r m t h e r a p y . B ut
sidered a m agical device th a t acts like a d e
a p a r t from cost effectiveness a n d th e need to
tergen t, w a s h in g a w a y a c c u m u la te d n e u ro tic
residues. It is assu m ed tr a d itio n a lly t h a t the
m in is te r to th e g ro w in g m u ltitu d e s of p eop le
w h o seek help , d y n a m ic s h o r t- t e r m t r e a tm e n t
longer a p a tie n t r e m a in s in p s y c h o th e ra p y , the

g re a te r the benefits h e will derive fro m it.
C o m m o n practice, how ever, convinces t h a t this
is ju stified o nly if it can p ro v e itself to be a

tr u ly useful m e a n s of d e a lin g w ith em o tio n al
T im e
is t r u e only u p to a certain p oint. Beyond such

a p oin t, resistances pile u p in a d is tu rb i n g
n u m b e r of p atie n ts , gain s a r e n e u tr a liz e d , a n d
a setback ensues. P e e rin g into the causes of
these m isfortunes, w e observe in th e r a p y th a t
goes on for too p ro tra c te d a period an e m e r g
ing sense of helplessness th a t m a y be concealed
by vario u s reactio n fo rm atio n s. T h e c onse
q u en ce is a sab otage of p ro g re ss a n d u ltim a te ly
an ex ac erb atio n of sy m p to m s. T h e th e r a p is t
th e n becomes for th e p a tie n t a crutch ; w ith o u t
p ro b le m s in th e vast m a jo rity of cases. In m y

o p in io n , this p ro o f has n o w been established.
A c k n o w le d g m e n t is m a d e to th e P o s t g r a d u
ate C e n t e r for M e n t a l H e a l t h , u n d e r w ho se
auspices this book w a s w r it te n , an d to its Staff
for th e s tim u la tio n th ey in spire d. T h a n k s a re
d u e to G r u n e & S tr a tt o n , th e p u b lish e rs of m y
books S h o rt-te rm P sy c h o th e ra p y a n d T he D y
n am ics o f P e rso n a lity (w ith J o h n K ild ah l) for
p e rm iss io n to utilize som e m a te ria l from these
v o lu m es in C h a p t e r s 7, 8, 9 a n d 16. C r e d it is
also d u e to m y secretary, A n n K o c h a n sk e , for
w h o m in d e p e n d e n t steps a r e avoided. T h i s is
h e r effective h e lp w ith th e physical p r e p a r a t i o n
p a rtic u la rly the case in sicker p a tie n ts w hose
of th e book a n d th e checking of references.
d ep end ency needs a re h a ll m a r k s of th e i r basic

pe rson ality stru c tu re , o r w h o have, b ecau se of
persisten t a nx iety , lost th e ir sense of m a s te ry
N e w Y ork, N e w Y o rk
an d d istru st th e ir o w n c apacities to function.
N o v e m b e r 1, 1979
L e w is R. W o lb e r g , M . D .
CHAPTER 1
Models of Short-term Therapy

B rief tr e a tm e n t is no n e w c o m e r on the
p s y c h o th e ra p e u tic scene. C h ro n ic le d in p r i m i
th e b eg in n in g of the tw e n tie th c e n tu r y m e th o d s
of t r e a tm e n t w e re sh o rt te r m ; even th e orig in a l
F r e u d i a n te c h n iq u e s w e re im p le m e n te d over a
tive archives of earliest rec orded h isto ry , p a r

ti cularly in E g y p t a n d G reece, a r e acc o u n ts of
p erio d of a few m o n th s. G r a d u a l l y p s y c h o a n a
lytic m eth o d s stretch e d o ut in tim e, a n d the
w h a t we m a y consider species of s h o r t-te rm

p sy c h o th erap y .
In
these
a n c ie n t
d o c u m e n ts
n u m b e r of w eek ly sessions increased as efforts

w e re directed at the task of resolving resistance
th e r e a re tra n sc rib e d e la b o r a te ritu a ls to heal

th e afflicted, to solace tr o u b le d souls, a n d to
to u n co nscio us conflict. A few c o n te m p o ra r ie s

of F r e u d , n o ta b ly A d ler, F e ren cz i, Stekel, an d
assuage a n g u is h an d distress. A m o n g such in

terv entio ns a re tr a n q u il iz i n g n o s tru m s , bodily
R a n k , tried h ero ically to s h o r te n th e p r o

tra cted tim e of psy ch o a n a ly sis, b ut th e i r m e t h
m a n ip u la tio n s , tr a n c e in can ta tio n s, persu a siv e

suggestions, a n d even r u d i m e n t s of rein fo rce
ods w e re re p u d i a te d by th e official a n a ly tic es

ta b lis h m e n t. S om e R a n k i a n a n d S teke lian stra-
m e n t th e r a p y , em o tio n al c ath a rsis, a n d i n t e r

p re ta tio n of fantasies a n d d re a m s . E la b o r a tio n s
of these th e r a p ie s c o n tin u e to th is d a y d r a p e d
te gem s survived, nevertheless, a n d h ave been

a d a p te d to fit in w ith p re s e n t-d a y styles a n d
c o n te m p o r a r y ideologies.
in th e soph istication of m o d e r n theories. U p to
Psychoanalytic Modifications in
Brief Dynamic Therapy
It w a s F r a n z A le x a n d e r in 1946 w h o most
strikin gly challeng ed th e validity of p ro lo n g ed
prior
to t e r m i n a t i o n ,
strateg ic
p l a y i n g of
stu d ie d roles, a n d co m b ined use of p s y c h o t h e r

a p y w ith d r u g a n d o th e r tr e a tm e n ts . A t th e
tim e as a necessary c o m p o n e n t of t r e a tm e n t
m eth o d s directed at rec on structive goals. R e a c
tim e th e ir e x p e ri m e n t s w e re considered as d a r
ing a n d innovative. P a r t ic u l a r ly re g a r d e d as
a b e r r a n t w e re th e e m p h a s is o n p ro b le m solv
ing a n d th e c o n sid e ratio n of t h e r a p y as a c o r
tion to A l e x a n d e r s u n o rt h o d o x y w a s at first
h a rs h , a n d a lth o u g h h e w a s accused of a b a n
d o n in g the psy c h o an aly tic sh ip, it is to his
credit th a t he resisted re c a n tin g his convictions.
rective em o tio n a l e x p erien ce th a t functioned to

b r e a k u p old reactio n p a tt e rn s . In some
A lo ng w ith F re n c h he p u b lish ed a p io n e e r
w o rk on b rief th e r a p y (A le x a n d e r & F r e n c h ,
1946) th a t q u estio n ed m a n y of th e a s s u m p tio n s
of lo n g -term classical p sy choanalysis.
In th eir v olu m e the a u th o r s describe e x p e r i
ca se s , th ey w ro te , th e d ev elo p m e n t of a fullfledged tr a n sferen ce n eu ro s is m a y be d e sir

able; in o th e rs it sho uld p e r h a p s be avoided
a l t o g e t h e r . In s o m e it is i m p e r a t i v e t h a t
m e n tin g w ith v a ry in g th e fre qu enc y of in t e r

views, the a lte rn a tiv e use of th e c h a ir a n d
couch, d e lib erate in te rr u p t io n s of t r e a tm e n t
e m o tio n a l d is c h a rg e a n d insight ta k e place

g ra d u a lly ; in o th e rs, w ith p a ti e n ts w h o se ego
stre n g th is g re a t e r , in terview s w ith g re a t e m o
tional tension m a y be not only h a rm le s s but
ti m e devoted to t r e a tm e n t w ith o u t d estro y in g
highly desirable. All this d ep en d s u p o n the
its
e ffe c tiv e n e ss
needs of the p a tie n t in a p a r t i c u l a r p h a s e of the
th e
o b serv a tio n s of A le x a n d e r
th e ra p e u tic p r o c e d u r e . T h e m odifications
suggested w e re form s of p sy ch oan aly sis based
M o r e o v e r, restrictio n of p a y m e n t s to a des
ig nated n u m b e r of sessions by in s u ra n c e c o m
on d y n a m ic p rin cip le s th a t a tt e m p t to secure a
p a n ie s h as forced even th o s e th e r a p is ts w h o by
m o re h a rm o n io u s e n v ir o n m e n ta l a d ju s tm e n t
w ith en h a n c ed d ev elo pm ent of o n e s capacities.
F r e q u e n t interview s over a lo n g - te rm p e
riod, th ey insisted, h a d a regressive conse
quence
o ften
gratify in g
th e
p a t i e n t s d e
has
rek in d led
interest
and
in
F re n c h .
t r a in i n g a n d conviction a r e dedicated to lo n g
te r m t h e r a p y to m odify th e i r tactics a n d to
b ri n g tr e a tm e n t to a h a lt w ith i n th e confines of
the alloted re i m b u r s e m e n t term . E con om ics
h a s th u s h a d a corrosive effect on ideology,
p end ency needs. T h e in itial soo th ing effect of
w h ich is p ro b a b l y all to the good in a field
th e prolo ng ed ou tlo o k g ra d u a l ly becomes c o r

ru ptiv e, a n d th e th e r a p is t, faced w ith th e task
w h e re bias a n d o p in io n h a v e frozen p ro fes

sionals to p o s tu la te s th a t could n ever h av e been
of driv ing the p a ti e n t from his co m fo rta b le in
o th e rw ise th a w e d o u t a n d revised.
fantile position, realizes a n e w h o w difficult it

is to force a n y o n e to give u p a c q u ir e d r i g h ts .
T h e w o r k of A le x a n d e r a n d F r e n c h p r o
vided th e fo u n d a tio n for o th e r dev elop in g sys
It w a s a fallacy, th ey con tend ed, to a ss u m e

th a t a n a n a ly sis o rien ted a r o u n d regressive
te m s of d y n a m i c s h o r t - t e r m t h e r a p y a n d
in s p ire d a n u m b e r of a n a ly s ts w h o th o u g h
m a te ria l w a s m o re th o r o u g h t h a n on e focused
on t h e i m m e d i a t e life co nflict. I n d e e d ,
loyal to the te ac h in g s of F r e u d refused to c o n

sider th e m as divine rev elatio n s ( M a r m o r ,
regressive m a te ria l w a s u su a lly a sign of n e u
1979).
rotic w i t h d r a w a l from a difficult life situ atio n .
concepts, th ey vouchsafed th e validity o f th e
It w a s the d u ty of th e th e r a p is t to d ivert this

re tre a t to w a r d n ew a tt e m p t s to solve p ro b le m s
d y n a m ic design. A m o n g th e best k n o w n of c o n
from w h ich the p a tie n t h a d fled in th e past.

A n o th e r d isa d v a n ta g e of too fr eq u e n t sessions
th e r a p y a r e th e w ritin g s of M a l a n , Sifneos,
and M ann.
w a s th a t tra n sferen ce w a s not allo w ed to a c c u

m u la te , being d ra i n e d off in sm all q u a n ti ti e s at
I n t h e s t u d y by M a l a n (1 9 6 3 ) a t th e
T a v i s t o c k C l i n i c in L o n d o n , t h e p a t i e n t s
each session, th u s lessening th e em o tio n al p a r
tre a te d w e re th ose w h o w e r e ab le to exp lo re

th e ir feelings a n d w h o gave the im p ressio n
ticipatio n. T h e y advised m a n i p u la t io n o f the

freq uency of sessions to intensify em o tio n al
reactions. A focus on th e p re s e n t he lped redu ce
th e evolvem ent of a tran sferen ce neu roses a n d
th e su b stitu tio n of tr a n sfere n c e gra tific atio ns
for real-life experiences. P u tt in g into practice
w h a t h a d been le a rn e d in th e r a p y e n co u rag ed
th e b olsterin g of self-confidence a n d the ov er
co m in g of n e u ro tic im p a ir m e n t . T h e p a ti e n t
d u r i n g th e course of his e x p e ri m e n t in g w ith
n ew p a tt e r n s w a s to be fo r e w a rn e d of failures
a n d the need to a n a ly z e the reaso ns for these
sh ou ld they occur, th u s tu r n i n g th e m to a d v a n
tage.
W i t h th e d e v e lo p m e n t of c o m m u n ity m en tal
h e a lth facilities a n d th e servicing of increasing
g ro u p s of p a tie n ts by staffs dep leted th r o u g h
s h r in k in g bud gets, the necessity of lim itin g
W h il e
c h a lle n g in g
classical
a n a ly tic
te m p o r a r y c o n tr ib u tio n s to d y n a m ic s h o r t-t e rm
th ey could w o r k w ith in te rp re tiv e t h e r a p y . All

of th e t h e r a p is t s involved w e re p sy c h o a n a lytically o rie n te d a n d w illin g to e m p lo y a n
active in te rp re tiv e te c h n iq u e . Sessions totaled
from 10 to 40. It w a s possible, M a l a n w ro te ,
u n d e r these co n d itio n s to o b ta in q u it e farre a c h in g im p ro v e m e n ts not m erely in s y m p
to m s, b u t also in n e u ro tic b e h a v io r p a t t e r n s in
p a tie n ts w ith relatively extensive a n d lo ng
sta n d in g n e u r o s e s . T h e best results w ere
achieved w h e n (1) th e p a ti e n t w a s hig h ly m o t i
v ated, (2) th e th e r a p is t d e m o n s tr a t e d h ig h e n
th u s ia s m , (3) tr a n sferen ce developed early ,
especially neg ative tra n sferen ce, a n d w a s i n t e r
p re te d , a n d (4) g rief a n d a n g e r b ecam e i m p o r
t a n t issues as te r m i n a ti o n a p p r o a c h e d . T h e
p ro gn o sis w a s also best w h e r e th e p a ti e n t a n d
MODELS OF SHORT-TERM THERAPY
th e r a p ist sho w ed a stro n g w illing ness to get in

volved the fo r m e r w ith a n in ten se desire for
needed to develop p r o p e r m o tiv atio n for t h e r

a p y , th a t rigid a n d d eep -se ated issues re q u ire d
help th r o u g h u n d e r s ta n d in g , th e la tte r w ith
m o r e w o r k t h a n th e lim ited tim e could allo w ,
s y m p a th y w h ile in te ra c tin g objectively a n d not

w ith c o u n te rtra n sfe re n c e . Even deep -seated
that
severe d e p e n d e n c e
and
o th e r
u n fa v o r
neu ro tic b eh a v io r p a tt e r n s could be lastingly

ch ang ed. T h e te c h n iq u e if p r o p e r ly used c a r
a b le in ten se tr a n sferen ce feelings w o u ld be

too o bstru ctive, o r th a t dep ressive o r psychotic
d is tu rb a n c e s m i g h t be p r e c ip ita te d o r in t e n
ried few d an g ers , even w h e re p e n e tr a ti n g i n
sified.
te r p re ta tio n s
w ere
made
fr o m
dream s,
Sifneos (1 97 2), c o n firm in g m a n y of M a l a n s
fantasies, a n d th e th e r a p is t - p a r e n t lin k of the
findings, a d d s som e o th e r crite r ia of selection
tra nsferenc e th a t connected th e p re s e n t w ith
for this form of d y n a m ic a n x ie t y - p r o v o k in g

th e r a p y th a t lasts fro m 2 to 12 m o n th s. S u it
ch ildhood experiences. M a l a n
gested
th a t
crucial
modestly su g
in g re d ie n t
in
ch a n g e
m ig h t not be th e te c h n iq u e em plo yed , bu t the

n o n s p e c ific f a c t o r of t h e a n a l y s t a p p l y i n g
a b le
p atien ts
are
those
who
p o ss e ss
five
qu alitie s: (1) existence of a b o v e-av erag e in

telligence, (2) possession of at least on e m e a n
him self e n th u s iastically to his te c h n iq u e ir
ingful re la tio n s h ip in th e p a st, (3) ab ility to
respective of w h e th e r it w a s an aly tic o r n o n analytic.
i n t e r a c t w i t h t h e i n i ti a l i n t e r v i e w e r w h ile
m a n ife stin g a p p r o p r i a t e e m o tio n s a n d a d egree
In a later stud y p u b lish ed in his book

F ro n tier o f B r ie f P sych o th era p y, M a l a n (1976)
of flexibility, (4) ab ility to identify a specific
confirm ed his prev io us conclusions r e g a r d in g

the utility of d y n a m ic s h o r t-t e rm th e r a p y and
oneself, to w o r k on oneself, to recognize o n e s
described som e p rin c ip le s of selection of s u i ta

ble p a tie n ts for th is form of tr e a tm e n t. In
v ealin g th in g s a b o u t oneself, to p a rt ic i p a te ac
tively in th e r a p y , a n d to m a k e rea s o n a b le
M a l a n s sa m p le the p a tie n ts w e re carefully

screened. C h o s e n w ere th ose w h o a p p e a r e d to
sacrifices (Sifneos, 1978).

F o r p a tie n ts w h o a r e selected, sessions are
have the basic stre n g th to sta n d u p to u n c o v e r

ing p s y c h o t h e r a p y , w h o w ere resp on siv e to
held once w ee k ly for 45 m in u te s in face-to-face

interview s. T h e initial interv iew deals w ith
in t e r p r e t a t i o n , a n d w h o could help fo r m u la te
h isto ry tak in g , p a r t ic u l a r ly a ju d ic io u s c o n
a c ircum scribed focus a r o u n d w h ich th e r a p y
fro n ta tio n
c o u ld
ty pe of q u e s t io n s . As a re a s of conflict an d
be
done.
S e v e r i ty
of p a t h o l o g y
or
chief c o m p la in t, (5) w illin gn ess to u n d e r s ta n d

s y m p to m s as psychological, to be ho nest in r e
by
o p e n -e n d e d
and
forced-choice
chronicity w e re no t c onsidered. O f all factors
m a l a d a p ti v e re actio n s o p en u p , th e th e r a p is t
in prognosis, m o tiv atio n for insigh t a n d th e

ability to focus on significant m a te ria l seem ed
asks q u e stio n s th a t will give h im a c le a re r pic
to be of p r i m a r y im p o rta n c e . T h e s e w e re con
able to m a k e a co nn ectio n b etw e en the u n
sidered to be m e a s u re s of successful i n t e ra c
tions b etw een p a tie n t an d th e r a p is t. P a tie n ts
w h o w e re excluded w ere alcoholics, h o m o s e x
uals, d r u g addicts, th ose w h o h a d at on e tim e
d e rly in g conflicts an d th e superficial c o m

p la in ts . Before long, tra n sfe re n c e feelings a re
a p t to em erge. T h e th e r a p is t m u s t th en con
fro n t th e p a tie n t w ith his tra n sfe re n c e feelings
m a d e serious suicidal a tte m p ts , w h o h a d a p e

riod of lo n g -term h o sp ita liz a tio n , w h o h ad
m o re t h a n one course of E C T , w h o suffered
a n d use th e m as th e m a in p s y c h o th e ra p e u tic
to o l . T h i s facilitates tr a c in g of o n e s e m o
tio n al p ro b le m s in the p a st a n d reco gn izin g
h o w conflicts give rise to o n e s sy m p to m s.
fr o m i n c a p a c i t a t i n g c h r o n i c o b s e s s io n a l o r
p h o b ic s y m p t o m s , a n d w h o w e r e g r o s s ly
destructive or self-destructive in ac tin g -o u t. As
w as predicted, reaso n s for rejection w e re th a t
the p a tie n t w o u ld have difficulty in m a k i n g
contact, th a t a g re at d eal of w o r k w o u ld be
t u r e of th e p sy ch o d y n am ics. H e m a y th en be
S o o n e r or later resistance a p p e a r s . T h e w ho le
to n e of the in terview s sta rt to c h a n g e , silences
a p p e a r , th e w h o le i n t e r v i e w s e e m s f r a g
m e n t e d . C o n f r o n t a ti o n a n d clarification a re
em p lo y ed as tools, b ut a tra n sfe re n c e neuro sis
HANDBOOK OF SHORT-TERM PSYCHOTHERAPY
is avoided. T h e p a ti e n t m u s t be c onfronted
w ith his a n g e r a n d his n egativ e feelings, a n d
these m a y flair u p w ith th e t h e r a p i s t s an x iety -
cated y o u n g p e o p le w h o gave freely of th e ir

tim e a n d w e re ea g e r to h e l p . W h il e th es e r e
p ro v o k in g questio ns. In te r p r e t a ti o n s h elp cla
q u ir e m e n t s a r e ideal, th e av erag e t h e r a p is t will

see a good n u m b e r of less s u itab le p a ti e n ts u r
rify the p a t i e n t s reactions. A w a re n e s s of his
g en tly d e m a n d i n g s y m p to m relief w h o se p r o b
o w n co u n te rtra n sfe re n c e is vital, a n d th e t h e r a

pist m u s t m a k e sure he is n ot u sin g th e p a tie n t
lems a r e lin ked to in n e r conflicts a n d w h o do

n ot fulfill the selection r e q u i r e m e n ts of Sifneos.
to gratify his o w n needs. R e p e a te d ly d e m o n
T h e y m ig h t still be co nsidered for d y n a m ic
stra tin g h ow the p a tie n t deals w ith his conflicts
th e r a p y , b u t a n x ie ty -p r o v o k in g
h av e to be avoided.
a n d th e adverse effects on h im , the th e r a p is t

acts as a n u n e m o tio n a lly involved te a c h e r .
T a n g ib l e evidence of p ro g ress is sh o w n by th e
tactics
may
Sifneos h a s no t neglected c o n sid e ra tio n of
p a t i e n t s ability to relate w h a t is g oin g o n to
o th e r classes of p a tie n ts no t qualified for th e

a n x ie ty -p r o v o k in g te c h n iq u e b u t a m e n a b le to
p a st sources a n d by im p ro v e m e n t in his in t e r
a n a n x i e t y - s u p p r e s s i v e f o r m of t h e r a p y .
perso n al re latio n sh ip s. T h e th e ra p ist m ust
S uch t h e r a p y is designed for p a tie n ts w ith
w ork u n in terru p ted ly to w ard term in atio n ,

h a n d li n g his co u n te r tr a n sfe re n c e a n d rea lizin g
w e a k ego s tru c tu r e s w h o h a b it u a ll y h ave p o o r
th a t th e r e a r e ce rta in b e h a v io r p a tt e r n s w h ich
lifelong e m o tio n a l difficulties. H e r e th e goal
c a n n o t be altered by p s y c h o t h e r a p y . At a p r o
pitio us tim e te r m i n a ti o n m u s t be discussed.
is
T h e p a t i e n t s reactio n s such as a n g e r, d e
pression, a n d fear m u s t be a n tic ip a te d an d
han d led .
T h e follow ing o u tlin es technical processes in
Sifneoss te chn iq ue:
1. T h e p a t i e n t is a s k e d to list in o r d e r of u r g e n c y
t h e p r o b l e m s t h a t h e w o u l d like to overcom e.
2. It is es sen tial to d ev elo p a r a p i d t h e r a p e u t i c
in te rp e r s o n a l
to
re la tio n s a n d
d issipate
a n x ie ty
by
a r e disposed to
such
tactics
as
re a s su ra n c e , advice giving, em o tio n a l cath a rsis,

e n v ir o n m e n ta l m a n i p u la t io n , p e rs u a s io n , h o s
p ita liz a tio n , o r m ed ication . W h e r e th e p a ti e n t
h a s a d e q u a t e m o tiv a tio n to receive h elp, reco g
nizes th a t his s y m p to m s a r e psychological, is
able to m a i n ta i n a jo b , a n d is w illin g to c o o p
e ra te w ith th e th e r a p is t , h e h a s th e best o p p o r
tu n ity
for relief.
Sessions
last from
a few
m in u te s to a n h o u r a n d a r e spaced every week,
al l i a n c e w i t h p a t i e n t , since t h e p a t i e n t s po sitive
twice a w eek, o r oftener. B rief crisis s u p p o r tiv e
fe elings t o w a r d t h e r a p i s t c o n s t it u t e a ch ie f t h e r a
t h e r a p y lasts u p to 2 m o n t h s an d is a im e d at
ov ercom ing th e e m o tio n al d ec o m p e n sa tio n .
p e u t i c tool. A g r e e m e n t m u s t be r e a c h e d r e g a r d i n g
th e p r o b l e m to be solved.
3. T h e t h e r a p i s t r a p i d l y a r r i v e s a t a te n t a t i v e
psychodynam ics and the und erly in g em otional con
flicts.
4. T h e focus in t h e r a p y is o n t h e s e conflicts, t h e
ob ject b e i n g to h e l p t h e p a t i e n t l e a r n n e w m o d e s of
so lving difficulties.
5. T h e
therap ist
m ust confront patien t w ith
a n x i e t y - p r o v o k i n g q u e s t io n s , h e l p i n g h i m to face
a n d e x a m i n e a r e a s of difficulty r a t h e r t h a n to av oid
t h e m , a n d e n a b l i n g h i m to e x p e r i e n c e his conflicts
a n d to co n s o l id a te n e w s o lu tio n s for th e m .
6. If successful in r e a c h i n g t h e g o a ls set fo rth , t h e
p a t i e n t s h o u l d be a b l e to u tiliz e his l e a r n i n g to
d e a l w i t h t h e n e w cr itical s i t u a t i o n s in t h e f u t u r e .
It m u s t be re m e m b e r e d th a t th e basis of
Sifneos a p p r o a c h w a s w o rk w ith a clinic
p o p u la t io n of self-referred, relatively w e ll- e d u
P a tie n ts w ith serious difficulties, h o w ever, m ay

re q u i r e s u p p o r t for a p ro lo n g ed period.
A n in terestin g fo rm of d y n a m ic b rief t h e r
a p y h a s been de taile d by M a n n (1973). A few
of th e p rin c ip le s w e re o rig in a lly described by
R a n k (1 9 36 , 1947). S tressin g the subjective
a n d objective m e a n in g s of tim e (e.g., s e p a r a
tion , loss, d e a th , etc.) b oth to th e p a tie n t an d
th e r a p is t, M a n n co ntends th a t am b ig u ity
a b o u t tim e lim ita tio n s of t h e r a p y m a y act as a
d e te r re n t to a cceptance of reality a n d th e w o rk
to be done. P a tie n ts , h e avow s, a r e b o u n d to
child t i m e , a n unco nscio us y e a rn i n g for
e tern ity , a n d m u s t be b r o u g h t to th e a c c e p
ta n c e of realistic lim ited a d u lt t i m e . H e o u t
lines a f ix e d 12 session fo rm of tr e a t m e n t based
o n p s y ch o an aly tic concepts a r o u n d w h ic h he
h a s stru c tu r e d a m eth od olo gy . E x p e rie n c e

ha s d e m o n s tra te d th a t 12 t r e a tm e n t sessions is
D e u t s c h s associative a n a m n e s i s (D e utsch ,
1 949) as o ne w a y of w o rk in g .
p ro b a b ly
series of d y n a m ic events to develop, flou rish,
E v en t h o u g h a n u m b e r of conflictual th em es
v ary , a c o m m o n one, th e r e c u r r i n g life crisis
a n d be a vailable for dis cussion, e x a m in a tio n ,
of s e p a r a ti o n -in d i v id u a t io n is th e su b s ta n tiv e
an d r e s o lu tio n .
ba se u p o n w h ic h th e tr e a t m e n t r e s ts . M a s t e r y
The
the
limited
m in im a l
tim e
interview
r e q u i r e d for a
is c o n cern ed
w ith
of s e p a r a ti o n a n x ie ty serves as a m odel for
clarifying w h a t th e p a tie n t seeks from th e r a p y .
o verco m in g o t h e r n e u ro tic a nx ieties. A m o n g
T w o o r m o r e sessions m a y be re q u ire d here.
basic u niv ersa l conflict s itu a tio n s th a t re la te to

th e s e p a r a tio n -in d iv id u a tio n th e m e a r e (1) in
In the course of this in q u iry a f o r m u la tio n of

the ce n tral conflict p ro d u ctiv e of th e p re s e n t
d e p e n d e n c e v e r s u s d e p e n d e n c e , (2) a c tiv ity
m an ife statio ns of distress can be m a d e . . . [the

th erap ist] telling the p a ti e n t w h a t is w r o n g
v e r s u s p a s s i v i t y , (3) se lf-s u ffic ie n c y v e r s u s

i n a d e q u a te self-esteem, a n d (4) un reso lved or
w ith h i m . T h i s m a y or m a y not accord w ith
d elay e d g rie f. M a s t e r y of s e p a r a ti o n - in d i v id
the p a t i e n t s incentive for seeking help. A d e
u a ti o n influences th e m a s te r y of all of th e l a t
lineatio n of o th e r u n co nscio us d e t e r m i n a n t s is
te r conflicts. D u r i n g te r m i n a ti o n of t h e r a p y the
a tte m p te d by e x a m i n in g p a st sources o f th e
p a ti e n t will u n d e r g o a deg ree of a n x ie ty reflec
cen tral conflict. A diag no sis is m ad e , a n d th ere

is a n assessm ent of the p a t i e n t s g en eral p sy
tive of th e a d e q u a c y of his re s o lu tio n of the

s e p a r a ti o n -in d i v id u a t io n p h a s e of his e a rly d e
chological state. T h e r e is th e n an e stim a te of
v elop m e nt. O n e o r a n o th e r of th e fo ur basic
h o w 12 h o u r sessions sho uld be d is trib u te d : 12

full sessions once w eekly, 24 h a lf -h o u r sessions
u niv ersa l conflicts will be activated d u r i n g the

te r m i n a ti o n p hase.
over 24 w eeks, o r 48 sessions of 15 m in u te s
M a n n advises no t to c o m p r o m is e th e 12-
over 48 weeks. T h e th e r a p is t expresses to the
session tim e lim it by m a k i n g a n y p ro m ise s to

co n tin u e t h e r a p y after the allotted p erio d has
p a tie n t his o p in io n of th e p a t i e n t s chief p r o b

lem an d w h a t he believes sh ou ld be done. H e
c onsults his c a le n d a r a n d a n n o u n c e s th e exact
end ed. In this w a y a fixed tim e s t r u c tu r e is
d a te of te r m in a tio n . H e settles dates a n d tim es
e sta b lish in g a d e p e n d e n t r e l a ti o n s h ip a n d of
of a p p o in t m e n t s a n d
w o r k in g t h r o u g h th e crisis of se p a r a tio n an d
discusses the fee.
He
assu res the p a ti e n t th a t if they find th e chosen

central issue e rro n e o u s, th e y will m ove on to
p re s e n te d to th e p a ti e n t in w h ich th e d r a m a of
ach ie v em ent of a u to n o m y is re p e a te d in a set
a n o th e r issue. T h e p a tie n t is th e n given th e
tin g th a t p e rm its a m o re satisfactory solution

t h a n th e in d iv id u al realized in his p a st early
privilege to accept o r reject th e stated c o n d i

tions. A ssu m in g th a t th e p a ti e n t h as sufficient
re la tio n sh ip s . In o th e r w o rd s , w e a r e provided
w ith tw o th e m e s in th e r a p y : th e first, th e
ego s tre n g th to neg o tiate a tr e a t m e n t a g r e e
c e n tra l issue for w h ic h th e p a ti e n t seeks t r e a t

m e n t, a n d th e second, th e m o r e basic s e p a r a
ti o n -in d iv id u a tio n th em e. T h e fact t h a t we
focus on a n a g re e d a r e a of inv estigation an d
m e n t a n d to to le ra te a stru c tu r e d schedule, a r
ra n g e m e n ts for th e r a p y a r e concluded.
T h e interview s a re c o nd ucte d on as h ig h an
em o tio n al level as possible, m ov ing fro m a d a p
tive issues to defenses to genetic o rig in s of c o n
flicts. T h is , of course, re q u ire s th a t th e t h e r a
pist be e m p a th ic an d th a t h e have a high
degree of co m p r e h e n sio n of d yn am ics. T h e
choice of the ce n tral issue will v a ry w ith the
t h e r a p i s t s u n d e r s t a n d i n g a n d e x p e r i e n c e .
Since free association is im p ra c tic a l in s h o r t
te rm th e r a p y , som e o th e r fo rm of c o m m u n ic a
tio n is n e e d e d . M a n n r e c o m m e n d s F e li x
th a t the p a ti e n t possesses k n o w led g e of i m

m i n e n t t e r m i n a ti o n lim its th e e x te n t of r e
gression in th e transference. T h e r a p i d m o b i
lization of a positive tr a n sferen ce in th e first
few sessions will b rin g s y m p to m relief a n d an
o u t p o u r i n g of m a te ria l. A lth o u g h th e focus is
o n th e c e n tra l issue, th e ad a p tiv e m a n e u v e rs of
the p a tie n t an d th e genetic roo ts of th e cen tral
issue will soon becom e a p p a r e n t . T h e t h e r a
pist, h ow ev er, m u s t resist th e te m p ta t io n to
H ANDBO OK OF SHORT-TERM PSYCHOTHERAPY
deviate from th e cen tral th em e. At all times,

th e
th e r a p ist
is active
th e r a p y , a c c o rd in g to M a n n , m ost p a tie n ts are
en
c a n d id a tes except th ose w ith b o rd e rlin e or p s y
c ourag ing , an d e d u catin g th e p a t i e n t . T h i s

does not m e a n giving advice o r gu idan ce.
chotic p ro b lem s. Y o u n g peo ple in a m a t u r a tion al crisis h ave difficulties exq uisitely r e
A bo ut
lated to th e s e p a r a tio n -in d iv id u a tio n p ro c e s s.

R e g a r d in g t h e r a p is t s w h o c an w o rk w ith this
the seventh
in s u p p o r tin g ,
session
the p a tie n t
will
begin to sense d is a p p o in t m e n t in t h e r a p y since

he is not allow ed to talk a b o u t all of th e th ing s
he w a n ts to b ri n g u p a n d m u s t confine him self
m e th o d , M a n n says: It is evident th a t this
to th e cen tral issue. At this p o in t negative

transferen ce will a p p e a r , a n d a m b iv ale n c e re
of skill, kn o w led g e, a n d experience. K n o w l
places positive tr ansference. R esistance re a r s

its h ead, an d sy m p to m s m a y r e t u rn . D esp ite
these reactions th e th e r a p is t m u s t w o r k to w a r d
te r m in a tio n . T h i s will be difficult for b o th p a
tien t a n d th e r a p is t since th e em o tio ns of t e r m i
n atio n an d se p a r a tio n (such as grief a n d a n g e r)
will be disconcerting. T h e p a tie n t will show
m a n y defenses ag ain st te r m i n a ti o n th a t will
have to be h an d led .
In te rp r e t a ti o n of th e p a t i e n t s reactio ns is
im p o r t a n t as th e p a tie n t expresses his a m
bivalent feelings, th e th e r a p is t e n u n c ia tin g the
k in d of p s y c h o th e ra p y re q u ire s a high degree

edge of th e psy ch o a n a ly tic theo ries of m e n ta l
fu n ctio n in g heavily b uttressed by e xp erienc e in
th e lo n g - te rm t r e a tm e n t of p a tie n ts is th e first
p r e p a r a t i o n for this t r e a tm e n t p l a n .
A n o th e r system of d y n a m ic s h o r t-t e rm t h e r
a p y is described by L e w in (19 7 0), w h o , fo llow
in g th e le a d o f B e r g l e r ( 1 9 4 9 ) , c o n s i d e r s
s y m p to m s a c on sequ en ce of psychic m a s o c h
is m , w h i c h is a u n i v e r s a l i n g r e d i e n t of
neu ro ses. T h e need to a p p e a s e guilt th r o u g h
suffering, h e av o w s, c an p re v e n t pro g ress in
th e r a p y . Ideally , th e core of the p a t i e n t s
m a s o ch ism , his b ad in tro ject, shou ld be e x
sta n d a b le since his ex pe ctatio ns a re n ot being
posed a n d rep lac ed, a lo n g w ith his sadistic

conscience. W h il e this m a y no t a lw a y s be
fulfilled. D a t a from th e p a t i e n t s past will

allow for a re la tin g of th e p a t i e n t s reactio ns to
possible, th e least th e th e r a p is t can do is to

c o n f r o n t t h e p a t i e n t w i t h h is m a s o c h is m .
early e xperiences w ith p a r e n t a l figures. T h e

last th ree sessions at least sho uld be devoted to
d ealing w ith the p a t i e n t s feelings a b o u t t e r m i
n ation .
A ssig nin g all of his p ro b le m s a n d sy m p to m s to

s e lf-p u n ish m e n t for guilt feelings in re la tio n to
idea th a t th e p a t i e n t s resp on ses a re u n d e r
As to selection of p a tie n ts for this ty pe of
p a r e n t a l figures provides th e p a tie n t w ith a

focus th a t, a cco rding to L e w i n , helps sh o rten
th e th e r a p e u tic process.
Eclectic Systems
S p u r r e d on by c o m m u n ity need, by stric
tu r e s on the n u m b e r of sessions financed by
m o re innovative, being influenced by beh av io r

t h e r a p y , by th e c o n te m p o r a r y e m p h a s is on ego
th i r d - p a r ty p a y m e n ts , an d by dissatisfaction
w ith th e resu lts of lo n g -te rm tr e a tm e n t, t h e r a
functions, by a n in creasin g interest in p ro b le m

solving as a p r i m a r y m e a n s of e n h a n c i n g
a d a p ta tio n , as well as by a re s u rg e n t flexible
eclecticism (G ra y s o n , 1979). A ccordingly, a
n u m b e r of m odels of s h o r t- t e r m th e r a p y have
been in tro d u c e d , an d som e of these will be
cited as ex a m p les. O t h e r excellent m od els u n
d o u btedly exist, b u t th ey c a n n o t be included
because of lack of space. A n e x a m p l e of how
pists of all d e n o m in a tio n s have ex p e rim e n te d

w ith briefer m e th o d s a n d co n tr ib u te d w ritin g s
to s h o r t-te rm th e o ry a n d practice. Som e of the
te chn iq ues a re a revival of th e m eth o d s e m
ployed in th e p re a n a ly tic a n d e arly an a ly tic
period. Som e a r e replicas of established case
w o r k a n d counseling p ro cedures. O t h e r s are

florid th e w ritin g s have become in s h o r t-te rm
re n d e r e d t h a t c a n ta k e th e form of a m in o r
th e r a p y is the a n n o ta t e d b ib lio g r a p h y of W ells

(1976), w h o in review in g th e li te r a tu re u p to
in te rp re ta tio n .
1 974 d e ta i ls 2 4 3 c i t a t i o n s c o v e r i n g m a j o r
w illing to en g a g e i n , in c o n tr a s t to th e p o si
tio n ta k e n by so m e th e r a p is ts like Sifneos to
j o u r n a l s in p sy ch iatry , psychology, a n d social

w o r k . T h e s e a r t i c l e s a r e c a t e g o r i z e d in to
theoretical a n d review articles, in d iv id ua l a d u lt
th e r a p y , indiv idu al t h e r a p y of ch ild ren an d
adolescents, g r o u p th e r a p y , fam ily th e r a p y ,
P sychotherapy
is
p lan n ed
w ith in th e f r a m e w o r k of w h a t the p a ti e n t is
th e effect th a t th e p a ti e n t m u s t fit th e t r e a t
m e n t chosen for h im by th e e x p e r t . In B eliak
a n d S m a l l s m e th o d d r e a m s m a y be elicited,
projective testing like th e T h e m a t i c A p p e r c e p
m a r ita l th e r a p y , an d t r e a tm e n t of ho sp italized
tio n
patients.
In 1965 B eliak a n d S m all w ro te a book (the
b ri n g ou t rep re ssed m a te ria l. A n a t t e m p t is
T est
used,
and
h y p n o sis em p lo y ed
to
m a d e to e stablish cau sal factors in re la tio n to

p re c ip ita tin g inciden ts a n d specific historical
second edition of w h ich a p p e a r e d in 1978)

th a t differentiated em ergen cy fro m b rief p sy
events a n d stru ctu res. J u d i c i o u s use of in t e r
c h o t h e r a p y . T h e y c o n te n d t h a t e m e r g e n c y
tr e a tm e n t is a t e m p o r a r y a p p r o a c h utilized in
p re t a ti o n to i m p a r t in sig ht, r e a s s u ra n c e a n d
s u p p o r t w h e n necessary, co un selin g, g uid anc e ,
crisis, w h ile b rief p sy c h o th e ra p y is a fore

sho rtened ap p lic a tio n of tr a d it io n a l p s y c h o t h e r
co njoint fam ily t h e r a p y , g r o u p t h e r a p y , dru g s,

e le c tr o c o n v u l s iv e t h e r a p y (as in s u ic id a l
apy , called into being e ith e r by th e life s itu atio n
d epression s), a n d e n v ir o n m e n ta l m a n i p u la t io n
of the p a tie n t or by th e setting in w h ic h t r e a t
will call for a good deal of flexibility, d ia g
m e n t is offered. T h e y offer a fo rm of brief p sy

c h o th e r a p y th a t is rooted in o r t h o d o x p sy c h o
nostic a c u m e n , a n d clinical j u d g m e n t on the
an aly tic th e o ry an d directed at s y m p to m s o r
th r o u g h
m a la d a p ta tio n s , av oiding th e re c o n s titu tio n of

pe rs o n ality th a t m ay, nevertheless, com e a b o u t
m a in te n a n c e of th e positive r e l a t i o n s h i p , they
p a r t of th e th e r a p is t. E m p h a s i s in w o rk in g is u p o n
im m e d ia te le a rn in g .
The
auto n o m o u sly . B rief p sy c h o th e ra p y m a y s t a b i

lize th e individual sufficiently so t h a t he m a y
state, avoids a sense of rejection in the

te r m i n a ti n g process a n d p e rm it s th e p a ti e n t to
re ta in th e th e r a p is t as a ben ig n , in trojected
be enab led to c o n tin u e w ith m o re extensive p sy

c h o th e r a p y . T h e tim e sp a n allotted for t r e a t
f ig u re . T r e a t m e n t is end ed by in fo rm in g the
p a ti e n t th a t th e th e r a p is t is ava ilab le in th e fu
m en t is one to six sessions. A positive t r a n s

ference is fostered, free a ssociation avoided, a n d
t u r e w h e n needed.
in t e rp re ta ti o n te m p e re d , b ein g cou pled w ith

o th e r types of in terv en tio n like medical, en vi
special te c h n iq u e s v au n te d by th e a u th o r s as
u n i q u e l y effective fo r s h o r t - t e r m t h e r a p y .
T h e i r e n th u s ia s m is u n d e r s ta n d a b l e because
ro n m e n ta l , etc. B rief th e r a p y , they observe, is

useful in n e a rly every kind of e m o tio n al dis
tu rb a n c e , even psychosis. W h il e extensive r e
s t ru c tu r in g of th e c h a ra c t e r is desired a n d po ssi
ble, o r w h e re a c tin g -o u t exists, how ever, it is
not suitable.
A detailed histo ry is essential w ith a c o m
plete ex p lo r a tio n of th e p re s e n tin g p ro b le m ,
th e p re cip ita tin g factors, the c o n te m p o r a r y life
situ atio n, a n d the d ev elo p m e n ta l histo ry , in
clud in g fam ily re latio nship s. T h e object is to
u n d e rs ta n d the p resen t illness in d y n a m ic
term s a n d related to p rec ed in g genetic, d e
ve lop m ental, a n d c u ltu ra l ev e n ts. O u t of this,
s o m e i m m e d i a t e t h e r a p e u t i c h e l p m a y be
T h e lite r a tu r e is rep lete w ith d e sc rip tio n s of
th e r a p ists becom e skilled in c e rta in m e th o d s to

w h ich they a r e by p ers o n a lity , o p e ra tio n a l
style, a n d theo re tical bias a ttu n e d . L est w e b e
come too r h a p s o d ic over a n y set of m etho ds,
h ow ev er, w e m u s t r e m e m b e r th a t w h ile they
m a y be effective in th e h a n d s of som e, th ey
m a y no t be useful for all th e r a p is ts . M a t c h i n g
p a tie n t a n d m e th o d is also a c h allen gin g p r o b
lem (B u rk e et al, 1979). E x c e p t for a few sy n
d ro m es, such as b e h a v io r t h e r a p y for p h o b ia s
an d p h a r m a c o t h e r a p y for psychoses, o u tc o m e
studies fail to cred it a n y special interv ention s
w ith global s u p e r io rity over o th e r a p p ro a c h e s .
Indeed, statistics in dicate eq u iv a le n t im p ro v e
m e n t rates for a host of av ailable tech niqu es.

N evertheless, a stu d y of th e v ario us m odalities
in c o n te m p o ra r y use is r e w a r d i n g if no m o re
t h a n to provide us w ith m odels th a t m a y selec
tively be useful.
A m o n g th e most c o m m o n tech niq ues, in a d
dition to those previously cited u n d e r d y n a m ic
th e ra p ie s , a re in terp re tiv e m eth ods th a t d r a w
th e ir sub stan ce from classical (F r e u d ia n ) an d
n o n c la s s ic a l ( A d l e r i a n , S te k e l i a n , R a n k i a n ,
16. G u id e d a ffe c tiv e im a g e r y ( K o ch , 1969).

17. H y p n o s i s
F ran k el,
S p iegel,
(C rasilneck
1973;
1 970;
M orra,
S p ieg el
&
H all,
1967;
&
1975;
R a b k in ,
S p ieg el,
1977;
1 978;
S tein,
A d le r ,
1972;
1 97 2; W o l b e r g , 1948, 1 9 64 , 1965).
18. In te r p r e tiv e
A nsbacher,
19 7 2;
D avanloo,
1978;
G illm an,
m e th o d s
Barten,
(K.
A.
1 971;
D avanloo
D.
&
Beck,
1968;
B e n o it,
1978;
1965; M . M o r e n o , 1 96 7 ; S m a l l , 1 971;
W a h l , 1972).
19. M e d ia tio n ( C a r r i n g t o n , 1 977; C a r r i n g t o n &
J u n g i a n , an d R eich ia n ) psych oan alysis as well

as fro m beh avioral m odels. T h e list t h a t fol
E p h r o n , 1975).
lows includes the m o re form al m od alities c u r

ren tly in use:
C lark,
20. M ilie u th e r a p y (B e c k e r & G o l d b e r g , 1 970;

1 9 7 2;
R askin,
G oldberg,
1971;
1 97 3;
S tain b ro o k ,
K nobloch,
1967;
1973;
V isher
&
O S u l l i v a n , 1 9 71 ; W i l k i n s , 1963).
1. A u to g e n o u s
tr a in in g
(Crosa,
1 96 7 ;
L u th e ,
2 2. P e rs u a sio n ( M a l t z , 1960).
1 963; S c h u ltz & L u t h e , 1959).

2. B e h a v io r a l m o d e ls (A yllon
& A zrin,
1968;
B a n d u r a , 1 969; C r o w e et al, 1 97 2 ; F e r b e r et al,

1 974;
Ferster,
W ilson,
1975;
1 964;
Franks,
G hadirian,
1 964;
1971;
F ranks
Hand
&
&
La-
M o n t a g n e , 1 974; H o f m e i s t e r , 1 97 9; L a z a r u s , 1976;
L ic k & B o o tz in , 1 970;
1 974;
P a t t e r s o n , 1 9 7 3 a , 197 3 b,
R ichardson & S uinn,
1 974; S t u a r t ,
1969;
3. B io e n e rg e tic s ( L o w e n , 1958; P a l m e r , 1971).

G lueck
(B lan ch ard
& S troebel,
1975;
&
Young,
Stroebel
1974;
& G lueck,
th e r a p y
(K erns,
1970;
U pham ,
6. C o g n itiv e le a r n in g ( B a k k a r &
B akkar-R ab-
(H .
Young
2 6. P s y c h o s y n th e s is ( T i e n , 1972).
2 7. R e a lity th e r a p y ( G l a s s e r , 1 965; G l a s s e r &
Z u n i n , 1972).
29. S c r e a m th e r a p y ( C a s ri e l , 19 72).
30. S e n s itiv ity
tr a in in g
(Q uaytm an,
1969;
S c h u t z , 19 67 ).
th e r a p y
( B i e r e r,
1 9 4 8;
F leisch l
&
W o l f , 1967).
1974;
th e r a p y
H ayw orth,
(D asberg
1973;
&
H ollister,
Van
Praag,
1970;
K al-
in o w s k y & H i p p i u s , 1969; O s t o w , 1962).
d a u , 197 3; G r e e n e , 1975).
7. C o g n itiv e th e r a p y (Beck, 1 97 1, 1976; Ellis,
1 95 7, 1 96 5 , 1 973; G l i c k e n , 1968; R u s h , 1978).
8. C o n fr o n ta tio n m e th o d s (G . A d l e r & Buie,
1 97 4; G . A d le r & M y e r s o n , 1973; G a r n e r , 1 9 7 0a,
1 97 0 b ; G o d b o l e & F a l k , 1 972; K a s w a n & L ove,
33. S tr u c tu r a l in te g ra tio n (Rolf, 1 9 58 ; S p e r b e r et

al, 1969).
34. S y m b o ld r a m a ( L e u n e r , 1969 ).
35. T r a n s a c tio n a l
Hollensbe,
a n a ly s is
1 97 6; J o h n s o n
&
(Brechenser,
1972;
C h atow sky,
1969;
S h a r p e , 1976).
1 969; Sifneos, 1972).

m e th o d s
p s y c h o th e r a p y
2 5. P sy c h o im a g in a tio n th e r a p y ( S h o r r , 1972).
32. S o m a tic
1 973; W a t t i e , 1 973; A. W o l b e r g , 1965).
9. C o u n s e lin g
24. P ro g ra m m e d
19 74).
31. S o c ia l
19 73).
5. C a s e w o r k
2 3. P r im a l th e r a p y ( J a n o v , 19 7 0).
28. R e la x a tio n ( B e n s o n et al, 19 74).
S u i n n et al, 1 970; W o l p e , 1964).

4. B io fe e d b a c k
21. M u ltim o d a l th e r a p y ( L a z a r u s , 19 76).
(G ross
&
D eridder,
36.
V id e o ta p e p la y b a c k
(A lg er,
1 97 2 ;
B e rg e r ,
1 9 7 0 , 1 97 1 ; G o n e n , 1 97 1; M e l n i c k & T i m s , 1974;
19 66).
10. D a n c e a n d m o v e m e n t th e r a p y ( S m a ll w o o d ,
S ilk, 1972).
19 74).
11. D ecisio n th e r a p y ( G r e e n w a l d , 1974).
12. E m o tio n a l c a th a rsis (N ich o ls, 1974).
Less fo rm al th e r a p ie s h ave d r a w n on th e fol

low ing tech niqu es:
13. E S T (K ettle, 1976).

14. G e s ta lt th e r a p y (P e ris , 1 96 9 ; A. C . S m i t h ,
19 76).
15. G o a l a t t a i n m e n t s c a lin g
C a l s y n , 1978).
1. B u d d h is t S a lip a tth a n a , o r m in d fu ln e s s m e d i
ta tio n ( D e a t h e r a g e , 19 75).
(La F erriere &
2. C o m m u n ic a tio n th e o r y ( K u sn etzo ff, 1 974; R.

C . M a r t i n , 19 68).

6. P s y c h o s o m a tic c o n d itio n s ( M e n t z e l ,
3. D r e a m a n a ly s is ( M e r r i l l & C a r y , 19 75).
4. E m o t iv e - r e c o n s tr u c tiv e p s y c h o t h e r a p y
( E R P ) , w h i c h c o m b i n e s t h e u se of i m a g e r y w i t h h y
p e r v e n t i l a t i o n ( F u l c h ie r o , 1976; M o r r i s o n & C o -
7. S e x u a l p r o b le m s ( K a p l a n , 1 97 4 ; L ev it, 1971;
M e a r s , 1 978; S p r i n g m a n , 1978).
8. S m o k in g
m e t a , 1977).
5 . F is c h e r - H o f f m a n
p ro c ess
(A.
C.
S m ith,
1969;
M e y e r , 1 97 8 ; M e y e r & Beck, 1978 ).
h a b its
(M arrone
et al,
1970;
H.
S p iegel, 1970).
9. U n r e so lv e d g r i e f ( V o l k a n , 19 71).
1976).
6. F lo m p m e t h o d ( H a g e l i n & L a z a r , 19 73).
10. U n to w a r d re a c tio n s to p h y s ic a l illn e ss (E . H .

S te in et al, 1 96 9; T u c k m a n , 1970).
7. M o n t a th e r a p y (R e y n o l d s , 19 76).
11.
8. N a ik a n ( Is h i d a , 1969).
W a r n e u r o se s ( P r u c h & B r o d y , 1946).
9. P a ra d o x ic a l i n t e n t i o n ( F r a n k l , 1 9 65 , 1966).
10. S o c ia l s k ills tr a in in g (A rg y le et al, 1974).
11. S o c ia l s y s te m s a p p ro a c h e s ( C l a r k , 1972).
M o r e o v e r , selected in terv e n tio n s h ave been

advised for specific categories of p atients:
12. S to r y te llin g ( D e L a T o r r e , 1972).

13. T e a m
s y s te m s a p p ro a c h e s
( D r e s s i e r et al,
14.
1. A lc o h o lic s ( K r i m m e l & F a l k e y , 19 62 ).
2. D y in g p a tie n ts ( C r a m o n d , 19 70).
19 75).
T h e r a p e u t ic
p a r a d o x t e c h n iq u e
(F u l
3. G e r ia tric p a tie n ts ( G o d b o l e et al, 1 9 72 ; G o l d -
ch ie r o , 19 76).
f a r b & T u r n e r , 1953).
Special tec h n iq u es h ave also been r e c o m

m e n d ed for p a r t ic u l a r sy nd ro m es:
J a c o b s , 1 976; L o r e t o , 1972; W . M i l l e r , 1968).
4. U n iv e r s ity s tu d e n ts ( B r a g a n , 1 9 7 8; K ille e n &
1. C o n v ersio n re a ctio n s ( D ickes, 1974).

2. D e p r e ss iv e re a ctio n s ( C a m p b e l l , 1974; N e u et
al, 1 978; R e g a n , 1965; Sok ol, 197 3 ).
3. H y s t e r i c a l p e r s o n a l i t y d is o r d e r s ( S e i b o v i c h ,
T h e use of s h o r t-t e rm a p p r o a c h e s in p r i
m a r y care an d m edical settin g s has been
described by B leek er (1 97 8), B u d m a n et al
(1979), C o n r o e et al (1978), a n d K ir c h n e r et al
(1978). A lth o u g h no t focused d irectly on s h o r t
4. O b se ssiv e -c o m p u lsiv e d iso r d e rs (Sue ss , 1972).
te r m th e r a p y , th e c o n tr ib u tio n s of S tr u p p
(1972) a n d F r a n k (1973) to re la te d aspects of
5. P h o b ia s ( S k y n n e r , 19 74).
t r e a tm e n t a r e n o te w o rth y .
19 74).
Short-Term Therapy in Outpatient Clinics
T h e urgency in m a n y clinics to a lte r tactics

of p sy c h o th e ra p y in line w ith the re q u i r e m e n ts
of the p a tie n ts being tre ated as well as th e dis
position of th e c o m m u n ity h a s resu lted in the
s h i f ti n g fr o m l o n g - t e r m t r e a t m e n t t o w a r d
eclectic s h o r t-te rm p ro g r a m s . F o r e x a m p le , at
the M o n t r e a l G e n e r a l H o s p it a l in C a n a d a a
c h an g e in th e t r e a tm e n t p h ilo so p h y a w a y from
th e lon g -term objective of p e rs o n a lity r e c o n
stru ctio n w a s necessary for practical reason s:
(1) because the kin d of p a ti e n t p o p u la t io n the
clinic dealt w ith w a s u n a b le to u tilize a
p ro lo n g e d t h e r a p e u ti c re la tio n s h ip an d (2) b e
cause some of th e th e r a p is ts w e re n ot fittingly
t r a in e d or w e re u n a b le to sp en d a sufficiently
long tim e to follow t h r o u g h w ith a p p r o p r i a t e
t r e a tm e n t m e a s u re s ( D a v a n lo o , 1978; S tr a k e r,
1968). T h e resu lt w a s a h ig h d r o p o u t r a t e or
th e ra p i d d e v e lo p m e n t of chro n ic clinic d e
p e n d e n c y . In ad d itio n , w a iti n g lists becam e
so g re a t th a t a c u te e m o tio n al crises could not
receive needed help. A b rief p sy c h o th e ra p y
p r o g r a m w a s sta rte d in 1961 based on p sy
ch o d y n a m ic fo rm u la tio n s . P a tie n ts w h o did
10
not q ualify for th e p r o g r a m received s u p p o r t-
u n d e rly in g th e p a t i e n t s psychological p r o b
tive kinds of help, p h a r m a c o th e r a p y , social
le m s
service assistance, w a r d care, a n d so on, ac
p ro c es s.
O t h e r clinics th a t have re m o d ele d th e s t r u c
cordin g to th e i r needs. W i t h this p r a g m a ti c

ch an g e the d r o p o u t ra t e decreased over five
times,
greatly
and
staff in terest
stren g th en e d .
an d
m o ra le
w ere
F o llo w -u p studies 2
years after in ta k e revealed th a t 66 p erc e n t of

the total case load h a d benefited sufficiently to
is
th e
key
is su e
in
th e
e v alu a tio n
tu r e of th e ir services a lo n g s h o r t-t e rm lines

also re p o r t an im p ro v e d rem ission ra te a m o n g
p a tie n ts a n d a h eig h ten ed staff m o ral. T h e
n u m b e r of sessions devoted to t r e a tm e n t is con
need no f u r th e r th e r a p y . P a tie n ts selected for
sidered a r b i t r a r y an d h a s ten de d to cluster

a r o u n d lo w er lim its, w h ic h in som e studies
a n d treated w ith b rief p s y c h o th e ra p y show ed
h av e yielded res u lts e q u a l to t r e a tm e n t w ith
a n 84 p ercen t rem issio n rate.
n u m erically
L a rg e ly
th r o u g h
D a v a n l o o s efforts th re e
I n te rn a tio n a l S y m p o sia w e re o rg a n iz e d , in
1975, 1976, a n d 1977, b rin g in g to g e th e r p r o
fe s s io n a ls in t e r e s t e d in b r i e f a p p r o a c h e s .
D a v a n l o o s m e th o d s resem b le th ose of Sifneos
a n d M a l a n . E v a lu a tio n c rite r ia for d y n a m ic
th e r a p y are, first, th e assay of the ability to es
tab lish m ean in g fu l re la tio n s h ip s based on the
higher
se s sio n s .
E rrera
et al
(1967) c o m p a r e d th e resu lts of p a tie n ts a t the

Y a le -N e w H a v e n M e d ic a l C e n te r P sy chiatric
O u t p a t i e n t C lin ic w h o w e re in t h e r a p y for
fro m 6 to 10 sessions w ith a sim ila r p o p u la t io n
w h o received 21 or m o r e t r e a tm e n t sessions
an d fou nd t h a t th e r e w a s no significant d iffer
ence in th e im p ro v e m e n t rates, n e it h e r as
re corded by th e th e r a p is ts n o r e v alu a te d by th e
p a t i e n t s h av in g h a d previo us e m o tio n a l ties
ra te rs.
w ith o th er people. E ven in th e first interview
L in g e rin g d o u b ts as to th e e x te n t of h e lp p a
tients receive h a s been all b u t dissipa ted by the
th e p a t i e n t s cap acity to in te rac t w ith th e t h e r

ap ist will be obvious. Second, th e r e is an esti
m a te of the eg o s cap acity to e xp erienc e an d
tolera te an x iety th a t will be mobilized in th e
interview . T h i r d , m o tiv atio n for tr u e ch an g e
m u s t be differentiated fro m a d esire to satisfy
an infantile need in th e r a p y . F o u r t h , p sy c h o
ex perie nce of clinics th a t h av e converted th e ir

services a lo n g s h o r t-t e rm lines a n d c onducted
follo w -up in q u iries. At th e B oston U n iv e rs ity
M e d ic a l C e n t e r P sy c h iatric C lin ic, for e x
a m p le , a stud y w a s con du cted by H ask e ll et al
logical m in d ed n ess an d cap acity for in tro s p e c
(1969) as to w h a t h a p p e n e d to p a tie n ts after

12 w eeks in s h o r t- t e r m th e r a p y . Significant
tion a re ju d g e d carefully. Fifth, th e most c r u
ch ang es w e re fou nd in th e g r o u p as a w h ole
cial criterio n is the p a t i e n t s ability to resp o n d

c o n s t r u c ti v e ly to i n t e r p r e t a t i o n d u r i n g th e
(a b o u t 71 p e rce n t) on five m e a s u re s of d e
pressio n, a n x iety , a n d o verall im p ro v e m e n t.
E v en th o u g h it w a s felt th a t th e ty p e of p a
tient w h o re s p o n d s to tim e -lim ited t h e r a p y dif
fers m a r k e d ly fro m the ty p e w h o re s p o n d s to
lo n g - te rm t h e r a p y , no cle a r-cu t criteria w ere
apparent.
C linics associated w ith colleges h av e also
n oted excellent re su lts w ith a sm all n u m b e r of
sessions ( M ille r, 1968; Speers, 1962; W h i t
e valu a tio n interview . Sixth, th e degree of in

telligence is an i m p o r t a n t factor in th e choice
of a p p ro a c h . S eventh, the e v a lu a to r m u s t d e
te r m in e the richness an d flexibility of availab le
defenses since these c o rre la te w ith effective
utilizatio n of d y n a m ic th e r a p y . D a v a n lo o is
w edded to classical a naly tic fo rm u la tio n s , such
as the s tru c tu r a l h ypothesis, an d fram e s his
la n g u a g e in these term s. T h e r e is g eneral
ag re e m e n t a m o n g m ost th e r a p ists w ith D a v a n
lo o s belief th a t selection of a p s y c h o t h e ra
peutic focus is vital in s h o r t-te rm t h e r a p y an d
t h a t identification a n d u n d e r s ta n d in g of the
psy cho dy nam ics a n d psychological processes
tin g to n , 1962). B ecause college s tu d e n ts a r e at

a n age level w h e r e p ro b le m s in identity, res o
lutio n of d e p en d e n c y w ith em erg en ce of a u
to n o m y , an d firm in g of sex ual role a r e b eing
w o rk e d th r o u g h , they a re , as a g ro u p , b o u n d
to e x p e rie n c e a good deal of stress. T h e pres-
11

ence of a facility th a t can offer th e m crisis-
stud ents.
o riented
s tu d e n ts w h o
p s y c h o l o g ic a l se rv ic e s c a n be e x -
For
e x a m p le ,
a p p lie d for
F ran cisco
review
of 3 ,0 0 0
h e lp at th e C ity
trem ely helpful in fostering a b ette r a d ju s t-
C ollege of S a n
m en t. E x p e rie n c e indicates th a t relatively few
av erag e n u m b e r of con tacts w a s below th r e e
sh o w e d
th a t
th e
sessions a re necessary for th e g re a t m a jo rity of (A m a d a , 1977).
W alk-In Clinics and Crisis Intervention

T h e g ro w th of c o m m u n it y p sy ch ia try has
ing is m o re effective th a n y e ars of passive
pro
w o r k i n g - t h r o u g h . P a tie n ts w h o r e q u i r e m o re
g ra m s o r g a n iz e d for p u rp o s e s of crisis i n t e r
h elp after t h e r a p y en d s a r e invited to r e t u r n
vention a n d the d ealing w ith em ergen cies (Annex ton , 1978; D o n o v a n et al, 1979; D . G o l d
a n y tim e the need a ri s e s , b u t not on a c o n

t i n u in g basis. T h i s a p p r o a c h h a s resulted in a
stein, 1978; R o b b in s, 1978). W a lk - in clinics

th a t b rin g h elp to v irtu a lly t h o u s a n d s of p eo p le
60 p erc en t im p ro v e m e n t r a t e w ith in five visits.

T h i s im p ro v e m e n t ra te , t h a t is a b o u t tw o-
e n c o u rag ed
m u ltitu d e
of s h o r t-te rm
have s p ro u te d th r o u g h o u t th e co un try . A n e x
th ird s of th e
a m p le is th e In ta k e R ece ptio n Service a t th e
s u b s ta n tia te d by m a n y o th e r w a lk -in clinics
p a tie n ts receiving th e r a p y ,
is
Psy chiatric C lin ic of the M a i m o n i d e s M e d ic a l
(G o ttsc h a lk et al, 1967; J a c o b s o n & W il n e r ,
Service in B ro o k ly n , N .Y ., w h ich fun ction s as

a w a lk -in clinic offering im m e d ia te h e lp to
1965). In a larg e stu d y of over 8 ,0 0 0 p a tie n ts

tre a te d on an em e rg en cy basis only 10 p ercen t
an y o n e a p p ly i n g (G elb & A llm a n , 1967). F o u r
required
to eight in divid ual sessions a r e given. If m o re

t h e r a p y is n eed ed, m a x i m a l use is m a d e of
(C o le m a n & Z w e r lin g , 1959). T h e valu e of

s h o r t-t e rm g r o u p crisis in te rv e n tio n h a s also
con tin u in g
long-term
th e ra p y
g ro u p an d fam ily th e r a p y . P rofessionals from

different disciplines a r e used, in c lu d in g p s y
been d e m o n s tra te d . In a stu d y of 78 cases

receiving six g r o u p sessions c o m p a r e d w ith 90
ch iatrists,
so cial
con tro l cases in u n lim ite d g r o u p s o r ind iv idu al
w o rk e rs, a n d psych iatric nurses. A n e x p e r i
th e r a p y , the s h o r t- t e r m g r o u p cases d e m o n
enced th e r a p is t m a y be a c c o m p a n ie d by a t h e r
stra te d g r e a t e r im p ro v e m e n t on a 5 -p o in t scale
of fu n ctio n in g ( T r a k a s & L loy d, 1971).
p s y c h o l o g is t s ,
p sy ch iatric
apist in tr a in i n g , w h o p a rtic ip a te s as a n o b
server. T h u s the session o p e ra te s as a t r a in i n g
tool. In dicatio ns for re f e rrin g a p a tie n t to a
psy chiatrist th e r a p is t a r e an y of th e following:
(1) som atic sy m p to m s, (2) m e n ta l illness in a
p a tie n t w h o is d a n g e ro u s to him self or o thers,
(3) a need for m ed icatio ns, (4) histo ry of a t
tem p te d o r th r e a te n e d suicide, or (5) a special
r e q u e s t for a p s y c h i a t r i s t . T h e a p p r o a c h
utilized is d y n a m ic a lly o rie n te d a n d is n ot co n
sidered, in the w o rd s of G e lb a n d A llm a n
(1967) a n em erg en cy sh o r tc u t o r a p o o r s u b
s titu te for an u n a tt a in a b l e ideal b u t is, in itself,
th e most effective an d h u m a n a p p r o a c h to o u r
p atients. . . . Im m e d ia te , active, e m p h a t ic a n d
acc u rate c o n fro n tatio n w ith n e u ro tic fu n c tio n
W alk-in
clinics
designed
to
p ro v id e
im
m e d ia te g o al-lim ited h elp (B eliak, 1964;

C o le m a n & Z w e r lin g , 1959; J a c o b s o n et al,
1965; N o r m a n d et al, 1967; P eck et al, 1966)
g e n e rally co n c ern them selves w ith crisis in t e r
ven tio n an d u su a lly restrict th e to tal n u m b e r of
sessions to six o r less. R e fe rra l for m o r e ex
ten d ed care is pro v id ed w h e r e necessary. A l
t h o u g h th e w o r k - u p d o n e in different clinics
w ill vary, it g e n e rally includ es som e d y n a m ic
f o r m u la tio n of th e p ro b le m , a n assay of ex ist
in g ego stre n g th s a n d w e akn esses, a n d a n esti
m a t e of the d e g ree of p a th o g e n ic ity of th e c u r
r e n t e n v ir o n m e n t. T o w a r d th is end N o r m a n d
et al (1967) h a v e described a j o i n t initial in t e r
12
view conducted by a p s y c h ia trist-so c ia l w o r k e r
8. T h o s e w h o seek to s o r t o u t t h e i r con flictin g
team . Such a te a m m a x im iz e s th e selection of
id eas. ( H e l p m e p u t t h i n g s in p e r s p e c ti v e . )
a n a p p r o a c h to the existing p ro b le m and

outlines a b lu e p r in t for action. A w o rk in g h y
s t a n d i n g a n d in s i g h t i n t o t h e i r p r o b l e m s . ( 1 w a n t
pothesis
is fo r m u la te d
a tt e m p t in g
to relate
in trap sy ch ic a n d / o r e n v ir o n m e n ta l aspects to
th e d is tu rb e d b e h a v io r or th e sy m p to m s, a n d it
is a r o u n d this hyp oth esis th a t choice of in t e r
9. T h o s e w h o t r u ly h a v e a d e s ire for se lf- u n d e r psych o th erap y . )

10. T h o s e w h o see t h e i r d is c o m f o r t as a m ed ical
p r o b l e m t h a t n e e d s t h e m i n i s t r a t i o n s o f a p h y s i c ia n .
( I need a p h y s i c i a n . )
11. T h o s e w h o re a lly seek s o m e p r a c t i c a l h e l p
ventions is m a d e from a w id e r a n g e of s u p
like d is a b il i t y a s sista n c e , legal a i d , o r o t h e r i n t e r
portive, e d u c a tio n a l, a n d in s ig h t-o rie n te d a p
cessio ns in t h e i r life s i t u a t i o n . ( I n eed y o u r legal
proaches. S h o u ld no im p ro v e m e n t occur, th e
w o rk in g h y p oth esis is re fo rm u la te d . T h i s a p
pow ers )
p ro a c h h as p ro v en itself to be pra ctic al as an

aid to p ro v id in g high q u a li ty m e n ta l h ea lth
c u r r e n t r e l a t i o n s h i p s a n d w a n t t h e clinic to i n t e r
services for th e p o o r
overw h elm in g ly
in the face of even
im p o s s i b le
e n v iro n m en tal
d epriva tion s. T h e r e is a feeling th a t p a tie n ts

from
lo w er socioeconomic classes d o
better
w i t h s h o r t - t e r m c risis i n t e r v e n t i o n t h e r a p y
t h a n w ith a n y o th e r a p p r o a c h (H a sk e ll et al,
1969; M e y e r et al, 1967; Sadock et al, 1968.)
W a lk - in clinics th u s p ro v id e a vital n eed in
the practice of c o m m u n it y p sy c h ia try by m a k
ing tr e a tm e n t im m e d iately a n d easily accessible
12. T h o s e w h o cr e d it t h e i r difficulty to o n g o i n g
cede. ( D o it for m e . )
13. T h o s e w h o w a n t i n f o r m a t i o n as to w h e r e to
get h e l p to sa tisfy v a r i o u s n eeds , a c t u a l l y se ek in g
so m e c o m m u n i t y re so u r c e . ( T e l l m e w h e r e I can
get w h a t I n e e d . )
14. N o n m o t i v a t e d o r p sy c h o tic p e r s o n s w h o a r e
b r o u g h t to t h e clinic a g a i n s t t h e i r will. ( I w a n t
n o th in g . )
W h e r e th e th e r a p is t is p ercep tive e n o u g h to
reco gn ize th e p a t i e n t s d esire a n d w h e r e h e is
c a p a b le of g ratify in g o r at least a c k n o w le d g in g
to all classes of patien ts. M a n y p ro b le m s can

be m a n a g e d th r o u g h this m e a n s th a t o th e rw ise
t h a t he u n d e r s ta n d s th e re q u e s t, he will have
w o u ld go u n a tt e n d e d . O n th e basis of a n a n a l
S h o u ld he by p ass th e p a t i e n t s im m e d ia te p lea
ysis of m a n y
for help or p ro b e for conflicts a n d o t h e r d y
in terv iew s
in
th e p sy ch iatric
been
able
to
s ta rt
a w o r k in g
re la tio n sh ip .
w a lk -in clinic of th e M a s s a c h u s e t ts G e n e r a l
n a m ic forces u n d e rl y in g th e re q u e s t, th e r a p y
H o sp ita l in B oston, w h ich h an d le s a b o u t 4 0
m a y n ever get sta rte d . O b v io u sly , fulfilling the
w a lk -in p a tie n ts each d a y (1 5 ,0 0 0 visits per

y ear), L a z a r e et al (1972) have listed 14 ca te
gories of patie nts.
p a t i e n t s d esire a lo n e m a y no t get to th e b o t
to m of th e p a t i e n t s tr o u b le s, bu t it will be an
av e n u e t h r o u g h w h ich o ne will be ab le to c o o r
d in a te a n d u tilize th e d a ta g a th e r e d in the
dia gn ostic e v a lu a tin g in tervie w . In clinics o r
p riv a te th e r a p y w h e re th e r e is lack of c o n
1. P a t i e n t s w h o w a n t a s t r o n g p e r s o n to pro tect
a n d c o n tr o l t h e m . ( P leas e t a k e o v e r . )
2. T h o s e w h o need s o m e o n e w h o will h e l p th e m
m a i n t a i n co n ta c t w i t h r e a lity . ( H e l p m e k n o w I
am real. )
3. T h o s e
who
feel
so
em pty
th ey
n eed
suc-
co r a n c e . ( C a r e for m e . )
4. T h o s e w h o need so m e clinic or p e r s o n a r o u n d
for se c u rity p u r p o s e s t h o u g h t h e co n ta c t be o cca
si o n a l. ( A l w a y s be t h e r e . )
5. T h o s e r i d d e n w i t h gu ilt w h o seek to confess.
( T a k e a w a y m y g u i l t . )
6. T h o s e w h o u r g e n t l y n eed to t a l k t h i n g s out.
( L et m e get it off m y ch est )
7. T h o s e w h o d e s i re adv ice o n p r e s s i n g issues.
( T e l l m e w h a t to d o . )
g ru e n c e b e tw e e n w h a t th e p a ti e n t seeks a n d
w h a t th e t h e r a p is t decides to prov ide, the
d r o p o u t ra te a fter th e first in terv iew i s 1 as
h ig h as 50 p e rc e n t (B o rg h i, 1968; H e i n e &
T r o s m a n , 1960).
T h e claim t h a t s h o r t- t e r m tr e a t m e n t acco rd s
w i t h s u p e r f i c i a l i t y o f g o a ls h a s n o t b e e n
p ro v e n , especially w h e re t h e r a p y is c on du cte d
a lo n g even m odest d y n a m ic lines. T h u s , a ty pe
of crisis in te rv e n tio n th a t a im s at m o r e t h a n
s y m p to m relief is described by M . R. H a r r i s et
al (19 6 3 ), w h o tr e a te d a g r o u p of 43 p a ti e n ts
13

w ith u p to seven sessions w ith th e objective of
assum ption
(1) reso lu tion of th e stress factor p re c ip ita tin g

the req u e st for h elp an d (2) clarifying a n d
w o u n d s . T h a t tim e fails m iserab ly in this task
th at
tim e
its e lf w ill
heal
all
resolving, if no t the basic conflict, th e seco n d
is evident by th e h ig h rate of m o rb id ity an d

m o r ta lity a m o n g survivors fo llow ing th e fatal
a ry derivative conflicts activated by th e c u r
event (K ra u s & Lilienfeld, 1959; Rees & L u t-
re n t stress situ a tio n . O u r h y p oth esis is th a t
kins, 1967; M . Y o u n g et al, 1963).
fa
R eco gn itio n of th ese facts h a s led to some
cilitated th e e sta b lish m e n t of a n ew a d a p tiv e
crisis in te rv e n tio n p r o g r a m s to prov id e s h o r t

te r m h e lp for the bereaved in th e service of
such
e x p lo ra tio n
and
w o r k in g
through
b a la n c e . D u r i n g th e r a p y th e m o tiv atio n for

f u r th e r tr e a tm e n t w a s also evalua ted . T h i r t y eight (88 p erce n t) of the p a tie n ts w e re helped
by b rief th e r a p y . T h i r t e e n (30 percen t) of th e
p a t i e n t s c o n t i n u e d in l o n g - t e r m t r e a t m e n t .
T hree
p a tie n ts
(7
percen t)
returned
for
second b rief series of contacts. D u r i n g in t e r

v iew ing w ith th is tr e a tm e n t, efforts w e re m a d e
to estab lish c onnections b e tw e e n conflicts an d
bo th p re v e n tio n a n d r e h a b ilita tio n (G e rb e r,

1969; Silver et al, 1957; P. R. S ilverm an ,
1967).
their
Success
fu rth er
of th ese
program s
develo p m en t
and
presages
expansion.
G e r b e r (1969) h a s described som e m e th o d s for

fostering e m a n c ip a ti o n fro m th e b o n d a g e of
g rief a n d r e a d j u s tm e n t to p re s e n t realities.
T h e s e in clu de (1) h e lp in g th e client to p u t into
th e p re c ip ita tin g stress since th is e n a b le d th e
w o rd s his o r h e r feelings of suffering, p ain ,
p a ti e n t to be b etter able to cope w ith his
g uilt, notio ns of a b a n d o n m e n t an d a n g e r as
distress an d achieve a n ew psychic e q u il ib

r i u m . H isto ric a l m a te ria l w a s utilized only
well as th e n a t u r e of th e p a st re la tio n s h ip w ith
w h e n it w a s s p o n ta n e o u sly b r o u g h t u p a n d r e
lated directly to the c u r r e n t difficulty. T h e a u
p la n of activities th a t d r a w s u p o n av aila ble
th o r s d eclare th a t w h e re lo n g - s ta n d in g vex
resolving practical difficulties involving h o u s
atio n s exist, m otivation for f u r th e r tr e a t m e n t

m a y in fact be increased by th e e x p erien ce of a
m en ts; (4) m a k i n g essential referrals for m e d i
successful b rief th e r a p e u ti c t r a n s a c t i o n . A d o p
tion of a p s y ch o d y n am ic stan ce in crisis in t e r
th e deceased, good a n d bad ; (2) o rg a n i z in g a

resources a n d friends; (3) len d in g a h a n d in
ing, economic,
legal, a n d fam ily r e a r r a n g e
cal assistance in clu d in g p re s c rip tio n of d ru g s

for d ep ressio n a n d in s o m n ia a n d offering fu tu re
vention can e n h a n c e th e q u a li ty of resu lts, as

L o u is (1966) a n d o th e r s h ave p oin ted out.
O f all d e v a sta tin g stressful ex perien ces, th e
d e a th of a loved one, o r a p e rs o n on w h o m the
assistance. Service to a b ereav ed p erso n is often
su rv ivo r is d e p e n d e n t, is p e r h a p s th e m ost m is
o r o th e r professional o r tr a in e d p a ra p r o fe s sional m a y be necessary before th e client will
m a n a g e d . A p a r t from to k e n consolations, a
c o n s p i r a c y o f sile n c e s m o u l d e r s u n d e r th e
best r e c o m m e n d e d
by the fam ily p h ysicia n,
a n d such r e c o m m e n d a t io n s m a y be a r e q u i r e
m e n t. A n in itial h o m e visit by a social w o r k e r
accept office visits.
Dealing with Unresponsive Patients

D e sp ite o u r best efforts to s h o rte n th e r a p y
th e r e will be som e p a tie n ts w h o will need co n
t in u in g tr e a tm e n t. C linics only too often b e
come clogged w ith such ch ro n ic p a tie n ts w hose
lems. T h i s is n o t to d ep re c ia te th e value of p r o
longed tr e a t m e n t in some lo n g - s ta n d in g e m o
tio nal p ro b le m s. H o w e v e r, from a p r a g m a ti c
s ta n d p o in t, for th e g re a t m a jo rity of ch ron ic
t r e a t m e n t b e c o m e s i n t e r m i n a b l e . T h i s ca n
result in long w a iti n g lists a n d a n en d to ready
access to t h e r a p y for even em ergen cy p r o b
p a tie n ts o th e r m odes of m a n a g e m e n t a r e not

only helpful, b u t ac tua lly a r e m o r e a tt u n e d to
th e c o n tin u in g needs of these patients. S u ch a l
14
terna tiv e m eth o d s involve, p e r h a p s for the r e

m a i n d e r of a p a t i e n t s life, occasional sh ort
co urag ed. In d iv id u al in tervie w s are for 15 to

25 m in u te s to a scertain th e p re s e n t physical
(10- to 1 5-m in ute) visits w ith a professional

perso n on a m o n th ly o r b im o n th ly basis,
an d e m o tio n a l state, to re g u la te th e d r u g in
ta k e if d ru g s a r e ta k e n , to offer r e c o m m e n d a
su pervision of d r u g in tak e, in tro d u ctio n in to a

g ro u p (th erap eu tic , social, o r re h a b ilitativ e),
a p p o in t m e n t for the nex t tim e. T h e p a tie n ts a re
and
u tilizatio n
of a p p r o p r ia t e
c o m m u n ity
resources. W h a t the th e r a p is t tries to avoid for

such a p a tie n t is s tim u la tin g d ep en d e n c y on
him self personally.
An e igh t-y ear e x p e rim e n t at an o u tp a tie n t
clinic dedicated to th e th e r a p y of th e c h r o n
tio n s for in te rv e n in g activities, a n d to m a k e an

th e n r e t u r n e d to th e w a iti n g a r e a for m o re
coffee a n d socialization. F a m i ly a n d couples
th e r a p y a r e d o n e if necessary. F r e q u e n c y of
visits r a n g e fro m w eek ly sessions to once every 6
m o n t h s a lt h o u g h p a tie n ts m a y r e t u r n v o lu n
ta rily if th ey need h elp. S h o u ld the p a tie n t d ro p
ically ill at th e U n iv ers ity of C h ic ag o H o s
ou t of t h e r a p y , he is p e r m it te d to r e t u r n in
pitals an d C linics is re p o r te d by R a d a et al
tim es of stress w ith o u t h av in g to go t h r o u g h a
(1969). T h e clinic is o pen every T h u r s d a y
re a d m iss io n p ro c e d u re . A fter th e clinic h o u r s
afte rn o o n for 2 / i h o u rs , p a tie n ts being seen in

o r d e r of a rriv al. P a tie n ts a re accepted only
after a diag no stic e v alu a tio n a n d initial w o r k
cuss th e d a y s p ro b lem s. T h e tw o a tt e n d in g p sy
ch ia trists d o no t see in divid ual p a tie n ts (except
u p by th e referral sources to m a k e su re th ey
in em ergen cies); they serve as ad m in is tra tiv e
the staff m eets briefly (30 to 45 m in u tes ) to d is
will be su itab le for th e clinic ro u tin es. T h e
sup ervisors a n d active p a r t ic i p a n ts in th e w a i t
staffing
is by psych iatric residents, medical
ing a re a e x p erien ce a n d the staff g ro u p m e e t
stud ents, a social w o rk e r, receptionist, a n d tw o
ings. P a tie n ts see th e sam e th e r a p is t (a residen t)

for 3 m o n t h s to a y e a r an d k n o w th a t th e y will
a tte n d in g staff su p erv isory p sy chiatrists, the

la tter four being the only p e r m a n e n t staff.
be tr a n sfe r re d to a n o th e r p rofessio nal from tim e
U p o n a rriv al, the receptionist greets th e p a

t i e n t a n d if t h e y c o m e , t h e f a m i l y a n d
to tim e. D ia g n o stic cate gories vary , a p p r o x i
bring s the p a ti e n t into th e w a iti n g ro om ,

w h e re light re fre sh m e n ts (cookies an d coffee)
m a te ly h a lf b eing psychotic, th e r e m a in d e r h a v
ing severe n eu ro s e s a n d p e rs o n a lity disorders.
F ees g e n erally s u p p o r t th e clinic an d a r e r e l a
are
tively low.
serve d.
P atien t
in te ra c tio n s
are
en
Short-term Hospitalization and Its Alternatives

S h rin k in g b ud gets h ave m a d e it m a n d a t o r y
to ta k e a h a r d look at costs versus benefits not
only in re g a rd to p sy c h o th e ra p y , bu t also
p ro tra c te d psyc hia tric h o sp ita liz a tio n . A p a rt
from p ra g m a tic d is a d v a n ta g e s or im p ra c tic a litie s of c o s t / b e n e f i t s , p r o l o n g e d i n s t i t u
tio n aliza tio n fosters regression a n d p a ra l y z in g
g r a m D av is et al (1972) d e m o n s tra te d t h a t a
te a m led by visiting n u rses g o in g to the h o m es
of p a tie n ts to oversee p r o p e r m ed ica tion could
p rev en t h o s p ita liz a tio n a n d im p ro v e r e l a ti o n
ships w ith in th e family. A n o th e r e x a m p le is
th e fin din g by Z w e r lin g a n d W i l d e r (1962)
th a t a da y -c a re tr e a tm e n t facility could often
d ep en d e n cies p lu s ex tend ed se p a r a tio n from

c o m m u n i t y life. T h e s e u n f o r t u a n t e c o n t i n
gencies have sp on sore d shifts fro m lon g -term
con fin em ent to s h o r t-te rm d eten tio n o rg a n iz e d
a r o u n d the objective of early d ischarge. A l
act as an a d e q u a t e su b s titu te for an in p a t ie n t

u nit. T h e r e a re , nevertheless, situ atio n s w h e n
h o sp ita liz a tio n is essential, for e x a m p le , to
p ro v id e security for d is tu rb e d o r suicidal p a
te rnatives to h o sp ita liz a tio n have also been e x

plored. F o r e x a m p le , in an e x p e rim e n ta l p r o
t i e n t s o r w h e r e c r i s i s - o r i e n t e d t h e r a p y is
needed an d it c a n n o t be d o n e on a n o u tp a t ie n t
basis. A limited h o psita l stay m a y be all th a t is
15
re q u ire d . Even in child ren s h o r t-t e rm h o s p i ta l
w ith i n
ization is som etim es considered (Shafii et al,

1979).
fo llow -u p r o u t in e alm ost t w o -t h ird s of all p a

tients h a d not been re h o s p ita liz e d o r t r a n s
T h a t it is possible to redu ce th e tim e of h o s
ferred after th e 3 -d ay intensive h o spita l t r e a t
1 y e a r of d ischarg e.
At th e
1-year
pitaliz atio n of p a tie n ts a d m itte d to an in s titu
m en t. T h i s c o m p a r e s favo rab ly w ith r e h o s p i
tion th r o u g h a crisis in te rv e n tio n p r o g r a m

u tilizin g a w id e r a n g e of t r e a tm e n t m o dalities
ta liz a tio n ra te s w ith lon ger t e r m th e r a p y .
has been d e m o n s tra te d by D e c k e r a n d S tu bblebine (1972) in a 2 ii y e a r stu d y of 315

you n g adults.
A t th e C o n n e c t i c u t
M ental
T h e function of th e u su a l s h o r t-t e rm h o s p i
taliz a tio n (i.e., 3 to 4 w eeks) is, first, to b rin g
about a rapid
rem issio n of s y m p to m s and ,
second, to p r e p a r e th e p a ti e n t for, a n d to see
H e a lth C e n te r a p r o g r a m of b rief (3 -d ay ) i n
th a t
tensive h o s p ita liz a tio n a n d 3 0 -d a y o u tp a t ie n t
afte rca re p ro g r a m . T h e first objective is ac
c a re has been used to deal w ith p a tie n ts

r e q u i r i n g h o s p i t a l i z a t i o n ( W e i s m a n et al,
com p lish ed by d r u g th e r a p y a n d E C T if n eces
1 9 6 9 ). In t h e h o s p i t a l , c ri s is i n t e r v e n t i o n
m eth od s a re em p lo y ed to w a r d re s to rin g the
p a tie n t to the prev iou s level of fu nctio nin g. O n
a n d m ilieu, o ccu p a tio n a l, a n d re h ab ilitativ e

th e r a p y , all ta ilo re d to th e p a t i e n t s needs. B e
c a u s e of t h e e m p h a s i s o n t h e c o n t r o l of
disch arge th e r e is a 1- m o n th o u tp a t ie n t p eriod

of tr e a tm e n t, w h ich is co nsid ered a fo llow -up
sy m p to m s r a t h e r th a n a lte ra tio n s in th e p e r
son ality s tru c tu r e , crisis-o rien ted b eha vio ra l
m ea su re. A n a g re e m e n t is m a d e in a d v an ce as
a p p ro a c h e s a lo n g eclectic lines a r e m ost com
to this limited tim e a r r a n g e m e n t to in s u re th a t

fect of the tim e -lim ited co n trac t is to establish a
m o n ly practiced. Ideally, b rief h o s p ita liz a tio n

sh o u ld prov id e p sy c h o th e ra p y to p r e p a r e the
p a tie n t for o u tp a t ie n t c a re (A. B. L ew is,
set w h ich p ro m o te s ra p id identification of

p ro b le m a reas an d re q u ire s p a tie n ts to begin
crucial to avoid th e revolving d o o r sy n d ro m e ,
tr e a tm e n t does not go on indefinitely. O n e ef
quickly developing new m odes of d e a lin g w ith

these p ro b l e m s . T h e p a ti e n t is seen e ach day
by several staff m e m b e rs w h o a r e u su a lly
nu rses or aides in o r d e r to d isch arg e d e
th e r e
is
made
av ailab le,
an
adequate
sary, indiv id ual fam ily an d g r o u p tr e a tm e n t,
1973). T h e second objective, a lt h o u g h m ost

is too often neglected. U n less th e p o s th o s p i
tal e n v ir o n m e n t is reg u la te d , e n su in g stress
will a lm o st inev itably p ro d u c e a re la p se in
sym p to m s. A m o n g th e m e a s u re s necessary to
pe nd ence on th e godlike figure of the doctor.
p re v e n t this a r e th e a d ju s tm e n t of living a r
T o expose p a tie n ts to different tactics, a fixed

style of a p p r o a c h is deliberately n ot used.
ra n g e m e n ts so th a t the least s tra in is im posed

o n th e p a t i e n t s cop ing capacities, th e use of
T e a m m e m b e rs also in te ra ct w ith p a tie n ts in

daily g ro u p th e r a p y an d fam ily th e r a p y . Self-
h a lfw a y houses, facilities p ro v id in g day an d

n ig h t care, su pervised d r u g m a n a g e m e n t, an d
relian ce is stressed by focusing on th e p a t i e n t s
r e h a b ilitativ e, social, h e a lth , a n d re c r eatio n al

p ro g r a m s . T h e selective use of c o m m u n ity
o u tp a t ie n t p sy c h o th e ra p y of a no t too intensive
variety w ith an e m p a t h ic th e r a p is t can be most
helpful.
responsibility, especially in m a k i n g p la n s after

discharge. W h i l e concern a n d in terest are
sh o w n , th e staff avoids d o in g th in g s for th e
p a tie n t w h ich he can be e n co u ra g e d to do
h i m s e l f . P s y c h o t r o p i c d r u g s a r e u s e d to
d i m i n i s h t a r g e t s y m p t o m s . T h e r e is e a r l y
fam ily involvem ent, a n d the e n tire h o sp ita l da y
is stru c tu re d w ith activities. As for resu lts, at
the end of brief h o sp ita liz a tio n of th e first 100
patients, 18 p ercen t w ere tr a n sfe r re d for longer
in p a tie n t care after the 3 -d a y intensive e x p e r i
ence since th ey re q u ire d lo ng er te r m h o s p ita li
zation . A n o th e r 19 p ercen t w ere re ho spitalized
T o sa fe gu ard a g a in s t the f r a g m e n ta tio n of

a n aftercare p r o g r a m , c o n tin u ity of tr e a tm e n t
w ith one p rofessional perso n can h elp p rev ent
t r e a tm e n t d e g e n e ra t in g into m a n a g e m e n t of a
series of em ergen cies w ith inevitable r e h o s p i
taliz atio n . T h i s perso n m u s t h ave e stablished a
r e la tio n s h ip w ith th e p a tie n t a n d k n o w th e his
to ry of the l a t t e r s illness a n d so m e th in g a b o u t
th e dy na m ics. W h a t causes most p a tie n ts to
16
r e t u r n to th e ho sp ital is p o o r aftercare p l a n
t h e r a p y can cut d o w n th e need for h o s p i ta l iz a
n in g w ith little or no provision for som e kind

of o n g o in g ind iv idu al o r g r o u p p sy c h o th e ra p y ,
i m p r o p e r m o n i t o r i n g of d r u g m a i n t e n a n c e ,
tion in a c u te cases of d e c o m p e n sa tio n . T o c o m

p a r e th e o u tc o m e of o u tp a t ie n t fam ily crisis
t h e r a p y w ith h o sp ita liz a tio n , F lo m e n h a ft et al
fa ilu re to u tilize em erg en cy m e a s u re s w h e n
(196 9 ) tre a te d w ith th e fo r m e r m o d ality 186
needed (such as E C T ) , stressful living c o n d i

tions, p o o r h o u sin g an d in a d e q u a te provision
p a tie n ts in n eed of a d m issio n to a m e n ta l h o s

p ital. A con tro l g r o u p of 1 50 p a tie n ts received
of essential social a n d re h a b ilita tiv e services.
h o sp ita liz a tio n . T h e
W h e r e possible, the th e r a p is t w h o h a s w o rk ed
av erag e of five office visits, o n e h o m e visit, an d
w ith th e p a tie n t in the ho sp ital shou ld be th e
th r e e tele p h o n e contacts. T h e results of o u t p a

tien t t h e r a p y w e re at least as good as h o s p i ta l i
z a tio n , in a d d itio n to bein g m o re econom ical
one w h o co ntin ues seeing th e p a tie n t a n d d i

recting the afte rca re p r o g r a m . So m etim es th e
ho sp ital m a y p ro vid e som e of th e a ftercare
services, b u t th e a d m i n is tr a t o r s sho uld alw a y s
strive to in te g ra te th e p a tie n t into the c o m m u
nity as r a p id ly as possible. T h i s is u su a lly the
best course. W h e r e r e t u r n to a fam ily w o u ld be
o u tp a t ie n t s received an
a n d less s tig m a tizin g . In a stud y by L an g sley

et al (1 9 69 ) 75 a cute d e co m p e n sa te d p sy
ch ia tric p a tie n ts w e re given a n av erag e o f six
sessions of fam ily crisis t h e r a p y o rg a n iz e d
a lo n g directive a n d su p p o r tiv e lines. A control
d is tu rb i n g for instance, w h e r e m e m b e rs are
g r o u p of 75 received h o sp ita liz a tio n a n d i n p a
too hostile, d e m a n d in g , an d rejecting p lace

m e n t in a h a lfw a y ho use a n d la te r in a foster
tien t tr e a tm e n t. In th e fam ily th e r a p y g r o u p 61

p a tie n ts w e re a b le to avoid h o s p ita liz a tio n a n d
h o m e m a y be advisable.
S h o rt-te r m h o sp ita liz a tio n does no t e lim i
o n l y 14 p a t i e n t s r e q u i r e d h o s p i t a l i z a t i o n
w ith i n a 6 - m o n th perio d. In th e h o s p i ta l iz a
n a te in te rm e d ia te -te r m intensive t r e a tm e n t in a
tion g r o u p 16 p a tie n ts r e q u i r e d r e h o s p ita l iz a

tion after d is ch arg e w ith i n a 6 -m o n th period.
ho spital, th a t is, 130 to 180 days, o r for lo ng er

pe rio d s w h e re th e a im is a p e rs o n a lity change.
H o w e v e r, custodial care in p a tie n ts w h o r e
O n l y a n a v e ra g e of 8.1 day s w e re r e q u i r e d for

im p ro v e m e n t in th e e x p e ri m e n t a l g r o u p as
q u ir e c o n tin u in g m a n a g e m e n t can u su a lly be

achieved ou tside of a h o sp ital facility. W a y n e
c o m p a r e d to 2 4 .3 day s in th e h o sp ita liz e d

g ro u p . T w o y e ars la te r a sim ila r stu d y w as
(1976) h a s a p p r o p r ia t e ly p o in te d ou t th a t w h a t
d eterm in es th e du ra tio n of h o sp ita liz a tio n is
re p e a te d w ith a la rg e r g r o u p of p a tien ts . It
con firm ed t h a t m ost p a tie n ts w ith s h o r t-te rm
f a m il y t h e r a p y c o u ld a v o id h o s p i t a l i z a t i o n
n ot th e diagn osis bu t th e persistence of a h a b i

tu a l d isru ptive life-style, severe fam ily, social,
a n d o c cu p a tio n a l difficulties, a n d th e p resen ce
of a serious physical disability o r h y p o c h o n
driasis. W h e r e th e p ro p e r e n v ir o n m e n t is m a d e
available a n d a fte rca re supervision p ro m o te d ,
even ch ro nic psychotic p e rs o n s can m a k e an
a d ju s tm e n t ou tsid e of a n institutio n.
T h e r e is evidence th a t s h o r t-t e rm fam ily
(L an g sley et al, 1971). At th e E a s te r n P e n n

s y l v a n i a P s y c h i a t r i c I n s t i t u t e t h e s e s t u d ie s
w e re rep lic ated , in d icatin g th e efficiency of
s h o r t-t e rm fam ily th e r a p y (R u b e n s te in , 1972).
F o cal t h e r a p y in a d a y h o s p ita l m a y also be
em p lo y ed as a n a lte rn a tiv e t r e a tm e n t (F ran ce s
et al, 1979).
Short-term Child and Adolescent Therapy

T h e q u e stio n is often asked as to w h e t h e r it
is possible to d o child t h e r a p y on a s h o r t-t e rm
basis since it is ge nerally accepted th a t a lo ng
p erio d of t r e a t m e n t of th e child p a ti e n t a n d
p a r e n t s is c u sto m a ry . T h e r e a re som e studies
ho w ev e r, th a t ind icate t h a t good resu lts m a y be
17
ob tain ed w ith s h o r t-t e rm a p p r o a c h e s (C r a m e r ,

1974; K ern s, 1970; M a r t i n , 1967; N egele,
1976; Nicol, 1979; P h illip s & Jo h n s to n , 1954;
R osen th al & L evine, 1970, 1971; S h a w et al,
1968; S k y n n e r, 1974). O t h e r studies verify th e
utility of s h o r t-t e rm g r o u p t r a in i n g for p a r e n t s
in m a n a g in g p ro b le m s in th e i r child ren (G . R.
P a tte rso n et al,
1973a; W a l t e r & G ilm o re ,
o th e r fam ily m e m b e rs. T h e child g e n e rally is

i g n o r a n t of w h y h e is a c tu a lly seeing th e t h e r a
pist, h a s little rea l notio n of his u n d e rly in g
p ro b le m , a n d no m o tiv atio n to d o a n y th i n g
a b o u t it. S h o u ld th e child be a w a r e th a t he is
seeing a
d o c to r ,
he m ay
regard
th is as
p u n is h m e n t for his crim es w h ile believing th a t

th e d o c to r ex pects h im to c h a n g e in accord
1973; W iltz & P a tte rso n , 1974). M a n y t h e r a

pists believe th a t w h e re th e child is u n d e r 7
w ith th e w ishes of his p a re n ts . If, o n th e o th e r
years of age the m a in th e r a p e u ti c w o r k is w ith
m a y ra tio n a liz e it as a ju s tified co n se q u en ce of
th e p a re n ts. F r o m ages 7 to 11 the child and

p a re n t s are seen sep a rately . F r o m 12 on fam ily
u n fa ir d e m a n d s a n d acts by his p a r e n t s a n d
oth ers. It m a y be essential in o r d e r to secure
c o o p e ra tio n w ith th e tr e a tm e n t p la n to w o rk
sessions seem best. P re a d o le sc e n t child ren w ith

acu te p ro b le m s have been m a te ria lly h e lp e d by
h a n d , th e child is c o g n iz a n t of his p ro b l e m , he
w ith th e child u n til he v erb aliz es a p ro b l e m on
p a r e n t g ro u p s focused on discussions of child

m a n a g e m e n t, p o w e r ploys of c h ild ren , a n d a l
w h ic h he w o u ld like to co nc entrate.
te r n a te a p p ro a c h e s to p ro b le m solving. T h e
event th e child seems ig n o r a n t of it is to con

fro n t the child w ith w h a t o th e r s say a b o u t him
ch ildren them selves a r e e n c o u ra g e d to e x p e r i

ment
w ith
m o re
m ature
b e h a v io r
th r o u g h
better w ays of cop ing w ith p eo p le a n d s i t u a

tions (E p stein , 1976).
U tiliz in g a so-called h e a l t h model, W e i n
b erg e r (1971) describes a fo rm of brief th e r a p y
for child ren w h ich sees clients basically c o p
ing a n d a d a p ti n g bu t ex p e rie n c in g p ro b le m s
caused by ig no ra nce , i n a p p r o p r i a t e e x p e c ta
tions,
social
su r ro u n d in g s ,
o r o th e r
factors
w h ich do not im p licate th e p a r e n t s as m alev

olent an d pa tho log ically m o t iv a t e d . T h i s is
seen as a p referred th e r a p y for th e m a jo rity of
child ren in c o n tra st to th e p re v a ilin g model
of s h o r t-te rm tr e a tm e n t, w h ich is e ith e r a
O n e w a y of focusing on th e p ro b le m in the
a n d to h a n d le his re actio n s to th e c o n fr o n ta
tion. W h y does he believe he is seeing th e t h e r
a p is t? O n c e th e child a d m its to a b eh av io ra l
d evia tion , o th e r w a y s of re a c tin g a re suggested
to him . A n y d is to rted w a y th e child conducts
him self w ith th e th e r a p is t m a y be a n i m p o r
t a n t m e a n s of b ri n g in g to his a tt e n ti o n ho w he
behaves, h o w o t h e r p eop le m a y be affected by
his b eha vio r, a n d h o w he h im self suffers the
co nseq uen ces o f th e ir re actio ns. T h e s e c o m
m e n ts a re m a d e w ith o u t a n g e r, d isgu st, accu
satio n , o r t h r e a ts of r e c r im in a ti o n , p ro v id in g
th e child w ith a different e x p e rie n c e in re latio n
to a n a u th o r it y figure. C o n c u r r e n t ly , th e t h e r a
com pressio n of lo n g - te rm tr e a tm e n t m e th o d s
o r a n elo ng ated diagnostic p r o c e d u r e th a t is
pist m a y w o r k w ith th e p a r e n t s o r see th e p a
a p p r o p r i a t e for only 5 to 10 p erc e n t of all

ch id ren sent for help.
As p a r t of the th e r a p e u ti c process, W e i n
b erg er states th a t it is im p o r t a n t to tr y to a s
certain h o w p a r e n t s view th e c h il d s p ro b le m
fam ily in fam ily th e r a p y . In conference w ith

th e p a r e n t s it is im p o r t a n t to alleviate th eir
guilt, to tr y to clarify w h a t is h a p p e n i n g in
an d w h a t th e ir e x p ec tatio n s a r e of the t h e r a
pist. T h i s leads to th e d r a w i n g u p of a verbal
c o n tr a c t of w h a t th e p a r e n t s an d th e r a p is t
expect of each o ther. U s u a lly th e goal is the
e lim in a tio n of u n d esired b ehav io r. T h e tim e
limit set is 6 w eeks d u r i n g w h ic h a m a x i m u m
of 12 sessions a r e a r r a n g e d for the child an d
tien t
to g eth e r
w ith
o th e r
m em bers
of the
th e i r re la tio n to th e child, to e x p la in u n
re a s o n a b le e x p e c ta tio n s a n d d e v e lo p m en tal
n o rm s , a n d to suggest a lte rn a tiv e w a y s of d e a l
ing w ith th e c h il d s b ehav ior. T h e ex te n t of d i
rectiveness of th e th e r a p is t will vary w ith th e
w illin gn ess a n d ab ility of th e p a r e n t s to m a k e
p r o p e r decisions on th e ir o w n.
T h e p la n of action a n d h o w it is c a rr ie d o ut
by th e child a n d p a r e n t s is m o n ito r e d by the
18
th e r a p is t in the r e m a in i n g sessions, th e p la n it
self being modified o r d iscard ed a n d a n ew one
sub stitute d d e p e n d in g on the p ro g ress t h a t is
being m ad e. A m a j o r p a r t of this w o rk in g
th r o u g h is to h elp th e p a re n ts not only recog
nize an d accept th e ir o w n an d th e i r c h il d s
en m e s h e d in th e i r o w n needs an d p r o b l e m s
(W e in b e rg e r, 1971). B ased o n 5 y e a r s e x p e r i
ence in th e clinic w ith a b o u t 3 ,0 0 0 cases,
W e in b e r g e r e stim ate s th a t 5 0 p ercent of all
child ren can be h a n d le d in b rie f th e r a p y . M o r e
extensive t h e r a p y is r e q u i r e d by 30 percen t,
li m itatio ns, but, to set m o re realistic goals for
an d
themselves as p a re n ts , a n d th e ir child as a
child w ith a u n iq u e life style of his o w n w hich
m u s t be u n d e r s t o o d , r e s p e c t e d , a n d n o t
classes, resid en tial p la c e m e n t, etc.) is re q u ire d
h e lp o t h e r t h a n p sy c h o th e ra p y (special
by 20 percent.
Short-term Group Approaches

M a n p o w e r sho rtage s reinforced by th e fac
to r of c o st/b e n e fit h ave accelerated th e use of
s h o r t-te rm g r o u p th e r a p y , both for h o s p i
talized perso ns a n d o u tp a tie n ts . M a n y g ro u p
p r o g r a m s h av e accordingly been in tro d u ce d ,
u tilizin g te c h n iq u e s th a t d r a w th e ir su bsta nce
from p sy choanalysis, b e h a v io r th e r a p y , co gni
tive th e r a p y ,
have a cc u m u la te d .
S h o r t - te r m g r o u p s a r e usu ally o p en -e n d e d
a n d fre q u e n tly con d u cted by c o th e ra p is ts
( G o o l i s h i a n , 1 9 6 2 ; S a d o c k et a l, 1 9 6 8 ;
S h r a d e r et al, 1969; T r a k a s & L loyd, 1971.
O u tc o m e stu d ies on g ro u p s re p o r t h ig h ly su c
im a g e ry o r a n y o th e r
cessful results, in some in stan ces being co n
th eoretical school to w h ich the t h e r a p is t s a re

dedicated.
a p y ( T r a k a s & L loy d, 1971). T h e uses a n d
1. C r is is
Crary,
g uid ed
gory, (A. W o lf, 1965) a n d since th e n m o re
i n t e r v e n t io n
1 968;
Donovan
g roups
et
al,
(B erlin,
1979;
1970;
M orley
&
B r o w n , 1 969; S t r i c k l e r & A llg ey er, 1967; T r a k a s &

L lo y d , 1971).
2. E x p e r i e n t i a l g r o u p s ( B a c k ,
1972; B u rto n ,
1 96 9; E l m o r e & S a u n d e r s , 1972; L e w is & M i d e r ,

1 973; P eris, 1969; R a b i n , 1971).
3. E d u c a tio n a l g r o u p s {D r u c k , 1978).
4. B e h a v io ra l g r o u p s ( A r o n s o n ,
h eim ,
1971;
M eachem
&
Lazarus,
W iesen,
1968;
1 969;
1974; F e n s t e r -
L ib e rm a n ,
S uinn
et al,
1970;
1970;
W o l p e , 1964).
5. I n s p i r a t i o n a l
G reen b latt,
1975;
g roups
(D ean,
H ersch elm an
&
1970-1971;
F re u n d lic h ,
19 72).
6. P s y c h o d r a m a tic g r o u p s ( C o r s i n i , 1966; M o r
e n o , 1966).
7. T ra n s a c tio n a l g r o u p s ( B e r n e , 1 964; T . H a r
ris, 1967; K a r p m a n , 1972).
8. A c c e le ra te d sh o r t-te r m g r o u p s ( W o l f, 1965).
B etw een 1947 an d 1962 over a h u n d r e d

p a p e r s w ere p u b lish e d on j u s t the last c ate
sidered as m o re effective t h a n in d iv idu al t h e r

ab uses of g r o u p s a r e described by I m b e r et al
(1979).
S h o r t - te r m g r o u p s w ith c h ild re n have been
g a in in g p o p u la r it y ( G r a h a m , 1976; R o se n th a l
& L ev in e 1970), som e r e p o r ts c la im in g su c
cesses e q u a l to th a t in lo n g - te rm th e r a p y
( R o se n th a l & L evine, 1971). A n e x a m p l e is
the stu dy by B u r d o n a n d N eely (19 66 ) w h o
tre a te d 55 boys w ith re p e a te d school failures.
A 5 -y e a r fo llo w -u p sho w ed increased school a t
te n d a n c e w ith 98 p erc e n t p a ss in g a n d 73 p e r
cent e a r n i n g p ro m o tio n s. S om e useful m eth o d s
for w o r k in g w ith c h ild re n in g r o u p s h av e been
o utlin e d by R h o d e s (1 97 3), E p s te in (1976),
a n d L evin & Rivelis (1970). S h o r t - te r m g r o u p
t r e a tm e n t m a y also be helpful for m a la d ju s te d
adolescents (E is e n b e rg , 1975; R iv era & B attagg ia, 1967), d u r i n g b rief in p a t ie n t c are for
adolescents (C h iles & S a n g e r, 1977; M o s e r ,
1975), for d e li n q u e n t a dolescents ( D a n n e r &
G a m s o n , 1968), adolescent d r u g users (D eeth s ,
1970), a n d yo u th fu l offenders in a d e te n tio n
19
u n it ( W o u ld & R eed, 1974). T h e need to dis
A n u m b e r of r e p o r ts hav e indicated th a t
ting uish b etw een adolescents w h ose p ro b le m s
s h o r t- t e r m m a r it a l t h e r a p y is at least as effec
a re the p ro d u c t of e n ta n g le m e n ts rela te d to th e
tive in d e a lin g w ith m a r it a l conflict as lo n g
d eve lop m e ntal process an d
th ose w ho se e n
te r m th e r a p y . G u r m a n (1975) re view ed a v a il
co u n te r w ith adolescence stirs u p u nreso lved
ab le d a t a a n d fo un d th a t a 7 6 p e rc e n t im p ro v e
m e n t r a t e w a s achie ved w ith a n a v e ra g e of
conflicts of e a rlie r stages of g r o w th will in flu

ence tech niqu es an d objectives (Sprince, 1968).
G r o u p w o rk w ith p a r e n t s of p ro b le m ch il
d r e n h a s a ls o p r o v e n r e w a r d i n g ( E p s t e i n ,
a b o u t 16 sessions. R eview stud ies by B a rte n

(1 9 69 ), R eid a n d E p ste in (1 97 2); a n d R eid
a n d S h y n e ( 1 9 6 9 ) c o n f i r m t h e s e p o s i ti v e
1970;
resu lts.
M aizlish
& H u rley ,
1963; T ra c e y ,
R a tin g s
at
te r m i n a ti o n
and
at
an
1970), th e t r a in i n g of p a r e n t s in b e h a v io ral
a v e ra g e of 2 Zi
m eth od s being especially p o p u l a r as a n effec
w ere involved in conjoint m a r it a l t h e r a p y (a

co m p a r is o n of these w ith r e p o r te d resu lts of
tive inte rve ntio n m e th o d (B ijou & R ed d , 1975;

F e r b e r et al, 1974; P a tte rs o n , 1973a, 1973b,
1974; W a l t e r & G ilm o re , 1973). O n e o f th e
most difficult s itu a tio n s for th e th e r a p is t is th e
u n m o tiv ated fam ily of c h ild re n w ith aggressive
b e h a v i o r d i s o r d e r s . A p il o t s t u d y a t th e
U n ive rsity of C h ic a g o School of M e d i c in e by
Safer (1966) describes w o rk w ith 29 such
p a re n t s w h ose ch ild ren ra n g e d in age fro m 4 to
y ears la te r of 49 co up les w ho
ou tco m e stud ies o n in div idu al s h o r t-t e rm p sy

c h o th e r a p y as well as w ith a n o t h e r fo rm of
co njoin t t h e r a p y a n d w ith psych o an aly sis) i n
d icate th a t th e conjoint a p p r o a c h h a s some
technical a d v a n ta g e s over a n d c o m p a r e s fa
vo ra b ly w ith these o th e r typ es of tr e a t m e n t
(F itz g e ra ld , 1969).
S h o r t - te r m fam ily t h e r a p y c o n tin u es to g ro w
16. F a m ily , conjoint a n d in div idu al sessions

pro d u ced im p ro v e m e n t in m ost c h ild ren , an d
in p o p u la r ity . Its tech n iq u e s a r e described by

B a r t o l e t t i ( 1 9 6 9 a , 1 9 6 9 b ) , B lo c h ( 1 9 7 3 ) ,
this w a s m a i n ta i n e d in follow -u p e v a lu a tio n s

after 4 to 16 m o n th s. T h e a r e a s of ch a n g e
D e u ts c h (1 96 6), E isler a n d H e r s o n (1973),

H a le y a n d H o ffm a n (1 96 7 ), F a n g s le y an d
b ro u g h t a b o u t by th e r a p y in families w ith d e
K a p la n
lin q u e n t adolescents h a s exposed som e in t e r e s t

ing findings. F o r e x a m p le , P a rs o n s a n d A le x
(1 96 4 a ), a n d W a tz la w ic k (1963). T h e n u m b e r
of sessions th a t a re o p tim a l for fam ily t h e r a p y
a n d e r (1973) discovered th a t o ne could utilize

in studies fou r in te ractio n m e a s u re s t h a t w ere
is d e a lt w ith in e x p e r i m e n t a l e v a lu a tio n s by
S tu a r t an d T r i p o d i (1973). T h e y r a n d o m ly
not a function of e x tr a n e o u s variables.

M a r ita l th e ra p y is also often conducted on a
s h o r t-te rm basis b oth in g r o u p s (L e ib l u m &
R osen, 1979; W ells, 1975) a n d w ith ind iv idu al
(1968),
P it tm a n et al (1966), S a tir
assigned 73 fam ilies w ith p r e d e l in q u e n t a n d

d e li n q u e n t adolescents to 15-, 45-, a n d 9 0 -d a y
b e h av io rally o rien ted tre a tm e n ts . O u tc o m e
m e a s u re s sh o w e d no difference b e tw een th e
couples (Bellville et al, 1969; F itz g e ra ld , 1969; g ro u p s. T h u s it w a s concluded th a t th e r e is no

K a lin a , 1974; P. A. M a r t i n & B ird, 1963; P. reaso n to choose lon ge r over s h o r te r fam ily
A. M a r t i n & Lief, 1973; S ag e r et al, 1968; tr e a tm e n ts. T h e idea th a t b rie f fam ily th e r a p y
S a tir, 1965; S im o n , 1978; W a tz la w ic k et al, yields su perficial resu lts is c halleng ed by H a u g
1967).
(1971), w h o describes a case w h e r e ego a l t e r a
A n in terestin g m odel is described by V e r- tion coincided closely w ith r a p i d an d p ers istin g
h ulst (1975). H e h as evolved an intensive 3- a lte ra tio n s in the body im age. H o w e v e r, w h e re
w eek a p p ro a c h re sem b lin g cognitive le a r n in g th e a d a p tiv e flexibility of p a r e n t s is blo cked by
(B a k k e r & B a k k e r - R a b d a u , 1973) th a t e m rigid defenses o r th e conflict in th e child is
p h a sizes c o n fro n ta tio n a n d p ro b le m solving m a r k e d ly in te rn a liz e d , tr a d it io n a l lo n g e r te r m
w ith the h elp of active, e n th u s iastic, facilita- p s y c h o th e ra p e u tic m e th o d s a r e p ro b a b ly m o re
tive th erap ists. O t h e r m e th o d s a r e o u tlin ed su ita b le ( H a u g , 1971).
e lsew here (W o lb erg , 1977, p p . 7 3 3 - 7 4 0 ) .
T h e c o m b in a tio n of g r o u p a n d fam ily t h e r
20
ap y a p p e a r s to possess som e a d v a n ta g e s, as
for w eek ly
K im b r o et al (1967) a n d D u r e ll (1 96 9) have
u tilized m o r e a n d m o r e a n d L a q u e u r (1968,
1972) h as w r it te n extensively on th e ra t io n a l e
poin ted o u t in th e i r re p o r t of a pilot stu d y of

t i m e - l i m i t e d m u l t i p l e f a m il y t h e r a p y w i t h
d istu rb ed
ad o lescents
and
th eir
fa m il ie s .
G r o u p s of th r e e families m et w ith a th e r a p is t
m eetings.
T h is
design
is being
a n d process of b rin g in g p r o b l e m families from

the sa m e b a c k g ro u n d to g e th e r as a w a y of e x
p e d itin g tr e a tm e n t.
Massing Therapy Sessions

A tte m p ts h av e also been m a d e to stu d y the
effect of m a s sin g th e r a p y sessions by literally
im m e r s in g th e p a tie n t in t r e a tm e n t t h r o u g h o u t
th e day. T h u s S w en so n a n d M a r t i n (1976)
tre a te d p a tie n ts on a full-tim e basis for 3 weeks
a p y m u ltip le im pact th e r a p y th a t has

p ro v en successful is described by M a c G r e g o r
(1962). G o o lis h ia n (19 62 ) em p lo y e d th e te c h
n i q u e w ith 60 fam ilies a n d th e ir p ro b le m
adolescents. A te a m consisting of a p s y c h ia
w ith c o m b in a tio n s of different m odalities th a t

they co n sid ered c o m p lem en ted each oth er.
trist, a psychologist, a n d a social w o r k e r m et
Assessing the p r o g r a m on 335 p a tie n ts at the
sessions. G r o u p a n d ind iv idu al t h e r a p y focused
tim e of d is ch arg e revealed significant im p ro v e
on m a jo r d y n am ics a n d self-reh ab ilitatio n .
ment
R esu lts w e re co nsid ered at least c o m p a r a b le to

c on ven tio nal p sy c h o th e ra p y .
M a r a t h o n g r o u p sessions (B a ch , 1966, 1967
in
th e
presenting
sym p to m s,
w ork
c a p a c i tie s , i n t e r p e r s o n a l r e l a t i o n s h i p s , a n d
ge n e ral level o f com fort. A fo llo w -up stu dy
show ed th a t th is im p ro v e m e n t w a s re tain ed .
M a s s e d tim e - li m it t h e r a p y sessions for as
th ree
tim es
w ith
th e
f a m il ie s
for a l l - d a y
a - d ; C a srie l & D eitc h , 1968; T e i c h e r et al,
lo ng as 10 h o u r s consecutively have been given
1974; V e rn a llis et al, 1970, 1972) w h ile no t as

p o p u l a r as in p rev io u s y ears co n tin u e to have
(B e r e n b a u m et al, 1969). A form of this t h e r
th e i r advocates.
Conclusion
S o m e h o w , s h o r t-t e rm th e r a p y has ac q u ir e d
th e re p u t a ti o n of b eing a s u b s ta n d a r d a p
p ro a c h in w h ic h q u a lity of results is sacrificed
on th e a lt a r of expediency. S u perficia lity of
a p y w ith a d u lts , adolescents a n d c h ild ren , as

well as in g ro u p , fam ily a n d m a r it a l th e r a p y .
A n u m b e r of m od els of s h o r t-t e rm th e r a p y
goals, u n c e rta in ty of resu lts, s u b s titu tio n of

sy m p to m s, a n d a g e n e ral glossing over of ef
h ave evolved fro m w h ich te c h n iq u e s m a y selec

tively be a d a p te d to th e w o rk in g styles of
p s y c h o th e ra p is ts tr a in e d in th e v ario u s t h e
fects a re said to be inevitable. T h e s e ideas have

p ro v en grossly in acc ura te. T h e r e is a m p le evi
d ence from th e re p o r te d clinical ex periences
w ith s h o r t-t e rm th e r a p y th a t it h as a utility
n ot only as a n econom ic e x p ed ie n t, b ut also as
a p r e f e r r e d f o r m of p s y c h i a t r i c t r e a t m e n t .
W h a te v e r con tro lled research studies exist,
these s u b s ta n tia te its valu e in in div idu al t h e r
oretical o rie n ta tio n s.

T h e ac tu a l m o dels in use a r e u su a lly c o n d i
ti o n e d by t h e e x p e r i e n c e a n d t h e o r e t i c a l
o r ie n ta tio n of th e p rac tic in g pro fessio nals a n d
th e policies of the agencies, if a n y , u n d e r
w h o se sup erv ision th e w o r k is bein g d on e. T h e
s h o rtc o m in g s of som e of these system s is th a t
th ey ten d to be m on olithic , c ir c u m v e n tin g fac
21
tors related to th e specific c o m p la in t a n d to

such elem en ts as th e stage of th e p a t i e n t s
fective le arn in g .
H e m a y utilize th e lessons
read ine ss for c h a n g e a n d p re fe rred l e a r n in g

p a tte rn s. N o t all p erso n s a r e ca p a b le of u tiliz
le a rn e d from p sy ch o an aly sis th a t h elp expose

an d resolve unco nscio us resistances, p a r t i c u
larly tr a n sferen ce a n d actin g -o u t. O b v iou sly
ing th e te ch n iq u e s th a t a re offered. T h i s is not

e x tr a o r d i n a r y since p a tie n ts g enerally h a r m o
for best resu lts th e th e r a p is t m u s t be h ig h ly se

lective a b o u t th e m o d alities h e uses so t h a t he
nize w ith som e in terv en tio n s a n d not w ith
does not s w a m p th e p a ti e n t w ith u n n e cess ary
o th ers. S om e do well w ith a cognitive a p

p ro ac h in w h ic h they can a b s o r b a b stra c t co n
activity. All t h e r a p is t s c a n n o t be e x p e rt in, o r
cepts a n d insights th a t h e lp th e m to a lte r th eir
exists. B ut sufficient flexibility sh o u ld prevail

to p re v e n t a sta le m a te w h e n th e p a ti e n t fails to
s i n g u l a r t h i n k i n g p a t t e r n s . O t h e r s fail to
benefit from such tactics. T h e y do b etter w ith
behavioral tec h n iq u es, e x p e r i m e n t in g w ith dif
even a w a r e of, every a v a ilab le te c h n iq u e th a t
re s p o n d to th e m e th o d th a t th e th e r a p is t is a p
p ly in g at th e m o m e n t.
ferent m odes of action, solidifying successful
T h e fact t h a t th e v a rio u s s h o r t- t e r m t h e r
ones th o u g h rein fo rcem en ts. Still o th e r s learn

by m o delin g them selves after a n a d m ire d a u
ap ies in th e h a n d s of co m p e te n t th e r a p is ts do
b ri n g a b o u t relief o r c u re indicates th a t the
th ority, g e n e rally th e th e r a p is t, b e sto w in g on
p a r t i c u l a r te c h n iq u e s a n d s t ra ta g e m s em p lo yed
are n ot th e o n ly i m p o r t a n t elem en ts re s p o n s i
h im virtues he m a y o r m a y not possess. An ef

fective s h o r t-te rm th e r a p is t is o ne w h o discerns
th e needs a n d le a r n in g proclivities of each p a
ble for im p ro v e m e n t. T h e p ro p o s itio n is inv it
tien t an d is flexible en o u g h to a lte r his m e t h
m e a n s of c o m m u n ic a t io n t h r o u g h w h ic h the
ods as he goes along.

R ig i d t h e r a p i s t s
th e r a p is t e n c o u ra g e s the e m erg en ce of positive,

a n d th e re s o lu tio n of negative, h e a lin g ele
d o g g e d ly
fo llo w
set
ing th a t t h e r a p e u ti c m a n e u v e rs m erely act as a
a g en d a into w h ic h th ey w ed ge all p a tie n ts w ith

little ro o m for eclectic m a n e u v e rin g . Yet one
m e n ts ( M a r m o r ,
h a rd ly ever sees a p a tie n t w h o could not utilize
t h a n w ith a less active one, w ith hy p n o sis
some of the effective in terv en tio n s of different
r a t h e r t h a n fo rm a l inte rv iew in g , w ith b e h a v io r
1966).
If a th e r a p is t feels
m ost c o m fo rta b le w ith a m o r e active a p p r o a c h
systems at successive stages of th e ir tr e a tm e n t.
th e r a p y r a t h e r t h a n a n a ly tic a lly o rie n te d t h e r
T h u s a th e r a p is t m a y w ith the sam e p a ti e n t be

active at some tim es a n d passive at o th ers; he
a p y , h e will p r o b a b l y be a b le to help m o r e p a
m ay
s elec tiv e ly
em ploy
c o n fro n ta tio n ,
re
tien ts th a n w e re he to force him self to use a

p ro c e d u r e w ith w h ich h e is not at ease o r
a ss u ran ce, o r suggestive o r persu asiv e te c h

niques. If fa m ilia r w ith th e m eth o d s, he m a y
utilize role play in g , p s y c h o d r a m a , re la x a tio n ,
a b o u t w h ich he is not en th u siastic. T h i s is not

to d ep re c ia te the v irtu e s of a n y of th e existing
hypnosis,
m i li e u t h e r a p y , s y s t e m a t i c d e n s e n s i t i z a t i o n ,
to o v e re m p h a s iz e te chnical v irtu o sity w h ile

m i n im iz i n g th e vital h e a lin g processes th a t
assertive tr a in i n g , an d o th e r b ehav io ra l te c h
niq u es w h e n necessary. H e m ay em p lo y
em e rg e in th e co urse of th e h e lp in g re l a ti o n
sh ip as a h u m a n experience.
f a m il y
th era p y ,
group
th e ra p y ,
psych otro pic d r u g s w h e n sy m p to m s block ef
models a n d tec h n iq u es. H o w e v e r, w e do tend
CHAPTER 2
A Rationale for Dynamic

Short-term Therapy
S h o rt-te rm th e ra p y g e n erally has three
goals: (1) m odifying o r re m o v in g th e s y m p to m
stra te d in fo llo w -u p studies of p a tie n ts w h o

h ave received a p p r o p r i a t e professional help
co m p la in t
over a brief s p a n . T h o u g h n ot a n tic ip a te d , sig
for w h ich
h e lp
is bein g sought,
w h ich is the im m e d ia te objective, (2) p r o d u c
nificant a n d lastin g c han ges in the self-image
ing
a n d th e q u a li ty of i n t e r p e r s o n a l re la tio n s h ip s
som e corrective
in fluence on
th e
in d i
v id u a ls g en eral a d ju s tm e n t, a n d (3) in itiatin g

essential a lte ra tio n s in th e pers o n ality s t r u c
h a v e been noted.
ture.
te r m t h e r a p y th a t ad d ress them selves to the

goal of p e rs o n a lity re c o n s tru c tio n , w e find th a t
we
W ith
may
p ro p erly
a n tic ip a te
c o n d u c te d
su b s ta n tia l
W h e n w e review th e m a n y system s of s h o r t
treatm en t
or
co m plete
s y m p to m relief as well as som e m odification
the
for the b etter of b eha v io ral coping. H o w e v e r,

w e m a y scarcely have b ro k e n g r o u n d on the
uncon sciou s conflict, a lo n g w ith th e c o n d itio n
m a jo rity
a c k n o w le d g e
th e
o p e r a t io n
of
th ird goal of p ers o n ality reco n stru c tio n . W e
n e u ro tic process. In d y n a m ic form s of th e r a p y

a p r i m e objective is h e lp in g th e p a ti e n t a c q u ir e
g r e a t e r k n o w led g e of oneself in clu d in g o n e s
ing of faulty h a b it resp on ses, as a source of th e
m a y hope, n evertheless, th a t th e exp erienc e of

tr e a tm e n t will have set into m o tio n a process
follow ing th e r a p y th a t over a lo n g -te rm perio d
h id d e n motives. A q u e stio n is w h e t h e r th e k ind
will resu lt in t r u e c h a ra c t e r p e rm u ta tio n s .

T h a t such ch an g es do occur h a s been d e m o n
o f t r e a tm e n t b eing em p lo y ed can lend itself to

th e ac hie vem en t of this objective.
Categories of Short-term Therapy

T h ro u g h o u t
th e
lite ratu re
one
finds
rem o ve sy m p to m s, to a lt e r fam ily h a b it p a t

tern s, a n d to rectify b e h a v io ra l deficits. T o a t
ta in th ese objectives, a v a rie ty of eclectic te c h
n iq u e s a re im p le m e n te d , d e p e n d in g on the
ido syn cratic needs of the p a ti e n t a n d the skills
a n d m eth od olo gical p references of th e t h e r a
pist. T h e n u m b e r of sessions varies, ra n g i n g
fro m 6 to 25. In d y n a m ic s h o r t- t e r m t h e r a p y
ten d e n c y to sub div ide s h o r t-t e rm t h e r a p y into

th r e e distinctive categories: (1) crisis in te rv e n
ti o n , (2) s u p p o r t i v e - e d u c a t i o n a l s h o r t - t e r m
th e r a p y , a n d (3) d y n a m ic s h o r t-t e rm th e r a p y .
T h e goals of crisis in terv e n tio n u su ally differ
from those in th e o th e r b rief m etho ds. H e re ,
after from 1 to 6 sessions, a n a tt e m p t is m a d e
to resto re h a b it u a l balanc es in th e e xistin g life
situ atio n. S u p p o rtiv e -e d u c a tio n a l a p p ro a c h e s ,
such as be h a v io r th e r a p y , co nstitu te form s of
in terv e n tio n th a t a re u n d e r t a k e n , a lo n g w ith
e d u c a t i o n a l i n d o c t r i n a t i o n , to re lie v e o r
the th r u s t is t o w a r d a ch ie v ing o r at least s t a r t

ing a process of p e rs o n a lity re c o n s tru c tio n .
Sessions h e re m a y e x te n d to 4 0 o r m ore.
S o m e form s of crisis in te rv e n tio n t h a t a re
being practiced a r e in d istin g u ish a b le fro m th e
22
RATIONALE FOR DYNAM IC SHORT-TERM THERAPY
23
kind of co unseling co m m o n ly do ne in social
tr a d itio n a l in terv iew in g , b e h a v io r th e r a p y , re
agencies. T h e focus is on m o b ilizin g positive
la x a tio n , h y p n o sis, biofeedback, som atic t h e r
forces in th e ind ivid ual to cope w ith th e crisis

situation , to resolve re m e d ia b le en v iro n m e n ta l
apy , G e s ta l t th e r a p y , sex th e r a p y , g ro u p t h e r
apy , etc., singly o r in co m b in a tio n . T h e n u m
difficulties as r a p i d ly as possible, u tiliz in g if
ber of sessions will vary a c cord ing to th e in d i
necessary a p p r o p r i a t e reso urces in th e c o m m u

nity, an d to ta k e w h a te v e r steps a r e essential to
vid ual th e r a p is t , w h o u su a lly a n c h o rs his deci
forestall fu tu re crises of a sim ila r or re la te d n a

ture. N o a tt e m p t is m a d e at diagn osis o r
p sych od yn am ic fo rm u latio n . O t h e r kin ds of
sion o n h o w lo ng it takes to con trol sy m p to m s

a n d e n h a n c e a d a p ta tio n .
T h e p h ilo so p h y th a t en join s t h e r a p is t s to
em p lo y d y n a m ic s h o r t-t e rm tr e a tm e n t is the
crisis interv ention a tte m p t pro vision ally to d e
conviction
tect u n d e rly in g in trap sy c h ic issues a n d past
p re s e n t b eh av io rs a r e roo ted in needs, conflicts,
th a t
many
of th e
derivatives of
form ative experiences a n d to relate these to
a n d defenses th a t reach into th e past, often as
c u rr e n t p ro b lem s. M o r e extensive goals t h a n
far back as e a rly ch ildhood. S o m e of the most
m ere em o tio nal sta biliz atio n a r e sought.
offensive of th ese c o m p o n e n ts a r e unconscious,
T h e social-counseling form s of crisis i n

terv ention a re g enerally em plo yed in w a lk -in
a n d w h ile th ey o b tr u d e them selves in officious
clinics an d crisis centers w h e re larg e n u m b e r s

of clients a p p ly for help a n d w h e re th e r e is a
tion alize d a n d shielded w ith a tena c ity t h a t is

fr u s tr a tin g b o th to the victim a n d to those
a n d often destructive w ay s, they a re u su a lly r a
need to avoid getting involved too in tim a te ly
a r o u n d him . T h e only w a y , a c cording to p r e
w ith clients w h o m ig h t get locked into a d e
v ailing theo ries, th a t on e can b ri n g these

m ischief m a k e r s u n d e r co n trol is to p ro p e l
p en d e n t rela tio n sh ip . V isits a r e as fr e q u e n t as

can be a r r a n g e d an d a re necessary d u r i n g th e
first 4 to 6 weeks. T h e fam ily is often involved
in som e of th e in terview s, a n d h o m e visits m a y
have to be m ade. T h e in tervie w focus is on th e
p rese n t s itu atio n al difficulty an d often is c o n
cerned w ith th e m ost a d a p tiv e w a y s of coping
th e m into consciousness so t h a t th e p a tie n t

realizes w h a t h e is u p ag ain st. By stu d y in g
h o w th e p a ti e n t utilizes the r e la tio n s h ip w ith
h im , th e th e r a p is t h as a n o p p o r t u n it y to d e
tect h o w th ese b u rie d a b e r r a ti o n s o p erate ,
projected as th e y a re in to th e tr e a t m e n t s i tu a
w ith im m e d iate p ressing p ro b le m s. V ig o ro u s
tion.
edu catio nal m e a s u re s a re som etim es exploited
n o n v e rb a l b eh av io r, a n d tr a n sfe re n c e m a n i
festations a r e co nsid ered a p p r o p r i a t e m e d ia for
to activate the pa tien t. T h e e m p lo y m e n t of

sup p o rtiv e m e a s u re s a n d th e use of o th e r h e lp
ing in dividu als a n d
D ream s,
fantasies, v erb al associations,
e x p lo r a tio n b e cause th ey em b o d y u nc onscious
agencies is e n c o u rag ed .
n eeds a n d conflicts in a sym bolic form . By his
T h e second, m ore a m b itio u s, go al-d ire cted

form s of crisis interv en tion a r e often seen o p e r
t r a in i n g , th e th e r a p is t believes him self cap ab le

of d ecoding these sym bols. Since i m p o r t a n t
a tin g in o u tp a t ie n t clinics a n d p riv ate practice.

If the assigned n u m b e r of sessions hav e been
ex h a u ste d a n d the p atie n t still re q u ire s m ore
un conscious d e t e r m i n a n ts s h a p e o n e s e veryday
be hav ior, th e th e r a p is t tries to estab lish a c o n
nection b e tw e e n th e p a t i e n t s p re s e n t p e r
son ality in o p e r a t io n , such as te m p e r a m e n t,
m oods, m o r a ls a n d m a n n e r s , w ith early p ast
exp erien ces a n d c on dition ing s in o r d e r to help
th e p a ti e n t a c q u ir e som e in sig h t into h o w p r o b
h elp, referral to a clinic o r p riv a te th e r a p is t or

con tin ued tr e a tm e n t w ith th e sam e th e r a p is t is
considered.
B r ie f s u p p o r t i v e - e d u c a t i o n a l a p p r o a c h e s
have sponsored a v ariety of te ch n iq u es, such as
lem s origin ate d.
24
Universality of Dynamic Principles

T h e subdivisions of s h o r t-te rm t r e a tm e n t
t h a t h av e been describ ed na m ely , crisis i n t e r
a p y re q u e s tin g h yp n o sis to e lim in a te his s m o k
sh o rt-term
ing h a b it w a s exposed to m y u su a l in d uc tion

m e th o d . A te c h n iq u e th a t I c u sto m a rily e m
th e r a p y , a n d d y n a m ic s h o r t-t e rm t h e r a p y a re
artificial. In p ractice th e ir b o u n d a rie s becom e
ploy is to ask th e p a ti e n t to lift his left in d ex

finger w h e n he exp erien ces certain th in g s th a t
v e n ti o n ,
su p p o rtiv e-ed u catio n al
diffuse. B ecause p a tie n ts re s p o n d selectively to
I suggest to h im , for e x a m p le , a f a n ta sy in g of
different tec h n iq u es, effective th e r a p is ts in all
ce rta in scenes. At the su ggestion th a t he p ic
th r e e categories of tr e a tm e n t will v ary th e i r in

terv entio ns a cco rd ing to th e im m e d ia te p r o b
t u r e h im self w a lk in g a lo n g th e street a n d th a t
he lift his left fing er (w h ich I to uch ed) as soon
lems a n d needs of th e ir p atien ts . M o r e o v e r, be
as the im ag e ca m e to h im , th e p a tie n t in stead
cause all o p e ra te w ith in th e m a t r i x of a r e l a
lifted his rig h t finger. H e also resisted sug ges

tion s th a t his left a r m w o u ld becom e so stiff
tio n sh ip th a t develops b etw een p a tie n ts and

th e ra p ists, u n d e rly in g p e rs o n a lity p ro b lem s
a n d heavy th a t he could no t move it. O n th e
a n d conflicts will su rface d u r i n g th e r a p y a n d
c o n tr a ry , he s p o n ta n e o u s ly w aved his a r m in
yield vitally significant d y n a m ic m a t e r i a l for

e x a m in a tio n . W h a t th e th e r a p is t does w ith th e
th e air. O n te r m i n a ti o n of th e in d u c tio n , I h u
m o r o u sly p o in te d o ut th ese facts a n d sp ecu
m a te ria l th e p a tie n t b rin g s u p d u r i n g in t e r
la ted
views can affect th e o u tco m e of tr e a tm e n t.

In d eed the techn iqu es a n d in terven tio n s u sed
b y the th era p ist to influence the p a ti e n ts
w a s p ro b a b l y a n ex p res sio n of o p p o sitio n al

tendencies. Said I, sm iling, C o u ld y ou be
sy m p to m s m a y
be less im p o rta n t than
the
fa n ta sies a n d beh avio ra l respon ses th e y evoke
th a t
his
n e g a tin g
of m y
su ggestions
a n o p p o sitio n al c h a ra c t e r w h o w o n t allow
him self to be p u s h e d a r o u n d ? H i s im m e d ia te
in the p a tie n t. F o r e x am p le, some m a n ife s ta
res p o n se w a s to la u g h h e a rtily an d to say th a t

peo ple considered h im a s t u b b o r n cu ss. It
ti o n s reflect p r o j e c t i o n s o f p a s t f e a r s a n d
r e q u i r e d n o g re a t effort to connect his o p p o s i
desires in re latio n to early a u th o r it y figures.
ti on al b e h a v io r w ith a c h ild ho od p a t t e r n of
T h e s e , if u n de tec te d or d is re g a rd e d , m a y effec
ass ertin g h im se lf w ith his p a r e n t s a n d old er

siblings by d is p la y in g n eg ativ is m a n d so m e
tively block th e r a p e u ti c progress. Such t r a n s

ference resistances a r e e x tre m e ly co m m o n and
are p ro b a b ly th e chief rea so n for failure s in
th e r a p y . F r e q u e n t ly th ey a re a p p a r e n t only in
n on v e rb al b eh avior, d re a m s, fantasie s, a n d i n
sidious a ctin g -o u t a w a y from th e t h e r a p i s t s of
fice. T h is is w h y a d yn a m ic a p p ro a ch , d u rin g
w hich the reaction s o f p a tie n ts to the th e ra p ist
a n d to the p e r v a d in g tech n iqu es, c o n sta n tly
assessed a n d taken into con sideration , can
p r o v e useful in a ll fo r m s o f sh o rt-te rm th erapy.
W h il e the in terv iew focus m a y be on s y m p
to m s , e n v i r o n m e n t a l d i s t o r t i o n s , a n d o t h e r
c o m p la in t factors, th e real th e r a p e u tic w o rk
will be o rg a n iz e d a r o u n d p e rs o n a lity reactions
an d conflicts m obilized by th e m a n e u v e rs of
th e th erap ist.
A m a n w ith e m p h y s e m a w h o cam e to t h e r
tim es violence to avoid w h a t h e c onsidered be

ing d o m in a te d a n d c rush ed. I co m m e n te d th a t
I c e rtain ly w a s n o t his p a r e n t , b u t t h a t he
m ig h t react to m e a n d to w h a t I w as d o in g for
h im as if I w a s so m ebody w h o w a n te d to
d o m i n a te a n d c ru s h him . H e could easily block
him self by such a n a tt it u d e fro m benefiting
fro m tr e a tm e n t. M y s t a te m e n t seem ed like a
re velation to h im . H e spec ula ted th a t this w a s
p r o b a b ly w h y his p rev io u s p sy c h o th e ra p e u tic
effort w ith a n o th e r th e r a p is t h a d failed. H e
never could u n d e r s ta n d w h y he w o u ld h ave
flashes of a n g e r t o w a r d th e th e r a p is t an d
w o u ld som etim es m u m b le to him self a fter he
left th e t h e r a p i s t s office, I w o n t let th a t sonof-a-bitch b r a i n w a s h m e . H e felt so a s h a m e d
of these re ac tio n s th a t he h a d concealed th e m
25

from his th e r a p ist, w h o failed to pick u p the
transferen ce resistance. By a n tic ip a tin g his
tra nsferenc e rea ctio n, I w a s able to secure his
coo peration an d to achieve a good res u lt in
tre a tm e n t.
H a d I not utilized hy p n o sis b u t j u s t a n o r
d in a r y in terv iew in g te c h n iq u e or b eh av io r
re con stru ctiv e c h a n g e shou ld th e p a ti e n t tr u ly

d esire to move a h e a d in his d evelo p m en t.
W e m u s t not expect to acco m p lish m iracles
w i t h d y n a m i c s h o r t - t e r m p r o c e d u r e s , even
w h e n executed w ith perfection. A t th e en d of
th e form al b rief tr e a tm e n t period w e usu ally
observe
som e
alteratio n
of
th e
p a t i e n t s
th e r a p y , th e p a ti e n t w o u ld u n d o u b te d ly have
sy m p to m s, a n alleviation of suffering, a n d a
revealed his o p p o sitio n a l tendenc ies w e re I to

look f o r th em if n ot in his b ehav ior, th e n in
c e rta in d egree of beh av io ra l co rrection . If we
d re a m s an d o th e r rep re se n ta tio n s . T h e p r i n
recognized fu n d a m e n ta l c h a ra c te r p ro b lem s
ciple th a t I a m try in g to illu s tra te is t h a t the
th a t a r e likely to c re ate difficulties in th e fu
th e r a p e u tic tactics em p lo yed , w h ile a im e d at

r e l ie v i n g t h e i m m e d i a t e c risis s i t u a t i o n o r
tu r e , a n d d u r i n g the tr e a t m e n t w e m a y have
h a v e diligently searched for th e m , w e will have
s y m p to m a tic up set, will usu ally set into m otio n
been ab le to s t a r t th e p a ti e n t o n a p rod uc tive

p a t h t o w a r d a lte rin g self-defeating p e rs o n a lity
cu sto m a ry resistances a n d defensive o p e ra tio n s
p a tte rn s . U n f o r t u n a te l y , th e la tte r objective is
th a t m a y th e n be closely ex a m in e d a n d w o rk e d
avoided by som e th e ra p ists. In m y o p in io n , in
th r o u g h , if possible, as a m e a n s of in culcatin g
m o st cases, th is is because th e th e r a p is t w rites
essential insights. In o th e r w o rd s, even th o u g h

the m eth od s m a y be n o n a n a ly tic , th e p a t i e n t s
it off as u n a t t a i n a b l e a n d h ence does n ot a p p ly
re actio ns to th e m a n d to th e th e r a p is t become
c a n n o t expect too rad ical a p e rs o n a lity r e o r g a

n iz a tio n w ith in th e limited tr e a t m e n t period.
an i m p o r t a n t e x p lo r a to r y focus, if no m o re
t h a n to deal w ith obstructive tra n sfe re n c e an d
o th e r b a rr ie rs to chan ge. P e rs o n a lity m odifica
tions e ventually m a y evolve from th is as a se
re n d ip ito u s div iden d, on e th a t m a y co n tin u e in
him self to its ac c o m p lis h m e n t. T o r e p e a t, we
T h e m ost to be h o p e d for is th e in itiatio n of

sufficient se lf-u n d e r sta n d in g to ch allen g e som e
values a n d defenses a n d to e n c o u ra g e e x p e r i
m e n ta tio n w ith n e w a n d m o r e constructive
a p ro p itio u s e n v ir o n m e n t for a n indefinite tim e

an d u ltim ately become a p e r m a n e n t change.
w a y s of re l a ti n g to o th e r s a n d to th e self. In
It w o uld seem p r u d e n t , obviously, in view of

the g reat d e m a n d for services from th e r e l a
t i n u in g for m o n t h s an d even y ears a fter the
th is w a y a c h a in reactio n m a y be set off, c o n

tr e a tm e n t p e rio d , th a t will ho pefu lly lead u lti
tively sm all c ad re of a v a ilab le tr a in e d t h e r a
m a tely to extensive p e rs o n a lity chan ge. T h a t
pists, th a t, at th e sta rt, at least, s h o r t- t e r m
such fa r -re a c h in g resu lts a re achie vab le in an

im pressive n u m b e r of p a tie n ts is th e fin din g
a m o n g m a n y th e r a p is ts w h o h av e ap p lied
them selves to a d y n a m ic a p p r o a c h in a dis
th e r a p y should practically be g eared to w a r d

goals of o p tim a l functioning. H o p efu lly , h o w
ever, even a b rief e x p o su r e to th e r a p y will u n
cover fu n d a m e n ta l
th e th e r a p is t, if h e
to scrutinize th e m ,
p a t i e n t s a tte n tio n
p e rs o n a lity conflicts, w h ich

d eem s th e p a ti e n t p r e p a r e d
m a y carefully b ri n g to th e
w ith th e object of inviting
ciplined w ay. T h e y a t t a in e d success because

th e y fo un d a n d w o rk e d on a specific im p o r t a n t
focus d u r i n g th e tr e a tm e n t.
Dealing with Unconscious Determinants

In p atien ts w ith intact p e rso n alities a few
w ell-conducted sessions, h o w e v er superficial
they m a y seem, m a y suffice to b ri n g a b o u t a n
a m e lio r a tio n o f sy m p tom s, a n d n o f u r th e r

tr e a t m e n t will be needed. H o w e v e r , t h e r e a re
m a n y patien ts w hose p ro b lem s are m ore
26
deeply en trenc hed w h o will re q u i r e f o r even

m ere sym p to m re lie f som e resolu tio n of p e r
sonality conflicts th a t a re in cessantly g e n e r a t
ing tro u b le for th e m . E ven le a r n in g b etter
modes
of p r o b l e m
s o lv in g
requires
so m e
in sight into in te rn a l forces th a t govern be

havior.
It is precisely because th e most d is tu rb in g
sources of tu rm o il so often lie b eyond a w a r e
ness th a t efforts in m a n y p a tie n ts a p p lie d e x
clusively to w a r d en v ir o n m e n ta l m a n i p u la t io n ,
pe rs u asio n , suggestion, rea s su ra n c e , re e d u c a
ti o n ,
or reco n d itio n in g
so o fte n
are
resistance. T h e s e in n o v a tio n s have becom e

firm ly in c o r p o ra te d into p sy c h iatric a n d p s y
chological th i n k in g a n d h ave in sp ired p r a c
tically all c u r r e n t system s of p sy c h o th e ra p y .
T h e y a r e in trinsic to o u r c o n te m p o r a r y ideas
a b o u t d y n a m ic a lly based s h o r t-t e rm p sy c h o
th e r a p y .
P s y c h o a n a l y s i s in its l o n g - t e r m c la s sic a l
form has no t p ro v en itself to be a p ractical
form of th e r a p y in th e m a jo rity of cases seek
ing h e lp not o n ly because it is ex pen sive an d
o n ly
d ra g s on for years, b u t also, even w h e r e fi

n ances a n d a w illingness to p a rt ic i p a te in a
pa rtia lly successful. T h i s is no t to d ep reciate
p ro lo n g e d th e r a p e u ti c re la tio n s h ip a re p res en t,
th e effectiveness of su p p o rtiv e a n d ed uc atio nal

m e asu res, for in suitable p atien ts , a p a r t from
only a small n u m b e r of p a tie n ts a r e s u ita b le

ca n d id a te s for th e tech n iq u e . Id entify ing w h o
b rin g in g a b o u t necessary relief from suffering,
m ight
a certain degree of p e rs o n a lity c h a n g e m a y oc
R o u g h ly , p e rs o n s w h o a re not too sick a n d not

too im m a t u r e , a so-called n o r m a l - n e u r o t i c
g r o u p , qualify. T h e s e c o n stitu te only a sm all
c u r th r o u g h
th e ir im p le m e n ta tio n .
U nfortu
nately, lasting ch aracte ro lo g ic a lte ra tio n s a re

r a r e . T h e chances a re th a t if w e really h o p e to
succeed in b rin g in g a b o u t explicit p e rs o n a lity
ch an ge, a ss u m in g th a t this is o u r goal, w e will
have to clarify a n d m a n a g e in n e r conflicts th a t
a re beyond the p e rip h e ry of a w a re n e s s in an
effort to p ro m o te g re a te r self-u n d erstan d in g .
T h e qu estio n in s h o r t-te rm th e r a p y is w h e th e r
th is can be d on e briefly in a specific case a n d ,
if so, h o w best it can be done.
T r a d it io n a l ly , th e m eth o d most often e m
ployed in de alin g w ith u nco nscious conflict is
lo n g - t e r m p s y c h o a n a l y s i s . A g o o d d e a l of
m is u n d e rs ta n d in g , h o w ever, still exists a b o u t
psychoanalysis, som e of w h ich stems from its
m isap p lic atio n to a re a s in w h ich its c o m
petence as a th e r a p e u tic p r o c e d u r e m a y be
challenged. S uch m isdirection h a s tend ed to
shred its au th en ticity . F r e u d s e n d u ri n g legacy
lies in his p e n e tr a ti n g insights into h u m a n b e
hav ior. T h e s e include th e concept of th e u n
conscious, the tr e n c h a n t n a t u r e of beh avio r,
th e indelible im p r i n t of ch ildh oo d e xp erien ce
on c h a ra c te r stru c tu re , the c o n s a n g u in u ity of
a b n o r m a l m e n ta l sy m p to m s an d n o rm a l m e n
tal processes, th e significance of a n x iety , the
s tru c tu r e of sy m bolism , th e n a tu r e of d re a m s ,
and
th e
im p ortance
of
transference
and
satisfacto rily
respond
is
d iffic u lt.
fraction of th e vast a r m y of peop le w h o cluster

a r o u n d clinics a n d p r a c t it io n e r s offices seeking
h e lp for a w id e variety of prob lem s.
A tte m p ts to find o th e r m e a n s t h a n classical
a n a ly sis to ex po se u n d e rl y in g sources of p r o b
lems c o n tin u e to this very day. B locking such
a tt e m p t s a r e o b stru c tio n s to su rfacin g of th e
un con sciou s a n d th e stra n g le h o ld th a t h id d en
needs an d defenses h ave on o n e s valu es a n d
b e h a v i o r . B e c a u s e su c h u n c o n s c i o u s i n
g re d ien ts a re frozen into th e c h a r a c t e r s t r u c
tu r e , efforts to d e m o n s tr a t e th e i r u n r e a s o n a b le
ness a r e resisted w ith a d e s p e r a te tenacity.
A re w e th e n d o o m ed in h e lp in g peo ple re ach
reco nstru ctiv e p e rs o n a lity t r a n s f o r m a t io n s ? It
is fallacious to c onclude th a t a seriously defec
tiv e c h i l d h o o d i m p o s e s a life s e n t e n c e o n
everyone. G r o w t h is possible at all stages of an
i n d i v id u a ls life, corrective e m o tio n al e x p e r i
en ce s b e in g s p o n s o r e d by c o n s t r u c t i v e life
events, p a r t ic u l a r ly m ean in g fu l in te rp e r so n a l
relatio n sh ip s . W h e r e a n in div idu al h a s lived
t h r o u g h a crisis a n d h a s resolved it success
fully, he m a y also be r e w a r d e d w ith n ew a n d
b e tte r p e rs o n a lity resp on ses th a t can serve h im
well in h a n d li n g fu tu re stressful situ a tio n s.
T h e idea th a t th e un con sciou s is forever co n

cealed unless u p ro o te d by form al p s y c h o a n a
lytic th e r a p y is no lo ng er accepted by disciples
27
j u s t to be able to recognize o n e s n eu ro tic

m i s e ry . W h a t e v e r th e involved m e c h a n ism s,
th a t a n individual is not a helpless p a w n of his
the i n d i v id u a ls sense of m a s te ry is helped.

Since the goal of s e lf-u n d e r s ta n d in g re q u ire s
unconscious. R a th e r the indiv id ual exercises a
th e u n co v erin g of at least som e un con sciou s d e
of m o d e rn cognitive a p p r o a c h e s w h o co nten d
certain degree of c o m m a n d over in n e r conflicts,
te r m i n a n ts , th e m a n n e r of th e i r e x p o su r e a n d
con stantly striv ing to m a k e th e m conscious so
th e tim in g a r e especially im p o r t a n t in s h o r t
te r m th e r a p y . G e n e r a ll y , the first few sessions
he can gain m a s te ry over th em . T o an ex tent,

he is even ca p a b le of exercising decisions a b o u t
w h ich aspects of his un conscious to reveal,
titra tin g th eir ex p o su r e ag a in st his to le ran ce of
will reveal d a t a from th e h isto rical m a te ria l

(an d p a r t ic u l a r ly the p re s e n t b e h a v io ral p a t
anxiety. As he w o rk s t h r o u g h his a n x ie ty , he
te r n s of the p a tie n t) th a t offer clues r e g a r d in g

th e o p erativ e dy n am ics. U s u a ll y it is u n w is e to
becomes in creasin gly
p re s e n t the p a ti e n t w ith su ch clues, no m a t te r
aw are
of segm ents of
him self th a t h ave been concealed a n d hence
how
have evaded detection a n d control. C o u n te r i n g

th i s , o f c o u r s e , a r e r e s i s t a n c e s t h a t m a y
h im self ex presses a w a re n e s s of w h a t is going
ob stru ct such a tt e m p t s at self-healing.

T h e virtu e of th e cognitive a p p r o a c h is the
p h ilo so p h y it espouses to the effect th a t te c h
n iq u e s o th e r th a n form al analy sis can be im
m ensely helpful in resolving resistance to the
s i g n if i c a n t
they
m ay
seem ,
u n til
he
on. E v en th e n a n y in t e r p r e ta ti o n s m u s t be c a u
ti o u s l y o ffered in t h e f o r m of te n t a t i v e
p re s e n ta tio n s (W o lb e rg , 1977, pp . 5 8 9 - 5 9 0 ) .
T h e re la tio n s h ip of e x pressed conflictual m a
terial to the p re s e n t c o m p la in t factor is vitally
o p e n in g u p of crucial a re a s for e x p lo r a tio n and
im p o r t a n t if such a r e la tio n s h ip can be d e m o n

strated.
u ltim a tely lead to self-u n d e rstan d in g . Left to

o n e s o w n resources, th e av e ra g e in dividual
to m y office w ith th e c o m p la in t of m ig ra in e
A m ild - m a n n e r e d , soft-spoken p a tie n t cam e
m a y not have sufficient m o tiv atio n, th e for
h eada che s. As he w alk e d into th e ro o m , he
titud e to strug gle w ith th e a n x ie ty inevitable to
tipped
th e
apologized
h a n d lin g
of re p u d ia te d
aspects
of th e
over
ch air
w h ile
and
th e n
a s h e s fr o m
p r o f u s e ly
his c i g a r e t t e
psyche, a n d th e w illingness to a b a n d o n th e
m a terial a n d subversive g ain s a c c ru in g to n e u
spilled over th e ca rp et. D u r i n g the interview I

got the im p re ss io n from his p o stu re , th e set of
rotic indulgence. O n th e o th e r h a n d , the in d i

vidual w h o t u r n s to a carefu lly designed a p
p ro a c h executed by a skilled e m p a t h ic th e r a p is t
his j a w , a n d slash in g m o v e m e n ts of his h a n d s

t h a t his fa w n in g , ob seq u io u s m a n n e r w as a
will lea rn to d eal w ith resistances to self-u nd ers ta n d in g an d s u p p o r t e x p e ri m e n t a ti o n w ith
m i n d I m a d e a c o n n e c t i o n b e t w e e n his
s m o ld e rin g ra g e an d his m ig ra in e . I also
m o re rea lity -o rien ted p a tte rn s.

H o w s e l f - u n d e r s t a n d i n g h e l p s to b r i n g
d eeper p ro b le m s to th e su rface a n d to e n
co urag e h e a lth ie r a d a p ta tio n is n ot entirely
clear. Roy Schafer (1973) expresses it this
w ay: It is im pressive th a t, as th ese ch ang es
t a k e p la c e in th e p a t i e n t s c o n c e p t i o n of
himself, often by d in t of a n d w ith the a c c o m
p a n im e n t of m u c h suffering, he begins to feel
b etter an d to function better. H is sy m p to m s
dim inish in scope a n d persistence; his mood
im proves; his social an d sexual rela tio n sh ip s
a re enh anced . It seems th a t it can be a gain
cover for an in n e r boiling pot of a n g e r. In my
specu lated th a t he w as n ot a w a r e of th e exten t

of his a n g e r a n d ho w he repre ssed it. T o have
con fro nted h im w ith m y h y p oth esis w ou ld
p r o b a b ly h av e e n d ed o u r re la tio n s h ip before it
b egan. Instead , I bided m y tim e u ntil I h ad
m o re evidence to con firm m y im p re ss io n w hile
w o r k in g on e sta b lish in g a closer re latio n sh ip .
A t th e fo u r th session the p a ti e n t spoke of
n eed in g some extensive d e n ta l w o r k because he
g r o u n d his teeth d u r i n g his sleep. T h i s r e i n
forced m y idea th a t his a n g e r, u n d e r control
u su ally , w a s stro n g en o u g h to b re a k th r o u g h
in sleep. R epetitiv e use of such p h ra s e s as
28
T h e m a n is all ch ew ed u p , It kills me
to th in k of h o w p eop le tak e a d v a n ta g e of
w ere too busy to devote them selves to a n y single
w e lfa r e , I sla u g h te re d h im at t e n n i s , an d
p a tie n t. T h i s w a s th e case also w ith som e
so on, en ab le d m e to say, I w o n d e r if you
p a re n ts , in clu d in g his o w n p a r e n t s , w h o had

s p en t little tim e w ith him .
hold back o n y o u r a n g e r w h e n you h av e a

rig h t to be u p s e t ? I th e n re p e a te d so m e i n
W i t h o u t a p o lo g iz in g for m y actions o r a c tin g

in d ig n a n t, I e n c o u ra g e d h i m to tell m e m o r e
cidents th a t he h a d revealed to m e in w h ic h he
ha d felt tak en a d v a n ta g e of b ut h a d failed to
a b o u t h o w h e felt, i m p l y i n g t h a t I a p
p rov ed of his f r a n k n e s s a n d his rig h t to feel
w h a t he felt. As I a n tic ip a te d , h e ba c k tra c k e d ,
assert his righ ts. T h i s led to a n ex p o stu la tio n

nefariou sn ess of peo ple w h o needed to J e w
ap o lo g izin g for his b oldness a n d ru den ess.

T h i s re ac tio n , I rep lied , w a s in service o f his
you d o w n .
guilt, a h a b it u a l p a t t e r n to keep his a n g e r
of in d ig n a tio n a t th e state of th e w o rld a n d the
Freud
w as
H is nex t association w a s th a t
a Jew
and
Freud
w a s a psy
c h o an aly st w h o w a s c u rr e n tly being criticized

in articles he h a d read. Is th e r e , I asked him ,
a n y th i n g I as a p sy ch o an aly tic p s y c h o t h e ra
u n d e r control. B u t , he re to rte d , I re a lly do

like doctors a n d J e w s . A n d th e r e is som e
J e w i s h blood in m y fa m ily .
O p en in g
up
so m e
tra n sfe re n c e
f e e lin g s
pist a m do ing th a t upsets you o r m a k e s you

a n g r y ? W h y , he rep lied asto n ish ed ,
shou ld I b e ? W e l l , I reto rte d , a r e y o u ?
served to h e lp o u r re la tio n s h ip ; a n d to s u p p o r t
his a bility to criticize his fam ily m o r e fr a n k ly
T h e p a tie n t th e n la u g h e d a n d in a n e m b a r
child. A no ticeab le ch an g e o c cu rre d in th e fre

q u e n c y of his m i g ra i n e a tta c k s, a n d at o u r
te r m i n a ti o n d a te he e xp re sse d g re a t satisfaction
rassed w a y talk e d a b o u t his re s e n tm e n t a t th e

fee I ch arg ed , a t th e pu n c tilio u sn ess of m y a p
p o in t m e n t tim es, a n d at th e fact th a t I h a d given
h im a n en d in g d a te w h e n he w a s su re he could
not get well in so sh o rt a p e rio d. T h e tro u b le ,
he insisted, w ith most do cto rs w a s th a t th ey
for som e o f th e w a y s h e w a s h a n d le d as a
w ith the benefits he h a d received fro m th e r a p y

bo th in relieving his h e a d a c h e s a n d giving h im a
g r e a t e r sense of freedom .
Conclusion
All perso ns, irrespective of the d egree of
e m o tio n al illness have a p o ten tial for im p ro v e
m e n t an d g r o w th , both sp o n ta n e o u sly th r o u g h
constructive life experiences a n d , m o r e e x p e d i
tiously, w h e n tre a te d w ith a p p r o p r i a t e p sych o
th e r a p y . F o r rad ic al a n d e n d u r i n g a m e n d m e n ts
in the p e rs o n a lity s t ru c tu r e som e cognitive
alte ra tio n is essential. W i t h o u t such chan ge,
im pro ved h a b it a n d beh av io ral p a tt e r n s a r e a p t
to be short-lived. D u r i n g th e r a p y fa r-re a c h in g
im p ro v e m en ts m a y be a p p ro a c h e d by e x p lo r
ing an d w o r k in g th r o u g h basic conflicts, esp e
c ia lly t h o s e r e v e a l e d in t h e t r a n s f e r e n c e .
W h e r e tran sferen ce is not a p p a r e n t in the
th e r a p e u tic situation , it m a y often be detected
in d isto rtio ns in the in d iv id u a ls re la tio n sh ip
w ith o th e r p eo p le as well as in th e d re a m s ,
fantasies, a n d ac tin g -o u t tendencies. Ir re s p e c
tive of the tec h n iq u e s t h a t a r e b eing em p lo y e d ,
(e.g., n on directive in te rv iew in g , active a n x ie ty p ro v o k in g co n fr o n ta tio n , a n a ly tic i n t e r p r e t a
tion, b e h a v io r t h e r a p y , G e s ta l t a p p r o a c h e s ,
etc.), th e p a ti e n t will re s p o n d to these te c h
n iq u e s w ith a w id e r a n g e o f h a b it u a l c h a ra c t e r o lo g i c r e a c t i o n s a n d r e s i s t a n c e s . T h e s e ,
u tilized as a p ro d u ctiv e focus o n w h ic h to c o n
c e n tr a te d u r i n g th e r a p y , m a y h elp p e n e tr a te
defenses a n d in itiate n ew w a y s of th in k in g ,
feeling, a n d b ehav ing . A p a r t fro m th e fact th a t
tim e in tr e a t m e n t is usu ally too sh o r t to p e r m it
th e d e v e lo p m e n t o f too intensive tra n sfe re n c e
reaction s t h a t re ach a p o in t of a tr a n sferen ce
29
neurosis, it is a c tu a lly n ot essential for th e p a
p rev a ilin g c h a r a c t e r p a tt e rn s , a n d th e i r orig in s
tien t to evolve a n d w o r k t h r o u g h a tr a n sferen ce
in e a rly life ex periences, th e process of re c o n
neu rosis to achieve extensive reconstructive

change. Indeed, th e effect of too g re at a n i n t e n
sification of tra n sfe re n c e m a y be to increase
structive ch a n g e is exp edited . Such ch a n g e m a y

co n tin u e th e r e m a i n d e r of th e in d i v id u a ls life,
p a r t ic u l a r ly w h e r e the p a t i e n t s e n v ir o n m e n t
resistance to t h e r a p y a n d to p ro lo n g tr e a tm e n t.
s u p p o r ts th e c h a n g e a n d h e c o n tin u e s self-
W h e r e a r e la tio n s h ip is fou nd betw een th e p a
o b serv atio n a n d e x p e r i m e n t in g w ith p ro du ctiv e
ti e n ts p re s e n tin g sy m p to m s an d c o m p la in ts,
n e w p a tte rn s.
CHAPTER 3
Criteria of Selection
u n d o u b te d ly
latio n w h o a p p ly to a clinic or priv ate p r a c t i
those w ho a re a d e q u a te ly m otivated for t h e r
W h ile
th e best p a tie n ts
a re
tio n e r for tr e a tm e n t. T h e ch alle n g e is w h e th e r
ap y , intellectually ca p a b le of g ra s p in g i m
m ed iate in te rp re ta tio n s , proficient in w o rk in g
p a tie n ts n o t so b o un tifu lly blessed w ith t h e r a

p eutically positive q u a lities c a n be tre a te d a d e
on an i m p o r t a n t focus in th e r a p y , no t too d e
q u ately
p e n d e n t, have h a d at least o ne good r e l a ti o n

sh ip in the p ast, an d a r e im m ed iate ly ab le to
c han ce of im p ro v in g th e ir g e n e ra l m o de s of
in tera ct well w ith th e th e r a p ist, th ey g enerally

con stitute only a sm all p erc en tag e of th e p o p u
m i n o r degree of p e rs o n a lity reco n stru ctio n .
on
a sh o rt-term
basis w ith
som e
p ro b le m solving a n d p e r h a p s of achie vin g a
Patient Classification
In practice one m a y d istin guish at least five
re a s o n a b le a d a p ta tio n . T h e im p ositio n of th e
classes of p a tie n ts w ho seek help. W e have
crisis ha s d e stro yed th eir cap acities for cop ing

a n d h a s p ro d u c e d a te m p o r a r y regression an d
c ategorized th e m as C lass
1 t h r o u g h 5. In
g en e ral, C lasses 1 to 3 r e q u i r e only s h o r t-te rm

th e r a p y . C lasses 4 a n d 5 will need m a n a g e
m e n t for a lon ger perio d after an initial s h o r t
te r m reg im en of th e r a p y .
e r u p t io n of n e u ro tic m e c h a n ism s. T h e object in

t h e r a p y for th ese p a tie n ts is essentially s u p p o r
tive in th e fo rm of crisis in terven tio n w ith the
goal of re e s ta b lish in g th e p rev io u s e q u ilib r iu m .
R eco nstru ctiv e effects w h ile not expected a r e a
Class 1 Patients
w elcom e dividend. G e n e ra ll y , no m o r e th a n six

sessions a re necessary.
A n e x a m p le of a C lass 1 p a tie n t is a satisfac
U n til th e onset of the c u r r e n t difficulty C lass

1 p a tie n ts have m a d e a good o r to lera b le a d
torily ad ju sted w o m a n of 50 y ears of age w h o

d ro ve a fr ie n d s a u to m o b ile w ith an e x p ire d
j u s tm e n t. T h e goal in th e r a p y is to r e t u r n
th e m to th e ir h a b itu a l level of functioning.
A m o n g such p a tie n ts a re those w ho se stability
h a s been te m p o r a r ily sh a tte re d by a c a ta
license a n d in th e process h a d a severe acci

d e n t, killing th e driv er of th e car w ith w h ich
sh e c o llid e d a n d se v e r e ly i n j u r i n g t w o
stro p h ic life event or crisis (death of a loved

one, divorce, severe accident, serious physical
illness, financial disaster, or o th e r calam ity ).
Som e in div id uals m a y have been b u rd e n e d
w ith extensive conflicts as far back as c h ild
p a s s e n g e r s in h e r o w n c a r , w h i c h w a s
d a m a g e d b eyond re p a ir. She herself sustain ed
a concussion a n d an in ju re d a r m a n d w as
m oved by a m b u l a n c e to a h osp ital, w h e r e she
re m a in e d for a week. C h a r g e d w ith d riv in g
violations, sued by the o w n e r of th e c a r she
hood but u p to the p re se n t illness h ave been

ab le to m a r s h a ll sufficient defenses to m a k e a
b o rr o w e d a n d by th e tw o in ju re d p a ss en g e rs,
she developed a d azed , dep ressed rea ctio n and
30
31
CRITERIA OF SELECTION
th e n perio ds of severe dizziness. T h e r a p y h e re
of th e p a t i e n t s a n x ie ty lay in th e last flight
consisted of a good deal of s u p p o r t, r e a s

su ran c e, a n d h e lp in fin d in g a good la w y e r,
th at
w h o counseled h e r successfully t h r o u g h h e r
e n tan g le d legal co m plications.
S om etim es a crisis o p en s u p closed t r a u
th e
m atic c h a p te rs in o n e s life. In such cases it
consisted of b e h a v io ra l sy stem atic d e se n s itiz a
m a y be possible to link p ast incidents, feelings,

a n d conflicts w ith th e p re s e n t u p se ttin g c ir
tion , w h ich in eig ht sessions resulted in a cure

of th e sym p to m .
c u m s t a n c e s e n a b l i n g t h e p a t i e n t to c la r if y
anxieties a n d h opefully to influence d e e p e r
s t ra ta of p erson ality . In th e case above, for e x
a m p le, the p a tie n t recalled an incident in her
ch ildhood
w hen
w h ile w h e e lin g
her
young
b ro t h e r in a c a rriag e, she accid entally u p set it,

cau sing a g ash in h e r sibling th a t r e q u i r e d s u
tu rin g . S h a m e d , scolded, a n d sp a n k e d , the
f r i g h t e n e d c h ild h a r b o r e d t h e e v e n t t h a t
p o w ere d fear a n d guilt w ith i n herself. T h e
she
had
ta k e n
y ea rs previously.
d is tu rb a n c e in on e of the en gin es re p o r te d to
pass e n g e rs
by
the
pilot
n ecessitated
r e t u r n to th e p o in t of o rig in . Since th a t tim e

M i s s J h a d n ot d a r e d e n te r a p la n e . T h e r a p y
In u tiliz in g th e v a rio u s eclectic tech n iq u e s

th e th e r a p is t a le r ts h im self to p a st p a tt e r n s
t h a t act as a p a r a d i g m fo r th e p r e s e n t
s y m p to m com plex , as well as to m an ifestatio n s
of resistance a n d transfe ren ce. In a certain
n u m b e r of cases th e p a ti e n t m a y be h elp ed to
o v e r c o m e r e s i s t a n c e s t h r o u g h r e s o l u t i o n of
provocative in n e r conflicts a n d in this w a y
achieve results beyond th e profits of s y m p to m
relief.
intensity of h e r feeling s u r p ris e d h e r, a n d th e ir

disch arg e d u r i n g th e r a p y fostered a n a s s u m p
tion of a m o re objective a ttitu d e to w a r d both
th e p ast an d the im m e d ia te crisis event. It m a y
not be possible in all cases, b u t a n a s tu te an d
e m p a th ic th e r a p is t m ay be able to h elp th e p a
tient m a k e im p o r t a n t co nnection s b etw een th e
p ast and p resen t.
Class 3 Patients
T h o s e in w h o m
b o th
s y m p to m s a n d b e
h a v io ra l difficulties a r e connected w ith d eepseated
in tra p sy c h ic
p ro b le m s
th a t
ta k e
the
fo rm of p e rs o n a lity d is tu rb a n c e s a n d i n a p p r o
p r i a te coping m e c h a n ism s m a k e u p th e C la s s 3
classification. Such p a tie n ts h ave fu nctio ned at
Class 2 Patients
least m a r g in a lly u p to th e tim e of th e ir b r e a k

d o w n , w h ich w a s p e r h a p s in itia ted by a n im
T h e chief p ro b le m for C la s s 2 p a tie n ts is not
m e d ia te p r e c ip ita tin g factor. M o s t of th ese p a
a critical s itu atio n th a t h a s o b tr u d e d itself into
ti ents seek h e lp to alleviate th e i r distress or to
th eir lives, bu t r a t h e r m a la d a p tiv e p a tt e r n s of

b ehav ior a n d / o r d is tu rb in g sym pto m s. T h e o b
solve a crisis. S o m e come specifically to achieve

g re a t e r p e rs o n a lity d ev elo p m en t. O n e v a lu
ject h ere is sy m p to m c u re or relief, m o d ifica

tion of destru ctive habits, a n d evolvem ent of
m o re ada p tiv e beh av ioral co nfigu ration s. M u l
tiform tec h n iq u es a re e m p lo y ed for 8 to 20
sessions follow ing eclectic su p p o rtiv e -e d u c a
atio n eith e r th e y a r e de em e d u n s u i ta b l e for

lo n g - te rm t r e a tm e n t, o r extensive t h e r a p y is
believed to be un ne cessary . T h e y often possess
the desire a n d ca p acity to w o r k to w a r d a c q u i r
ing s e lf-u n d e rsta n d in g .
tion al m odels u n d e r the ru b r ic of m a n y term s,

such as s h o r t-te rm b eha vio ra l th e r a p y , s h o r t
T h e goal for C lass 3 p a tie n ts is p e rs o n a lity

reco n s tru ctio n a lo n g w ith sy m p to m a tic a n d b e
h a v io ra l im p ro v e m e n t. T e c h n i q u e s a re usually
te r m reeducative t h e r a p y , a n d so forth.
A p h o b ia to a ir travel exem plifies th e c o m
p lain ts of a class 2 p a tie n t. T h i s w as a g reat
h a n d ic a p for M is s J since job ad v a n c e m e n t
p s y ch o an aly tic ally o rien ted , involving in t e r

v iew ing, co n fr o n ta tio n , d r e a m an d tran sfere nce
in te rp re ta tio n s , an d occasionally the use of a d
necessitated visits to rem o te a reas. T h e o rigin
ju n c tiv e te c h n iq u e s like hypn osis. S o m e t h e r a
32
pists confine the te rm d y n a m ic sh o rt-te rm th er
ou t h e r violent rage. She rea lize d th e n th a t h e r
a p y to this class of p a tie n ts an d often em p lo y a
o b se q u io u s b e h a v io r to w a r d h e r h u s b a n d w as
careful selection process to e lim in ate p a tie n ts

w h o m th ey feel w ou ld n ot w o rk too well w ith
a cover for h e r hostility. A ctin g on th is insight,
th eir
D av an lo o ,
discuss h e r re actio n s w ith h e r h u s b a n d an d the
1978, M a l a n , 1963; Sifneos, 1972; U r s a n o &

D ressie r, 1974).
re a s o n s for h e r rages. T h i s op e n e d u p c h a n n e ls
of c o m m u n ic a tio n w ith a d r a m a ti c res o lu tio n
An e x a m p le of a C la ss 3 p a tie n t is a yo ung
m o t h e r w h o b ro u g h t h e r son in for c o n s u l ta
of h e r s y m p to m s a n d an im p ro v e m e n t in h e r
tion because he w a s gettin g such low m a r k s in
peo ple, con firm e d by a 5 -y e a r follow -up.
tech n iq u es
(B uda,
1972;
she w a s soon a b le to ex p ress h e r a n g e r a n d to
feelings a b o u t h erse lf a n d h e r attitu d e s to w a r d
th e final y e a r of hig h school th a t th e chances

of h is g e t t i n g in to co lle g e w e r e m i n i m a l .
M o r e o v e r, he firm ly a n n o u n c e d his u n w ill in g
Class 4 Patients
ness to go to college, insisting on find in g a job

after g r a d u a t io n so th a t he could bu y a n a u
tom ob ile a n d p u rs u e his tw o hobbies: baseball
an d girls. D u r i n g th e inte rview w ith th e boy it
P a tie n ts of th e C la ss 4 cate go ry a r e those

w h o se p ro b le m s even a n effective th e r a p is t
w a s obvious th a t he h a d m otiv ation n e it h e r for
m a y be u n a b le to m ed ia te in a b rie f sp a n an d
w h o will r e q u i r e m o r e p ro lo n g e d m a n a g e m e n t
f u r th e r college e d u ca tio n n o r for an y k in d of
after th e initial s h o r t-t e rm pe rio d of fo rm a l
t h e r a p e u tic help. It w as a p p a r e n t too th a t his

s tu b b o rn refusal to stu d y a n d to go on to
t h e r a p y h as disclosed w h a t in terv e n tio n s w ou ld
h ig h e r le a r n in g w a s a w a y of fighting off the

d o m in a tio n of his m o t h e r an d step fath e r. Ac
sh o u ld be stressed because n ot all lo n g - te rm

m o da lities need be, an d often a r e not, best
cordingly, the m o t h e r w a s advised to stop n a g

gin g the boy to c o n tin u e his schooling. Instead
vid u als w h o a p p e a r to r e q u i r e help over a n e x
best be indicated. T h e w o r d m a n a g e m e n t
a im ed at in tra p sy c h ic a lte ra tio n s. A m o n g i n d i
she w as u rg ed to p e rm it h im to e x p e ri m e n t
w ith fin din g a jo b so th a t he could learn th e
ten d ed s p a n a r e th ose w h o se p ro b le m s a r e so
va lue of a d o lla r a n d to discover for h im se lf the
for th e m is to keep th e m in re a s o n a b le reality
k ind s of positions he could get w ith so little

education.
f u n c t i o n i n g , w h i c h t h e y c o u ld n o t a c h ie v e
severe a n d dee p -ro o ted th a t all t h e r a p y can do
w ith o u t a p ro lo n g e d th e r a p e u ti c resource.
T h e nex t d ay th e m o th e r tele p h o n e d a n d r e
p o rted th a t she h a d
instru ction s. H o w e v e r,
p o in tm e n t for herself
tense an d suffered from
followed th e d o c to r s
she asked for a n a p
since she w a s overly
bad b ackaches th a t her
C la ss 4 p a tie n ts includ e th e following:

1. I n d i v id u a ls w i t h c h r o n i c p sy c h o tic r e a c t i o n s
a n d psy c h o ses in r e m i s s io n w h o r e q u i r e s o m e s u p e r
v isory i n d i v i d u a l o r g r o u p w i t h w h o m co n t a c t is
o rth o p e d ist claim ed w ere d u e to n e rv e s .

W h a t she w a n te d w a s to learn self-hypnosis,
w hich h e r d o c to r claim ed w o u ld h elp he r
relax . A bidin g by h e r re q u e s t, she w a s ta u g h t
r e g u l a r l y m a d e o v er su fficiently sp a ced in t e r v a l s to
self-hypnosis not only for re la x a tio n p u r

poses, but also to d e te r m in e th e sources of h er
a n d to s u d u e t h e p e r i l s o f p sy c h o tic p ro cess es w h e n
tension. T h r o u g h in terv ie w in g aid ed by in

duced im a g e ry d u r i n g hyp n osis, she w a s able
to recognize h o w a n g r y she w a s at m e for not
satisfying h e r desire to force h e r son to go to
college. Im ag es of a tta c k in g h e r fath er, w h o
fr u s tr a te d an d d o m in a te d her, soon b r o u g h t
provide
ever
som e
tenuous
k in d of h u m a n
t h is
psychotropic d ru g
may
be,
relationship,
to
o versee
how
essential
i n t a k e , to r e g u l a t e t h e m ilieu ,
th e s e a r e p e r i o d i c a l l y release d . S u c h p a t i e n t s d o no t
u s u a l ly r e q u i r e f o rm a l p r o l o n g e d p s y c h o t h e r a p y o r
r e g u l a r se ssio ns w i t h a p s y c h o t h e r a p i s t ; th ey co uld
do
as
w ell,
or
better,
w ith
paraprofessional
counselor. M ilie u th e ra p y , r e h a b ilita tio n p ro ce

d u r e s , a n d social o r g r o u p a p p r o a c h e s m a y be h e l p
ful.
2. P e r s o n s w i t h se rio u s c h a r a c t e r p r o b l e m s w i t h
CRITERIA OF SELECTION
33
ten d en cies t o w a r d a l c o h o lism a n d d r u g ad d ictio n

w h o r e q u i r e r e g u l a r g u i d a n c e , s u r v e illa n c e , g r o u p
a p p r o a c h e s , a n d r e h a b i l i ta t iv e services ov er a n i n
d efin ite p erio d.
8. P a r a n o i d a l p e r s o n a l i t i e s w h o r e q u i r e a n i n c o r
r u p t i b l e a u t h o r i t y for r e a l i t y testin g .
9. I n d i v i d u a l s w i t h s e v e r e l o n g - s t a n d i n g p s y
c h o s o m a t ic a n d h y p o c h o n d r i c a l c o n d i t i o n s , s u c h as
3. I n d i v i d u a l s w i t h u n c o n t r o l l a b l e t e n d e n c i e s
u lc e r a tiv e colitis, o r c h r o n i c p a i n s y n d r o m e s t h a t
t o w a r d a c t i n g - o u t w h o n eed c o n t r o l s f ro m w i t h o u t
h a v e re sisted m i n i s t r a t i o n s f r o m m e d ic a l, p s y c h o
to r e s t r a i n t h e m fro m e x p r e s s i n g i m p u l s e s t h a t will
logical, a n d o t h e r h e l p i n g reso u r c e s . O f t e n these
get t h e m in to difficulties. E x a m p l e s a r e th o se w h o
sym ptom s
a r e o ccasion ally d o m i n a t e d by d a n g e r o u s p e r v e r
p sy c h o tic d i s i n t e g r a t i o n .
sions,
d esires
for
violence,
lust
fo r
are
m a n i f e s t a t i o n s of defen se s a g a i n s t
crim in a l
10. P e o p l e p r e s e n t i n g w i t h d e p r e s s i v e d i s o r d e r s
activities, m as o ch istic n eed s to h u r t th e m se lv e s, a c
w h o a r e in d a n g e r of a t t e m p t i n g su ic id e a n d r e q u i r e
cid en t p r o n e n e s s , se lf- d efeatin g g a m b l i n g , a n d o t h e r
c a r e f u l r e g u l a t i o n of a n t i d e p r e s s i v e m e d i c a t i o n s or
c o r r u p t i o n s . M a n y s u c h p e r s o n s r e c o g n i z e t h a t th ey
e l ectr o co n v u lsiv e t h e r a p y follo w ed by p s y c h o t h e r a p y
n eed c u r b s on t h e i r u n c o n t r o l l a b l e w a y w a r d desires .
u n t i l t h e risk o f a r e l a p s e is over.
4. P e r s o n s so t r a u m a t i z e d a n d fix ated in t h e i r d e
v e l o p m e n t t h a t th ey h a v e n e v e r o v e r c o m e in f a n tile
a n d child ish need s a n d defenses t h a t c o n t r a v e n e a
Class 5 Patients
m a t u r e a d a p t a t i o n . F o r in stan c e, t h e r e m a y be a
c o n s t a n t e n t r a p m e n t in r e l a t i o n s h i p s w i t h s u r r o g a t e
p a r e n t a l figure s, w h i c h u s u a l ly evolve for b o th s u b
j e c t s a n d hosts into a s a d o -m a s o c h i s t i c p u r g a t o r y .
Yet su ch
p e r s o n s c a n n o t f u n c tio n w i t h o u t a d e
In C lass 5 w e p lace th ose in d iv id u als w h o

seek an d r e q u i r e extensive re con stru ctiv e p e r
son ality c h a n g e s an d h ave th e finances, tim e,
p a r e n t a l ag ency .
fo rb e a ra n c e , a n d ego s tre n g th to to le ra te lo n g
te r m p sy ch o an aly sis o r p sy ch o an aly tically
S o m e of th ese p a t i e n t s m a y need a d e p e n d e n c y s u p
o rie n te d p s y c h o th e ra p y . In a d d itio n , th ey have
p o r t t h e r e m a i n d e r of t h e i r lives.
M a n y of t h e p a t i e n t s in th is c a t e g o r y fall into
h a d th e good f o r tu n e of fi n d in g a w e ll-tra in ed ,
ex p e rie n c ed , a n d m a t u r e a n a ly s t w h o is c a p a
devastating fru s tra tin g d ep endency relatio n sh ip s
ble of d ealin g w ith d e p e n d e n t tr a n sferen ce an d
during
o th e r resistan ces as well as w ith o n e s p e rs o n a l

c o u n tertra n sferen ces . P a tie n ts w h o can benefit
p e n d e n c y p r o p , a n d t h e t h e r a p i s t offers h i m s e l f as a
m o r e ob jective a n d
therapy
or
nonpunitive
alternatives
to
therapy
fro m
w h ic h th ey c a n n o t o r will n o t e x t r i c a t e th em se lv e s.
R e a l iz in g t h e d a n g e r s of t h is c o n t i n g e n c y , w e can ,
how ever,
plan
our
st r a t e g y
accordingly,
for e x
a m p l e , by p r o v i d in g s u p p o r t i v e p r o p s o u t s i d e of t h e
t r e a t m e n t si t u a t i o n if s u p p o r t is ne e d e d . N o r need
w e a b a n d o n r e c o n str u c tiv e ob jectives, o n ce w e m a k e
p r o p e r a l l o w a n c e s for p ossible regre ssiv e i n te r lu d e s.
In f o l lo w -u p con tacts, I w a s p l e a s e d to find , t h e r e
h a d b een c h a n g e af ter 5, 10, a n d i n s o m e cases 15
y e a r s in p a t i e n t s w h o I believed h a d little c h a n c e to
achieve p e r s o n a l i t y c h an ge.
5. P e r s o n s
w ith
persistent
and
u n c o n t r o l la b le
a n x i e t y r e a c t i o n s p o w e r e d (a) by u n c o n s c i o u s c o n
flicts of long s t a n d i n g w i t h
e x is tin g d efense s so
f ragile t h a t t h e p a t i e n t is u n a b l e to c op e w i t h o r
d i n a r y d e m a n d s of life o r (b) by a n o x i o u s a n d i r r e
m e d i a b l e e n v i r o n m e n t from w h i c h t h e p a t i e n t c a n
no t escape.
6. B o r d e r l i n e p a t i e n t s b a l a n c e d p r e c a r i o u s l y o n a
r a z o r edge of r a t i o n a l it y .
7. I n t r a c t a b l e o b s e s s iv e - c o m p u l s i v e p e r s o n s
w h o s e re a c t i o n s se rv e as defenses a g a i n s t psychosis.
m o r e from lo n g - te rm reco nstru ctiv e th e r a p y

th a n from d y n a m ic a lly o rie n te d s h o r t-te rm
t h e r a p y a r e often b u rd e n e d by in terfe rin g ex
te r n a l cond itio ns th a t m a y be so stro n g , or by
th e press o f in n e r neu ro tic needs so intense,
th a t th ey c a n n o t proceed o n th e i r o w n t o w a r d
t r e a tm e n t objectives after th e s h o r t-t e rm t h e r a
peu tic p erio d h a s ended. C o n t i n u i n g m o n i to r
ing by a th e r a p is t is essential to p re v e n t a r e
la p s e . In c e r t a i n c ases t h e c h a r a c t e r o l o g i c
d e ta c h m e n t is so g reat th a t th e p a tie n t is u n a
ble to establish close a n d t r u s ti n g contact w ith
a th e r a p is t in a b rief p eriod , a n d a c o n sid e ra
ble b u lk of tim e d u r i n g th e s h o r t- t e r m sessions
m a y be occupied w ith e sta b lish in g a w o rk re la
tion sh ip.
A special g r o u p of p a tie n ts r e q u i r in g lon g
te r m t h e r a p y a r e high ly d is tu rb e d c h ild re n a nd
adolescents w h o h ave been s tu n te d in the
34
process of p e rs o n a lity d eve lop m e nt and w h o
ally con stitu te less th a n o n e - q u a r t e r of the p a
re q u i re a c o n tin u in g rela tio n sh ip w ith a t h e r a

pist w h o functions as a g uid in g , e d u c a tio n a l,
tien t load c a rr ie d by the av e rag e p s y c h o t h e r a

pist. T h e b u lk of o n e s prac tice will g e n e rally
benevolent p a r e n t a l figure.
L o n g -te r m p a tie n ts in C lasses 4 an d 5 u s u
be com po sed of p a tie n ts w h o m a y a d e q u a t e ly

be m a n a g e d by s h o r t-t e rm m ethods.
Conclusion
If we a re p ra g m a tic a lly disposed to tr e a t as
m a n y p a tie n ts as possible for econom ic or
em o tio n a l p ro b le m s c an w ith efficient s h o r t

te r m m e th o d s achieve satisfactory resu lts an d
o th e r reasons, we m ay say th a t all p a tie n ts i r

r e s p e c ti v e o f d i a g n o s i s , a n d s e v e r ity a n d
m a y even go on by them selves, w ith th e l e a r n

ings th ey h ave a c q u ir e d , to a tt a in som e d eg ree
chro nicity of p ro b le m s a r e p o te n tia l c an d id a tes
of p e rs o n a lity g ro w th . A few m a y re q u i r e an
for s h o r t-te rm th e r a p y . S h o u ld a n y p a tie n ts

fail to resp o n d to a b b re v iated m eth od s, w e can
ad d itio n a l visit o r tw o from tim e to tim e to r e
alw a y s con tin u e tr e a tm e n t, h avin g ac q u ir e d in

valu ab le in fo rm atio n d u r i n g th e s h o r t-t e rm ef
fort as to w h a t inte rve ntio ns w ou ld best be in
dicated for th e i r pro b lem s. Even w h e r e th e
yardstick of cost effectiveness is n ot p a r a m o u n t ,
th e m a jo rity of in dividuals w h o seek h elp for
solve som e p ro b le m s th a t they a re u n a b le to

h a n d le by them selves. T h e y t h u s will have
been able t h r o u g h a practical b rief th e r a p e u ti c
a p p r o a c h to h ave been s p a r e d th e expense,
inconvenience, a n d in som e cases th e d a n g e rs
of lo n g - te rm th e r a p y .
CHAPTER 4
A General Outline of
Short-term Therapy
T h e r e obviously a re differences a m o n g t h e r
w o r k in g r e l a ti o n s h ip w ith a p a tie n t. E m p a t h y
apists in the w a y th a t s h o r t-t e rm t h e r a p y is

im p le m e n te d for e x am p le, th e focal a re a s
p a r t i c u l a r l y is a n i n d i s p e n s i b l e p e r s o n a l i t y
q u a li ty th a t h elp s to solidify a good t h e r a p e u ti c
chosen for atte n tio n a n d e x p lo r a tio n , th e r e l a
alliance.
tive e m p h a s is on c u r r e n t as c o m p a r e d to past
G e n e ra ll y , at th e initial in terv iew , the p a
issues, the a tte n tio n paid to tr an sferen ce , the
tient is greeted c ou rte ou sly by n a m e , th e t h e r a
w a y resistance is h a n d le d , th e d e p th of p r o b
pist in tro d u c in g h im self as in this excerpt:
ing, the d ealin g w ith un con sciou s m a te ria l th a t

surfaces, th e precise m a n n e r of in t e r p r e ta ti o n ,
T h . How
do
y ou
do,
W o n t
M r.
you
R oberts,
sit
down
I am
o v er
D r.
the degree of activity, the a m o u n t of advice giv
W olberg.
there
ing, the kinds of in terv en tio n s a n d ad jun ctiv e

devices em p lo yed , a n d the p rescrib ed n u m b e r
a n d I ll see w h a t I can d o to h e l p y o u (p a tie n t
(p o in ti n g to a c h a ir ), a n d w e 'l l t a l k t h i n g s over
g e ts se a te d ).
of sessions. M o r e o v e r, all t h e r a p is t s have to
P t.
T h a n k yo u , d o c to r , (p a u se)
deal w ith th eir o w n p erso nalities, pre jud ices,

th eoretical biases, an d skills, all of w h ich will
A d etac h ed d e a d p a n pro fession al a ttitu d e is
influence th e w a y they w o rk . In spite of such

differences, th e r e a re ce rta in basic principles
p a r t ic u l a r ly fatal. It m ay , by eliciting p o w erfu l

feelings of rejection, pro v o k e protective d efen
t h a t have evolved from th e exp erien ces of a

w ide a s s o rtm e n t of th e r a p is ts w o rk in g w ith
e s ta b lish in g a w o r k in g r e la tio n sh ip .
sive m a n e u v e rs th a t n e u tr a li z e efforts to w a rd
diverse p a tie n t p o p u la tio n s th a t h av e p ro d u ce d

good results. T h e p r a c t it io n e r m ay find he can
It is difficult, of course, to d e lin eate exact

ru le s a b o u t h o w a th e r a p e u ti c allian ce m a y be
establish ed ra p id ly . E a c h th e r a p is t will utilize
a d a p t at least some of these p rin cip les to his

o w n style of o p e ra tio n even th o u g h he co n
him self u n iq u e ly to w a r d th is end in te r m s of
tinu es to em p lo y m eth o d s th a t have p rov en
his o w n tec h n iq u e s a n d cap acities for r a p p o r t.
them selves to be effective w ith his p a tie n ts and
Some
a re not exactly in accord w ith w h a t o th e r p r o

fessionals do. In th e p ages th a t follow 20 te c h
ab ility even d u r i n g th e first session, as th e p a

tient describes his p ro b le m a n d associated feel
ings, of p u tt in g the p a tie n t at ease, of m o b iliz
n iq u es are suggested as a g en eral gu ide for

sh o r t-te rm th e r a p y .
th erap ists
p o ss e ss
an
ex trao rd in ary
ing his faith in the effectiveness of m eth o d s th a t

will be utilized, a n d of s u b d u i n g th e p a t i e n t s
d o u b ts an d concerns. A confident en th u s ia stic
m a n n e r an d a conviction of o n e s ability to
h elp so m e h o w c o m m u n ic a te s itself no n v e rb ally
Establish as Rapidly as Possible a

Positive W orking Relationship
(Therapeutic Alliance)
to the p a tie n t. T h e r a p i s t e n th u s ia s m is an im
p o r t a n t in g red ien t in tr e a tm e n t.
T h e follow ing suggestions m a y p ro ve h e lp
ful:
A n a tm o s p h e re of w a r m t h , u n d e rs ta n d in g ,
an d acceptance is basic to achiev ing as positive
35
36

V erbalize w h a t the p a tie n t m a y be fe e lin g
y ou rself, I see n o r e a s o n w h y y o u c a n t get
P u tt in g into w o rd s for th e p a tie n t w h a t he
b etter.
m ust be feeling bu t is u n a b le to con cep tua lize

is o ne of th e m ost effective m e a n s of esta b lish
W h e r e th e p a tie n t becom es self-d eprecatory
ing contact. R e a d in g betw ee n the lin e s of
a n d m asochistic, the positive aspects of his

re a ctio n s m a y be stressed. F o r e x am p le, should
w h a t th e p a tie n t is ta lk in g a b o u t will yield i n

terestin g clues. Such sim ple s ta te m e n ts as,
You m u s t be very u n h a p p y an d upset a b o u t
w h a t has h a p p e n e d to y o u o r I can u n d e r
he say he is co n stan tly fu riou s, one m ig ht

rep ly , T h i s indicates th a t you a re ca p a b le of
feeling stro n g ly a b o u t th i n g s . If he says he
s ta n d h ow u n h a p p y an d up set you m u s t be
de tac h es a n d does not feel a n y th i n g , the a n
u n d e r the c ir c u m sta n c e s p re sen t th e th e r a p ist
sw e r m a y be, T h i s is a sign y o u a r e tr y in g to
as an e m p a th ic person.
p r o t e c t y o u r s e l f fr o m h u r t i n g . C o m m e n t s
E ncourage the p a tie n t th a t his situ ation is
such as th ese a r e inte n d ed to be protective in

o r d e r to p rese rv e th e r e l a ti o n s h ip w ith th e
n ot hopeless
th e r a p is t. L a t e r w h e n it becomes a p p a r e n t th a t
It is s o m e t i m e s a p p a r e n t t h a t , d e s p i t e
p re s e n tin g h im self for h elp, th e p a tie n t is co n
vinced th a t he is hopeless a n d th a t little will
th e re la tio n s h ip is sufficiently solid, the t h e r a
actually be accom plished from th e r a p y . W h e r e
p is ts c o m m e n ts m a y be m o r e provocative a n d
c h a l l e n g i n g . T h e p a t i e n t s d e fe n s e s b e in g
th r e a te n e d , a n x ie ty m a y be mobilized, b u t th e
p r o b a b ly feel th a t y o u r s itu atio n is hop eless be
p a ti e n t will be su s ta in e d by th e th e r a p e u ti c
allian ce a n d he will begin to u tilize it r a t h e r
cause you have a lr e a d y tried v ariou s th in gs
th a n r u n a w a y fro m it.
the th e r a p is t suspects this, he m a y say. You
th a t h a v e n t been effective. B u t th e r e are th in gs

th a t can be do ne, th a t you can do a b o u t y ou r
situa tio n an d I shall gu ide you to w a r d m a k i n g
an effort. E m p a t h i z i n g w ith th e p a tie n t m ay
be im p o rt a n t: P u tt in g myself in y o u r p o si
tion, I can see th a t you m u st be very u n h a p p y
a n d upset a b o u t w h a t is h a p p e n in g to y o u .
S om etim es it is useful to define the p a t i e n t s
role in d eveloping a n d su s ta in in g his p ro b le m
in a n o n acc u sin g w a y: You p ro b a b ly felt you
h a d no o th e r a lte rn a tiv e t h a n to do w h a t you
d i d . W h a t y o u a r e d o i n g n o w seem s
r e a s o n a b le to you, bu t th e r e m a y be o th e r
w ay s th a t could create few er p ro b le m s for
y o u .
W h il e no p ro m ise is m a d e of a cu re, the
th e r a p ist m u s t convey a n a ttitu d e of conviction
a n d faith in w h a t he is doing.
Deal With Initial Resistances

Among
th e
resistan ces
com m o n ly
en
c o u n tered at the first session a re lack of m o ti

vation a n d d is a p p o in t m e n t th a t th e th e r a p is t
does not fulfill a stereotype. T h e t h e r a p i s t s
age, race, n a tio n a lity , sex, a p p e a r a n c e , profes
sional discipline, a n d religion m a y not c o rr e
sp o n d w ith the p a t i e n t s ideas of so m eo n e in
w h o m he w a n ts to confide.
T h . I n o tice t h a t it is difficult for you to tell m e

a bout your problem .
P t.
( O b v io u s ly in d isc o m fo rt) I d o n t k n o w w h a t
to say . I ex p e c te d t h a t I w o u l d see a n o ld e r
p e r s o n . H a v e y ou h a d m u c h e x p e r i e n c e w ith
cases like m e ?
P t.
I feel h o p eles s a b o u t g e t t i n g w ell.
D o you
t h i n k I c a n get ov er th i s t r o u b l e of m i n e ?
T h . D o you re a lly h a v e a d es ire to get o ver this
T h . W h a t c o n c e r n s yo u is a f ear t h a t I d o n t h av e
as m u c h e x p e r i e n c e as y o u believ e is n eces sa ry
a n d t h a t a n o ld e r p e r s o n w o u l d do a b e t t e r j o b .
t r o u b l e ? If you re a lly do, this is n i n e - t e n t h s of
I c a n u n d e r s t a n d h o w y o u feel, a n d y o u m a y
t h e b attle. Y o u will w a n t to a p p l y y o u r s e l f to
do b e t t e r w i t h a n o ld e r p e r s o n . H o w e v e r , s u p
t h e j o b of g e t t i n g well. I will p o i n t o u t som e
p o s i n g you tell m e a b o u t y o u r p r o b l e m a n d t h e n
t h i n g s y ou can do, a n d if y o u w o r k a t th e m
if y o u w i s h I will refe r you to t h e best o l d e r
37
GENERAL OUTLINE OF SHORT-TERM THERAPY

t h e r a p i s t w h o c a n t r e a t t h e k i n d of co n d itio n
p r o b l e m s y ou h a v e t h a t a r e c a u s i n g te n s io n ,
y o u hav e.
a n d also lift t h e ten s io n. T h i s s h o u l d h e l p y o u r

pain.
T h i s tactic of acceptin g th e resistan ce a n d
P t.
I w o u l d like t h a t . I get te n s e in m y j o b w i t h
t h e p e o p l e I w o r k . S o m e of t h e m a r e c r u m b s .
inviting th e p a ti e n t to tell you m o re a b o u t

him self can be a p p lie d to o th e r stereoty pes
[.P a tie n t g o e s on ta lk in g , o p e n in g u p p o c k e ts o f
a n x ie ty .]
besides age. In a w ell-con du cted inte rview the

th e r a p is t will reveal him self o r herself as an
e m p a th ic u n d e r s ta n d in g p e rs o n , an d the p a
tient will w a n t to c o n tin u e w ith h im or h e r in
th erap y .
A n o th e r co m m o n form of resistan ce occurs
in th e perso n w ith a psych oso m atic p ro b le m
w h o has been referred for p sy c h o th e ra p y an d
w h o is not at all convinced th a t a psychological
p ro b le m exists. In such cases th e th e r a p is t m a y
proceed as in this excerpt.
P t.
tim e being. A ctu ally, as h a s been in dicated , it

m a y be a n essential a d a p ta tio n a l sy m p to m , the
p a ti e n t n eed in g it to m a i n ta i n a n e q u il ib r iu m .
D e a lin g w ith a r e a s of ten sio n u su a lly will h elp
relieve the s y m p to m , a n d as p sy c h o th e ra p y
tak es hold, it m a y m a k e it u n n e c e ss a ry to use
th e sy m p to m to preserv e psychological h o m e o
stasis.
M o tiv a t io n a l lack m a y o b stru c t t h e r a p y in
D r . J o n e s se nt m e h ere. I h a v e a p r o b l e m w ith
o th e r s itu a tio n s, as w h e n a p a tie n t does not
s t o m a c h a c h e s a lo n g t i m e a n d h a v e been se eing
come to t r e a t m e n t on his o w n accord b u t is
d o c to r s for it for a lo ng tim e.
T h . As yo u k n o w , I a m a p s y c h i a t ri s t. W h a t m a k e s
y ou feel y o u r p r o b l e m is p sy c h o lo g ic a l?
P t.
T h e object is to accept th e phy sical condition

as it is an d not label it psychological for the
1 d o n t t h i n k it is, b u t D r . J o n e s says it m ig h t
sent or b r o u g h t by relatives o r c o n cern ed

p a rtie s. A d d itio n a l e x a m p le s a r e ch ild re n or
adolescents
w ith
b e h a v io r
p ro b le m s,
p eo p le
w h o a r e ad d icted (drug , alcohol, food, g a m
be, a n d he sent m e here.
Th . D o you t h i n k it is?
bling), a n d p eo p le receiving p e n sion s for p h y s i
P t.
cal disabilities. C a s e 1 in C h a p t e r 6 illustrate s

the m a n a g e m e n t of a n o n m o tiv a te d a d o le s
N o , I c a n t see h o w this p a i n c o m es f ro m m y
head .
Th . W e l l , it m ig h t be o r g a n i c , b u t w i t h s o m e o n e
cent.
M o r e on h a n d li n g lack of m otiv atio n
w h o h a s suffered as lo n g as y o u h a v e t h e p a i n
is
will cause a go od de al of t e n s io n a n d u pset.
458-470).
detailed
elsew he re
(W o lb e rg ,
1977,
pp.
[T o in sist on th e id ea th a t th e p r o b le m is p s y
ch o lo g ica l w o u ld be a p o o r tactic. F irst, th e
th e r a p is t m a y be w r o n g , a n d th e co n d itio n
m ay
be
o r g a n ic
p r e s e n t- d a y
th o u g h
u n d e te c ta b le
tests a n d e x a m in a tio n s .
by
S eco n d ,
Gather Historical Material and

Other Data
th e p a tie n t m a y n e e d to re ta in h is n o tio n o f th e
s y m p t o m s o r g a n ic ity a n d even to be a b le to
e x p e r ie n c e a tte n u a te d p a in fr o m tim e to tim e
a s a d e fe n s e a g a in st o v e r w h e lm in g a n x ie ty or,
in certa in se rio u s c o n d itio n s, p s y c h o s is . )
P t.
It s u r e does.
T h . A n d t h e te n s io n a n d d e p r e s s i o n p r e v e n t t h e
st o m a c h f ro m h e a lin g . T e n s i o n i n ter fer es w i t h
h e a l i n g of even t r u e p h y sic al p r o b l e m s . N o w
w h e n you re d u c e te n s io n , it h e l p s t h e h e a lin g .
It m i g h t h e l p y o u even if y o u r p r o b l e m is o r
ganic.
P t.
I h o p e so.
T h . So w h a t w e can do is try to f i g u re o u t w h a t
T h r o u g h sy m p a th e tic lis te n in g the p a

tien t is allow ed to tell his story w ith as little
i n t e r r u p t io n as possible, th e th e r a p is t in t e r p o
latin g q u estio n s a n d c o m m e n ts th a t in dicate a
c o m p a s sio n a te u n d e r s ta n d in g of th e p a t i e n t s
situ atio n. T h e d a ta g a th e r e d in the in itial in
terv iew sho uld ho pefu lly p e r m it a ten tativ e
diag no sis a n d a n o tio n of th e etiology a n d p o s
sibly th e p sy ch o d y n am ics. S h o u ld th e p atie n t
not b ri n g th e m a t t e r u p , he m a y be asked w h a t
he considers his most i m p o r t a n t p ro b l e m to
be? W h y h a s he come to tr e a tm e n t at this
38
tim e? W h a t has he do ne a b o u t the p ro b le m to
ou t scoring. T h i s is o p tio n a l, of course. T h e

th e r a p is t does not hav e to be a clinical p s y c h o l
d a te ? H a s he him self arriv ed at a n y idea as to

w h a t is c a u sin g his difficulty? W h a t does
he expect o r w h a t w o uld he like to get from
ogist to do this, bu t he o r she sh o u ld h ave read

som e m a te ria l on the R o rsc h a ch . T h e p a tie n t
th e r a p y ?
m a y also be given a sheet of p a p e r a n d a pencil
It is often a d v a n ta g e o u s to follow an o u t
a n d be asked to d r a w a p ic tu re of a m a n an d a
line* in o rd e r to do as co m plete a histo ry o r
w o m a n . Som e th e r a p is ts p refer s h o w in g the
be hav ioral analy sis as possible d u r i n g the first
p a tie n t
r a p id ly
session o r tw o. T h i s m a y necessitate i n t e r r u p t
Cards.
W hat
ing th e p a tie n t after the th e r a p is t is convinced
t i e n t s respo nses a n d d r a w in g s ? C a n o ne c o r
re la te these w ith w h a t is h a p p e n i n g s y m p to
t h a t he has o b ta in e d sufficient helpful d a ta

a b o u t a n y one topic.
A m o n g the q u e stio n s to be exp lo re d a r e the
following:
1. H a v e t h e r e been p r e v io u s u p s e t s t h a t r e se m b le
t h e p r e s e n t o ne?
2. W e r e t h e p r e c i p i t a t i n g e v e n t s o f p r e v i o u s
3. W h a t m e a s u r e s a g g r a v a t e d t h e p r e v i o u s u pse ts
are
from
the
m ost
h elp is s o u g h t ,
being experienced
depression,
A p p e rc e p tio n
m atic ally ? T h e s e tests a r e no su b stitu tes for

e s s e n tia l p s y c h o l o g ic a l te s ts w h e r e n e e d e d ,
w h ic h can best be d o n e by a n ex p erien ced c lin
ical psychologist. B u t th e y c an fulfill a useful
p u r p o s e in p ic k in g u p gross defects in the
p hy sic al
im p o rtan t
problem
w h at other sym ptom s
(su ch as te n s io n , a n x i e t y ,
sym ptom s,
se x u al
p o t e n t i a l i t i e s , p a r a n o i d a l te n d e n c i e s , d e
pressive m an ifesta tio n s, a n d so on. N o m o re
t h a n 10 o r 15 m in u te s sh o u ld be utilized for
a n d w h i c h alleviated t h e s y m p t o m s ?
4. A p a r t
T h em atic
th i n k in g p rocess, b o rd e r lin e o r sch iz o p h re n ic
u p se ts in a n y w a y s i m i l a r to t h e r ecen t o n e s ?
for w h i c h
th e
d is to rtio n s a p p e a r in th e p a
problem s,
p h o b i a s , obse ss io ns, i n s o m n i a , excessive d r i n k i n g ?

5. W h a t t r a n q u i l i z e r s , e n e r g i z e r s , h y p n o t i c s , a n d
o t h e r m e d i c a t i o n s a r e b e in g t a k e n ?
Statistical d a ta a re r a p id ly recorded (age,

e d u catio n , o c cu p atio n , m a r ita l statu s, how
long m a r r ie d , a n d ch ild ren if any). W h a t w as
(an d is) the p a t i e n t s m o th e r like? T h e f a th e r?
A n y p ro b le m s w ith b ro th e rs o r sisters? W e r e
th ere a n y p ro b le m s ex perienced as a child (at
hom e, at school, w ith h e a lth , in re la tio n sh ip s
w ith o th e r ch ild re n )? A ny p ro b le m s in sexual
d eve lop m e nt, c a re e r choice, o c c u p a tio n a l a d
ju s tm e n t? C a n th e p a tie n t re m e m b e r any
d re a m s , especially n ig h t m a r is h an d repetitiv e
d re a m s ? W e r e th ere previo us psychological or
psych iatric tr e a tm e n ts ?
T o o b ta in f u r th e r d a ta , th e p a ti e n t m a y be
exposed to the R orsc hach card s, gettin g a few
resp on ses to th ese u n s tr u c tu r e d m a te ria ls w i t h
this p u rp o s e .
An e x a m p l e of ho w R o rsc h a c h c ard s can
help reveal u n d e rl y in g im p u ls e s no t b r o u g h t
out by r e g u l a r in te rv ie w in g m e th o d s is illu s
tr a te d in a severely d ep re sse d m a n w ith a co n
trolled, o bsessional c h a ra c t e r w h o se passivity
a n d in a b ility to ex p ress aggression re s u lte d in
o th e rs ta k in g a d v a n ta g e of h im at w o r k a n d in
his m a r r ia g e . W h e n q u estio n ed a b o u t feelings
of hostility o r agg ressio n, he d enied th ese w ith
som e pride. T h e follow ing w e re his resp on ses
to th e R o rs c h a c h C a rd s.
1. T w o t h i n g s flyin g a t each o t h e r .
2. S o m e t h i n g sa i li n g i n t o so m e th i n g .
3. T w o
fig u res
pulling
som e thing
apart;
tw o
adults pulling tw o infants a p a rt.

4. A n i m a l s fu r s p r e a d o u t. X - r a y (d ro p s ca rd )
5. F l y i n g in sect, su r g ic a l i n s t r u m e n t , forcepts.
6. A n i m a l o r insect sp lit a n d f la tte n e d out.
7. X - r a y
fluo ro sco p e of e m b ry o ;
ado lescen ts
l o o k i n g a t e a c h o t h e r w i t h t h e i r h a i r w h i p p i n g u p in
th e w in d .
8. T w o
a n i m a l s c l i m b i n g a tree, o n e o n each
side; fe m a le o r g a n s in all of th e s e c a r d s.
* F u r t h e r details on history ta k in g a n d conve nient a p p r o p r i a t e f o r m s m a y b e f o u n d in W o l b e r g , 1 9 7 7 , p p . 401
4 0 9 ,1 1 7 6 -1 1 7 8 .
9. F o u n t a i n t h a t goes u p a n d s p i l l i n g blo od.

10. U n d e r w a t e r sc ene, fish s w i m m i n g , c r a b s , I n
side of a w o m a n s body.
39

T h e conflicts re lated to aggression a n d being
E x a m p le /. A sy m p to m a tic fo cu s
to rn a p a r t so a p p a r e n t in th e re spo nses becam e

a p rin cip a l th e r a p e u tic focus a n d b ro u g h t forth
T h . I get t h e i m p r e s s io n t h a t w h a t b o t h e r s you
m o st is te n s io n a n d a n x i e t y t h a t m a k e s it h a r d
his repressed a n g e r at his m o th er.
for y o u to get a lo n g . Is it y o u r fe eling t h a t w e

s h o u l d w o r k t o w a r d e l i m i n a t i n g th ese?
P t.
Select the Symptoms, Behavioral

Difficulties, or Conflicts that You
Feel are Most Amenable for
Improvement
Yes. Yes, if I c o u ld get rid o f feelin g so u p se t, I

w o u l d be m o r e h a p p y . I m so i r r i t a b l e a n d
j u m p y a b o u t everything.
E x a m p le 2. A fo cu s on a p re c ip ita tin g even t
T h . W h a t you a r e c o m p l a i n i n g m o st a b o u t is a
se nse of h o p e le s sn e s s a n d d e p r e s s i o n .
T h e selection w ith the p a tie n t of a n i m p o r

ta n t p ro b le m a r e a o r a d is tu rb i n g s y m p to m on
w h ich to w o rk is for th e p u rp o s e of av oid ing
If w e
fo cuse d on these a n d w o r k e d t o w a r d e l i m i n a t
in g t h e m , w o u l d y o u a g r e e ?
P t.
I s h o u l d say so, b u t I w o u l d also like to see
excursions into reg ion s th a t , w h ile p e r h a p s
h o w I c o u ld i m p r o v e m y m a r r i a g e . I t s been
ch allenging, will d ilu te a m ean in g fu l effort.
g o i n g d o w n h i l l fast. T h e last fight I h a d w ith
T h u s , w h e n you have decided on w h a t to co n

cen trate, in q u i re of th e p a ti e n t if in his op in io n
these a re w h a t h e w o u ld like to e lim in a te or
c h a n g e . A g r e e m e n t is i m p o r t a n t t h a t th is
chosen are a is significant to th e p a tie n t a nd
m y h u s b a n d w a s t h e lim it.
T h. W ell, suppose we take u p the p roblem s you are

h a v i n g w i t h y o u r h u s b a n d a n d see h o w th ese
a re connected w ith your sym ptom s.
P t.
I w o u l d like t h a t , d octo r.
w o r th y of c o n c e n tra te d a tte n tio n . If th e p a tie n t

co m p la in s th a t the selection is too limited, he is
assured th a t it is best to move one step at a
time. C o n tr o l li n g a sim p le situ a tio n o r a lle v ia t
E x a m p le 3. A d yn a m ic fo cu s
W h e n e v e r possible the th e r a p is t sh o u ld a t
te m p t to link the p a t i e n t s s y m p to m s a n d c o m
ing a s y m p to m will h e lp s tre n g th e n th e p e r
p la i n ts to u n d e rl y in g factors, th e connections
sonality, a n d p e rm it m ore extensive prog ress.
w ith w h ic h th e p a ti e n t m a y be only dim ly

a w a r e . C a re fu lly p h ra s e d in t e r p r e ta ti o n s will
T h u s the focal difficulty a r o u n d w h ich t h e r

a p y is o rg an iz ed m a y be d ep re s sio n , an x iety ,
be re q u ire d . It m a y not be possible to detect
m a y be a s itu a tio n a l p r e c ip ita tin g factor o r a
basic conflicts in th e first in tervie w , only sec

o n d a r y o r deriv ativ e conflicts being a p p a r e n t .
crisis th a t h a s im posed itself. It m a y be a d is

tu r b in g p a tt e rn o r som e le a r n e d a b e r r a ti o n . It
th e r a p is t all th e facts d u e to resistance, guilt,
m a y be a pervasive difficulty in re la tin g o r in
o r an xiety. O r facts m a y be defensively dis
fu nctioning. O r it m a y be a conflict of w hich

the p a tie n t is a w a r e or only p a rtia lly a w a re .
O n c e a g re e m e n t is reac h e d on th e a r e a of
focus, the th e r a p is t m a y succinctly su m u p
w h a t is to be done.
torted . It is often helpful (w ith the p erm iss io n

of th e p a tie n t) to in terv iew , if possible, the
spouse or a n o t h e r in divid ua l w ith w h o m the
tension, o r som atic m a n ifesta tio n s of tension . It
T h . N o w t h a t w e h a v e d ecided to focu s on the

p r o b l e m \d esig n a te] t h a t u p s e t s you , w h a t w e
will
do is try to u n d e r s t a n d
what
it is all
a b o u t , h o w it st a r t e d , w h a t it m e a n s , w h y it
c o n tin u e s . T h e n w e ll e s t a b l is h a p l a n to do
s o m e th i n g a b o u t it.
M o r e o v e r, th e p a tie n t m a y not h ave given the
p a tie n t is related after th e first o r second in t e r

view. T h e s u p p l e m e n t a r y d a ta o b ta in e d m ay
com p letely ch a n g e th e in itial h y p o th etical
a s s u m p tio n s g lean e d from th e m a te ria l exclu
sively revealed by th e p a tie n t.
N eve rth eless, som e in v a lu a b le o b serv atio n s
m a y be m a d e from th e historical d a ta an d in
terv iew m a te ria l th a t will lend them selves to
in te r p r e ta ti o n for definin g a focus. T h u s a p a
40
tient p res en tin g g rea t inferiority p ro b le m s an d
in
repetitive difficulties in w o rk s itu a tio n s w ith
d is tu rb e d o r rejec ting perso n fro m w h ic h th e
supervisors, w h o as a child fought b itterly w ith
p a ti e n t ca n n o t e x tric a te him self is a n e x a m p le .
an
unsatisfacto ry
relatio n sh ip
w ith
an old er sibling, w a s told the following: It is
It m a y be necessary to e n c o u ra g e c o n tin u in g
possible th a t y o u r presen t a n x ie ty w h ile r e
c on versatio n
lated to ho w you get a lo n g w ith y o u r boss
ask in g po in te d q u e stio n s in the effort to help
touches off tro u b les y o u ve ca rrie d a r o u n d w ith

you for a long tim e. You told m e you a lw ay s
th e p a ti e n t see the re la tio n s h ip b etw een his

sy m p to m s a n d w h a t he m a y h ave considered
felt in ferior to y o u r b ro th e r. In m a n y cases this
u n re l a te d no x io u s events. S h o u ld th e p atie n t
sense of inferiority c on tin ues to b o th e r a p e r
fail to m a k e th e con nections, th e th e r a p is t m a y
son
spell th ese ou t, ask in g p e r t in e n t q u estio n s th a t
in
relation
to
all
kind s of n ew
old er
b rothe rs. It w o u l d n t be m y s te rio u s if this w e re
about
suspected
p re c ip ita n t,
m a y h elp th e p a ti e n t g ra s p th e association.
h a p p e n in g to you. W h a t do you t h i n k ? T h i s
c o m m e n t sta rte d off a p ro d u ctiv e series of
rem iniscences re g a r d in g his exp erien ces w ith
Evolve a W orking Hypothesis
his b ro th e r, a focus on w h ich resulted in con

sid erab le u n d e r s ta n d in g a n d b e tte rm e n t of his
A fter the first session th e th e r a p is t sho uld
c u r r e n t relation ship s.
As has been indicated, m o re f u n d a m e n ta l
h ave g a th e r e d e n o u g h d a ta from th e p rese n t

a n d p a st h isto ry , fro m a n y d r e a m s th a t are
n u c le a r
revealed, a n d from th e g en eral a ttitu d e a n d be
conflicts
may
be
revealed
in
later
sessions (for e x a m p le , in the above p a tie n t an
h a v io r of th e p a tie n t to p u t to g e th e r some
alm ost classical oedipal conflict existed), espe

cially w h e n tra n sferen ce an d resistan ce m a n
f o r m u la tio n a b o u t w h a t is g oin g on. T h i s is
ifest themselves.
e m p lo y in g concepts w ith w h ich th e p a ti e n t h as

som e fa m ilia rity . T h is fo rm u la tio n should
Define the Precipitating Events
a l a r m i n g th e p a tie n t. R a t h e r a concise, r e
s tra in e d , o p tim istic pictu re m a y be p a in te d
p re s en ted to th e p a tie n t in sim p le la n g u ag e ,
never be couched in d is m al term s to avoid
It is essential th a t w e identify clearly the

p re c ip ita tin g factors th a t led to the p a t i e n t s
p rese n t upset o r w h y th e p a tie n t ca m e to t r e a t
m e nt at this time.
w i t h o u t t r o u b le u ntil y o u r d a u g h t e r told you

a b o u t t h e af fa ir she is h a v i n g w i t h t h is m a r r i e d
m a n . D o y ou believe th is s t a r t e d you off on th e
d o w n s li d e ?
D octor,
I c a n t tell y ou the sh o ck th is w a s to
me. J a n i e w a s su ch a n ideal child a n d ne ver

w a s a bit of a p r o b l e m . A n d t h e n t h is t h i n g
happened
S h e s c o m p le te ly
h ypo th esis should
id e a l ly
b rack et th e
im
m ed ia te p re c ip ita tin g agencies w ith w h a t h as

g on e on before in th e life h isto ry a n d , if possi
T h . It se em s as if y o u w e r e m a n a g i n g to get a l o n g
Pt.
m a k i n g this co n tin g e n t on th e p a t i e n t s c o o p e r
a tio n w ith th e t h e r a p e u ti c p la n . Aspects of the
changed, and
ble, ho w th e p a t i e n t s p e rs o n a lity s t ru c tu r e h as
influenced th e w a y th a t he h a s reacted to the
p re c ip ita tin g events.
A w o m a n ex p e rie n c in g a severe a n x ie ty a t
tack revealed th e p r e c ip ita tin g incident of dis
covering h e r h u s b a n d s m a r it a l infidelity. As
she discussed this, she disclosed the pa in fu l
episode of h e r f a t h e r s a b a n d o n in g h e r m o t h e r
for a n o th e r w o m a n .
c a n ' t u n d e r s t a n d it.
T h . Is it p o ss ib le t h a t y o u a r e a f r a id y o u r h u s b a n d
S om etim es th e events a r e obscured o r denied
b e c a u s e th e p a t i e n t h a s a n i n v e s t m e n t in
su sta in in g s itu a tio n a l ir rita n ts even w h ile he
seeks to escape from th eir effects. Involvem ent
will d o to y ou w h a t y o u r f a t h e r d id to y o u r
m other?
Pt.
(b r e a k in g o u t in tea rs) O h , i t s so te r ri b l e . I
s o m e ti m e s t h i n k I c a n t s t a n d it.

Th. S t a n d his l eav ing you o r t h e fact t h a t he h a d
Pt.
I h a d g r e a t p a i n s a n d t r o u b l e fi g h ti n g for m y
r i g h ts w h e n I w a s s m a l l a boss y m o t h e r a n d
a n affa ir ?
Pt.
41
I m e a n if he w o u l d
f a t h e r w h o d i d n t care. I g u e s s I f inally gave
T h. Yo u w o u l d forget w h a t h a d h a p p e n e d ?
Pt. p a u s e ) Y es Yes.
Th. H o w y ou h a n d l e y o u r se lf will d e t e r m i n e w h a t
T h . D i d yo u give u p t r y i n g to a d j u s t a t h o m e o r
If it co uld e n d r i g h t n o w ,
u p.
sto p , it (p a u se).
h a p p e n s . Yo u can see t h a t y o u r p r e s e n t up se t
w ork?
Pt.
Not
exactly .
But
f ig h tin g
never
g ets
any
w h e r e s . P e o p l e j u s t d o n t listen.
is p r o b a b l y l in k e d w i t h w h a t h a p p e n e d in y o u r
h o m e w h e n y ou w e r e a child. W o u l d you tell
Make a Tentative Diagnosis
m e a b o u t y o u r love life w i t h y o u r h u s b a n d ?
T h e focus on th e r a p y w a s th e re a fte r c o n
D e sp ite th e fact th a t o u r c u r r e n t nosological
cerned w ith th e q u a li ty of h e r r e la tio n s h ip
system s leave m u c h to be d esired, it m a y be

necessary to fit the p a tie n t into som e diagn ostic
schem e if for no o th e r re a s o n t h a n to satisfy in
w ith h e r h u sb a n d . T h e r e w ere evidences th a t

the p a tie n t herself p ro m o te d w h a t in w a rd l y
she believed w a s a n in evitable a b a n d o n m e n t.
s titu tio n a l r e g u la tio n s a n d in s u ra n c e r e q u i r e

m ents. T h e r e is a te m p ta t io n , of course, to
T h e th e r a p is t in m a k i n g a te nta tive th r u s t at
the dy n am ics of a p ro b le m sh o u ld p re s e n t it in
c o o rd in a te d iagn osis w ith accepted labels for
sim ple term s th a t th e p a tie n t can u n d e rs ta n d .
w h ich re im b u r s e m e n t will be m ad e. T h i s is
T h e e x p la n a tio n should not be so do g m atic ,

how ever, as to p rec lu d e a revision of the h y
pothesis at a la te r d ate, sho uld f u r th e r elicited
m a te ria l d e m a n d this. T h e p a tie n t m a y be
asked ho w he feels a b o u t w h a t th e th e r a p is t
u n f o r tu n a te since it te n d s to lim it flexibility

a n d to in v alid a te utilizing case records for p u r
poses of statistical research . Even th o u g h clini
cal diagn osis b e a r s little r e l a ti o n s h ip to p r e
h as said. If he is h azy a b o u t th e con ten t, his

confusion is e xp lored a n d clarification con
ferred th e r a p e u ti c tech n iq u e s in som e sy n

d ro m e s, in o t h e r sy n d ro m e s it m a y be helpful
to w a rd
in s titu tin g
a ratio n a l
pro g ram
tinued.
(W o lb e rg , 1977, p p . 6, 6 2 - 6 3 , 4 1 0 - 4 1 8 ) .
F o r e x a m p le , a p a tie n t w ith m i g r a i n e is
p resented w ith th e h y po thesis th a t a n g e r is
w h a t is creatin g his sy m p to m . T h e p a tie n t
then m ak es a c onnection w ith p a st re s e n tm e n ts
an d the denial defenses th a t he erected, w h ich
a p p a r e n t ly a re still op erativ e in the presen t.
T h . Y o u r h e a d a c h e s a r e a g r e a t p r o b l e m ob vio usly
since t h e y block you in y o u r w o r k . O u r a i m is
to h e l p r e d u c e o r e l i m i n a t e t h e m . F r o m w h a t
you tell m e, th ey s t a r t e d w a y b ack p r o b a b l y in
Convey the Need for the Patient's

Active Participation in the
Therapeutic Process
M a n y p atie n ts , accu sto m e d to d e a lin g w ith
medical doctors, expect th e th e r a p is t to p r e
scribe a f o r m u la o r give advice th a t will o p e r
ate a u to m a tic a lly to p a llia te th e p ro b le m . An
w i t h c e r t a i n e m o tio n s. F o r e x a m p l e , u pse t feel
e x p la n a tio n of w h a t will be expected of th e p a

tient is in ord er.
in g s
y o u r ch ild h o o d . T h e y a r e a p p a r e n t l y co n n ected
for
T h . T h e r e is no m a g i c a b o u t g e t t i n g well. T h e w ay
h e a d a c h e s, bu t t h e r e m a y be o t h e r t h i n g s too,
w e can best a c c o m p l i s h o u r g o als is to w o r k
like r e s e n t m e n t s . W h a t w e will do is e x p l o r e
t o g e t h e r as a p a r t n e r s h i p t e a m . I w a n t y o u to
and
ten sio n s
are
often
basis
w h a t goes o n in y o u r e m o t i o n s to see w h a t
tell m e all t h e i m p o r t a n t t h i n g s t h a t a r e g o ing
co n nections
O ften
o n w i t h y o u a n d I will t r y to h e l p y o u u n d e r
r e s e n t m e n t s o n e h a s in the p r e s e n t a r e th e
s t a n d t h e m . W h a t w e w a n t to do is to develo p
resu lt of s i t u a t i o n s s i m i l a r to t r o u b l e s a p er so n
n e w , h e a l t h i e r p a t t e r n s . M y j o b is to see w h a t
h ad in c h ild ho o d.
is b lo ck in g yo u f ro m a c h i e v i n g t h is objective by
we can
com e
up
w ith.
42

p o i n t i n g o u t so m e t h i n g s t h a t h a v e a n d a r e still
blo ck in g y ou.
Pt.
Y o u r j o b is to act to p u t into
p r a c t i c e n e w p a t t e r n s w e decid e a r e n ecessary,
A n y t h i n g y o u sa y, do cto r. If m o r e a r e neces
sary, O K .
T h . It is r e a lly best to k eep t h e n u m b e r o f se ss io ns
y ou telling m e a b o u t y o u r e x p e r i e n c e s a n d feel
as lo w as po ssib le to av oid g e t t i n g d e p e n d e n t
ings. P s y c h o t h e r a p y is like l e a r n i n g a n e w l a n
o n t h e m . S o w e ll p l a y it by e a r .
g u a g e . T h e l e a r n e r is t h e o n e w h o m u s t p r a c
Pt.
T h a t s fine.
tice t h e la n g u a g e . If t h e t e a c h e r did all the

ta l k i n g , t h e s t u d e n t w o u l d ne v e r be a b le to
c a r r y o n a co n v e r sa tio n . So r e m e m b e r you a r e
T h e a p p o i n t m e n t tim es m a y th en be set a n d
th e fee discussed.
g o in g to h a v e to c a r r y t h e ball, w i t h m y h e l p of
course.
Utilize Whatever Techniques are

Best Suited to Help the Patient
with Immediate Problems
Make a Verbal Contract With The

Patient
T h e r e sho uld be a n a g re e m e n t re g a r d in g the
frequ ency of a p p o in t m e n t s , th e
sessions, a n d th e te r m i n a ti o n date.
E x a m p le 7.
num ber
of
W h ere L im ita tio n o f the
N u m b e r o f Sessions is D e e m e d N ecessa ry in
A dvance
F o llo w in g th e in itial in terv iew , te c h n iq u e s

th a t a re ac cep tab le to th e p a tie n t, an d t h a t a re
w ith i n the tr a i n i n g r a n g e a n d c o m petence of
th e th e r a p is t, a r e im p le m e n te d , b e a ri n g in
m in d th e need for activity a n d flexibility. T h e
te c h n iq u e s m a y in clude s u p p o rtiv e , e d u c a
tio na l, a n d p s y c h o an aly tically orien ted in t e r
ventions a n d a host of a d ju n ctiv e devices, such
T h. W e a r e g o i n g to h ave a to tal of 12 sessions. In

t h a t t im e w e s h o u ld h av e m a d e a n i m p a c t on
y o u r a n x i e t y a n d d e p r e ss io n . N o w , l e t s c o n
sult t h e c a l e n d a r . W e will t e r m i n a t e t h e r a p y
o n O c t o b e r 9, a n d I ll m a r k it d o w n here. C a n
you also m a k e a n o te of it?
P t.
W i l l 12 sess ions be e n o u g h ?
Th . Yes. T h e least it co uld do is to get you on the

r o a d to re a l l y w o r k i n g o ut th e p r o b l e m .
P t.
W h a t h a p p e n s if I m n o t b e t t e r ?
Th . Y o u a r e a n in tellig en t p e r s o n a n d t h e r e is n o
r e a s o n w h y y ou s h o u l d n t be b e t t e r in t h a t
tim e.
as p sy ch o tro p ic d ru g s , h y pn osis, biofeedback,

b ehav io ral a n d g ro u p a p p ro a c h e s , a n d so on ,
in w h a te v e r c o m b in a tio n s a r e n ecessary to
s a tisf y th e p a t i e n t s i m m e d i a t e a n d f u t u r e
needs. A n e x p la n a tio n m a y be given th e p a
tien t a b o u t w h a t will be done.
T h . A t t h e s t a r t , I believ e it w o u l d be h elp fu l to
r e d u c e y o u r te n s io n . T h i s s h o u l d be beneficial
to y o u in m a n y w ays. O n e of t h e bes t w a y s of
d o i n g this is by t e a c h i n g y o u s o m e r e l a x i n g e x
ercises. W h a t I w o u l d like to do for you is to
m a k e a r e l a x i n g cas ette t a p e . D o you h av e a
casette t a p e r e c o r d e r ?
S ho uld the th e r a p is t dally a n d c o m p ro m ise

his confidence in th e p a t i e n t s cap acity to get
well, the p a tie n t m ay in ad v an ce cancel the
Pt. N o , I h a v e n t.
T h . Y o u c a n b u y o ne q u i t e i n ex p en s iv ely . H o w do
te r m in a tio n in his o w n m in d in favor of an

in d e te rm in a te fu tu re one.
Pt. It s o u n d s g reat.
T h . O K . O f co u r se, t h e r e a r e o t h e r t h i n g s w e will
you feel a b o u t this?
do, b u t t h is s h o u l d h e l p us get off to a good
E x a m p le 2. W hen th e T erm in a tio n D a te is

L eft O pen
T h. It is h a r d to e s t im a t e h o w m a n y se ss io ns w e
will r e q u i r e . I like to k eep t h e m below 20. So
let us b eg in on t h e bas is of t w ice a week.
st a rt .
M a n y t h e r a p is t s p ra cticin g d y n a m ic s h o r t
t e r m t h e r a p y ask th e ir p a tie n ts to reveal an y
d r e a m s th a t o ccu r d u r i n g th e r a p y . S o m e p a
tien ts insist th a t they ra r e ly o r never d r e a m or

if th ey do, th a t they do no t re m e m b e r th e ir
Pt.
43
(p a u se ) Y o u k n o w , d o c to r , I m a f r a id o f losing
c o n t r o l , of w h a t m i g h t c o m e out.
d ream s.
I gu ess I
d o n t t r u s t a n y b o d y .
T h. It is i m p o r t a n t to m e n t i o n a n y d r e a m s t h a t
T h . A f r a i d of w h a t w o u l d h a p p e n h e r e , of w h a t I
m i g h t do if you s h u t y o u r ey es? (sm ilin g )
c o m e to you.
Pt. I c a n t get ho ld of t h e m . T h e y slip a w a y .

T h. O n e t h i n g y o u c a n d o is, w h e n you r e tire , tell
Pt.
(la u g h in g )
I g u e s s so. Silly. B u t t h e t h o u g h t
c a m e to m e a b o u t s o m e t h i n g se x u al.
y o u r se lf y ou will r e m e m b e r y o u r d r e a m s .
Pt. W h a t if I c a n t r e m e m b e r .
T h . K e e p a p a d of p a p e r a n d a pencil n e a r t h e
h e a d of y o u r bed. W h e n you a w a k e n as k y o u r
self if yo u
dream t.
Then
w rite the d ream
d o w n . Also , if y o u w a k e u p d u r i n g t h e n ig h t.
Study the Patient's Reaction and

Defense Patterns
While the Focus at all Times is on

the Present, be Sensitive to How
Present Patterns Have Roots in the
Past
E x a m i n in g h o w th e p a ti e n t w a s re a r e d an d
th e re la tio n s h ip w ith p a r e n t s a n d siblings is
p a r t ic u l a r ly
to
estab lish
revealing.
p attern s
An
a tt e m p t
th at
have
is m a d e
operated
T h e utilization of a n y te c h n iq u e or strat e g e m w ill set in t o m o t i o n r e a c t i o n s a n d
th r o u g h o u t th e p a t i e n t s life o f w h ich the c u r
defenses th a t a r e grist for th e t h e r a p e u ti c mill.

T h e p a tie n t will disp lay a r a n g e of p a tt e r n s
t h a t you can study. T h i s will p e rm it a d r a
tion. T h i s d a ta is for th e t h e r a p i s t s o w n co n
s u m p tio n a n d shou ld no t be too ex hau stiv e,
since th e p a ti e n t if en c o u ra g e d to e x p lo re th e
m atic d e m o n s tra tio n of th e p a t i e n t s defenses

an d resistances in actu al o p e ra tio n r a t h e r t h a n
p a st m a y go on endlessly, a n d th e r e is no tim e
for this. At a p ro p itio u s m o m e n t, w h e n th e p a
as theories. T h e p a t i e n t s d r e a m s a n d fantasies
will often reveal m o re th a n his actions o r v e r
tient a p p e a r s to h ave som e a w a re n e s s of co n
b alizatio ns, an d he sho uld c o n tin u a lly be e n

couraged to ta lk a b o u t these. T h e skill of the
th e r a p is t in w o rk in g w ith a n d in t e r p r e tin g th e
p a t i e n t s s i n g u l a r p a t t e r n s w ill d e t e r m i n e
w h e t h e r th e s e w ill be i n t e g r a t e d o r w ill
g e n e ra te f u r th e r resistance. G e n e ra lly , a c o m
passio nate, tentative ty pe of in te r p r e ta ti o n is
best, s p r in k lin g it if possible w ith a casual
light h u m o r o u s attitud e. A p a ti e n t w h o w a n te d
nections of his past w ith his p re s e n t, a p r o p e r

in te r p r e ta ti o n m a y be m ade. A t th a t tim e a r e
la tio n s h ip m a y be cited b etw een genetic d e
te r m i n a n ts , th e ex istin g p e rs o n a lity p a tte rn s,
a n d th e s y m p to m s a n d c o m p la in ts for w hich
t h e r a p y w a s o rig in a lly sought.
Watch for Transference Reactions
a f ra id I c o u l d n t d o it. W h a t y o u d t h i n k of
T h e im m e d ia te re a c h in g for h e lp en co u rag es
proje ctio n o n to th e th e r a p is t of positive feelings
a n d attitu d e s re late d to a n idealized a u th o r it y
figure. T h e s e sh o u ld no t be in t e rp re te d o r in
an y w a y dis co u rag ed since th e y act in th e in
terest of a llev iatin g tension a n d s u p p o r tin g the
placeb o elem en t. O n th e o th e r h a n d , a n eg a tive
tra n sferen ce re a c tio n sh o u ld be d e a lt w ith
r a p i d ly a n d sy m p a th e tic a lly since it will in t e r
me. T h a t I d fail. I g u ess I m a f ra id of docto rs.
fere w ith th e th e r a p e u ti c alliance.
hy pn osis to con tro l s m o k in g a p p e a r e d restless

d u r i n g induction:
T h . I n oticed t h a t w h e n I a s k e d y o u to lean b ack in

t h e c h a i r a n d t r y r e l a x i n g to m y su gg e stio n s,
y ou w e r e q u i t e u n e a s y a n d k e p t o n o p e n i n g
y o u r eyes. W h a t w e r e yo u t h i n k i n g a b o u t ?
Pt.
r e n t stress s itu a tio n is a n im m e d ia te m a n ife s ta
(e m o tio n a lly ) M y h e a r t s t a r t e d b e a t i n g . I w a s
M y h u s b a n d is t r y i n g to get m e to see a g y n e
cologist.
T h. B u t you kep t o p e n i n g y o u r eyes.
T h . [n o tin g th e p a tie n t's h e s ita n t s p e e c h ] Y o u seem

to b e u p se t a b o u t s o m e th i n g .
44
Pt. W h y , s h o u ld I be u p s e t ?
T h . Y o u m i g h t be if I did s o m e t h i n g y o u d i d n t
Pt.
H e is alw a y s
relieved as th e session h o u r comes to an end.
(p a u se) N o I m a f r a id , j u s t a f r a i d I m no t d o
H e recognizes th a t his reac tion s a r e co un te r th e r a p e u tic , a n d he ask s him self if th ey a re
I still h a v e t h a t p a n i c k y feeling f ro m t i m e to
tim e . D o o t h e r p a t i e n t s d o b e t t e r ?
T h . Y o u se em to be c o m p a r i n g y o u r s e l f to m y o t h e r
patients.
I I I gu ess so. T h e y o u n g m a n t h a t c a m e
before
m e.
He
se em s
so self-confid ent
and
really ju stified . T h e im age of his o w n m o t h e r

th en comes to his m in d , an d he realizes th a t he
h a d m a n y of th e sa m e feelings of e x a s p e r a tio n ,
d is p lea su re, a n d disgust w ith his o w n p a re n t.
R eco g n izin g t h a t he m a y be tr a n s f e r r in g in
ch eerful. I g uess I felt in f e rio r , t h a t you w o u l d
part
find fau lt w i t h me.
w h ose physical a p p e a r a n c e an d m a n n e r r e
T h . D o you t h i n k I like h i m b e t t e r t h a n I do y o u ?
Pt. W e l l , w o u l d n t y o u , if h e w a s d o i n g be tte r
than I was?
T h . T h a t s in t e r e s t i n g . T e l l m e m ore.
P t.
feeling a n n o y e d a n d e n rag ed .
like.
in g w h a t I s h o u l d . I ve been h e r e six ti m e s a n d
Pt.
p erio dically he finds him self scolding h e r and
I ve been t h a t w a y . M y p a r e n t s , I felt, p r e
som e of th ese a ttitu d e s to his p a tie n t
m in d h im of his m o th e r, he is b etter ab le to
m a i n ta i n objectivity. S h o u ld self an aly sis, h o w
ever, fail to h a lt his a n im o sity , he m a y decide
to send th e p a ti e n t to a n o th e r th e r a p is t.
ferred m y o ld e r b r o t h e r . H e a l w a y s c a m e
in o n top. T h e y w e r e p r o u d o f his a c c o m p l i s h
m e n t s in school.
T h . So in a w a y y o u feel I s h o u l d be a c t i n g like
Constantly Look for Resistances

That Threaten to Block Progress
your parents.
Pt. I c a n t h e l p feeling t h a t w ay.

T h . D o n t y ou t h i n k t h is is a p a t t e r n t h a t is really
se lf-defeatin g ? W e o u g h t to e x p l o r e t h is m o re.
Pt.
(e m o tio n a lly ) W e l l ,
I re a lly t h o u g h t t o d a y you
w e r e g o i n g to se n d m e to a n o t h e r d o c to r b e
ca u s e you w e r e sick of me.
T h . A c tu a lly , t h e t h o u g h t ne v e r o c c u r r e d to m e to
O b s tr u c tio n s to successful th e r a p e u ti c ses

sions a r e n u r t u r e d
by m isco nceptio ns a b o u t
th e r a p y , lack of m o tiv atio n , needs to m a i n ta i n

c e rta in benefits th a t ac crue fro m o n e s illness,
a n d a host of o th e r sources, conscious a n d
unconscious. W h e r e resistances a re too s t u b
o u t b e c a u s e w e w ill be a b le to e x p l o r e so m e of
b o rn to b u d g e re ad ily o r w h e re they o p e ra t e
w ith little a w a r e n e s s th a t th ey exist, th e few
y o u r i n n e r m o s t fears a b o u t h o w p e o p l e feel
sessions assigned to s h o r t- t e r m th e r a p y m a y
a b o u t you.
not suffice to resolve th em . O n e w a y of de alin g
do t h a t . B u t I m g lad y ou b r o u g h t t h i s m a t t e r
w ith resistances once th ey a r e recognized is to
Examine Possible
Countertransference Feelings
If you notice p ersisten t irritability, b o red o m ,
an g e r, e x tr a o r d i n a r y in terest in o r a ttra c tio n to
an y p a tie n t, ask yourself w h e th e r such feelings
an d attitu d e s do n ot call for self-exam in atio n.
T h e i r c o n tin u a n c e will a lm o st ce rtain ly lead to
interference w ith a good w o rk in g rela tio n sh ip .
F o r e x am p le, a th e r a p is t is tr e a tin g an u n s t a
b le m i d d l e - a g e d fe m a le p a t i e n t w h o m he
r e g a r d s as a p lu m p is h , slo p p y biddy w h o sticks
h e r nose into o th e r p e o p le s affairs. H e tries to
m a i n ta i n a n im p a rt ia l th e r a p e u tic stance, bu t
b ri n g th e m ou t o p en ly in a n o n c o n d e m n in g
m a n n e r . T h i s can be d o n e by s ta tin g t h a t the
p a ti e n t m a y if he desires hold on to th e m as
defenses, bu t if this is so, he m u s t suffer the
consequences. A f r a n k discussion of w h y th e
resistances h av e value for th e p a tie n t a n d th e ir
effects on his tr e a t m e n t is in o rd er. A n o th e r
te c h n iq u e is to a n tic ip a te resistances fro m th e
p a t i e n t s p a st m o des of a d a p t a t i o n , d re a m s ,
a n d the like, p re s e n tin g th e p a ti e n t w ith th e
possibility of th e ir a p p e a r a n c e an d w h a t could
be d o n e a b o u t th e m sho uld they a p p e a r . T h e
t h e r a p i s t s h o u l d w a t c h fo r m i n i m u m a p
p e a ra n c e s of resistance, h o w e v e r m i n o r th ey
m a y be, t h a t w ill se r v e a s p s y c h o l o g ic a l
45

ob structio ns. M e r e ly b rin g in g these to th e a t
Even a bit of insig h t m a y be a saving g race. As
ten tio n of th e p a tie n t m a y r a p i d ly d issip ate
soon as feasible, m oreov er, ask th e p a ti e n t to
them .
review his idea of th e e volution of his p ro b le m
P t.
I d i d n t w a n t to co m e h ere. L a s t t i m e I h a d a
c ir cu m stan ces th a t reinforce th e p ro b le m or
t e r r i b l y se vere h e a d a c h e .
alleviate his sy m p to m s. P ra ctice schedules m a y
a n d w h a t he c a n do to co n tro l o r re g u la te the
I felt d i z z y in the
h e a d , (p a u se)
Th . I w o n d e r w h y . D i d a n y t h i n g h a p p e n h e r e t h a t
u p se t you; did I do a n y t h i n g to u p se t y o u ?
P t.
N o , i t s f u n n y b u t it s s o m e t h i n g I c a n t u n d e r
sta n d . I w a n t to co m e h e r e , a n d I d o n t. I t s
like I m afra id .
(P a u se; p a tie n t flu s h e s .) I c a n t u n d e r s t a n d it.
some cues r e g a r d in g h o w he m a y w o r k on
P e o p le a r e a l w a y s t r y i n g to c h a n g e me. As far
h im self to reverse som e basic destructive p e r

sonality p a t t e r n s t h r o u g h such m e a s u re s as
b ack as I c a n r e m e m b e r , at h o m e , at school.
T h . A n d you resen t t h e i r t r y i n g to c h a n g e yo u.
P t.
a c q u ir in g m o r e u n d e r s ta n d in g a n d insig ht, r e
w a r d i n g h im se lf for positive actions, self-hy p
Yes. I feel t h e y c a n t leave m e alone.
T h . P e r h a p s you feel I m t r y i n g to c h a n g e you.

P t.
(a n g rily ) A r e n t y o u ?
T h . O n l y if y o u w a n t to c h a n g e . In w h a t w a y do
y ou w a n t to c h a n g e , if a t all?
P t.
want
to
get
rid
of
my
headaches,
and
st o m a c h a c h e s , a n d all t h e rest of m y aches.
Th . P .t y ou d o n t w a n t to c h a n g e to do this.
Pt.
T h . A r e yo u s u r e the w a y y o u w a n t to c h a n g e will
F o r e x a m p le , th e follow ing suggestion w as

m a d e to a p a ti e n t w h o ca m e to t h e r a p y for
h e lp to a b a te m i g ra i n e attacks:
T h . W h a t m a y h e l p you is u n d e r s t a n d i n g w h a t
t r ig g e r s off y o u r h e a d a c h e s a n d m a k e s t h e m
h e l p you get rid o f y o u r s y m p t o m s ?
w o r s e . S u p p o s i n g you k e e p a d i a r y a n d j o t
B u t t h a t s w h y I m c o m i n g h e r e so y o u w ill tell
d o w n t h e f r e q u e n c y o f y o u r h e a d a c h e s . E v ery -
me.
ti m e y o u get a h e a d a c h e w r i t e d o w n t h e
T h . Bu t y ou r e s e n t m y m a k i n g su g g e stio n s to y ou
P t.
nosis, a n d so on. T h e s e tactics m a y be p u rs u e d

bo th d u r i n g t h e r a p y an d fo llow ing t h e r a p y by
oneself.
W e l l , d o c to r , th is i s n t tr u e . I w a n t to c h a n g e
th e w a y I w a n t to.
P t.
m a y be e n jo in e d to keep a log re g a r d in g in
cidents th a t e x a g g e ra te his difficulties an d
w h a t th e p a ti e n t h a s d o n e to avoid o r resolve
such incidents. T h e p a tie n t m a y also be given
T h. A f ra i d ?
P t.
be a g reed on t o w a r d o p p o sin g the situ a tio n s o r

tendencies th a t r e q u i r e co n trol. T h e p a tie n t
day
and
tim e .
Even m ore
im portant,
write
b ecau s e s o m e h o w y o u p u t m e in t h e clas s of
d o w n t h e ev en ts t h a t i m m e d i a t e l y p r e c e d e d th e
e v e r y b o d y else w h o y o u believ e w a n t s to t a k e
onset
y o u r i n d e p e n d e n c e a w a y . A n d t h e n you s h o w
th o u g h ts
r e sis ta n c e to w h a t I a m t r y i n g to do.
h e a d a c h e is s t o p p e d by a n y t h i n g t h a t h a s h a p
(la u g h s) I s n t t h a t silly, I re a l l y d o t r u s t you.
pened, or
T h . T h e n s u p p o s i n g w h e n yo u b e g in to feel you
of
the
headache
you h ad th a t
or
the
brought
feelings
it o n.
by a n y t h i n g y o u t h i n k
or
If a
about or
fig u re o u t , w r i t e t h a t d o w n , a n d b r i n g y o u r
a r e being d o m i n a t e d y o u tell m e, so w e can
diary w hen
ta l k it o u t . I r e a lly w a n t to h e l p y o u a n d n o t
about w hat has happened.
y ou c o m e h e r e so w e c a n ta l k
d o m i n a t e you.
P t.
T h a n k yo u , d o c to r , I d o feel b e tte r .
Give the Patient Homework
Keep Accenting the Termination

Date if O ne was Given the Patient
Involve the p a tie n t w ith a n a ss ig n m e n t to
In p r e p a r i n g th e p a tie n t for te r m i n a ti o n of
w o rk on h o w his sy m p to m s a re re lated to h a p
pen ing s in his e n v ir o n m e n t, to attitu d e s, to
fallacies in th in k in g , to d is tu rb e d in te rp e r s o n a l
relation sh ips, or to conflicts w ith in him self.
t h e r a p y , th e c a le n d a r m a y be referred to p rio r
to th e last th r e e sessions a n d th e p a tie n t
re m in d e d of th e d ate. In som e p a tie n ts th is will
activate s e p a r a ti o n a n x ie ty a n d n egativ e tr a n s-
46
ference. Such responses will necessitate active
t h e e n d of t h e five sessions, y o u s h o u l d be a b l e
in te rp re ta tio n of the p a t i e n t s p ast d ep en d en cy

a n d fears of a u to n o m y . E vidences of p ast re a c
to c a r r y on.
tions to se p a r a tio n m a y h elp th e p a tie n t ac

q u ir e an u n d e r s ta n d in g of the u n d e r p i n n in g s
of presen t reactions. T h e th e r a p is t sh o u ld e x
pect a recrudescence of th e p a t i e n t s sy m p to m s
as a defense ag a in s t being on his o w n a n d as
an
ap p e a l
for c o n tin u in g
tr e a tm e n t.
These
m an ifestatio ns a re dealt w ith by f u r th e r in t e r

p re ta tio n . D o n o t p ro m ise to co n tin u e t h e r a p y
P t.
B u t s u p p o s i n g I d o n t m a k e it?
T h . T h e r e yo u go, see, a n t i c i p a t i n g failu re. T h i s is

a g e s t u r e to h old on.
P t.
W e l l , d o c to r , I k n o w y ou a r e r i g h t. I ll keep
w o r k i n g o n it.
Terminate Therapy on the Agreedupon Date
even if the p a ti e n t predicts failure.

W h il e som e th e r a p is ts do not co n sid er it
P t.
I k n o w w e re s u p p o s e d to h a v e o n ly o n e m o r e
se ss ion.
But
get
scared
not
having
you
wise to invite th e p a ti e n t w h o h a s p ro g ressed

satisfactorily to r e t u r n , o th e r s find it a helpful
T h . O n e o f o u r a i m s is to m a k e y o u s t r o n g e r so
a n d r e a s s u ri n g aid for m ost p a tie n ts to do so at

the final session. I g e n e ra lly tell th e p a ti e n t to
around.
you w o n t n eed a c r u t c h . Y o u k n o w e n o u g h
w rit e to m e so m e tim e to let m e k n o w th in g s
a b o u t y o u r se lf n o w to t a k e s o m e ste p s o n y o u r
a r e co m in g alo ng . In th e event p ro b le m s d e
o w n . T h i s is p a r t of g e t t i n g well. So I w a n t
velop th a t on e c a n n o t m a n a g e by oneself, th e
you to give y o u r se lf a chance .
p a ti e n t sho uld call for a n a p p o in t m e n t . R a re ly
M a n y p a tie n ts will resent te r m i n a ti o n of
is th is in vitatio n ab u se d a n d if th e p a tie n t does

r e t u r n (w h ich is n ot too c o m m o n in m y e x p e r i
t h e r a p y after th e d e sign ated n u m b e r of sessions

have ended. At the m idd le p o in t o f t h e r a p y ,
ence) th e difficulty can be r a p i d ly h a n d le d ,

e v e n tu a tin g in re in fo rc e m e n t of o n e s u n d e r
th erefo re, the th e r a p is t m a y b rin g u p this

possibility. T h e th e r a p is t sho uld search for in
stan din g.
cidents in the past w h e re se p a r a tio n s have
T h . T h i s is, as y o u k n o w , o u r last se ss ion. I w a n t
created u n t o w a r d reactio ns in th e p a tie n t. I n
y ou n o w to t r y t h i n g s o u t on y o u r o w n . K e e p
div id u als
who
w ere
se p arated
fr o m
th eir
practicing the things 1 ta u g h t you the re la x a
an
early
age,
had
school
tio n exercise s \w h e r e th e se h a v e b een u se d ],
p h o b ias p ro d u c e d by in ability to b re a k ties

w ith the m o th e r, a n d w h o a re excessively d e
p e n d e n t a r e p a rtic u la rly v u ln e ra b le a n d a p t to
re s p o n d to te r m i n a ti o n w ith anx iety, fear,
an g e r, an d d epressio n. T h e te r m in a tio n p ro c
ess h e re m a y con stitu te a p r i m e focus in t h e r
ap y a n d a m e a n s of e n h a n c i n g ind iv id u a tio n .
the figuring out w h a t brings on your sym ptom s
p a re n ts
at
who
a n d t a k e s t h e m a w a y , a n d so f o rt h . Y o u s h o u l d
c o n t i n u e to get be tte r . B u t se tb a c k s m a y o c c u r
f r o m t i m e to tim e. D o n t let t h a t u p se t you.
T h a t s n o r m a l a n d y o u ll get ov er t h e setback.
In fact, it m a y h e l p y o u f i g u re o u t b e t t e r w h a t
y o u r s y m p t o m s a r e all a b o u t . N o w , if in t h e
f u t u r e you fin d y o u n eed a little m o r e h elp ,
d o n t h e s i ta te to call m e a n d I ll try to a r r a n g e
T h . W e h a v e five m o r e sessions, as you k n o w , a n d
an appointm ent.
t h e n w e w ill t e r m in a te .
P t.
I r e a l i z e it, b u t I a l w a y s h ave t r o u b l e b r e a k i n g
a w a y . M y wife ca lls m e a h o l d e r - o n e r .
T h . Yes, t h a t s exactly w h a t w e w a n t to avoid, the

d e p e n d e n c y . You a r e likely to r e s e n t e n d i n g
t r e a t m e n t for t h a t r e a s o n . W h a t d o yo u t h i n k ?
P t.
(la u g h in g ) I ll t r y n o t to.
A ctually relatively few p a tie n ts will tak e

a d v a n ta g e o f th is inv itatio n, b u t th ey will feel
r e a s s u re d to go o ut on th e i r o w n k n o w in g th ey
will not be a b a n d o n e d . S h o u ld they r e t u r n for
an a p p o in t m e n t , o nly a few sessions w ill be
T h . W e l l , k e e p t h i n k i n g a b o u t it a n d if y ou h av e
needed to b rin g th e p a tie n t to a n e q u i l ib r iu m
a n y b ad r e a c t i o n s l e t s t a l k a b o u t it. I t s i m p o r
a n d to h e lp le a r n a b o u t w h a t p ro d u c e d th e r e
lapse.
t a n t n o t t o m a k e t r e a t m e n t a w a y o f life. By
47
Stress the Need for Continuing

Work on Oneself
ti ents will re q u i r e lo n g - te rm th e r a p y . In this

reference th e r e
a re som e p a tie n ts w h o will
need h e lp for a p ro lo n g ed p erio d of tim e; som e

re q u i r e
T h e m a tte r of c o n tin u in g w o r k on oneself
after te r m in a tio n is very m u c h u n d e re s tim a te d .
P a tie n ts will usu ally re t u r n to a n e n v ir o n m e n t
th a t co ntinu es to sp o n so r m a l a d a p ti v e re a c
tions. T h e p a tie n t will need some c o n sta n t
re m in d e r th a t old neu ro tic p a tt e r n s la ten tly
a w a it revival a n d th a t he m u st alert h im se lf to
signals of th eir a w a k e n in g . In m y p ra c tic e I
hav e found th a t m a k in g a re la x in g t a p e (a
tec h n iq u e detailed in C h a p t e r 15) s p rin k led
w ith positive suggestions of a n e g o-buildin g
only
an
occasional
c on tac t
th e r e
m a i n d e r of th e i r lives. T h e co ntac t does not

h a v e to be intensive or fr e q u e n t. P erson s w ith
an
e x tr e m e
d ep en d e n c y
character
d is o rd er,
b o rd e rlin e cases, a n d s ch izo p h ren ics often do

well w ith sh o rt visits (15 to 2 0 m in u tes ) every
2 w eeks o r lo ng er. T h e idea th a t a su p p o rtiv e
p e rs o n is av aila ble m a y be all th a t the p a tie n t
d e m a n d s to k eep h im in hom eo stasis. I n t r o d u c
ing th e p a tie n t into a g r o u p m a y also be h e lp
ful, m u ltip le tran sferen ce s d ilu tin g th e hostile
n a tu r e serves the in terest of c o n tin u e d g ro w th .
tran sferen ce th a t so often occurs in individual

th e r a p y . A social g r o u p m a y even suffice to
In th e event the p a tie n t h a s d one well w ith

h o m e w o rk d u r i n g the active th e r a p y period ,
prov ide th e p a ti e n t w ith
th e sa m e processes m a y c on tinu e. In s titu tio n of

a p r o p e r ph ilo so ph ica l outlo ok m a y also be in
referral to a n o t h e r th e r a p is t w h o specializes in
a different te c h n iq u e , for e x a m p le , to som eone
o rd e r p ri o r to disch arge. Such a ttitu d e s m a y be

e n c o u rag ed as the need to isolate the past from
w h o does biofeedback, o r b e h av io ral t h e r a p y ,
th e
p rese nt,
th e
re a liz a tio n
th a t
som e m e a n s of a
h u m a n re la tio n sh ip . Som e p a tie n ts will need
or a n o th e r m o dality.
certain
a m o u n t of tension a n d a n x ie ty a re n o r m a l, the
need to ad ju st to h a n d ic a p s an d realistic ir r e
T h . N o w , w e h a v e c o m p le te d th e n u m b e r of
se ssio n s w e a g re e d o n . H o w do yo u feel a b o u t
m ediab le conditions, th e urg en c y to w o r k at
m a tte r s n o w ?
correcting rem e d ia b le e le m e n ts in o n e s en vi
ro n m e n t, th e recognition of th e forces th a t tr ig
P t.
ger off o n e s p ro b le m s a n d the im p o rta n c e of
T h . T h a t s h o u ld get b e tte r a s tim e goes o n . 1
B e tte r, d o c to r, b u t n o t w ell. I still h a v e m y in

s o m n ia a n d feel d isc o u ra g e d a n d d e p re ss e d .
s h o u ld lik e to h a v e you c o n tin u e w ith m e in a
rectifying these, a n d the w isd o m of sto p p in g
g ro u p .
reg re ttin g the p a st and of avo idin g a n tic ip a tin g

disaster in the fu tu re. It m u s t be recognized
th a t w hile the im m e d ia te a c c o m p lis h m e n ts of
s h o r t-te rm t h e r a p y m a y be m odest, the co n
tin u ed a p p lic a tio n of the m e th o d s th e p a tie n t
ha s learned d u r i n g his t h e r a p y will help b rin g
a b o u t m ore s u b s ta n tia l changes.
P t.
Y ou m e a n w ith o th e r p e o p le I ve h e a rd o f it.
It sc a re s m e, b ut I d lik e to do it.
W here
th e
p atie n t
is to
be
referre d
to
a n o t h e r th e r a p is t, he m a y be told:
T h . Y ou h a v e g o tte n a c e rta in a m o u n t o f h e lp in
c o m in g h e re , b u t th e k in d of p ro b le m s you
h a v e w ill be h e lp e d m o re by a sp e c ia list w h o
Arrange for Further Treatment if

Necessary
d e a ls w ith su ch p ro b le m s. I h a v e so m e o n e in
m in d fo r yo u w h o I b eliev e w ill be a b le to h elp
you.
If yo u a g re e , I sh a ll te le p h o n e h im to
m a k e su re he h a s tim e for you.
T h e qu estio n m a y be asked r e g a r d in g w h a t
to do w ith the p atie n t w h o at te r m i n a ti o n
show s little o r no im p ro v e m e n t. C e r t a i n p a
P t.
I d lik e th a t. W h o is th e d o c to r?
T h . D r _________ If he h a s n t tim e. I ll get som eone

else.
48
Conclusion
T w e n t y o p e ra tio n s a re re c o m m e n d e d for an
a lo n g d y n a m ic lines. T h e s e m ay b e c ro w d e d in to a
effective d y n a m ic a lly o rie n te d s h o r t-te rm t h e r
s p a n of a few w eek s, o r th e y m ay be d is tr ib u te d o v er
a p y p ro g r a m . T h e y consist of (1) e stab lish in g a

r a p i d positive w o rk in g re la tio n s h ip ( t h e r a
a n u m b e r of m o n th s. S om e th e r a p is ts p re fe r to see
p e u ti c a l l i a n c e ) , (2) d e a l i n g w i t h i n i ti a l
resistances, (3) g a th e r in g historical d a ta , (4)
tw ic e a w eek th e o p tim a l fre q u e n c y . In so m e cases
selecting
focus for
th e r a p y ,
(5) defining
p recip ita tin g events, (6) evolving a w o rk in g

hy pothesis, (7) m a k in g a te n ta tiv e diagnosis,
th e ir p a tie n ts o n a o n c e -a -w e e k b asis; o th e r s find

4 0 to 50 se ssio n s a r e still c o n s id e re d a c c e p ta b le for
s h o r t- te rm co v erag e. T im e lim its a r e o ften set in
a d v a n c e w ith th e p a tie n t.
2. S e le c tio n o f cases. A li ty p e s o f p ro b le m s of
a c u te a n d c h ro n ic d u r a tio n a r e c o n sid e re d s u ita b le .
(8) conveying the need for th e p a t i e n t s active
E v en p a tie n ts w ith s e rio u s p sy c h o p a th o lo g y a r e c a n
p a rtic ip a tio n
in the t h e r a p e u ti c process, (9)
d id a te s . S o m e th e r a p is ts w h o c o n fin e th e m se lv e s to
m a k in g a verbal con tract, (10) utilizin g a p p r o
d y n a m ic s h o r t- te rm th e r a p y b eliev e selectio n o f a p
p ria te tech n iq u es in a n
m a n n e r , (11 ) s t u d y i n g
p r o p r ia te p a tie n ts is m a n d a to ry .
active an d flexible
th e r e a c t i o n s a n d
defenses of the p a tie n t to the tec h n iq u es being

em p lo yed , (12) re la tin g p re s e n t-d a y p a tt e r n s to
p a tt e r n s th a t have o p e rated t h r o u g h o u t th e p a
t i e n t s life, (13) w a tc h in g for tran sfe re n c e re a c
tions,
ference
(14) e x a m i n in g possible c o u n t e r t r a n s
fe elin g s,
(1 5 )
a le rtin g
oneself
to
3. G o a ls. R e c o n stru c tiv e c h a n g e s a r e d ee m e d n ot

o n ly d e s ira b le b u t also o b ta in a b le in s u ita b le p a
tie n ts ,
e sp e c ia lly
w ith
th e
u se
of d y n a m ic
ap
p ro a c h e s , p ro v id e d th e r e e x is ts p r o p e r m o tiv a tio n
a n d c o n c u rre n c e o f re c o n s tru c tiv e objectiv es on th e
p a r ts of p a tie n t a n d th e r a p is t.
4. D e g r e e o f th e r a p is t a c tiv ity . A re la tiv e ly h ig h
d e g re e of a c tiv ity is g e n e ra lly p re fe rre d .
resistances, (16) assig nin g h o m e w o rk , (17) a c
5. F o c u s o f th e r a p y . A r e s tric tio n of focus to a
centing the te r m i n a ti o n d ate, (18) te r m i n a ti n g
z o n e a g re e d on by p a tie n t a n d th e r a p is t is im p o r
th e r a p y , (19) assign ing c o n tin u in g self-help

activities, a n d (20) a r r a n g i n g for f u r th e r t r e a t
ta n t, if n o t e s s e n tia l. If a n u c le a r co n flict is id e n tifia

ble a n d th e p a tie n t does n o t d efen siv ely av o id it too
m u c h , its c o n s id e ra tio n a s a focus is d e s ira b le in d y
m e n t if necessary.
T h e s e o p e ra tio n s m a y be utilized in toto o r
n a m ic a lly o rie n te d a p p ro a c h e s . C o n s id e re d sig n ifi
in p a r t by th e r a p is ts w h o can a d a p t th e m to
th eir styles of w o rk in g . Irrespective of th e
c a n t a r e tr a n s fe re n c e p h e n o m e n a , w h ic h in som e
oretical
p e rs u a sio n ,
th e r e
are a n u m b e r of
a re a s of g en eral a g re e m e n t a m o n g different
professionals p racticin g s h o r t-t e rm th e r a p y :
sy ste m s m ay o c c u p y a p o sitio n o f c e n tra l im p o r

ta n c e .
6. T e c h n iq u e s . T h e full r a n g e o f eclectic s u p p o r
tiv e, e d u c a tio n a l, a n d re c o n s tru c tiv e te c h n iq u e s a re
u se d in c lu d in g , in d y n a m ic a p p r o a c h e s , tr a d itio n a l
a n a ly tic te c h n iq u e s of tra n s fe re n c e a n a ly s is, in te r

T im e . T h e m ost f re q u e n tly d e s ig n a te d n u m b e r p r e ta tio n of re s is ta n c e , d r e a m a n d fa n ta sy e x p lo r a
of se ssio n s ra n g e fro m 3 to 6 for crisis in te rv e n tio n ,
tio n , a n d th e re la tin g o f tr a n s fe re n c e to g e n e tic d e
1.
fro m 6 to 12 fo r su p p o rtiv e -e d u c a tio n a l a p p ro a c h e s ,

a n d fro m 12 to 2 0 for m o re e x te n siv e p sy c h o th e ra p y
te r m in a n ts .
CHAPTER 5
The Initial Interview

A. Common Questions
T h e initial interv iew is p e r h a p s th e most
his u n d e rly in g p ro b le m an d a n assay of w h a t
vital of all sessions since in its conduct rests the
h e can do to h e lp him self. N a t u r a l l y , m o st p a
fate of the th e r a p e u tic a llian ce a n d , even m ore
tien ts will r e t u r n for m o re sessions unless the
im p o rta n tly , th e e v en tu a lity of w h e th e r or not

the p atie n t will re t u r n for f u r th e r tr e a tm e n t.
th e r a p is t has failed to incite th e i r confidence or

h a s c o m m i t t e d s e r io u s e r r o r s in a p p r o a c h
(d e ta ch m en t, belittling a ttitu d e s, frig h ten in g
H o w m u ch tim e should ideally be sp en t on h is

tory ta k in g ? S h o u ld th e in terview be la rgely
th e p a tie n t w ith d e p th
in t e rp re ta ti o n s , h o s
tility, etc.).
diagnostic or th e r a p e u tic ? W h a t degree of co n

fro n tatio n can safely be e m p lo y ed ? T h e s e an d
H o w t h o r o u g h s h o u l d h i s t o r y t a k i n g b e in
the in itial in te rv iew ?
m a n y o t h e r q u e s t i o n s c h a l l e n g e th e i n t e r
viewer.
In the p re sen t c h a p te r som e of the
po ints m en tio n ed in the last c h a p te r will be e x
D u r i n g th e initial in terv iew exh au stive, r i
p o u n d e d by p re s e n tin g relev an t q u e stio n s (a nd

a n sw e rs) b ro u g h t u p in teac h in g a n d s u p e r
tualistic tak in g of a h isto ry is u nn ecessary. All
visory
fo rm a tio n to allo w for tr e a tm e n t p la n n i n g a n d
sessions
w ith
th e r a p is ts
th a t is re q u ire d is the g a th e r in g of sufficient in
of different
p e r h a p s for th e m a k i n g of a ten tativ e d ia g
theoretical p ersuasio ns.
nosis.
W o u ld you c o n sid e r the

t h e r a p e u t i c o r d ia g n o s tic ?
In la te r sessions on e m a y fill in this
skeletal o u tlin e of history . M o r e in fo rm a tio n

will be revealed as th e p a ti e n t g ain s confidence
in th e th e ra p ist.
first sessio n
W h il e the initial in terv iew is co nd ucted for

the p u rp o s e of assessing the p re s e n tin g p r o b
In a p p r a i s i n g t h e d e g r e e o f t h e p a t i e n t s
m a l a d j u s t m e n t at t h e i n i t i a l i n t e r v i e w ,
are th e re an y c rite ria th at can be a p p lie d ?
lem an d p la n n i n g tr e a tm e n t strategy , it sho uld

be m a n a g e d so th a t it registers a co nstru ctive
im p act on the p a tie n t. It m ust be stressed th a t
T h e r e a r e a n u m b e r of a d ju s tm e n t scales
a sizable n u m b e r of p atie n ts , especially those

t h a t come to o u tp a t ie n t clinics, do n ot r e t u r n
for a second interview . F o llo w - u p stu dies show
t h a t th e initial interview c an have a definite
t h e r a p e u tic effect a n d m ay even s ta rt the p a
th a t a re in use, no n e of w h ic h is perfect. It is
helpful to view the p re s e n t difficulty ag ain st
th e b a c k d ro p of p rev io u s m a l a d a p ta t io n s , p a r
ticu larly th ose d u r i n g ch ildhood. T h e d a ta
h e re is not e n tire ly definitive since th e p a tie n t
could, in spite of a d is o rg a n iz e d e a rly life h is
tient on the ro a d to recovery. T h e th e r a p is t,

therefore, sh ou ld assum e th a t the first in t e r
view will be the only o p p o r t u n it y to w o rk w ith
tory, still m a k e a re a s o n a b le a d u lt a d ju s tm e n t
u n d e r p ro p i ti o u s circu m stan ces. T h e second
item one m a y consider is th e q u a lity of the
the p a tie n t a n d th u s th a t e n o u g h w o rk m u s t be
done so th a t the p a tie n t can leave th e session
p re s e n t p e rs o n a l re la tio n sh ip s , th e a d ju s tm e n t
to o n e s m a r it a l p a r t n e r a n d ch ild ren , th e e x
w ith so m ething positive to g ra p p l e onto. T h e

initial interview shou ld be co nd ucted in such a
w a y as to give the p a tie n t a b etter idea a b o u t
te n t of creativity, an d th e v alues th a t m o ld be
49
50
havior. T h i r d , one m ay e s tim ate th e degree of
em otion s u n d e rlie th e p a t i e n t s m anifest b e
an x iety th a t is manifest or th a t expresses itself
hav ior. V e ry fr e q u e n tly these e m o tio n s ca n n o t

be exp ressed in w o rd s, a n d th e th e r a p is t will
in term s of such sy m p to m s as depressio n and

psychosom atic m anifestations.
A fo u rth possibility is to e x a m in e th e n a tu r e
have to m a k e a s s u m p tio n s th r o u g h o bserva tion

of th e p a t i e n t s behavior. F o r in stance, in th e
of defenses a g a in st anxiety, for instance, th eir

ability to co n tain th e an x ie ty an d the effect
event th a t a d e li n q u e n t boy is referre d for t h e r

ap y, the boy m a y sulk in his c h a ir, fidget, be
th a t th ey have on th e to tal functioning. Fifth,
evasive, a n s w e r in a d is a r m i n g m a n n e r , ex
we p o n d e r the ex ten t of a d a p ta tio n a l collapse.

H e r e even th o u g h th e p a tie n t seems to be m a k
press disinte rest, or show negativism . T h e

th e r a p is t m a y g ain the im pre ssio n from o b se rv
ing a good a d ju s tm e n t, we m u s t ask at w h a t

expense. T h u s , a d etac hed perso n m a y show
ing the attitu d e s of the boy t h a t th e boy resents

b eing at th e interview . H e , therefore, m ig h t
on the surface a fairly good a d ju s tm e n t. C o n
say to th e boy, Y ou p ro b a b l y res en t co m in g

h e r e , o r P ro b a b l y you feel th a t you o u g h t
seq uen tly, it is essential to estim ate h o w tru ly

a d e q u a te this is in te r m s of w h a t is h a p p e n in g
to the indiv idu al as a w hole. H e m a y be e s c a p
ing a n x ie ty a n d w o rk in g a d e q u a te ly on ly by
th e tactic of isolating him self from people. O r a
d ep e n d e n t p erso n m ay be fun ctio nin g solely by
no t to h ave com e h e r e , or I can u n d e r s ta n d

th a t you feel k in d of m a d a b o u t this s i t u a t i o n .
Such a r e m a r k cuts into th e em o tio n of th e boy
a n d m a y en a b le h im to perceive th a t his feel
ings a re u nd ers to o d .
a tta c h in g him self to a p a re n t a l figure. T h e
A n o th e r e x a m p l e is th a t of a w o m a n r e
kind of a d a p ta tio n h elps us to d e te r m in e the

degree of s u p p o r t th a t will be re q u ire d at the
ferred by a social agency on th e basis t h a t th e
sta rt of tr e a tm e n t, the a m o u n t of p a rtic ip a tio n

one m a y expect from th e p a tie n t a n d h o w ac
tive the th e r a p is t should be in the re latio n sh ip .
Is it a d v i s a b l e to s p e n d m o r e ti m e o n t h e
i n i t i a l i n t e r v i e w t h a n o n o t h e r se ssion s?
If possible, yes. So m uc h h a s to be do ne d u r
ing th e first in terv iew th a t th e usual 45 o r 50
m in u tes of tim e allotted for a session m a y be
insufficient. E x te n d i n g th e tim e, how ever, m ay
not be p ractically possible. H ence, tw o sessions
m a y be necessary in som e cases to accom plish
all essential tasks. A n ex pe rien ced in terv iew e r,
h o w ever, m ay re q u ire no m o re th a n one
session.
agency believes she is suffering fro m an e m o

tion al p ro b le m for w h ich she sh o u ld get help.
Even if she is n ot yet p r e p a r e d to receive this
help , she m a y still a p p e a r for t h e r a p y in o r d e r
to a p p e a s e th e ca se w o rk e r o r as a m ean s
t h r o u g h w h ic h she can g ain f u r th e r aid from
th e a g e n c y .
H e r m o tiv atio n , c o n seq u en tly ,
w o u ld be to give as little in f o rm a tio n as possi

ble a b o u t he rself o r to be as evasive as she can
w ith o u t offending. U n d e r th ese circu m stances,
once th e th e r a p is t realizes w h a t is going on, he
m ig h t say the following:
T h . I c a n very w ell see th a t yo u w o u ld feel r e s e n t

ful o r u n c o m fo rta b le a b o u t c o m in g h e re . Y ou
p ro b a b ly do n o t feel th a t it is n e c e ssa ry an d
m ig h t b elieve th a t yo u c o u ld v ery e a sily do
w ith o u t th e r a p y . I do n o t b la m e y o u for feelin g
Is it im p o s s i b l e to w o r k w i t h a n u n m o t i
v a t e d p a t i e n t , a n d if so, c a n y o u g iv e
s o m e e x a m p l e s o f h o w t h is c a n b e d o n e ?
It is not at all im possible pro vided one deals
w ith w h a t is b ehin d th e lack of m otiv atio n. T o
do this the th e r a p is t m ay try to retrie ve u n e x
pressed or u nc onscious em o tio n s th a t a re a c t
ing, o r will act, as resistances to th e r a p y . Such
th is w a y in a s m u c h a s you d id n o t re a lly com e

to th e a g e n c y in o r d e r to seek h e lp fo r a n e m o
tio n a l p ro b le m .
T h i s e x p la n a tio n p ro b a b l y w o u ld re la x the
w o m a n co nsid era bly , since she w o u ld sense in
th e th e r a p is t a s y m p a th e tic perso n . S he m igh t
th e n begin to ex press h e r feelings a b o u t the
THE INITIAL INTERVIEW: COM M O N QUESTIONS
51
agency and at th e end be w illin g to talk a b o u t
v erbalize freely sh o u ld soon estab lish a t h e r a
herself a n d h e r p roblem s.
A co m m o n p ro b le m is pro vid ed by th e p a
tient w h o views p s y c h o th e ra p y in th e sam e
light as c on sulting an internist. T h e p a tie n t
p eu tic a lliance, an d t h r o u g h th is th e p a tie n t
tells the doctor a b o u t d is tu rb in g sy m p to m s,
p atien ts
a n d th e doctor prescribes a rem edy. T h e p a
ag a in s t th e ir free will, such as c o u rt cases,
tient, co nseq uen tly, will b o m b a r d the th e r a p is t

w ith a flood of sy m p to m s a n d co m p la in ts w ith
spouses of c o m p la in in g m ates, p e rs o n s collect

ing disability p a y m e n ts, a n d in d iv id u als d e
the ho pe th a t e v eryth ing will th en be ta k e n
riv in g stro n g seco n d ary g ain s from th e ir

sy m p to m s t h r o u g h avo idin g h a r d w o rk , s u p
care of in som e m ysteriou s w ay. T h e p a tie n t

really has n o m ean s of u n d e r s ta n d in g w h a t is
supposed to go on in th e r a p y o th e r th a n
th r o u g h exp erien ces w ith p reviou s h e a lth v e n
dors. T h e d is a d v a n ta g e w ith such a n a ttitu d e
m a y be helped to com e to g rip s w ith his w o r

ries an d conflicts.
A final e x a m p l e is p ro v id e d by th e host of
who
are
sheparded
in t o
th erap y
p o rt in g d ep en d e n c y needs, a n d ge ttin g a tt e n
tion a n d sy m p a th y . Such p a ti e n ts ca n n o t be
forced to ch a n g e. T h e p r i m a r y task here, as in
th e case of th e p syc ho som a tic p a tie n t, is to first
is th a t once th e p a tie n t h a s e la b o r a te d the

p ro b le m , respo nsib ility for it is tra n sfe re d to
establish a t h e r a p e u ti c alliance. N o h a r d - a n d -
the th e r a p is t an d a c u re will be expected.
r e q u i r e i n n o v a t i v e s t r a t e g e m s d e s i g n e d for
th e ir special situ atio n s. P a tie n ts receiving d is a
S ho uld th e th e r a p is t become a w a r e of th is a t
titude, he m a y offer th is in te rp re ta tio n :
T h . It is u n d e r s ta n d a b le th a t yo u h a v e su ffered so
lo n g th a t y o u feel it is im p o ssib le for you to do
a n y th in g a b o u t y o u r p ro b le m
y o u rself. It is
n a tu r a l fo r y ou to w a n t so m e b o d y to ste p in
a n d do fo r y ou w h a t you h a v e n t b een a b le to
do fo r y o u rself. B u t y o u a n d I h a v e to w o rk
to g e th e r as a te a m . I sh a ll h e lp you to u n d e r
s ta n d w h a t is h a p p e n in g to y o u , a n d you
w ill find th a t y o u can do m a n y c o n stru c tiv e
fast ru les can be given since each p a tie n t will
bility checks a r e p a r t ic u l a r ly difficult to co n

vince th a t a n y th i n g psychological keeps th e m
fro m r e t u r n i n g to w o rk . O n e tactic is n ever to
im p ly th a t th e p a tie n t is in a n y w a y p sy c h o
logically m a n u f a c tu r in g his s y m p to m s because
this will o b stru c t th e e sta b lish in g of a w o rk in g
rela tio n sh ip . T h e a p p r o a c h at first m a y , as
in th e p sy cho som atic p a tie n t, be o rg an iz ed
a r o u n d tension re d u ctio n to h e lp th e p a tie n t
th in g s fo r y o u rself. T o g e th e r w e sh o u ld m a k e
assu ag e suffering. As tensio n is lessened, the

p a ti e n t will begin ta lk in g m o r e a b o u t him self
p ro g re s s.
a n d p e r h a p s a b o u t some fam ily a d ju s tm e n t
T h e p a tie n t w ith a psych oso m atic p ro b le m

is often unconvinced th a t his physical s y m p to m
is or can be e m o tio n ally d ete r m in e d . T h e best
w a y of losing such a p a tie n t is to insist th a t his
p ro b le m is psychological. Since the p a tie n t
m a y , at least te m p o ra r ily , need his sy m p to m ,
the th e r a p ist is wise at th e s ta rt of t h e r a p y to
allow the p a ti e n t to re ta in th e idea of its organicity. H e m a y inform th e p a tie n t t h a t a ny
sy m p to m , even a n o rg a n ic sy m p to m , creates
tension because of discomfort o r p ain . T h e te n
sion delays healing. W h a t needs to be d o n e is
to reduce tension , an d this can stim u la te the
h ealin g process. T e a c h in g th e p a ti e n t sim ple
r e la x in g m eth o d s a n d a llo w in g th e p a ti e n t to
p ro b le m s. T h e th e r a p is t m a y soon be a b le to
in q u i re a b o u t th e hopes, a m b itio n s, a n d goals
of th e p a tie n t. Q u e stio n s m a y be asked such as
W h a t w o u ld you like to d o ? H o w w ou ld
you like to feel? W h a t d o you en joy m o s t?
V e ry often w h e n th e p a tie n t realizes th a t the
th e r a p is t does no t expect c o n fo rm ity to s t a n d
a rd s th a t o th e r s set for the p a tie n t, a t h e r a
p eutic allian ce will begin. Reflecting the p a
t i e n t s a n g e r w ith o u t c o n d e m n in g it h elp s c o n
vince th e p a ti e n t th a t he is n ot b ad for feeling
th e w a y he does. H o w th e p a ti e n t can go a b o u t
fulfilling his o w n goals is th e n p la n n e d . A n in
teresting article on te c h n iq u e s of d ealin g w ith
such u n m o tiv a te d p a tie n ts has been w r it te n by
S w a n so n an d W o o ls o n (1973).
52
If a p a t i e n t is r e f e r r e d
for tre a tm e n t, how
p r e p a r e t h e p e r s o n to
th e rap ist w h e n th ere
r e c e iv e h e l p ?
w h o is u n p r e p a r e d
does a c o u n selo r
a c c e p t r e f e r r a l to a
is n o i n c e n t i v e to
A n e x a m p le m a y illu s trate th e situ atio n . A

college stu d en t is referred to a co un selor by h e r
possible for you to rectify this. P e r h a p s th e r e

is n t an y desire to go o u t because th e r e a re
fears of e x po sing yo urself to som e sort of co n
ta c t . T h e p a ti e n t m a y t h e n d en y this v e h e
m ently.
If th e c ou nselo r h a s g o tten th e s tu d e n t to
school advisor because she w as b ecom ing m o re
ta lk a b o u t herself, the ch an ces a re she will ask

for a n o th e r co nference w ith th e counselor. At
an d m o re of a recluse, avo id in g social activities

an d even stay ing a w a y from classes. O n in t e r
th e nex t visit she will p e r h a p s say th a t she h as

th o u g h t th e m a t te r over a n d she does feel th a t
view she is m anifestly depressed. H o w e v e r, she
p e r h a p s she m ig h t be co n cealing from h erself
h a s no desire for th e r a p y a n d no idea th a t

th e r e is a n y th i n g w ro n g w ith the w a y she is
re aso n s w h y she does n ot w a n t to go out.

U n d e r these circu m sta n c es th e co un selor m a y
behaving. She insists in d ig n a n tly th a t th e r e is
in fo rm h e r th a t th e r e a r e c e rta in p e rs o n s w h o
n o th in g w r o n g w ith h e r m in d . B ecause she

refused to go o u t does n ot m e a n she needs a
th e p a st p s y c h o th e ra p is ts w e re looked u p o n as
p sychiatrist. T h e q u estio n is h o w to get this
p eo p le w h o m in is te red to only severe e m o
girl to accept psyc h o th erap y .
tion al difficulties, b u t in recen t years they h ave
specialize in h a n d li n g p ro b le m s of this type. In
In h a n d lin g this ty pe of p ro b lem , th e first
been h a n d li n g bo th m i n o r a n d m a j o r p ro b le m s
th in g the c o un selo r w o u ld w a n t to do is es
tablish som e sort of a n incentive for th e r a p y .
W i t h o u t th is incentive, it w o u ld be useless to
of n o r m a l p eople; p eop le w h o could be m u c h

m o r e h a p p y w ith i n them selves a n d m o re effi
cient
refer the p a tie n t to a th e r a p ist. H o w to create

an incentive is th e case in p oint. O n e w a y is to
p s y c h o th e ra p e u tic help.
Before re f e rrin g a p rosp ectiv e p a ti e n t to a
ask if she is com pletely satisfied w ith
th erap ist
her
in
th e ir
it
w ork
w ou ld
or
be
stu d ies w ith
im p o rtan t
fo r
som e
th e
p re s e n t-d a y life a n d a d ju s tm e n t. If she says

t h a t e ve rythin g is g oin g a lo n g well, th e t h e r a
c ou nselor (1) to estab lish th e existence of a
pist m a y say: It is very g ratify in g to feel th a t

yo u a r e c o m p l e t e l y sa tis f ie d , a n d u n d e r
to deal w ith o r to clarify w h a te v e r resistan ce

t h e r e m a y e x is t t h a t m a k e s t h e p e r s o n
s tan d a b ly u n d e r th ose circu m stances, you will
re lu c ta n t to con sult a th e r a p is t, a n d (3) to c o r

rect a n y e x isting m isco nce ptio ns a b o u t p sy c h o
th e r a p y . H o w tr u ly m o tiv ated for tr e a tm e n t
w a n t to do very little a b o u t yourself. T h e r e

m ay, how ever, be certain a r e a s th a t a r e not as
p le a s a n t for you as you m ig h t w a n t. A re you
satisfied the w a y e v eryth ing is going in every
a r e a ? S ho u ld th e a d a m a n t reply be th a t
th in g s n ow a re perfect, th e th e r a p is t m a y have
no a lte rn a tiv e t h a n to b rin g o ut the p re v a ilin g
a d ju s tm e n t difficulties, such as stay in g a w a y
from classes. At the end of the session th e still
unconvinced s tu d e n t is invited to r e t u r n at a n y
tim e she feels she w a n ts to talk th in g s over.
O n th e o th e r h a n d , the s tu d e n t m a y a d m it
th a t w h ile th in g s a re no t too b a d , th e r e is th e
p ro b le m th a t she does n ot seem to h ave th e
e n erg y to go o u t w ith boys t h o u g h she likes
boys. T h e cou nselo r re to rts : If you really
have a desire to get m o re energy, it m a y be
definite p ro b le m for w h ic h help is nee d e d , (2)
th e p a ti e n t will be w h e n a th e r a p is t is co n
sulted will d e p e n d on h o w good a j o b th e
co u n selo r h a s do ne. B u t, g ettin g th e p a ti e n t to
a th e r a p is t is th e first step.
S in c e t h e p r e s e n c e o f e m p a t h y is u s u a l l y
m e n t i o n e d as t h e k e y n o t e to a t h e r a p e u t i c
a l l i a n c e , w h a t h a p p e n s if y o u s i m p l y c a n
n o t e m p a th iz e w ith a p a rtic u la r p atien t?
D o e s t h is m e a n y o u c a n n o t t r e a t t h a t p a
tient?
It often h a p p e n s th a t a th e r a p is t does not
like th e k in d of h u m a n bein g th e p a ti e n t is at
th e tim e he p re s e n ts h im self for t r e a tm e n t, n o r
m a y th e th e r a p is t be a b le to co n d o n e th e life
53
THE INITIAL INTERVIEW: CO M M O N QUESTIONS

the p a tie n t h a s led, n o r a p p r o v e of his a t
titudes, m orals, values, o r objectives. T h i s does
no t m e a n one c an n o t w o r k w ith th e p a tie n t.
P ro b le m s develop w h e re th e th e r a p is t because
of in t o l e r a n c e , is h o s t il e o r j u d g m e n t a l .
P a rtic u la rly destructive to e sta b lish in g a w o r k
ing re latio n sh ip is re petition by th e th e r a p is t of
th e sam e kin d of a r b i t r a r y a n d d is a p p ro v in g
m a n n e r disp layed by o th e r a u th o r itie s w ith
w h o m th e p a ti e n t h a s come in to contact. T h e
p a tie n t h a s a lr e a d y set u p defenses ag a in s t
m ig h t as well co m m it suicide. (2) I feel d e

g ra d e d th a t I h a v e finally h a d to resort to p sy
ch iatric help. (3) If a n y b o d y finds o u t a b o u t
th e re a l m e, it will be too b a d for me. (4) I will
p ro b a b l y be b la m e d , rejected o r h ated . (5) I feel
foolish to com e h ere. It is silly for me to t h i n k I
need h elp for m y m in d . (6) T h i s m u s t m e a n I
a m g oin g in sane.
T h e th e r a p is t sh o u ld also c o u n te n a n c e w h a t
m a y be going on in th e t h e r a p i s t s o w n m ind.
T h e s e th o u g h ts a r e very ra r e ly a ckn o w led ged ,
these a u th o ritie s th a t will block his d eveloping
let
confidence in a th e r a p is t w h o m h e identifies
w ith past au th o rities. If the th e r a p is t can e x
f o r m u l a t i o n s s u c h as t h e fo l lo w in g : (1) I
w o n d e r if I m going to like this p a tie n t? (2) I
ercise control over im p ulses to v erbalize d i s a p
w o n d e r if he is going to like m e ? (3) I w o n d e r
p rov al,
criticism
if I m able to h e lp this p a ti e n t o r w h e t h e r his
gestures,
k in d of p ro b le m is th e sort th a t I can tr e a t? (4)

I w o n d e r if he can p a y m y fee a n d h o w a m I
th ro u g h
an d
can
facial
avoid
d is p la y in g
exp ressio n s
and
aspects of th e p a t i e n t s p e rs o n a lity will so on er

o r late r come t h r o u g h th a t m a y kindle w a r m
feelings in the th e ra p ist. M a n y p a tie n ts a t th e
s ta rt often tr y to test a th e r a p is t by d is p lay in g
a n g e r o r by p re s e n tin g the most sh ock in g or
alo n e
faced.
They
involve
all
sorts of
go in g to h a n d le th e s itu atio n in th e event th a t

h e is u n a b le to afford t r e a tm e n t w ith m e?
A s s u m in g on e can h a n d le o n e s o w n feel
ings, th e th e r a p is t m a y d ip lo m a tic a lly a sk the
d isag reeable aspects of them selves. If th e t h e r a

pist does n ot fall into this tr a p , th e w o r k in g r e
p a ti e n t q u e stio n s such as I w o n d e r if y ou a re
latio n s h ip m a y very well develop even in the

first session.
q u estio n s
H o w can y ou c o m m u n ic a te e m p a th y ?
suggested by o b se rv ing th e p a t i e n t s reaction s

a n d r e a d in g b etw e en the lines of w h a t th e p a
tien t is saying.
u p set a b o u t co m in g h e r e ?
about w hat
Do
I m ight
you have
be t h i n k in g
a b o u t y o u ? Y o u m a y feel this is the last

r e s o r t ! O t h e r q u e stio n s a n d c o m m e n ts will be
O n e m ay sh o w interest in w h a t th e p a tie n t
is saying by listen ing carefully, by ask in g
p ro p e r q uestions, a n d by d is p la y in g a p p r o
p r i a te facial expressions. S o m etim es c o m m u n i
catin g w h a t m u s t be on th e p a t i e n t s m in d
from clues given, v erbally a n d n o n v erb a lly , can
be helpful. T h e th e r a p is t m a y a sk him self,
W h a t goes o n in the p a t i e n t s m in d as h e sits
th e r e ta lk in g ? If one can p e n e tr a te b eyond
the facade of th e p a t i e n t s m anifest v e rb a l iz a
tions a n d get to th e core of w h a t he m a y
actu a lly be feeling, w h a t fears, a n d anxieties
exist, one m a y m a k e a stro n g im p ress io n on
th e patient. W h e n the p a ti e n t first comes to
Is t h e r e a n y w a y o n e c a n e x p e d i t e e m
p a th y to w a rd a p e rs o n w h o com es fro m a
socio eco no m ic g r o u p w ith w h ic h a t h e r a
p is t h a s li t t l e a f f in ity ?
In listening to a p a tie n t w h o belongs to a
s t r a t u m of society w ith w h ic h on e is n ot too fa
m ilia r, o ne m a y tr y to u n d e r s ta n d th e e x
pressio ns a n d id iom s th e p a ti e n t em p lo y s and
to utilize th e s a m e la n g u a g e form s so th a t one
c a n c o m m u n ic a te o n th e sa m e w av e length.
O n e m a y also tr y to find o u t if th e destructive
p a tt e r n s the p a ti e n t ind u lges a re th ose co m m o n
th e r a p y , he is u su a lly q u it e up set, fearful,

an g ry , o r fru stra te d a n d he m a y a n tic ip a te to o r co nd on ed by the p a t i e n t s su b c u ltu ra l
co un terho stility or d is a p p ro v a l. T y p ic a l ideas g ro u p , for e x a m p l e alcoholic excesses, d a n
th a t occupy the p a t i e n t s m i n d a re these: (1) g ero u s d r u g u sag e, o r delin q u en cy . It is neces
T h i s is m y last resort. If th is d o e s n t w o rk , I sary to m a k e su r e at th e s ta rt th a t o ne does not
54
convey d is a p p ro v a l o r disgust at in dulgences

the p a tie n t m a y co nsider n o rm a l. L a t e r on,
w h e n a w o rk in g r e la tio n s h ip exists w ith the
p a tie n t, it m ay be possible to p o in t o ut d e s tru c
tive p a tt e r n s th a t s u p p o r t the p ro b le m s for
w h ich h elp is bein g sought. T h e th e r a p ist m a y
also keep ask in g himself, especially w h e n th e
p a tie n t comes from a d isad v a n ta g e d g ro u p ,
I n s p it e o f a ll t h e e f f o rts y o u m a k e to be
t o l e r a n t , w h a t d o y o u d o if y o u still f i n d
y o u rself b ein g u n sy m p a th e tic , even
actually disliking th e p atien t?
If y o u r feelings interfere w ith y o u r do ing
t h e r a p y , sim ply tr a n sfe r th e p a tie n t to a n o th e r
th e r a p is t. B u t, in all p r o b a b ility th e p a tie n t
will leave you first.
ho w the th e r a p is t w ou ld feel a n d w h a t he
w ou ld do if he h a d to e n d u r e th e into leran ces
an d abuses th e p a tie n t w e n t th r o u g h in th e p a
t i e n t s p ast life. W o u ld he be a n y different?
T h e th e r a p is t m a y th e n b e tter be able to e m p a
th iz e w ith the patient.
W h a t d o y o u d o if a p a t i e n t t u r n s o n y o u
a n d a tta c k s y o u v e r b a l l y d u r i n g t h e i n i t i a l
in te rv iew ?
H ow w o u ld y ou show a p a tien t you are

to le ra n t of b e h a v io r a b o u t w h ich the p a
t i e n t p e r s o n a l l y is a s h a m e d a n d c a n n o t o r
w ill n o t do m u c h a b o u t?
S o m e p a ti e n ts will expect you, p e r h a p s even
w a n t you to d is a p p ro v e of th e ir b eh av io r. If
you co m p ly w ith th is w ish, it m a y te m p o r a r ily
be stab ilizin g by fu r n is h in g th e p a ti e n t w ith an
outside control. T h e im p ro v e m e n t, h ow ev er,
w h e n they come to th e in itial interview . T h e
will be short-lived as long as th e p a ti e n t h a s a

stake in destructively actin g o u t p a tte rn s . T h e
M any
p a tie n ts a re in w a rd l y very hostile
reaso ns for this vary. T h e p a tie n t m a y r i g h t
p a ti e n t will th e n defy you o r deceive you by
fully resent w a itin g for an a p p o in t m e n t , the
p e r p e t u a ti n g th e p a t t e r n s secretly at th e sam e
r o u tin e of a clinic, the fee to be p ay ed, a n d

o th e r facts of life. O r hostility will stem from
ti m e th a t a n g e r a n d gu ilt a c c u m u la te . T h e
in n e r sources not at all relate d to reality. T h e

th e r a p ist m u st accept this hostility a n d n ot act
th r e a te n e d by it n o r re s p o n d in a n y adverse
best w a y to m a n a g e a n y rev elation of conduct

a b o u t w h ich th e p a tie n t seem s gu ilty is to
r e m a r k th a t th e p a tie n t a p p e a r s to be guilty
w ay . H ostility sho uld be h a n d le d by b rin g in g

it out in the op en d u r i n g th e in terv iew , clarify
a n d a s h a m e d of w h a t he or she is doing. T h e
follow ing ex cerpts illu s trate h o w I h a n d le d tw o
ing the reaso n for th e d is tu rb in g reality s i tu a
such cases:
th e r a p e u tic allian ce will, th erefo re, suffer. T h e
tion if o ne exists. O r w h e re hostility is not e x

plicable, a c asu al sta te m e n t m a y be m a d e such
as th e following:
T h . So w h a t?
T h . It is u n d e r s ta n d a b le th a t you h a v e su ffered a
T h . W e ll w h a t? Is th a t w h a t y o u ca m e to see m e
P t.
P t.
g r e a t d eal fro m y o u r p ro b le m . P e o p le w h o su f
I w a n t y o u to k n o w th a t I a m h o m o se x u a l.
(p a u se) W e ll?
a b o u t?
fer a g re a t d e a l o ften a r e re s e n tfu l of th e su ffer
P t.
in g th e y h a v e e x p e rie n c e d a n d th e ineffective
T h . Y ou
n ess of th e m e a s u re s th ey h a v e a d o p te d to g a in
N o , b u t h o w do yo u feel a b o u t it?
m u st feel th a t
I d is a p p ro v e o r sh o u ld
d is a p p ro v e .
h e lp . Y ou m ay be a n g ry a t th e fact th a t you
P t.
a r e ill, o r b ecau se of w h a t h a s h a p p e n e d to
T h . W h y sh o u ld I if i t s so m e th in g yo u w a n t to do.
D o n t y o u ?
yo u . M o s t p e o p le do feel re s e n tfu l of w h a t h a s
Y ou
h a p p e n e d to th e m . T h is is u n d e r s ta n d a b le . It
a n x io u s a good d e a l o f th e tim e . I s n t th a t
is n a tu r a l n o t to w a n t to ta lk a b o u t o n e s feel
to ld
m e th a t
y o u w e re d e p re ss e d
and
w h a t yo u ca m e to see m e a b o u t?
in g s of r e s e n tm e n t, too. T h e re a so n I a m te ll
P t.
Y es, it is.
in g y ou th is is th a t it is p o ssib le yo u m a y even
T h . So l e ts w o rk at th a t. N o w , if y o u r ch o ice o f a
feel a n g r y a t m e o r a t th e c lin ic as a re s u lt. If
s e x u a l p a r tn e r h a s so m e th in g to do w ith th ese
y ou d o , do n o t feel g u ilty if y o u ta lk a b o u t it.
s y m p to m s w e ll ta lk a b o u t th a t.
THE INITIAL INTERVIEW: COM M O N QUESTIONS

P t.
[o b v io u sly re lie ved \
F in e ,
I k n e w you w e re
lib e ra l a b o u t th ese th in g s.
h ave for m a n y y ea rs em p lo y ed it in c a se w o rk on
a s h o r t- t e r m basis. S im ila rly som e c o un selin g
A p a tie n t in h e r m id dle 60s ca m e for h elp to

relieve p ain follow ing a b reast a m p u t a t i o n for
cancer.
a p p r o a c h e s h av e o p e ra te d a r o u n d a s i m i la r e x
p o s u r e of th e i m m e d i a te c o m p la in t factor. B oth
ca se w o rk a n d co u n selin g h a v e often s u b s ta n ti
ated im p ro v e m e n t b ey on d th e m e r e a lt e r a t io n of
th e
P t.
I h a v e to tell y o u , d o c to r (la u g h s ) th a t I h a v e a
little
h a b it th a t
I am
55
asham ed
en v iro n m en tal
d istu rb a n c e s
or
sym p-
tom ic u p sets th a t initiated th e c o n su lta tio n s.
to tell you
a b o u t.
T h . A re y ou a fra id o f w h a t m y r e a c tio n w ill be?
P t.
N o , I g u ess 1 d o n t lik e it m yself. I t s th a t

w h e n e v e r I go in to a sto re , I lift-sn e a k a little
th in g in m y p u rs e o r bag.
T h . H o w d o y o u feel a b o u t it?
P t.
I g u ess I do it fo r th e e x c ite m e n t. I u su a lly

d o n t n eed th e tr in k e t. I g u e ss y o u d call it
k le p to m a n ia . I re a d a b o u t it.
T h . Y ou m u st d is a p p ro v e of it, o r d o e s n t it b o th e r
you?
P t.
M y h e a rt tre m b le s fo r h o u rs a f te rw a rd . W h a t
if I m c a u g h t? T h e d isg ra c e .
T h . If it d o es b o th e r y ou e n o u g h , w e o u g h t to ta k e
P t.
H o w d o e s a t h e r a p i s t k n o w w h e t h e r h is
a p p r a i s a l o f a c h o s e n f o c u s is t h e c o r r e c t
one?
A t h e r a p i s t s j u d g m e n t c o n c e rn in g existing
core p ro b le m s involves sp ecu latio n s t h a t are
not a lw a y s con sistent w ith w h a t a n o th e r t h e r a
pist m a y hy po the size. G iv en th e sam e d a ta ,
different t h e r a p is t s will v a ry in w h a t th ey co n
sider is th e m ost significant a r e a on w h ic h to
focus. In a sm a ll e x p e r i m e n t th a t I c o nd ucte d
th r e e e x p erie n c ed th e r a p is ts tr a in e d in the
sa m e a n a ly tic school w itn essed the first tw o
it u p in o u r ta lk s h e re .
s e s sio n s
D o you th in k
t h r o u g h a o n e -w a y m i rro r . E a c h th e r a p is t h a d
a s o m e w h a t different idea of w h a t m e an in g fu l
I ca n get o v er th is h a b it? It
s ta rte d sh o rtly a fte r m y h u s b a n d d ied .

T h . P e r h a p s you felt d e p riv e d . B u t if y o u re a lly
w a n t to g et o v e r it, t h a t s n in e - te n th s o f th e
b a ttle .
A re r e a s o n s f o r s e e k in g h e l p at t h e t i m e o f
c o m i n g fo r h e l p a g o o d t h i n g to fo c u s o n ?
H a r r i s et al (1964) describe a 3 -y e ar project
at th e L an g ley P o r t e r N e u ro p s y c h i a tr i c I n
s titute in S an F ra n c isco w h e re a m e th o d of u p
to seven sessions w a s designed a r o u n d th e focus
of th e factors th a t enjo in ed th e p a tie n t to come
to th e clinic. T h e q u estio n s e x p lo re d w e re w h y
the p a tie n t w a s seeking h e lp a t th is tim e an d
w h a t he or she expected o u t of th e contact w ith
the clinic. T h i s a p p r o a c h served n ot only as a
satisfactory in ta k e m e th o d , b u t also p ro d u c e d a
r e t u r n to a d e q u a t e fu n c tio n in g in a significant
n u m b e r of patien ts. F o r the r e m a in i n g p a tie n ts
the brief ex perien ce help ed d e lin e a te th e p r o b
lem, clarified th e exten t of m o tiv atio n , an d
acted as p r e p a r a ti o n for c o n tin u in g h e lp or in
tensive tr e a tm e n t. F o cu sing on the h elp -seek in g
factors is n o th in g new . S o cia l-w o rk agencies
cond u cte d
by
fou rth
colleague
topic w a s best o n w h ic h to focus. In m y

o p in io n , such differences a re n ot significant b e
c au se m u ltip le p ro b le m s c an exist a n d these
a re u su ally in te rre la te d . Even w h e re one
strik es
th e
p a t i e n t s c o re
d if fic u ltie s
tan-
g entially, o ne m a y still reg ister a n im p a c t an d

s p u r the p a tie n t o n t o w a r d a b e tte r a d a p ta tio n .
A fter all, a re a s o n a b ly in tellig en t p a t i e n t is
c a p a b le of m a k i n g con nection s a n d even of c o r
rectin g the m isp e rc e p tio n s of a th e r a p is t w h e re
a good w o r k in g r e l a ti o n s h ip exists a n d the
th e r a p is t does not re s p o n d to b eing criticized
too d ras tica lly w ith a d isp lay of w o u n d e d n a r
cissism. F r o m a p r a g m a ti c s ta n d p o in t, the
focus is an a c c u ra te on e if th e p a ti e n t re s p o n d s
positively to it.
C a n a p e r s o n g e t w e ll w i t h o u t n e e d i n g to
w o r k o n b a s ic n u c l e a r c o n flic ts?
G e tti n g well e m b r a c e s m a n y d egrees of
im p ro v e m e n t. M o s t p eo p le m a k e a fairly good
a d a p ta tio n w h ile re t a in i n g som e aspects of
56
th e ir deepest conflicts. In s h o r t-t e rm th e r a p y

we usually deal w ith seco nd ary derivative co n
flicts because of th e lack of tim e for d e p th
p ro b in g a n d the w o r k in g - th r o u g h of resistance.
H o w e v e r, p e rs o n a lity c h a n g es can result over a
H o w w o u l d y o u a c c o u n t f o r t h e fact t h a t
e v e n t h o u g h fe w o r n o p s y c h o d y n a m i c s
m a y b e a p p a r e n t d u r i n g t h e f irs t i n t e r
v i e w , t h e p a t i e n t still m a y e x p e r i e n c e a
g o o d d e a l o f re li e f ?
period follow ing th e r a p y if th e p a tie n t co n
T h e r e a re m a n y reaso n s for this. F ir st, th e
sistently w o rk s on h im self an d his p ro b lem s.
e m p a t h ic u n d e r s ta n d in g of th e th e r a p is t e n a
A p p a r e n tl y n u c le a r conflicts m a y som etim es be
bles th e p a tie n t to u n b u r d e n h im self o r herself

in a n a tm o s p h e r e sh o r n of b la m e a n d a u th o r -
influenced t h r o u g h re solu tio n of th e i r m a n i

festations in s eco n d ary conflicts. H itch coc k a n d
M o o n e y (1969), for e x a m p le , have w ritte n
h o w in m e n ta l h ea lth c o nsultio n d ealin g w ith
atativ e p res su re. S im p ly relieving o neself of

p a in fu l t h o u g h t s reduces ten sion . B u t m o r e i m
th e c o n su ltee s w o rk -e g o function a lo n e can
p o r t a n tl y , p u t t i n g into w o rd s feelings th a t float

a r o u n d in a n e b u lo u s w a y ten ds to identify
h ave a m o re th a n superficial effect. D. Beck
th e m an d h elps the p a tie n t g a in co ntrol over
(1968) h as also w rit te n an in tere stin g article
th em . M o r e o v e r , reve alin g ideas a n d e x p e r i
accentin g th e valu e of w o r k in g on derivative
ences to a n a u th o r it y w h o does no t re s p o n d th e
w a y o th e r p a st a u th o r itie s h ave acted, o r the
conflicts. In m a n y types of s h o r t-t e rm th e r a p y

o p e n in g u p a b a g of w o r m s t h r o u g h b lu n t
in t e rp re ta ti o n of a n u c le a r conflict m a y create
w a y th e p a ti e n t im a g in e d th e y w o uld act or
m o r e p ro b le m s th a n it solves. T h e th e r a p is t
im ag e an d relieves guilt. F a i t h a n d tr u s t a re
kindled. T h e placeb o ele m e n t to the effect th a t
m u s t j u d g e h ow re a d y th e p a tie n t is for a n in
t e r p r e t a t i o n th a t is, h o w conscious th e p a
tien t is of an e x istin g conflict before e x p lo r
ing it. W h e r e th e p a ti e n t h a s such a n a w a r e
ness a n d w ishes to deal w ith his conflict, th ere
is no reaso n to avoid it.
sh o u ld
act,
softens
th e
intro jected
p a re n ta l
so m e th in g is a v a ilab le th a t can h elp a n d th a t

m a t te r s a r e no t hopeless, a n d th e im p a c t of d i
rect o r in direct sug gestions m a d e by the t h e r a
pist m a y in s p ire th e p a tie n t t o w a r d ta k i n g a
corrective p a th of t h i n k in g a n d beh avin g. O f
course, th e e x te n t of th e p a t i e n t s ta k i n g a d
S u p p o s e , in e v o l v i n g a w o r k i n g h y p o t h e
sis o f t h e p r o b l e m , t h a t t h e t h e r a p i s t h a p
p e n s to b e w r o n g . W o u l d it n o t b e b e t t e r
to w a it u n t i l m o r e facts a r e a v a i l a b l e
b e f o r e s p e c u l a t i n g a b o u t w h a t is g o in g
on?
W h il e th e th e r a p is t will w a n t to develop a
w o r k in g h y p oth esis of th e p ro b le m , he m u st
consider it te n tativ e at best. N o t all of th e facts
m a y be a vailab le d u r i n g th e first few in t e r
views. E ven if th e th e r a p is t is w r o n g or
v a n ta g e of these positive e le m e n ts will d ep e n d

on his re ad ine ss for ch ang e. W h e r e a re ad in ess
for c h a n g e exists in good m e a s u re , th e im p act
of th e first interv iew c an be d r a m a ti c even
t h o u g h basic n u c le a r conflicts a r e no t touched.
A n d th e p a ti e n t m a y be able to achieve an
e m o tio n al e q u il ib r iu m at least e q u iv a le n t to
th a t w h ich p re v a iled p r i o r to the onset of th e
p re s e n t illness.
C a n o n e p ro g n o stic a te fro m th e severity

o f s y m p t o m s o r t h e s ic k n e s s o f a p a t i e n t
the p o ssib ility of im p r o v e m e n t o r cu re?
p a rt ia l ly w r o n g in th e initial analysis, he will

be able to co rrect o r modify his ideas late r on.
If a c onnection w ith p e rs o n a lity factors o r in
n e r conflicts is n ot a p p a r e n t at the beginn in g,
o r if th e p a tie n t is not re a d y to co u n te n a n c e th e
N o . S o m etim es th e sickest p a tie n ts , even

h a llu c in a tin g psychotics, recover ra p id ly , w hile
w h a t seems like a mild d ep res sio n , a n x ie ty , or
im p licatio n s of such c on nections, i n t e r p r e t a

ti on s m a y be confined to the im m e d ia te en vi
c h a r a c t e r p ro b le m will scarcely budge. M a n y

v a ria b le s obviously exist o th e r th a n th e c u r r e n t
ro n m e n ta l p re c ip ita n ts w h ile w a itin g for m o re

d a t a before lin k in g th ese to u n d e rly in g in n er
sy m p to m s, w h ic h a re re la te d to th e p a t i e n t s
la t e n t ego s t r e n g t h , f l e x ib i li ty o f d e fe n s e s ,
read in ess for ch an g e, seco nd ary g a in , selective
difficulties o r m o r e o bscure e x te r n a l events.

resp on se to tech niqu es, capacity for develo pin g
a th e r a p e u tic alliance, skill a n d p e rs o n a lity of
th e th e ra p ist, an d m a n y o th e r factors. T h e s e
will all influence th e outcom e. T h e effect of
these variab les ca n n o t be a n tic ip a te d in a d
57
comes to t h e r a p y w ith some basic tr u s t in the

t h e r a p is t as a professional w h o can help.
N a t u r a l l y , th e r e a r e a lw a y s la ten t som e ele
m e n ts of fear
and
d is tru s t, th e degree d e
vance since th ey display them selves only after
p e n d e n t on p rev io us e xp erie nce s w ith i r r a

tio nal a u th o r it y a n d w ith in c o m p e ta n t p ro fe s
th e r a p y has started .
sionals. It is u su a lly no t necessary to focus on

th e
Is t h e r e o n e f a c to r y o u w o u l d c o n s i d e r
t h e m o s t i m p o r t a n t o f all in i n s u r i n g g o o d
r e s u l t s in t h e r a p y ?
re la tio n s h ip
un less th e r e a r e evidences,
from th e b e h a v io r a n d v e rb a liz a tio n s of th e p a

tien t, th a t th e r e la tio n s h ip is no t going well o r
T h e r e a r e m a n y factors th a t a r e o p erativ e,
th a t tr a n sfe re n ce exists th a t is a c tin g as a

resistence to t r e a tm e n t. A s lo ng as the re l a ti o n
b u t I w o uld co nsid er th e q u a li ty of th e r e l a
sh ip a p p e a r s to be good, th e r e is no re a s o n to
tio n sh ip b e tw een th e th e r a p is t an d p a ti e n t th e
p ro b e o r c h a llen g e it.
most im p o r t a n t of all factors.
H o w m u c h c o n fro n ta tio n can be u tiliz e d

d u r in g the in itial in te rv iew ?
T h e r e a re v a ry in g o p inio n s. W h e r e th e first
in terview is e m ploy ed as a screen in g device to
de te rm in e the suitability of a p a tie n t for an
a n x ie ty -p ro v o k in g typ e of th e r a p y , such as
practiced by Sifneos, co n fr o n ta tio n is p a r t of a
selection p ro c ed u re. As a g en e ra l ru le, h o w
ever, w ith the a v e rag e p a tie n t, co n fro n ta tio n is
D o e s n o t t h e r e l a t i o n s h i p its e lf s p o n s o r
re c o n stru c tiv e ch a n g e w h e r e the th e ra p ist
is a c c e p t i n g a n d t o l e r a n t ?
A n a s s u m p ti o n is often m a d e th a t everyone
h a s w ith in oneself th e ca pac ity to achieve
th e r a p e u ti c c h a n g e , p ro v id e d th e r e is a n on j u d g m e n t a l , n o n p u n it iv e a tm o s p h e r e in w hich
to ex p ress feelings w ith o u t fear of re ta lia tio n
o r censure. G r o w t h is said to be co n tin g e n t on
th e c onstructive r e l e a rn i n g th a t comes a b o u t as
best delayed u n til a good t h e r a p e u ti c allian ce
a b y -p ro d u c t of a n o n t r a u m a t i c rela tio n sh ip .
h a s been established to su s ta in th e p a t i e n t s
hostility a n d anx iety . O t h e r w is e the p a ti e n t is
The
ap t
to d ro p
o ut of t r e a tm e n t
p r e m a tu r e ly ,
in d iv idu al
h a s a n o p p o r t u n it y h e re to
revise in h e r e n t concepts of a u th o r it y o ut of a
n ew e x p e rien ce w ith th e th e r a p is t w h o o p e r
n er as an atta ck o r because he is u n a b le to
ates as a different kind of p a r e n t a l sym bol. In

practic e this h a p p y result does not often follow
h a n d le th e em o tio n s stirred u p in h im se lf as a
re sult of the po in ted challenges. In som e cases,
because th e in div idu al, even in a com pletely

n o n cen so rio u s e n v ir o n m e n t, will u su a lly p e r
how ever, the th e r a p is t is ca p a b le o f setting u p

a w o rk in g r e la tio n s h ip r a p i d ly in the first
ju stified a n d un ju stifiab le a ss u m p tio n s. Even
e 'th e r because h e m istakes th e th e r a p i s t s m a n
p e tu a te p e rs o n a l p ro b le m s by cling in g to u n
se s sio n , u n d e r w h i c h c i r c u m s t a n c e c a r e f u l
th o u g h
em p a th ic con fro n tatio n m a y be g ainfully e m

ployed.
p a r e n t a l attitu d e s o r d isp lay th e ir in tolerance,

th e p a tie n t m a y react as if th e o rig in a l a u t h o r
ities w e re still presen t. T h i s is because the
S h o u l d n o t t h e t h e r a p i s t c h o o s e as a
p r e f e r r e d fo c u s t h e r e l a t i o n s h i p b e t w e e n
h im s e lf a n d th e p atien t?
p ro b le m h a s been in te rn a liz e d a n d forces the

p a ti e n t to o p e r a t e w ith a sense of values th a t,
merciless as it is, is u n c o rrecte d by reality.
In d eed, the p a ti e n t m a y even becom e in d ig n a n t
to w a r d th e t h e r a p i s t s to le ra n t s ta n d a r d s an d
Effective le a r n in g can proceed only in the

m e d iu m of a good in te rp e r s o n a l re latio n sh ip .
T h e la tter serves as th e m a t r i x for w h a te v e r
th e o r e ti c a l a n d m e t h o d o l o g i c a l s t r u c t u r e s
fashion the tr e a tm e n t m a n e u v e rs of th e t h e r a
pist. O n e u su ally a ssu m es th a t th e p a tie n t
th e
th e rap ist
does
not rep eat
th e
b e h a v io r as offering te m p ta t io n s for w h ic h one

will late r p a y d early . T h i s serves as resistance
a g a in s t a lte rin g o n e s values. W e , nevertheless,
tr y to p ro m o te ch a n g e by detection of negative
58
attitu d e s a n d tra n sferen ce feelings an d by th eir

in te rp re ta tio n an d w o rk in g - th ro u g h .
H ow im p o rta n t are o p tim ism an d

th u siasm on th e p a rt o f th e th e ra p ist?
en
V e ry im p o rta n t. O p tim is m an d e n th u s ia s m
in sp ire faith a n d tr u s t an d tend to n e u tr a liz e
d e s p a ir and hopelessness. T h e th e r a p i s t s belief
in him self an d in his tec h n iq u es m u s t, of
course, be real, since sim u la te d o p tim ism will
easily be detected a nd will d a m a g e th e r e l a
tionship.
cord in gly tries to correct attitu d e s th a t will i n

terfere w ith estab lish in g a th e r a p e u tic alliance.
S h o u ld the th e ra p ist p r e p a r e the p a tie n t

f o r t e r m i n a t i o n o f t r e a t m e n t at t h e first
in te rv iew ?
P r o p e r p r e p a r a t i o n of th e p a tie n t for t e r m i
n a tio n is a n ex tre m e ly i m p o r t a n t, yet th e most
grossly neglected, aspect of tr e a tm e n t. T h e
t h e r a p is t sh o u ld be ale rte d for signs, even in
th e first interview , of i m p e n d in g p ro b le m s w ith
t e r m i n a ti o n since the e n d in g of tr e a t m e n t can
be e x trem ely difficult an d d is tu rb i n g for som e
p atien ts . M o r e o v e r , th e th e r a p is t will need to
T h e r e is s o m e c o n t r o v e r s y a b o u t t h e r o l e
o f p o s it iv e e x p e c t a t i o n o n t h e p a r t o f th e
p a t i e n t in p r o m o t i n g c h a n g e . D o e s e x p e c
tatio n in flu e n ce s h o rt-te rm th e ra p y ?
d e p e n d e n t on h im . T h e th e r a p is t m a y co nsid er
t h e t e r m i n a t i o n o f t r e a t m e n t a f o r m of
be a w a r e o f his o w n guilt at d is c h a rg in g som e

p atien ts , p a r t ic u l a r ly th ose w h o h ave become
As is usual in som e q u estion s, the a n s w e r is
a b a n d o n m e n t. O n th e p a t i e n t s p a r t , t e r m i n a
yes an d no. E x p e c ta tio n th a t one will ch an g e
tion m a y k in d le p re vio us u p se ttin g re actio ns
acts as a place bo e n h a n c in g th e p a t i e n t s faith
w ith exp erien ces of s e p a r a ti o n o r loss even as
in th e th e r a p is t a n d
in the o p erativ e te c h
far back as child ho od . T h e p a ti e n t m a y in t e r
n iq ues. T h e t h e r a p e u ti c s itu atio n itself is a
p re t te r m i n a ti o n as a sign of th e t h e r a p i s t s ir
suggestive a r e n a th a t p ro m o te s e x p ecta tio n s of

change. O n the o th e r h a n d , e x pec tatio n m a y
resp on sibility or lack of concern a n d this will

activ ate a d evalu ed self-image. If a t th e first in
be bridled to certain a s s u m p tio n s a b o u t th e

t h e r a p i s t s p o w e r an d invincibility th a t can be
terv iew th e th e r a p is t discusses w ith th e p a tie n t
unrealistic. W h e n the p atie n t learn s th a t the

th e r a p is t h as no m agic a n d th a t th e p a tie n t
tr e a tm e n t w ith re s e n tm e n t a n d feelings of loss,
h im self m u st w o r k to achieve c han ge, his e x

p ecta tions m ay d w in d le to n o th in g a n d m ay
even act as a negative placebo.
Is y o u r i m m e d i a t e i m p r e s s i o n o f w h e t h e r
y o u lik e a p e r s o n o r n o t a g o o d g a u g e o f
h o w t h e r e l a t i o n s h i p w ill d e v e l o p ?
T h a t d ep e n d s on w h e th e r th e th e r a p is t is
able to a n a ly z e his o w n c o u n te rtra n sfe re n c e
an d prejudices. In itial im p ression s a re often
the p ro d u cts of p ast ex periences w ith a perso n
o r p erson w h o m the p atie n t resem ble s o r of in
toleran ce related to th e p a t i e n t s race, religion,
sex, age, facial ex pression , m a n n e r , speech,
a n d th e like. M isco n cep tio n s can a b o u n d , but
a m a t u r e th e r a p is t keeps a n a ly z in g his ow n
reaction s to see w h e th e r th ey a re the result of
co u n te r tr a n sfe re n c e o r prejudice, an d he ac
t h a t som e p a tie n ts re s p o n d to te r m i n a ti o n of
this m a y ease, th o u g h no t entirely dissipa te,
th e p a t i e n t s even tua l reactio n of a n g e r an d
d is a p p o in tm e n t.
W h e r e the histo ry reveals a n e arly loss of,
s e p a r a tio n from , o r a b a n d o n m e n t by a p a r e n t ,
th e th e r a p is t m u s t be trip ly m ind fu l of th e
need to p r e p a r e th e p a tie n t for te r m i n a ti o n an d
to w a tc h for e a rly signs of a n g e r, d ep ression ,
a n d grief. T h e p a tie n t, as p a r t of tr e a tm e n t,
should be en co u ra g e d to talk a b o u t develo ping
s e p a r a tio n re actio ns as well as past se p a r a tio n
experiences. A m o n g th e e m e r g in g se p a r a tio n
reactio ns will be a r e t u r n of old c o m p la in ts
a n d the d ev elo p m e n t of n ew sy m p to m s such as
an x iety , d e pre ssio n, an d p sy cho som atic c o m
plain ts. S om e p a tie n ts re s p o n d to te r m i n a ti o n
by d enial; w h e re th e r e a re signs of th is, th e
th e r a p is t m u s t actively in t e r p r e t th e resp on se.
V astly im p o r t a n t is the need for th e th e r a p is t
59
not to consider the p a t i e n t s hostility as a p e r
w a iti n g list after a n in itial interview . F o r e x
sonal affront.
a m p le , in on e stu d y (S loan e et al., 1975) 94
A re p s y c h o lo g ic a l tests n e c e s s a r y in s h o r t
te rm th erap y ?
p a tie n ts w ere seen initially by ex perienced

th e r a p is ts a n d th e n ra n d o m ly assigned to (1) a
G e n e ra lly , no, A ra p id e x p o su r e of th e p a
w a iti n g list, (2) s h o r t-t e rm b e h a v io r t h e r a p y ,

a n d (3) s h o r t- t e r m p sy c h o an aly tically o rien ted
tient to the R o rsc h a ch c a rd s an d to a m a n w o m a n d r a w i n g , t h o u g h th e y a r e s t r ic t ly
p s y c h o th e ra p y for 13 or 14 sessions. F o llo w - u p

after 4 m o n th s by assessors sh o w ed th a t ta rg et
sp eak in g not tests in the form al sense, a re
sy m p to m s in all th r e e g ro u p s im p ro v e d , but
so m e w h a t m o re so in the tre a te d g ro u p s . W o r k
som etim es helpful d iag no stically a n d to w a rd

sp ottin g a d y n a m ic focus. T h e sam e c a n be
said for the T h e m a t i c A p p e rc e p tio n C a r d s .
W hat ab o u t the M in n e so ta M u ltip h a sic

T e st?
an d social a d ju s tm e n t sh o w ed no differences.
A ll th ree g ro u p s 1 y e a r an d 2 years after the
initial in tervie w h a d im p ro v e d significantly
re gard less of w h e th e r o r not f u r th e r t r e a t
m e n t w a s received d u r i n g this p e r i o d . W e
A g re at deal of in fo rm a tio n can be gotto n
m ig h t c onclude fro m this th a t w ith the n o
from the M M T , a lth o u g h a good in terv ie w er

can get sufficient m a te ria l to w o rk on th r o u g h
t r e a tm e n t g r o u p d o in g a lm o st as well as the
tre a te d g ro u p s after 4 m o n t h s a n d fully as well
o r d i n a ry history tak ing . M o s t th e r a p is ts do not
after 1 a n d 2 years, form al p s y c h o t h e ra p y w as
give th e ir p a tie n ts r o u t in e tests like th e M M T ,

intelligence tests, an d the like, unless th e r e are
d ispensable.
special reason s for testing.
T h e fallacy of this a s s u m p tio n is th a t w e fail

to credit th e in itial in terv iew w ith th e t h e r a
p eu tic im p act th a t it c an score by itself even
Is it a d v i s a b l e to m a k e a n i n i t i a l d i a g n o s i s
o n e v e r y case?
Yes, for m a n y reasons. T h e initial diagnosis,
how ever, m a y have to be c h a n g e d as m o re in
w h e re no f u r th e r professional h elp is secured.

N o r is it tr u e th a t a p a ti e n t on a w a iti n g list
la ng uish es w ith o u t e x p lo itin g o th e r h e lp in g
resources. O fte n after a good in itial interv iew
fo rm a tion is o b ta in ed d u r i n g th e r a p y .
the p a tie n t will h av e o b ta in e d sufficient s u p

p o rt, r e a s s u ra n c e , a w a re n e s s , a n d h o p e to
A re p a s t d r e a m s i m p o r t a n t to e x p l o r e in
the in itial in te rv iew ?
ble h e lp in g aids ou tsid e of form al tr e a tm e n t.

W e sho uld , th erefo re, con sider even a single
m u s te r latent co p in g capacities or to find s u i ta
V e ry m u c h so. D r e a m s often reveal th e o p

erative d y n a m ic s not o b ta i n a b le th r o u g h u su al
interview tech niqu es. R epetitive d r e a m s an d
n ig h tm a r e s a re especially im p o r t a n t. A sk in g
for d re a m s th a t th e p atie n t can re m e m b e r from
ch ildhood m a y also be valuable.
It h a s b e e n s ta te d t h a t p a t i e n t s w h o w e r e
i n t e r v i e w e d a n d p u t o n a w a i t i n g lis t d i d
a l m o s t as w e ll o n t h e i r o w n as t h o s e w h o
w e r e a c c e p te d f o r f o r m a l t r e a t m e n t . If
th is is t r u e , is n o t t h e r a p y s u p e r f l u o u s ?
in ta k e interview a form of s h o r t- t e r m th e r a p y .
T h a t even o n e or tw o sessions have on fol
lo w -u p registered them selves th e r a p e u tic a lly
on p a tie n ts h a s been r e p o r te d by a n u m b e r of
observers, such as M a l a n et al (1975). N o t
o nly h a d s y m p to m a tic im p ro v e m e n t occu rred ,
b u t in so m e ca ses th e s o l i t a r y i n t e r v i e w
a p p e a r s to h a v e r e l e a s e d fo rces p r o d u c i n g
noticeable, a n d in som e cases significant an d
lastin g d y n a m ic , changes. At the B eth Israel
Some skeptics d o w n g ra d e p s y c h o th e ra p y byp o in tin g ou t th a t th ere is no a d v a n ta g e in
Flospital in B oston a sizable g r o u p of p a tie n ts

w ere given a d iag n o s tic inte rview in th e form
of a tw o-session eva lua tion . N o o th e r th e r a p y
w a s a d m in is te re d . A follow -u p in terview 1
formal tr e a tm e n t to sim p ly being placed on a
m o n th
late r revealed
a subgroup
who
im
60
p rov ed w ith no o th e r th e r a p y . T h e results

co nfirm the con ception of th e diagn ostic in t e r
view as a d y n a m ic in te rp e r s o n a l process a n d
ad ds s u p p o r t to th e evidence th a t b rie f psy
c h iatric contac t d u r i n g tim es of stress can
su stain
or co n tin u e th e ir im p ro v e m e n t will
p ro b a b l y d e p e n d on th e n a t u r e of th e ir t r a n s
f o r m a t i o n , t h e i r p r e v a i l i n g m o t i v a t i o n to
c h a n g e , t h e i r a b i l i t y to r e l e a s e th e m s e l v e s
fro m th e ir m a l a d a p ti v e co p in g p a tt e rn s , a n d
p ro d u c e significant c han ges in affect a n d b e
w h e th e r o r no t th e i r e n v ir o n m e n t reinforces o r
h a v io r . W h e t h e r p a tie n ts w h o im p ro v e will
d isco ura ges th e dev elop in g a lte ra tio n s.
CHAPTER 6
The Initial Interview

B. Case Histories
A lth o u g h every initial interv iew will be co n

ducted so m e w h a t differently d e p e n d in g o n the
terview s th a t b ri n g ou t som e salient featu res

c o m m o n ly en c o u n te re d in first, a d e v e lo p m e n
p rese ntin g p ro b le m , the ca p a city for v e rb a l iz a
tal p e rs o n a lity p ro b le m , second, a n obsessive
tion, the p e rs o n a lity of th e p a tie n t, th e initial

resistances, co u n te rtra n sfe re n c e a ro u s a l, a n d so
n eurosis,
on, certain basic tech n iq u es a re m anifest. T h i s
te r m th e r a p y .
and,
th ird ,
schizoid p e rs o n a lity
d is o rd er, w h o is no t d eem e d s u ita b le for s h o r t
c h a p te r consists of th ree tra n sc rib e d in itial i n
Case 1
boy w ho se
a b o u t his difficulties, b u t to con fro n t th e p a
p a re n ts called for an a p p o in t m e n t , say in g th a t

he w as failing at school, defying his p a re n ts ,
tient. C o n f r o n t in g this boy w ith his resistan ce
f i g h ti n g w i t h
as a shock s tim u lu s s ta rtin g h im off to w a r d e n
The
p a tie n t
is a
16 -year-old
so m e o f h is c l a s s m a t e s
and
a n d v e rb a liz in g his rig h t to be a n g ry m a y act
W h a t concerned
listing the th e r a p is t as an ally to m a n i p u la t e
th e m most, h o w ever, w a s his go ing steady w ith

a girl. T h e y d id no t a p p ro v e on th e basis th a t
th e p a r e n t s to a b id e w ith his o w n desires. In

this w a y a re la tio n s h ip gets sta rte d th a t m ay
he w a s too y ou ng for a serio us relatio n sh ip .

T h e y w ere d e sp e r a te for som e direction as to
have th e r a p e u ti c p o ten tialities.
w h a t to do. T h e boy h ad resisted going to see a
T h . So th e y fin a lly c a p tu r e d y o u a n d b r o u g h t you
th e r a p ist un til th ey cut off his allow an c e , an d
h e re , h u h ? ( T h e r a p is t sm ile s a n d th e p a tie n t
then he consented to one a p p o in t m e n t . T h e
lo o k s u p , o b v io u s ly su rp ris e d . H e p a u s e s , th en
gen erally being o bn oxious.
b re a k s o u t in an e m b a r ra s se d la u g h .)
p a re n t s a c co m p a n ied h im a n d sat in th e w a i t
ing roo m . T h e session b rin g s ou t h o w to deal
w ith a defiant adolescent so th a t he m a y co n
tinu e in th e r a p y as well as h o w to select a d y
n am ic focus.
At the a p p o in te d tim e th e p a tie n t en te re d
my office, slouched into a chair, an d looked
a b o u t the ro o m in a n o n c o m m itta l w ay. T h e
P t.
Y es sir.
T h . A r e n t yo u so re a b o u t it?
P t.
N o , I g u e ss n o t.
T h . I d be fu rio u s , if I w e re in y o u r p o sitio n .
P t.
N o , I m n o t.
T h . A fter a ll, w h y w o u ld y o u co m e to see m e, e x

cept th a t th e y in v eig led y o u in to th is ? (s m ilin g
as i f jo k i n g )
tactic I have found useful in de alin g w ith such

reactio ns is not to engage in criticism s o r accu
T h . H o w d id th e y s p r in g it on y o u ?
sations, an d no t even to qu estio n th e p a tie n t
P t.
P t.
I fo rg o t a b o u t th is u n til last n ig h t.
W e h a d a n a p p o in tm e n t a t 1 0 :3 0 , th e y said.
62
T h . W h a m , j u s t lik e t h a t for w h a t re a so n d id
th e y give y o u ?
P t.
T h . W h a t do th e y ob ject to a b o u t h e r?
P t.
I d o n t k n o w th e y th in k I m sick I guess.
d o n t
T h . Y ou m e a n th e y th in k y o u re m e n ta lly sick?
P t.
P t.
m y m o th e r felt sh e s h o u ld n t h a v e called u p , I
u p so m e th in g is w ro n g .
g u ess. I s h o u ld h a v e ju st g o n e th e r e a n d m et
h e r. I d o n t k n o w w h a t it w as.
N o.
T h . In o th e r w o rd s, w h a t th e y a r e tr y in g to do is to
b r e a k th is th in g u p ?
th e sto ry o n th a t?
P t.
1 d o n t k n o w i t s j u s t th e w a y I get a lo n g
T h . A h h h , is th a t w h a t th e w h o le sto ry is a b o u t?
P t.
Yes.
w ith y o u r p a r e n ts ?
P t.
W e ll, ju s t so m e tim e s th e y re d iffe re n t, I d o n t

k n o w , th ey h a v e d iffe re n t v iew s a b o u t k id s an d
I d o n t k n o w . I g u ess it s tw o w ays.
th a t. T h a t s th e big g est g rip e , w ith th a t g irl.
T h . A re yo u g iv in g th e m a h a r d tim e ? A re you
T h . W ho
re a lly ? W h a t a re you d o in g ?
do
you
get
a lo n g
w ith
b e tte r ,
your
m o th e r o r y o u r fa th e r?
I d o n t k n o w , I d o n t go o u t of m y w a y , b u t I
P t.
have
T h . N e ith e r o n e of th e m . T h e y re b o th d ifficu lt
little
g ru d g e
a g a in s t
th e m .
I d o n t
k n o w , (p a u se)
sa m e th in g ? (p a u se) D o you th in k th a t if you
th e g ru d g e ?
g av e u p th is g irl th e y d be a n y d iffe re n t?
I d o n t k n o w .
P t.
T h . T h e y m e n tio n e d so m e th in g o n th e te le p h o n e .
Y o u re a t sch o ol n o w , a w a y fro m h o m e a n d
y o u ve g o t
N e ith e r.
r ig h t a t th is tim e ? A n d th ey b o th h a r p on th e
T h . W e ll, w h a t h av e th ey d o n e do th e y d eserv e
(p a u se) S o ?
g ir lf r ie n d is
th a t
th e
[ / n o te th a t th e p a tie n t se e m s
I d o u b t it.
T h . T h e y d p ick on so m e th in g else?
P t.
sto ry ?
a n g ry a n d fid g e tty . I d ecid e to s h o w h im th a t
I d o n t k n o w , you k n o w m y s is te r a n d I a re
very close, (p a u se)
T h . Y o u r sis te r a n d you a r e very close.

P t.
A n d yo u k n o w , s h e s u p a t co lleg e r ig h t n o w .
in c o n tr a st to h is p a r e n ts I b elieve h e h a s the
W e w rite . S h e w ro te m e a le tte r th a t i t s so
rig h t to ch o o se h is o w n c o m p a n y .] W h y do
d is a p p o in tin g
y ou th in k th e y stick th e ir nose in to th a t th in g ?
a n y tim e th a t sh e fin d s a b o y frie n d , o r a n y tim e
I d o n t k n o w .
T h . D o n t y ou re se n t it? D o y o u tell th e m e v e ry
th in g ?
to c o m e
hom e
because
th a t
I fin d so m e o n e w e ll, th is is re a lly th e first

g irl
I ve b een
p r e tty
s e rio u s
o v e r I d o n t
k n o w , th e y find ex cu ses a n d th e y re th e w o rst
I tell th e m to a d e g re e . T h e y fin d o u t a n y h o w .
T h . H ow
P t.
Yes
T h . A n y th in g else? A ny o th e r beefs th a t yo u have
p a tie n t m a y be fe e lin g .]
P t.
I d o n t k n o w , a n d th e r e w a s a c a m p re u n io n
W e w e re g o in g to h a v e a c a m p re u n io n , a n d
tim e ? \H e r e I a m tr y in g to v e r b a liz e w h a t th e
P t.
her
I d o n t k n o w . I th in k th ey th in k I m m ix ed
can ta lk a b o u t th a t. A re th ey g iv in g yo u a h a rd
P t.
B e cau se
w h a t th e re a l p ro b le m is.
T h . Y o u r r e la tio n s h ip s , (p a u se ) W e ll, m ay b e w e
P t.
fo rth .
a n d h e r m o th e r let h e r go on th e b u s w ith m e.
w ith th e m o u r re la tio n s .
P t.
so
sp o k e n to th e m ex cep t b riefly . So I d o n t k n o w
T h . H o w w o u ld th e y get th a t c o n c e p tio n ; w h a ts
P t.
and
h e r b ir th d a y for d in n e r once.
T h . D o yo u feel y ou a r e m ix ed u p ?
P t.
h e r,
T h . So, w h a t s th e b ig d e a l a b o u t th a t?
T h . W h a t do th ey th in k in w h a t a r e a ? I h a v e n t
P t.
lik e
p a r e n ts th e y in v ite d m e o v er to h e r h o u se on
I d o n t k n o w th e y th in k s o m e th in g is w ro n g
I g u ess.
T h e y sa y h e r p a r e n ts a r e to o fo rw a rd , th ey
w o u ld th e y find o u t if yo u k e p t it to
ex cu ses. I m e a n th e y re re a lly b a d . T h e y h av e
t h e ir re a so n s . T h e y say y o u c a n t do th is, you
y o u rself?
c a n t d o th a t. W e ll, D o tty s a id lik e w h e n sh e
I d o n t k n o w . S o m e tim e s I see h e r, th e n I ll
c a m e h o m e last tim e sh e sa id it w a s a d is a p
co m e h o m e , a n d th e n th ey seem to find o u t.
p o in tm e n t to h e r. H e r v a c a tio n s ta rte d w h e n
T h . H o w w o u ld th e y k n o w th a t y o u see h e r?
sh e w e n t b ack to school. S h e sa id sh e w a s m o re
P t.
If so m e o n e sees m e w ith J a n e , th e n th e y tell
h u r t w h e n sh e c a m e h o m e lik e, sh e s a id , w h e n
th e m .
y o u re a w a y , e v e ry th in g
T h . Y ou m e a n th e y r e p o rt o n y o u ?
P t.
is p ro g re s s in g
an d
w h e n y o u com e h o m e , i t s ju s t a s s ta g n a n t as
W e ll, so m e o n e m u st b ecau se I k n o w I once
i t s a lw a y s b een , a n d , I d o n t k n o w , it looks
w e n t o v er to h e r h o u se . N e x t tim e w h e n I w as
p r e tty b a d . T h e y w o n t c h a n g e .
n o m e , th e y sa id . " Y o u saw h e r , d id n t y o u ?
T h . A n d you m u st k n o w , th e y h a v e th e ir o w n ideas
63
THE INITIAL INTERVIEW: CASE HISTORIES

a n d th e y co m e fro m a d iffe re n t w o rld th a n you
P t.
T h . Is sh e y o u r s te a d y g irlfrie n d n o w ?
com e fro m . I m e a n , y o u r frie n d s a n d y o u r a s
P t.
so c ia tio n s a n d y o u r p h ilo s o p h y a r e d iffe re n t
T h . I m e a n a r e y o u g o in g ste a d y ?
th e s e d a y s th a n in th e ir d a y . So you m u s t feel
P t.
th e y a re tr y in g to im p o se o ld -fa s h io n e d ideas
T h . W o u ld you m a r r y a g irl lik e th is ?

P t.
I d o n t k n o w , p r e tty m u c h tr y in g to p u t th e ir
T h . E v e n tu a lly ?
id e a s o n m e. L ik e if th e y say y o u c a n t see h e r,
P t.
to go w ith o th e r g irls, I m e a n , b u t a t th e b e
y o u re all set to fig h t th e n e x t lin e.
g in n in g th e y sa id she h a d n o th in g in co m m o n
w ith m e. I m n o t s a y in g s h e s n o t in co m m o n
w ith m e, b u t I m sa y in g (p a u se).
I k n o w . R ig h t n o w m y p a r e n ts n o tice it, a n d
T h . W e ll, sh e d o es h a v e s o m e th in g in co m m o n
w ith y o u ; y o u w e n t to c a m p to g e th e r.
t h a t s v ery u p se ttin g , b u t a n y tim e th e y s ta rt to

ta lk to m e, I d o n t k n o w , I get set for a fig h t o r
P t.
tiv e g irl, I d o n t k n o w , S h e s s m a rt m y p a r e n ts
T h . B e cau se y o u feel th e y re c ritic a l of you. W h a t
say.
w o u ld be th e w o rst th in g th a t co u ld h a p p e n if
T h . Is sh e a g o o d -lo o k in g g ir l? S e x y ? S o -so ?
you co u ld see th is g irl a ll you w a n te d ?

N o th in g , b u t th e y feel th a t. W e ll, it sta rte d
P t.
off I w a s a lw a y s se e in g o n e g irl. It w a s h er.
T h . A n d s h e s e asy to ta lk to ?
T h is w a s a fte r last s u m m e r, a n d th e n th e y said
S h e s n o t sex sta rv e d , b u t s h e s all rig h t.
P t.
Y e a h , w e sit a r o u n d a n d ta lk , a n d w ith h e r
I c o u ld n t go o u t w ith o n e g irl, a n d yet I h a d
p a r e n ts .
b een o u t w ith h e r o n ly th re e tim e s. I h a d been
p a r e n ts a n d h e r b r o th e r.
We
all
get
a lo n g
real
g ood,
o n ly th re e tim e s? D o you give th e m a n a c
P t.
I g u e ss e v e ry o n e does.
T h . E v e ry b o d y s o w n p a r e n ts a r e n o g o o d , you
m ean?
c o u n tin g of e v e ry th in g th a t goes o n ?
P t.
I d o n t tell th e m a n y th in g .
T h . Y ou feel t h a t s y o u r b u sin e ss, r ig h t? H a v e you
Y eah .
T h . S h e h a s a m o th e r a n d fa th e r.
th o u g h t y o u sh o u ld go o u t w ith o th e r g irls too
P t.
ju s t to p le a s e th e m ?
T h . B u t h e r p r e s e n t s te p fa th e r is a nice g u y ?
I c a n , b u t I m a d e th e m ista k e th e n , yo u k n o w .
P t.
to
d a te
one
g ir l, th e n a n o th e r ,
th e n
W e get a lo n g good lik e w h e n I go o v er th e re .
T h . C a n t y o u ta lk th a t w a y w ith y o u r o w n d a d ?
a n o th e r . If I w a n te d I could d a te th is g irl, th e n
P t.
u p , a n d th e n th e y fin a lly sa id , Y o u c a n t go
I d o n t k n o w , I c la m u p w h e n I m a r o u n d h im .
I d o n t k n o w w h y .
a n o th e r a n d a n o th e r , see. A n d I d id n t follow
T h . D o you feel h e s lo o k in g d o w n on y o u , o r h e s
c o n d e m n in g y o u ? O r w h a t?
o u t w ith h e r .
P t.
T h . A t a ll?
P t . A t a ll, th is is
a lo n g tim e
tin u e d to see
h e r a little
d o n t
la s t
know ,
I th in k h e r f a th e r d ied .
H e a n d I w ill s ta r t ta lk in g fo r a w h ile .
I k in d o f u n d e r s ta n d it, b u t th e n th e y sa id I
had
her
T h . D o y o u lik e h e r p a r e n ts b e tte r th a n y o u rs?
o v er h e r h o u se a n d stu ff lik e th a t.
T h . H a v e y ou b een o v er since y o u ve b een h o m e
ag o , a n d th e n I c o n
b it, a n d th e n w e, I
T h a n k s g iv in g , w e
had
I d o n t k n o w w h a t it is, b u t h e b o th e rs m e a n d
I w is h h e d i d n t.
T h . Y o u d lik e to g et h im off y o u r b ac k ? I d lik e to

h e lp yo u get h im off y o u r b a c k , re a lly , if th a t is
w h a t yo u w a n t, b u t h o w ? [H e r e I a m j o i n in g
p r e tty b a d w eek e n d .
th e p a t i e n t s fe e lin g s . T h is is in lin e w ith th e
T h . O h , y ou m e a n th e last tim e yo u w e re h o m e ?
d e sire to fo r m an a llia n c e w ith th e p a tie n t. ]
T h e fu r w a s fly in g ?
P t.
Y e a h , th e r e s a lo t of th a t stu ff a n d s h e s n o t
a th le tic in th e m u s c u la r se n se, b u t s h e s a n a c
so m e th in g .
P t.
I m e a n I m n o t g o in g to sta y w ith h e r fo r th e
U s u a lly w h e n th e y sa y , Y o u c a n t see h e r ,
see h e r, in w a rd ly y ou s ta r t re b e llin g .
P t.
I d o n t see w h y n o t.
re st o f m y life u n til I g e t m a r rie d . I m b o u n d
T h . In o th e r w o rd s, th e m in u te th e y say y o u c a n t
P t.
No
o n yo u .
I d o n t k n o w , I t s a lw a y s th e sa m e excuse.
P t.
I d o n t c o n s id e r it; m y p a r e n ts say so.
Y es, th e n th ey sa id , fin a lly , Y o u c a n n e v e r see
P t.
h e r a g a in . W e ll call h e r if w e th in k i t s n eces
T h . I d o n t k n o w if I c a n , b u t I ll tr y , if y o u give
I h o p e you can .
sa ry . W e ll sp e a k to h e r p a r e n ts a n d tell th e m
m e a n id e a w h a t I ca n do. W h a t I co u ld tell
th a t th e y re b rin g in g u p th e ir c h ild w r o n g .
h im is th a t th e ta c tic s th e y a r e u sin g a r e n ot
M a y b e i t s n o t fo r m e to say , b u t w h o a r e th e y
th e r ig h t ta c tic s. A ll th e y do is a n ta g o n iz e you.
to sa y th e y re n o t b rin g in g u p th e ir ch ild rig h t?
A fter a ll, th is g irl is n t g o in g to do a n y th in g
64

te r rib le to y o u . [ / a m n o t su r e w h e th e r o r n o t
T h . G o a w a y to co lleg e yo u m e a n ? W h a t a r e you
g o in g to do th is su m m e r?
th e p a tie n t is g iv in g m e th e rig h t d a ta a b o u t
th e p r o b le m . H e s o u n d s re a so n a b le in re se n t
P t.
ing, a t h is age, th e in te rfe r e n c e o f h is p a r e n ts
T h . W e ll liste n , b e tw e e n y o u a n d m e, w h y c a n t
in w h a t se e m s to be an a vera g e b o y - g ir l rela
y o u go a r o u n d w ith o th e r g irls a n d th e n do
w h a t you w an t an y w ay s?
tio n sh ip . I f w h a t h e sa y s is co rrect, it is th e
p a r e n ts
who
n e e d s o m e c o u n s e lin g
about
a d o le sc e n t n ee d s a n d p r o b le m s a n d th e p r o p e r
P t.
I d o n t k n o w yet.
P t.
(la u g h in g )
T h . Y ou k n o w you c a n h a v e a r u n n in g b a ttle g o in g
w a y to m a n a g e th e m se lv e s. ]
o n w ith th e m all th e tim e th e w a y th in g s a re .
I d o n t k n o w , s h e s k in d o f c u ltu re d in a w ay.
T h e r e s no se n se to it, b e c a u se th e y ll get very
T h . S h e s c u ltu re d .
u p se t a n d s ta r t b u s tin g y o u r re la tio n s h ip s u p .
P t.
Y e a h , I d o n t k n o w w h a t th e y g ot a g a in s t h e r.
A p p a r e n tly , yo u d o n t w a n t th e m b u ste d u p.
S h e k n o w s h o w to b eh a v e a t d iffe re n t tim es.
Y o u ve got to be s m a rt a b o u t th e s e th in g s . I m
n o t tr y in g to give yo u a n y a d v ic e o n h o w to
Y o u k n o w sh e k n o w s ju s t h o w to act.
T h . S h e so u n d s v ery nice.
c o n d u c t y o u rse lf, b u t I k n o w th a t th e s e th in g s
P t.
c a n get v e ry , v ery stick y . Y ou c a n g e t y o u rse lf
T h a n k y o u , t h a t s w h a t sh e is, b u t do you
k n o w a b o u t F a irv ie w w h e re w e live. T h is n ew
in to
elite a n d th e n th e v illag e?
n o m ic a lly d e p e n d e n t o n th e m fo r a w h ile a n y
a ja m
w ith
th e m ,
and
yo u
are
eco
T h . (sm ilin g ) Y o u m e a n t h a t s w h e re all th e k id s
w a y s. So w h y c a n t yo u give th e m a n id e a th a t
th a t h av e p a r e n ts w h o h a v e p ro b le m s live. T h e
y o u r e g o in g o u t w ith o th e r g irls to o ? M a y b e
P t.
p a r e n ts h a v e p ro b le m s n o t th e k id s? (la u g h in g )
b r in g o n e o r tw o a r o u n d y o u k n o w . W h a t s
O h (la u g h in g ). W e ll, m y f a th e r sa id th e re a so n
th e b ig d e a l, yo u co u ld go o u t w ith o th e r g irls
th ey d i d n t lik e h e r , sh e w a s u sin g m e a s a b a it
if yo u w a n te d to, c a n t y o u ? [In g iv in g th e p a
to c lim b so cially.
tie n t th is a d vice, I a m te s tin g m y o w n c a p a c ity

to in flu e n c e h im a t th is p o in t. I a m n o t su r e he
T h . D o e s y o u r g i r l s fa m ily com e fro m a lo w e r eco
w ill ta k e m y a d vice to d e fu s e th e s itu a tio n .]
n o m ic s ta tu s class?
P t.
I d o n t th in k so. T h e y u sed to live in Q u e e n s ,
P t.
w h ic h is n t g o o d , a n d th e y m oved to w h e re
T h . I m e a n , y o u d o n t ev en h a v e to te ll th is gal
a n y th in g a b o u t it if you d o n t w a n t to.
th e y a r e n o w . A nice h o u se , b u t th e n m y f a th e r
said so m e of h e r b est frie n d s a r e k id s th a t m y
P t.
W e ll, y o u see lik e la s t n ig h t, I w a s su p p o s e d to
fa th e r lik es. So I to ld h im I th o u g h t th is w o u ld
go to a p a r ty . W e ll, I to ld m y p a r e n ts it w a s
m a k e h im lik e h e r o r s o m e th in g , a n d h e said
g o in g to be a p a r ty . It w a s k in d a m y fa u lt. I
w h a t sh e is d o in g is sh e is c lim b in g , sh e is u s
sa id it w a s C h r is tm a s E v e, a n d if sh e w a s
in g th ese frie n d s to c lim b u p th e la d d e r. All
g o in g to be a t th is p a r ty a n d if sh e w a s g o in g , I
sh e w a n ts is h e r frie n d s in o u r a r e a for th e
w a s g o in g w ith m y b est frie n d a n d som e g irl he
m o n ey , etc.
k n e w . A n d I w a s g o in g to go, a n d I a sk ed m y
m o th e r, a n d sh e sa id I co u ld go p r o v id in g
T h . H o w d o es h e k n o w th a t, he d o e s n t even k n o w
P t.
I ca n .
h e r?
a n d t h a t s o n ly o n e th in g w e a s k you to do a n d
I th in k h e s seen h er.
t h a t s n o t to see th is g ir lj u s t lik e th a t. A n d
T h . H o w ca n h e a n a ly z e w h a t sh e is d o in g w ith o u t
sh e sa id , Y o u ll h a v e to give y o u r f a th e r a ll
ta lk in g to h e r. [ / a m d e lib e r a te ly s id in g w ith
th e d e ta ils , e tc ., h o w th e p a r ty is g o in g to be,
P t.
th e p a tie n t to f i r m u p o u r r e la tio n s h ip .]
h e w a n ts to k n o w m o re a b o u t i t . So I to ld m y
I d o n t k n o w , b u t th is is w h a t he sa y s. S h e s
frie n d to go a h e a d a n d see h is g irl la s t n ig h t.
tr y in g to c lim b so c ially , a n d s h e s j u s t g o in g to
A n d w h a t w e w e re g o in g to d o ? W e w e re
d r o p m e. T h is is w h a t h e says.
g o in g to p la n a good o n e th e r e w o u ld be in
v ita tio n s.
T h . T h a t s w h a t h e sa y s, b u t th a t d o e s n t m e a n i t s
so, is it? [again, s id in g w ith th e p a t ie n t to p r o
T h . Y o u re le ttin g so m e b o d y else do th e in v itin g ,

a n d y o u re ju s t b e in g in v ite d to a p a r ty ?
m o te a n id e n tific a tio n ]
P t.
I k n o w , b u t h o w ca n I a rg u e w ith h im ? I d o n t
k n o w , th e w a y 1 fig u re it is I w o n t be h o m e
th a t lo n g a n d th e re w ill be a c o u p le o f a r g u
m e n ts o r so, a n d th e n I ll go a w a y .
P t.
I d o n t k n o w . T h e y u s u a lly fin d o u t a b o u t th a t
stu ff a n y h o w .
T h . W e ll, lo o k , w h a te v e r th e y fin d o u t, t h a t s it.

Y ou d o n t h a v e to tell th e m e v e ry th in g you do
at your age, do you?

P t.
N o , I d o n t in te n d to.
65
P t.
T h . A ll rig h t, if y o u w a n t m e to I ll tr y to tell th e m
sc re w e v e ry g irl I see.
th a t th ey a re m a k in g a big fu ss o v er n o th in g .
T h . W e ll, w h a t y o u d o is y o u r o w n b u sin e ss, t h a t s
[I g e t th e im p re ss io n th e p a ti e n t n e e d s an a lly ,
th e p o in t. W h a t yo u do is y o u r o w n b u sin e ss
a n d 1 a m p r o p o s in g a n a d vo ca cy ro le on m y
y o u c a n sc rew th e g irls y o u w a n t if t h a t s w h a t
p a r t.]
P t.
Y o u , I m e a n th a t I m n o t g o in g to go o u t a n d
See,
y o u w a n t.
if y o u
tell
th e m
t h a t I d o n t
S o m e tim e s th e y a lw a y s h a v e good sto rie s, like
[s u p p o r tin g th e p a t i e n t s rig h t to
a u to n o m y ]
know .
P t.
W h a t I m e a n is if th e y r e g o in g to a ct lik e if
s o m e th in g w ill go o n in th e h o u s e y o u k n o w
th o s e a r e th e ir m o tiv es for b r e a k in g th is u p
b etw een m y m o th e r a n d I a n d th e n w h e n m y
th e n th e y ll do it w ith th e n e x t g irl a n d th e
f a th e r co m es h o m e a n d I liste n to h e r te llin g
h im w h a t goes o n . Y o u k n o w , it n e v e r w e n t
n e x t g irl.
T h . T h e y m ig h t, th e y m ig h t, i ts p o ssib le , b u t th e
on.
facts a r e
if y o u w a te r th a t s itu a tio n d o w n ,
T h . So th a t m a k e s y ou v ery fu rio u s.
y o u ll p ro b a b ly g e t th e m off y o u r b ack . W h a t
P t.
I m e a n th e y ca n tw ist a sto ry so th a t th e y re
y o u d o p riv a te ly is y o u r o w n b u sin e ss, a n d if
th e w h ite k n ig h ts. I m e a n w h e n th e y re h e r e
y o u sc rew a n y b o d y , I g u ess yo u h a v e e n o u g h
i t s n o t u s a n d h e g o es o u t I do go o u t for
se n se to
a r g u m e n ts I m e a n , w h e n th e y m a k e m e a n g ry .
ch a n c e s. Y o u k n o w w h a t I m e a n ? B u t t h a t s
u se a r u b b e r a n d
d o n t ta k e a n y
T h . W e ll, it m u st m a k e you f u rio u s a n d yo u p r o b a
y o u r o w n b u sin e ss a n d n o b o d y ev er n eed k n o w
bly feel y o u ll sp lit a g u t u n le s s y o u com e o u t
a b o u t it yo u n e v e r n eed tell th e m o r a n y b o d y
w ith y o u r feelin g s. Y o u see w h a t th e y object
else, [again, b a c k in g th e p a t i e n t s r ig h t o f a u
to n o m y ]
to , I th in k , th e y d o n t lik e to h a v e you lie.

T h e y d o n t like to h a v e you p u t o n e o v er on
P t.
th e m . T h e y say y o u re n o t s u p p o s e d to d o it,
s u d d e n ly sa id , G iv e m e y o u r w a lle t, a n d she
a n d th e y ex p ect th a t y o u w o n t d o it. N o w ,
w e n t th r o u g h it a n d I h a d a r u b b e r stu c k in
th e in sid e of it.
o b v io u sly , it w o u ld be silly to e x p e c t y o u to
give u p s o m e th in g th a t is v ery v a lu a b le to y o u ,
T h . D id sh e fin d it?
b u t yet th e y still h av e a fe e lin g y o u re still ju s t
P t.
fig u re d it w a s fo rg o tte n . A n d th e n m y f a th e r
A n d som e p a r e n ts n e v e r get o v e r th a t feeling
w e w e re g o in g to get p iz z a o r s o m e th in g a n d
a b o u t th e ir k id s. T h e y w a n t to be p ro te c tiv e ,
he s ta r ts a s k in g m e d id yo u ev e r u se it, w h e n
a n d th ey com e th r o u g h as c o n tro llin g . T h e y
d id yo u u se it, a n d so o n . A n d I sa id , W h a t
d o n t re a liz e th a t y o u h a v e y o u r o w n n eed s,
am
a n d y o u r o w n life, a n d e v e ry th in g else. A n d
p o se d to sa y J a n e a n d I d id t h i s o r S u e an d
I s u p p o s e d to s a y ? T h e n
I m n o t s u p
th e y w o n t get off y o u r b ack on th a t a c c o u n t.
I , a n d It w a s on th e th ird n ig h t o f M a y o r
W h a t y ou h a v e to d o is re a s s u re th e m say to
s o m e th in g .
c a n re a s s u re th e m
is to c o n v in c e th e m
T h . T h is is y o u r o w n p r iv a te a ffa ir, a s lo n g a s you

are
th a t
c a re fu l
and
y o u d o n t get y o u rse lf too
to o s e rio u s a b o u t th is b u s i
d e e p ly m essed u p a n d in v o lv ed . T h a t s y o u r
n e ss th e r e s n o th in g too s e rio u s a b o u t y o u r
o w n b u sin e ss a n d y o u re r ig h t in re s e n tin g h e r
se e in g th is g irl a n d th a t y o u re n o t g o in g to
ta k in g y o u r p o c k e t b o o k a n d g o in g th r o u g h it,
t h e r e s n o th in g
m a r ry h e r. [m o r e a d vice g iv in g to test o u r rela

tio n sh ip ]
an y w a y s .
P t.
T h a t s tr u e ,
and
o h , th e o th e r th in g , th ey
D o y ou th in k th e y feel I a m ? ( T h e p a tie n t acts
fo u n d P la y b o y s in m y ro o m , so o h h h h h h h h , no
su r p ris e d .)
s m u t in th e h o u se , a n d th e y s ta r t y e llin g a n d a t
T h . T h e y m ay feel y o u re g o in g to be so se rio u s
th a t y o u m ay ev en get h e r p r e g n a n t o r so m e
th e sa m e tim e , I k n o w , I d o n t see a n y th in g
w r o n g w ith it.
T h . T h e r e is n t a n y th in g w ro n g w ith it, b u t w h a t
th in g . Y o u ll be in a j a m th e n .
P t.
Y es, a n d sh e to o k it. S h e d i d n t say m u c h a n d I
th is b ig (in d ic a tin g a s m a ll s iz e w ith fin g e r s ) .
th e m w h a t is tr u e . I th in k th e best w a y you
P t.
O n e d a y , fo r so m e re a so n o r o th e r , m y m o th e r
W e ll, if th e y d o th is w ith ev ery g irl, I m e a n , if
th e y a p p a r e n tly feel is th a t th e y w o u ld like to
th e y feel w e re g o in g to h a v e th ese g r e a t tim es
h a v e a son th e id e a l, m o r a l, s tu d io u s k in d of a
and
g u y . I th in k m o st p a r e n ts w o u ld lik e to p ic tu re
e v e ry th in g ,
i t s g o in g to
tim e . T h e y h a v e to a d m it it.
T h . A d m it w h a t?
happen
every
th e ir c h ild re n a s th a t. I m e a n fro m a n ideal

s ta n d p o in t, a n y th in g th a t goes b elo w th a t ideal
66

a n d th ey s ta r t b la m in g th em se lv e s, s ta r t feeling
T h . N ig h tm a r e s ?
g u ilty , feel y ou m ay be h e a d in g fo r a lot of
P t.
tro u b le . I w o u ld th in k th e ir a n x ie tie s a re n ot
T h . H o w a b o u t d r u g s ? T a k i n g a n y p ills o r th in g s ?
to h u r t y o u th e ir a n x ie tie s a r e m o tiv a te d by a
P t.
c o n c e rn a b o u t y o u . T h e i r m o tiv es a r e p ro b a b ly
N o , n o th in g . S o m e o f th e k id s ta k e g ra ss . I
d o n t lik e it.
h o n o ra b le o n es, you k n o w w h a t I m e a n ? A t
T h . N o w tell m e a little a b o u t y o u r m o th e r.
least th e y h av e a d e s ire to see th a t you d o n t
P t.
get in to p ro b le m s , th a t yo u d o n t get c a u g h t by
a n y g irl, th a t you d o n t get a n y g irl p r e g n a n t,
W hat
c o u ld
tell.
She
P t.
p ro b a b ly w h a t th e ir m o tiv es a re . T h e y m ay be
T h . H o w a b o u t y o u r fa th e r?
liv in g in th e last g e n e ra tio n a n d n o t in th is
P t.
your
p r o b le m
is.
Is
th a t
w hy
th e y
T h . I d o n t th in k y o u re m ix ed u p in so f a r a s w h a t
I c a n t g et to h im . H e d o e s n t
W e g et a lo n g fine. I c a n ta lk to h e r. W e used
to fig h t w h e n I w a s sm a ll. W e lik e each o th e r
now .
T h . H o w d id yo u get a lo n g w h e n yo u w e re a k id ,
d o m in a te a n d c o n tr o l h im .]
I d o n t k n o w I w a s g o in g to ask you.
I to ld y o u .
H o w do y o u get a lo n g ?
P t.
b ro u g h t y ou h e re ? [I a m d e fe n d in g th e p a r e n ts
th e ir p u r e ly se e k in g to
N o.
T h . H o w a b o u t y o u r sis te r, s h e s a few y e a rs o ld e r.
to see i f I can g iv e h im a n o th e r m e a n in g f o r
th e ir b e h a v io r th a n
f a th e r
u n d e r s ta n d .
a n d n eed ed ad v ice a n d th a t 1 s h o u ld e v a lu a te
w hat
my
T h . S c a re d o f h e r?
th a t y ou d o n t get a v e n e re a l d ise a se . T h e s e a re
d ay s. I su p p o s e th e y felt yo u w e re all m ix e d u p
bosses
a r o u n d . K eep s te llin g m e w h a t to do.
on e. T h e y m a y n o t k n o w w h a t goes on th ese
P t.
I d o n t re m e m b e r.
a t h o m e , a t sch o o l?
P t.
O K , I g u ess.
T h . N o p ro b le m s?
you h a v e to ld m e is c o n c e rn e d . [ / g e t th e im
P t.
p re ss io n th a t w e are d e v e lo p in g a re la tio n s h ip .
T h . H a v e m a n y frie n d s ?
N o , n o n e I ca n th in k of.
T h e p a tie n t trie s to m o v e h is c h a ir clo ser to
P t.
m e.] So fa r y ou h a v e n t to ld m e a th in g th a t is
T h . A n y p re v io u s tr e a tm e n t w ith a p s y c h ia tris t o r
a b n o r m a l. \A t th is p o i n t I in tro d u c e q u e s tio n s
a b o u t o th e r s y m p to m s a n d c o m p la in ts.]
O h , yes.
p sy c h o lo g ist?
P t.
N o.
T h . I w a n t to a sk y o u a few q u e s tio n s a b o u t an y
[ / d e c id e to s h o w th e p a t i e n t th e R o rsc h a c h
sy m p to m s y o u m a y h av e. H o w a b o u t te n s io n ?
c a rd s to see i f I can p ic k u p a n y u n d e r ly in g d y
D o you feel te n s e ?
n a m ics. F ro m th e d a ta h e h a s g iv e n m e I c a n
S o m e tim e s I m e a n , yes. N o t a lw a y s.
n o t y e t d isc ern p r o b le m s o th e r th a n p a r e n ts
P t.
T h . U n d e r w h a t c irc u m sta n c e s ?
a n d a d o le sc e n t in co n flic t o v e r b e h a v io r th a t is
P t.
n o t too u n u s u a l. H is sto r y m a y co n cea l o th e r
W h e n I get u p se t a t th in g s.
T h . A n y a n x ie ty , a feelin g y o u re fa llin g a p a r t?
P t.
a sp e cts th a t h e d e lib e r a te ly or u n c o n s c io u sly is
W h y no.
h o ld in g back. I t is p o s s ib le th a t s o m e th in g w ill
T h . D e p re s s io n ?
com e
P t.
R o rsc h a c h cards o r in d ra w in g s. ]
N o t to o b ad .
th ro u g h
in
h is
re sp o n ses
to
th e
T h . P h y sica l c o m p la in ts o r sy m p to m s , lik e h e a d
T h . I m g o in g to sh o w y o u so m e c a rd s, a n d I w a n t
ac h e s, sto m a c h tr o u b le , b o w el tr o u b le , a n d so
y o u to tell m e w h a t yo u see. T h is re a lly is n o t
on?
a te s t ju st a n id e a o f y o u r im p re ss io n s . ( /
s h o w h im th e fi r s t card)
P t.
I d o n t th in k so.
T h . H o w a b o u t se x u a l p ro b le m s?
P t.
T h . P h o b ia s o r fe a rs o r th o u g h ts th a t c ro p u p th a t
P t.
A re th o se th e p ic tu re s yo u look a t a n d I m
su p p o s e d to say w h a t it looks lik e ?

T h . T h a t s r ig h t ev e r seen th e m ?
P t.
N o.
T h . W h a t does th a t look lik e ? (fir st card)

P t.
S le e p O K .
T h . D o y ou d r e a m a little o r a lot?
P t.
OK
frig h te n y o u ?
T h . H o w do y o u sle e p ? A ny in s o m n ia ?
P t.
P t.
N o th in g lik e th a t.
A lo t, b u t I d o n t re m e m b e r a n y d re a m s.
I ve h e a rd a b o u t th e m .
I d o n t k n o w , a n in se ct. C a n I tu r n th is a n y
w a y I w a n t?
T h . A n y w a y yo u w a n t.
P t.
O r a m ask .
T h . R e m e m b e r a n y c h ild h o o d d re a m s ?
T h . A n y th in g else?
P t.
P t.
L ik e o f fa llin g , sc ary .
N o.

T h . O K . W h a t d o es th a t look lik e ? (se c o n d card)
67
P t.
A n y th in g th a t com es to y o u r m in d . So fa r you
T h . A ll rig h t. N o w I m g o in g to a s k y o u to d ra w
a re d o in g v ery w ell.
P t.
I d o n t k n o w ,
it lo o ks lik e a fo o tp rin t o r
so m e th in g . I d o n t k n o w , a face o r so m e th in g .
T h . W h e r e s a face?
P t.
It looks lik e th e a n a to m y o f so m e b o d y I
d o n t k n o w , ( h a n d s c a r d b a ck)
m e a p ic tu r e of a p e rso n .
P t.
A p e rs o n ?
T h . Y es, a n y th in g yo u w a n t. T h is is n o d r a w in g
T h a t.
c o n test.
T h . S h o w m e.
P t.
P t.
T h e r e , th e lo w e r p a r t th e ey es th e n o se
T h . A n y th in g j u s t a p ic tu r e a n y th in g yo u w a n t.
th e eyes.
P t.
I say
I c a n say th e r e s n o th in g se rio u s ly w ro n g w ith
D o y ou m e a n rac e -w ise ?
y o u r m in d .
P t.
W h a t s th e p u r p o s e of h a v in g m e d r a w th is?
T h . I ll tell y o u w h e n you get th r o u g h O K , now
I d o n t k n o w th e y look lik e b o th m en an d
d r a w m e a p ic tu r e of a p e rso n .
P t.
T h . W h a t m a k e s th e m look like m e n ?
A w om an?
(P a tie n t d ra w s an
u g ly w o m a n
w ith large b re a sts h o ld in g a s tic k .)
T h e r e , (p o in ts to p r o je c tio n )
T h . N ow a m an.
T h . Y ou m ean th is is a p e n is ?
P t.
R ig h t.
Y ou d o n t m in d if i t s in s id e ? ( H e d ra w s a
m u s c le m a n liftin g w e ig h ts .)
T h . A n d w h a t m a k e s th e m look lik e w o m e n ?
P t.
D id
y o u re n o t n u ts if t h a t s w h a t y o u re a fra id of.
w o m en .
P t.
w e ig h ts .
T h . N o . Y ou d id p r e tty g ood. I c o u ld testify th a t
T h . N o , n o , a r e th e y m e n , w o m e n ?
P t.
liftin g
It lo o k s lik e tw o p eo p le d a n c in g it looks like
T h . A n y th in g else? W h a t k in d of p e o p le a r e th e y ?
P t.
about
tw o p e o p le d a n c in g b ack to b ack th e o th e r
w ay .
P t.
I ll d r a w
a n y th in g w ro n g w ith th o se p ic tu re s ?
T h . H e r e s th e th ird one.
P t.
Boy o r g ir l?
T h . It d o e s n t m a tte r . [ / g e t th e im p re ss io n fr o m
T h e y look like th ey h a v e b re a s ts r ig h t h ere.
h is re sp o n se s to th e R o rsc h a c h ca rd s th a t h e is
T h . N o w , th is is th e fo u rth one.
im m e r s e d in in c o m p le te se p a r a lio n -in d w id u a -
P t.
U g h , it lo o k s like a d e a d r a b b it. A lso looks like
tio n , fe e ls c r u s h e d
a b a t o r so m e a n im a l th a t got h it w ith a ste am
w ith a p r o b le m in id e n tity ( th ir d card). I co n
ro lle r.
je c tu r e th a t th e w o m a n w ith a stic k in h is fi r s t
(fo u rth
a n d s ix th
cards)
T h . A ll rig h t, h e r e s th e fifth one.
d r a w in g is h is stro n g , p u n i ti v e m o th e r a n d the
P t.
m a n , h is c o m p e n s a tin g m a s c u lin e s e lf] N o w ,
T h a t looks lik e a b a t, th a t re a lly does.
you see I g av e yo u a te s t, a n d th e test w o u ld
P t.
se em to in d ic a te th a t y o u r basic d efen ses a re
N o.
T h . A ll rig h t, h e r e s th e n e x t one. (six th card)
p r e tty good a n d th a t y o u ve g o t a lot of o o m p h ,
P t.
s p a rk , a lot of fire [an a tte m p t a t re a ss u ra n c e ].
It looks like a cat th a t k in d of got h it.
T h . P u ssy cat?
B u t you d o w ith d r a w a n d you do in h ib it w h en
P t.
th in g s g et to o to u g h fo r y o u [sparse re sp o n ses
I d o n t k n o w , so m e so rt of c a t, n o th in g else.
T h . O K , th is is th e sev en th one.
P t.
on ca rd s]. Y ou p u ll b a c k a n d you ju s t d o n t let
A re th ese a n y sp ecial p a tte r n s ?
y o u rse lf co m e o u t o f y o u rself. It a lso in d ic a te s
T h . N o , ev ery b o d y h a s d iffe re n t a sso c ia tio n s.
th a t
P t.
m a s c u lin ity , th a t so m e h o w y o u re n o t too co n
U m m m m m n o th in g .
T h . W e ll, look a t it closely.

P t.
O h,
oh,
it
looks
lik e
are
w o rk in g o u t
y o u r feelin g s of
fid en t a b o u t y o u r feelin g s of m a s c u lin ity a t th e

tw o
p e o p le
d a n c in g
a g a in th e y re w e a rin g a s k ir t o r d resses o r
w h a te v e r. H a v e lo n g h a ir d o s. T h a t s all.
T h . O K , h e r e s th e n ex t o n e. (e ig h th card)
P t.
yo u
p re s e n t tim e . W h y d o y o u sm ile ?
P t.
I fo rg e t. [I g e t th e fe e lin g f r o m th e n o n v e r b a l
re sp o n ses to th e in te r p r e ta tio n s I h a v e m a d e
th a t th e in te r p r e ta tio n s a re co rrect a s s u m p
T w o m en h a n g in g o n to s o m e th in g . T h is w a y it
tio ns. H is r e m a r k I f o r g e t in d ic a te s to m e an
looks lik e a face. I guess th a t looks like a
a c tiv e d e s ire to d e n y . T h e d y n a m ic fo c u s to be
b o m b , (n in th ca rd ) I d o n t k n o w m ay b e som e
w o r k e d o n , i f I a m correct, w o u ld th e n be
m u sc u la r g u y o r s o m e th in g s ittin g in th e back.
h is
Y ou k n o w th e b ack an g le .
p r o b le m s .]
T h . O K , h e r e s th e last one.
s e p a r a ti o n - in d i v id u a ti o n
and
i d e n t it y
T h . A ll r ig h t, n o w w h e re w o u ld th ese p ro b le m s
com e fro m ? F ro m
y o u r r e la tio n s w ith y o u r
68

m o th e r a n d y o u r fa th e r? D o th e y h a v e a lot of
T h . L o o k , y o u ll n e v e r p ro v e it th a t w a y . I t s b e tte r
tr o u b le to g e th e r?
P t.
to k e e p a w a y fro m fig h ts b ec a u se a ll it w ill do
Y e a h a little b it a lot.
is c re a te p ro b le m s fo r you. [ / a m p u s h i n g a d
T h . Y ou see a p erso n is b r o u g h t u p in a fa m ily a n d
vice h o p in g th a t I h a v e e s ta b lis h e d s u ffic ie n t
y ou see h o w th e m o th e r a n d f a th e r g et a lo n g
c r e d ib ility f o r h im to fo llo w th is a d vice sin c e h e
to g e th e r a n d
c o u ld g e t in to se rio u s tro u b le tr y in g to p r o v e
you
b eg in
to
p ick
up
id eas
h is m a s c u lin ity th ro u g h vio le n c e a n d fig h tin g .]
a b o u t h o w m a le s fu n c tio n w ith fem ales. D oes

sh e kick h im a r o u n d ? d o m in a te h im ?
P t.
P t.
Y e a h , I k n o w , lik e th e la s t tim e I w a s h o m e.
L ik e o n e k id s a id , H o w s sc h o o l? a n d I sa id ,
S o m e tim e s m o st o f th e tim es.
T h . T h a t m a k e s a w o m a n a s tro n g p e rs o n in th e
I t s n o t b a d , a n d h e sa id , It m u st be a
c o n c e p tu a l th in k in g o f a boy. H e w o u ld lik e to
p a n s y s c h o o l o r so m e th in g lik e th a t. A n d I
id e n tify w ith a s tro n g f a th e r w h o is a b le to
sa id , L o o k i t s k in d a h a r d , a n d h e sa id ,
s ta n d u p to h is w ife, to k eep h e r fro m being
W e ll, th e n it m u st be a g o o d sc h o o l, a n d
to o
th e n h e sa id , If y o u re g o in g th e r e , th e k id s
c o n tr o llin g ,
and
s to p
h er.
W h e r e th e
w o m a n is to o s tro n g in th e fa m ily , i t s a p t to
m u st be a b u n c h o f J O s . A n d g o in g on like
reflect o n th e b o y s feelings th a t w o m e n a r e th e
th is. T h is is o n e k id I h a te . A n d it w a s j u s t
s tro n g p e o p le . N o w , th is h a s a n im p a c t o n th e
y e s te rd a y a n d I w e n t to to w n j u s t lo o k in g for
b o y s d e v e lo p in g sense o f m a s c u lin ity . A n d th is
h im . A n d th e n b efo re I left for sc h o o l th e last
is th e o n e p ro b le m it d o e s n t m a k e you daffy
t im e I j u s t w e n t a ll o v e r to w n lo o k in g for o n e
kid.
o r a n y th in g lik e th a t, b u t it is s o m e th in g th a t
P t.
y ou h av e to w o rk o u t y o u h a v e to b eg in to
T h . T o b e a t th e h ell o u t o f h im ?
d ev elo p a d iffe re n t c o n c e p tu a liz a tio n o f y o u r
P t.
h a p p e n e d b e tw e e n m e a n d a g ir l o r so m e
s tr o n g in te r p r e ta tio n , b u t I b elieve I a m rig h t.
th in g lik e t h a t a n d h e w a s th e ca u se o f it. It
I w o n d e r h o w th e p a ti e n t w ill h a n d le th e in te r
w a s n t th is
p r e ta tio n . 1} h e d e n ie s it o r b y p a sse s it, a g re a t
re a lly m a d th e n , a n d I to ld th e g irl, T e ll h im
g irl J a n e a n o th e r g irl.
I w as
d e a l o f w o r k w ill be n ecessa ry on h is d efenses.
if I see h im a g a in , I ll look for h im to m o r r o w .
W h e re a p e r s o n s id e n tity p r o b le m s a re too
T h e n so m e k id ca lle d m e u p , o n e o f h is frie n d s,
s tr o n g
w h o m u st be a s e n io r n o w , a n d h e sa id , If
and
w h e re
th e y are
re sp o n sib le fo r
m a n y a d ju s tm e n t d iffic u ltie s, lo n g -te r m th e r
yo u lay a h a n d o n h im , I ll k n o c k th e sh it o u t
a p y m a y be n eed ed . ]
o f y o u , a n d I g ot a m a r in e frie n d w h o is g o in g
W e ll,
know
w hen
w as
in
to
e le m e n ta ry
do th is to
m a rin e s ,
sc h o o l I d o n t k n o w w h y b u t it u sed to be if
th e
y o u .
a rm y ,
Y ou
know
lik e th a t.
th e
A nd
w h o le
I sa id ,
th e boys w a n te d to sh o w off befo re th e g irls,
W e ll, th is is j u s t b e tw e e n m e a n d h im , you
th e y d j u m p
I u sed to be s m a lle r an d
k n o w ; if h e s so to u g h let h im be t h e r e . I
e v e ry th in g a n d th e y d say le ts j u m p o n th e
d o n t k n o w I sp e n t th e w h o le d a y in to w n , he
m e.
n e v e r ca m e a r o u n d .
fag o r so m e th in g lik e th a t.
T h . Y ou ca n h a v e beefs w ith k id s, a n d m a y b e you
T h . W h o w o u ld say th a t?
P t.
If I co u ld j u s t fin d h im . B e cau se so m e th in g
self a s a s tr o n g m a s c u lin e p e rso n . [ T h is is a
s h o u ld be ab le to d efen d y o u rself. T h e r e s no
O h , so m e o f th e kids.
T h . T h e k id s w o u ld say to w h o m ?
r e a s o n w h y y o u s h o u ld n t le a r n h o w to defen d
P t.
T o m e. T h e y d j u m p on m e a n d th e y d say
y o u rse lf,
th is to th e o th e r k id s t h a t s I k in d a I ve
m a tte r.
been
d o in g
w e ig h t s t h a t s
p ro b a b ly
th e
P t.
but
to
look
for fig h ts is a n o th e r
I th in k j u j it s u is k in d o f for th e b ird s. I m e a n if
re a so n I d re w th a t. T h e n th e o th e r d a y , I w e n t
y o u get in to a fig h t, y o u k n o w . I u sed to th in k
d o w n to w n j u s t lo o k in g for a fig h t I d o n t
J u d o is p r e tty good u n til la s t y e a r. I sa w a k id ,
k n o w , m a y b e to p ro v e m y self w h o k n o w s.
a n d h e sa id , I ta k e j u d o , a n d th e o th e r kid
[ T h e p a t i e n t s a d m issio n th a t h e h a d concern
s ta rte d la u g h in g lik e a n y th in g , a n d th e n he
a b o u t o th e r s c o n s id e rin g h im h o m o s e x u a l, h is
j u s t stood th e re la u g h in g , a n d th e n th e kid
re a liz a tio n th a t h is d r a w in g refers to h im se lf,
s ta r ts th e fancy a d v a n c e s, a n d th e n th e n e x t
h is in sig h t a b o u t p r a c tic in g w ith w e ig h ts a n d
th in g yo u k n o w th e j u d o e x p e r t w a s o n th e
lo o k in g f o r f ig h ts to c o m p e n s a te f o r h is fe a r o f
g r o u n d , a n d he s ta rte d b le e d in g .
la ck o f m a s c u lin ity are g o o d signs. ]

T h . D o th ey h a v e to u g h k id s in th a t p la c e y o u re
69
Pt.
in ?
I d o n t k n o w , to give m e a c e rta in feelin g o r

so m e th in g .
Pt. N o t w h e re I live, b u t d o w n to w n , yes.

T h . W e ll, liste n , I th in k th a t yo u a r e co n c e rn e d
T h . B u t I t h in k y o u c a n be m u c h s m a r te r th a n
a b o u t d e fe n d in g y o u rse lf b e c a u se o f y o u r o w n
d o in g is jo in in g in o n a b a ttle w ith th e m . Y ou
d o u b ts of y o u r o w n c a p a c ity to d efen d y o u rse lf
are
a n d y o u r o w n feelin g s o f low m a s c u lin ity . B u t
h a v e n t g o t a c h a n c e w ith th e m u n le s s yo u use
y o u ve b e e n ,
y ou w a n t to co m e a n d see m e a n d ta lk a b o u t
lo w
m an
w hat
on
th e
yo u
to te m
have
b een
p o le. Y ou
a n o th e r k in d o f tactic.
t h a t s a p ro b le m y o u w o n t w o rk o u t by fig h t
in g . Y o u w o rk it o u t b y ta lk in g a b o u t it, a n d if
th e
b ecau se
Pt. H o w ?
T h . Y ou h a v e to be k in d of s m a rt in c o m m u n ic a t
th e se th in g s , I ll b e g la d to see y o u . B ecause
ing w ith th e m . L et th e m k n o w y o u r feelings,
y ou ca n d o a lo t b e tte r by v e rb a liz in g th a n you
b u t d o n t te ll th e m e v e ry th in g a b o u t w h a t you
ca n by fig h tin g , jI m te s tin g m y e ffe c tiv e n e ss in
d o, a b o u t th e s e g irls . Y o u ca n tell th e m w h a t is
th e in te r v ie w h ere. H a v e I e s ta b lis h e d a rela
tr u e . W h y n o t sa y a b o u t y o u r g irl, T h is is n t
tio n sh ip a n d d o es h e h a v e su ffic ie n t co n fid e n c e
s e rio u s . If th e y say , A re yo u g o in g to see
in m e to s ta r t th e r a p y w ith m e ? H is re sp o n se
h e r ? yo u co u ld say , L o o k I h a v e c e rta in
to m y in v ita tio n w ill tell. ]
th in g s th a t I h a v e to k e e p to m yself, a n d I m
Pt. T h a t s w h a t J i m sa id , yo u k n o w J i m S lo a n ,
g o in g to k e e p th e m to m yself. I m n o t g o in g to
m y frie n d . I to ld h im y e s te rd a y . H e w a n te d to
do a n y th in g th a t w ill e m b a r ra s s y o u , o r h u r t
go o u t a n d I to ld h im I g o tta sta y h o m e , a n d I
you. I m n o t g o in g to m a r r y a n y b o d y , I m n o t
to ld h im I w a s g o in g to see a p s y c h ia tris t. A n d
g o in g to g e t a n y b o d y p r e g n a n t.
h e sa id , y o u re re a lly lu ck y 'c a u s e th e y ca n do
Pt.
I to ld th e m o ften . W e h a d a b ig a r g u m e n t o n e
a lo t o f g o o d fo r y o u . H e said w h e n yo u w a lk
n ig h t. I sa id s o m e th in g lik e, I d o n t k n o w
in th e re , tr u s t h im , h e sa id , so m e tim e s it m ay
w h a t y o u re so c o n c e rn e d a b o u t r ig h t n o w . I m
ta k e a few tim e s, to tr u s t h im eo u g h to ta lk to
n o t g o in g to la tc h o n to o n e g irl u n til I m a r ry
h im , b u t o n ce y o u c a n , y o u re lu ck y . I d i d n t
h e r . I sa id . D o n t w o rry . I m n o t stu p id ;
believe h im . I d i d n t w a n t to com e, b u t I m
I m n o t g o in g to get in to t r o u b le . T h e y get
g lad I cam e.
u p s e t if a g irl is n t o u r re lig io n . I t s a big
T h . W e ll, if y o u ca n c la rify som e th in g s for y o u r
th in g . T h e y j u s t w a n t to k n o w , I d o n t k n o w ,
self, y ou a r e lu ck y . B elieve m e, in sig h t a n d
b u t th e r e s a w h o le b u n c h o f th e s e a r g u m e n ts ,
u n d e r s ta n d in g ca n be th e g re a te s t sa v io r of
a n d I sa y , D o n t w o rry a b o u t th is , th is is n t
y o u r life. If y ou h a v e a n id e a o f w h a t s co o k in g
g o in g to h a p p e n , a n d
w ith y o u a n d w h e re it o r ig in a te d , y o u ca n ta k e
g o in g to see J a n e , a n d so f o rth a n d so fo rth .
a s ta n d
h a v e n t th e
B e c a u se th e o th e r n ig h t I c a m e h o m e a n d m y
fa in te st id e a of w h a t s g o in g o n , a ll y o u feel a re
m o th e r h a d g o n e to sle ep a n d it w a s a b o u t
a g a in s t
it.
B u t if yo u
th ey say , A re you
em o tio n s a n d b a d feelin g s, a n d th e n y o u ve g ot
1 1 :0 0 o clock I ca m e in, a n d h e s ta r ts to ta lk to
to g e t rid o f th ese feelings. A n d b e fo re you
m e. I h a d th is feelin g h e w a n te d to h it on
k n o w it, y o u re in a m ess. Y ou d o n t solve
s o m e th in g , a n d I sa id , G e t to th e p o in t, D a d ;
a n y th in g . A lo t o f th e feelin g s y o u ve b een h a v
w h a t is i t ? A n d he sa id , I m n o t h ittin g on
in g w ith y o u r p a r e n ts a r e th e s e b a d feelings
a n y th in g . I j u s t lik e yo u to g o o u t w ith o th e r
th a t a re c o m in g u p b ecau se you c a n t co m
g ir ls , a n d so fo rth .
m u n ic a te w ith th e m . N o w , m a y b e i t s im p o ssi
ble to c o m m u n ic a te . I d o n t k n o w w h a t y o u re
T h . W h e r e a b o u ts is th e p la c e th a t y o u re g o in g to
school ?
b o th of th e m . B u t I d o b elieve th e y m u st h av e
Pt. H a v e r s to w n .
T h . I w o n d e r if I co u ld fin d a p e rs o n for you to
u p a g a in s t w ith th e m b e c a u se I d o n t k n o w
y o u r w e lfa re a t h e a r t. T h e i r m o tiv es a t least
ta lk to lik e y o u re ta lk in g to m e. W o u ld you
a re g o o d , b u t th e w a y th e y e x p re s s th em se lv e s
w a n t to see so m e o n e to ta lk th in g s o v e r. [-Smce
m ay b e b a d .
H a v e r s to w n is f a r fr o m N e w Y o rk , I a m co n
Pt. D o y ou re a lly feel th a t o r a r e you j u s t sa y in g

th a t?
T h . W h y sh o u ld I say th a t to you if I d id n t m e a n
it?
te m p la tin g
r e fe rr in g
th e p a tie n t
to a n o th e r
th e r a p is t w h o liv e s in th e n e ig h b o r h o o d o f th e
sch ool. ]
Pt. T h a t w o u ld be p r e tty good.
70
T h . Y ou h a v e n t g ot c o m m u n ic a tio n w ith y o u r
Pt.
p a r e n ts . Y o u n eed c o m m u n ic a tio n w ith so m e

body. B e cau se y o u re g e ttin g too b o ttle d u p
to a s s u m e re s p o n s ib ility f o r h is o w n tre a tm e n t.
w ith in y o u rself. T h e s e k id s a t sch o o l, y o u c a n t
In m y m i n d I a lre a d y h a v e d e c id e d th a t I w ill
ta lk to k id s th e w a y yo u w o u ld ta lk to a th e r a
see th e p a r e n ts also, w h o w ill m a k e u p f o r th e
p ist. T h e y d o n t k n o w w h a t i t s all a b o u t.
s m a ll fe e th e b o y can a ffo rd to p a y . T h e y w ill
Pt. M y sister is p r e tty s m a rt.

T h . S h e s fine. Y o u ca n ta lk to h e r , b u t s h e s n o t
know
Y o u rse lf, d e p e n d s on h o w m u c h yo u co u ld af
fo rd to p a y w h a t co u ld you affo rd to p a y ?
Pt.
in to to w n , b u t it w o u ld be b e tte r if y o u h ad
so m eb o d y n e a rb y . T h a t w o u ld be g re a t. H o w
too th a t th e b o y is c a r r y in g h is o w n
tr e a tm e n t costs.}
Th
aro u n d .
Pt. T h a t s tru e .
T h . I ll b e g la d to see you w h e n e v e r you ca n com e
It d e p e n d s if I c o u ld sen d yo u m y a llo w a n c e
fro m school.
Th
w o u ld you feel a b o u t th a t?
I w o u ld n t w a n t to ta k e a w a y y o u r allo w a n c e ,
I d w o rk o u t so m e th in g . W h a te v e r y o u could
Pt. T h a t w o u ld be p r e tty good.

T h . B u t th e re m a y n o t be a n y b o d y a r o u n d th e r e in
a ffo rd to p a y . I ll w o rk th a t o u t w ith y o u n ex t
t im e .
H a v e rs to w n .
Pt.
S u p p o se I w a s to be p a y in g fo r th is. [77!!* is a
g o o d sig n a n d in d ic a te s th a t th e p a ti e n t w a n ts
W e ll,
l e t s le a v e
w h e n e v e r y o u ca n
it
t h is
w a y th a t
co m e in to to w n , let m e
k n o w a c o u p le d a y s in a d v a n c e . T h is w ill be
h av e a frie n d in o n e of th e te a c h e rs . E v e ry so
ju s t b e tw e e n y o u a n d m e. T h e y w o n t h av e
o ften h e ll tell m e to d r o p in to h is ro o m , h is
a n y I m
a p a r tm e n t, a n d m ay b e w e ll h av e a ta lk o r
a b o u t w h a t w e ta lk a b o u t. I t s th e o n ly w a y I
so m e th in g like th a t.
ca n w o rk w ith a p e rs o n . If I w e re to rev eal
I t s a h ic k to w n ; i t s r ig h t n e a r n o th in g . B u t
not
g o in g
to
tell
th e m
a n y th in g
T h . Y ou n eed so m e b o d y w h o h a s m o re tr a in in g ,
a n y th in g yo u to ld m e, it w o u ld d e s tro y o u r r e
re a lly m o re e x p e r t in th is ty p e o f th in g . Y ou
la tio n s h ip , a n d it w o u ld n t be h e lp fu l p a r tic u
n eed so m e b o d y w h o k n o w s a b o u t d y n am ics,
la rly . T h e o n ly th in g I ca n te ll th e m a b o u t m y
a b o u t e m o tio n a l p ro b le m s, a b o u t re la tio n s h ip s
ta lk w ith y o u to d a y is th a t, in m y o p in io n , you
w ith
d o n t h a v e a n y th in g se rio u sly w ro n g w ith you,
and
b etw e e n
p a r e n ts ,
th e in v o lv em en t
w ith o n e s o w n sense of self. T h is is a h ig h ly
th a t
sp e cialized a n d c o m p lic a te d b u sin e ss. A n e d u
n o r m a l w a y , a n d th a t th e y h a v e to e s ta b lis h
c a to r u s u a lly d o e s n t h a v e th is ty p e of t r a i n
b e tte r c o m m u n ic a tio n w ith y o u . A n d th ey h av e
ing.
to
(p a u se) If th e r e s n o b o d y tr a in e d n e a r
H a v e rs to w n , I ll su g g e st th a t you com e a n d see
sto p
g o in g
and
th r o u g h
d e v e lo p in g
your
p o ck ets.
in
T hat
w o u ld be g re a t if I co u ld p u t th a t ac ro ss to
m e as o ften as you ca n . H o w o ften can you

com e in to th e c ity ?
y o u r e e v o lv in g
th e m , w o u ld n t it?
Pt.
T h a t w o u ld be fin e, b u t so m e tim es, I m a y be
Pt. P re tty o ften .

T h . C a n y o u ? I ll be g lad to see y o u w h e n e v e r you
w ro n g , b u t so m e tim e s I feel th e y th in k th ey
can get a w a y . Y ou k n o w it w ill also m a k e y o u r
of a ta lk . I d o n t k n o w , th e y sa y , Y o u ve h a d
p a r e n ts feel a s if y o u re n o t g o in g to get y o u r
it to o easy , w e ve g iven you e v e r y th in g . T h e y
self in to tro u b le . Y ou k n o w , y o u h a v e a lot on
say w h y w e d o n t tr u s t you is b ecau se you
Pt.
can get th r o u g h to m e by g iv in g m e so m e th in g
th e b a ll, a n d y ou h av e a lot o f very good stu ff
w e re
in yo u . I w o u ld n t say th a t yo u a r e a b n o rm a l,
J a n e . T h e y d o n t e x p e c t m e to say I m n ot
b u t you c a n get in volved in tro u b le w ith all
g o in g to go th e re , a n d if sh e m e a n s a n y th in g to
th ese feelin g s to act o u t, th is fe a r of n o t b e in g a
m e, th e y d o n t e x p e c t m e to sa y I m n o t g o in g
m a n . Y ou h a v e to w o rk it o u t on a n o th e r level.
to go. A n d th e y a r e tr y in g to c o r n e r m e in to
I d o n t m e a n to be u n ta c tfu l, b u t h o w m u ch
sa y in g I ll n e v e r go a n d give m y w o rd th a t I
d o es o n e visit co st?
T h . I h a v e a slid in g scale. In o th e r w o rd s, d e p e n d -
th e r e
anyw ay,
m e a n in g
about
seeing
w o n t go.
Th
W e ll, I ll do m y best. I m tr y in g to fig u re o u t
in g u p o n w h a t a p e rso n ca n p a y ; in o th e r
w h a t I c a n tell th e m to tr y to h e lp th e s itu a
w o rd s, if a p e rs o n is a b le to p a y a h ig h fee, i t s
tio n . I ll tell th e m th a t w e ta lk e d th in g s over
g o in g to cost m o re. If h e c a n t p a y a h ig h fee, I
a n d th a t I th in k th a t it w o u ld be b e tte r fo r you
scale it d o w n .
to ta lk to so m e b o d y else th a n to ta lk to th e m ,

a n d th a t I to ld y ou I d be v ery h a p p y to see
Fa. W e ve b e e n ta k in g it.
you. If a n y p ro b le m s com e
u p , you w o u ld be
T h . Y o u ve
ab le to d iscu ss th e m w ith
m e. H o w fa r fro m
been
r e a l ly
ta k in g
it?
S u r v iv in g ?
W h a t s b een h a p p e n in g ?
Fa. I t s b een to u g h , th e so n , h e s been b e llig e re n t,
N e w Y o rk C ity is H a v e rs to w n ?
P t.
71
A ll I k n o w is th a t it s a b o u t 75 m iles.
and
h e s b een
w a lk in g w ith
sh o u ld e r
P t.
K n o ck it off, you k n o w . T h e r e s n o ta lk in g to
Th.
P t.
O h , I co u ld ta k e a tr a in in.
Y ou co u ld com e in o n ce in
tw o w eek s, o nce in
to ta lk
is n t b ad .
n o th in g .
to h im ?
M o . I c a n t.
I m se rio u s.
Fa. I j u s t c a n t get th r o u g h . I d o n t lik e w h a t s d e

v e lo p in g , d e v e lo p in g in h im .
T h . I d o n t lik e w h a t s d e v e lo p in g in h im e ith e r,
th a t if an y p ro b le m s com e u p , yo u w ill w a n t to
b e tw e e n
d iscu ss th e m w ith m e. I ll tell th e m th a t I ve
h im se lf in to a h ell of a lot of tr o u b le th e w a y
seen y o u , a n d I th in k it w o u ld be v ery h e lp fu l
if I co u ld h av e so m e ta lk s w ith y o u . I ll tell
you
and
m e,
because
he
ca n
get
he feels.
M o . W e ll, h e s he d o e s n t w a n t to do a n y th in g .
th e m th a t y ou h a v e n o se rio u s in te n tio n of g e t
H e j u s t lik es to d o n o th in g . I t s v ery h a r d to sit
tin g y o u rse lf so c o m p le te ly im m e rs e d a n d in
a n d w a tc h th is for h o u rs , I g u e ss. I feel, I a l
volved w ith a n y b o d y t h a t s g o in g to in te rfe re
m o st feel I d o n t give a d a m n .
w ith y o u r free d o m . Y ou k n o w , give th e m som e
T h . I c a n u n d e r s ta n d y o u r e m o tio n s. I k n o w you
k in d of a s s u ra n c e so th a t th e y w ill sto p b u g
ta k e it on th e c h in . H e s a v ery h a n d s o m e boy
g in g y o u a b o u t th is th in g . Y o u k n o w w h a t I
w ith a lot of stu ff on th e b a ll, b u t he is n o t liv
m e a n ? T h a t s if y ou a g re e , I sh o u ld tell th em
in g u p to h is o w n p o te n tia l. H e s a c tin g o u t
th a t.
a n d so o n . I g a v e h im so m e te s ts to see w h a t s
I m e a n I a g re e w ith yo u a b o u t w h a t y o u re
w h a t. H e s g ot a lot o n th e b a ll, b u t h e s ju s t
g o in g to te ll th e m , b u t h o w a m I su p p o s e d to
fu ll o f e m o tio n . H e s a n e x tre m e ly e m o tio n a l
a c t? S u re w e can sit h e re a n d ta lk , b u t I h av e
kid , re a d y to e x p lo d e a n y tim e , b u t h is defenses
to live w ith th e m .
a r e p r e tty good. I m e a n h e s a b le to h o ld o n to
T h . Y ou h av e to live w ith th e m , I k n o w . W h y c a n t
h is e m o tio n s. T h e
o n ly
b asic p ro b le m
th a t
y ou j u s t say , L o o k , M o m a n d D a d , I d o n t
com es u p is o n e c o m m o n a t h is ag e , a fe a r of
w a n t to fig h t w ith you. I d o n t w a n t to go b e
h is o w n c a p a c itie s as a g ro w in g boy, a n e e d to
h in d y o u r b ack a n d do th in g s th a t a r e b a d . I
p ro v e h is o w n
can a s su re y o u th a t I m g o in g to go o u t w ith
w ith ex e rc ise s a n d w e ig h t liftin g is O K , b u t
m a s c u lin ity .
P ro v in g h im se lf
o th e r p e o p le , b u t I also p ro b a b ly w a n t to see
w a n tin g to g et in to fig h ts th is is a se rio u s
J a n e .
p ro b le m th a t I to o k u p w ith h im . H e need s
I c o u ld n t say th a t to th e m ; th e y w o u ld s ta rt
th e r a p y . N o w , i t s g o in g to be v ery d ifficu lt to
an
is m e n
fin d a n y b o d y a r o u n d H a v e r s to w n . T h e r e s n o
a rg u m e n t.
b o d y in th a t a r e a w e ca n c all o n . I believe I
A n y tim e it h a s b een m e n tio n e d in th e p a s t,
w a s a b le to get to h im , to c o m m u n ic a te to h im ,
a rg u m e n t.
tio n e d , th e r e
A n y tim e
is g o in g
th a t
to
be
nam e
an
t h e r e s a n a r g u m e n t. A n d I k n o w i t s a very
to r e la te w ith h im . I th in k he tr u s ts m e, a n d he
se n sitiv e su b je ct. W h a t could I sa y ?
o p e n e d u p w ith m e. H e c a m e in v ery d e fe n
T h . W h y n o t say sim p ly : L o o k , I m g o in g to ta lk
P t.
to h im . T h e r e s no r a p p o r t, th e r e s
ta lk to m e, n o k id d in g a b o u t it?
like to com e a n d ta lk th in g s o v er w ith m e a n d
P t.
th is big.
T h . (A d d r e s s in g th e m o th e r ) C a n y o u g e t th r o u g h
O n c e a m o n th I co u ld com e in.
T h . Y o u tell th e m th e n th a t you w o u ld v ery m u ch
P t.
w id e ly )
h im . I k n o w I c a n t get th r o u g h to h im . I try
th re e w eek s, o n ce a m o n th . Y ou k n o w th a t
T h . D o y ou re a lly w a n t to com e a n d see m e a n d

P t.
(se p a ra te s h a n d s
a c h ip on his
T h . H o w w o u ld y ou get h e re ?
sively as yo u k n o w . I w a s a b le to c u t th ro u g h ,
th in g s o ver w ith D r. W o lb e rg . G e t th e id e a ?
b u t y o u c a n ju d g e th a t b e tte r w h e n y o u ta lk to
OK
h im . I th in k th e w o rst th in g yo u can do is k eep
T h . I b e tte r see th e m
for a c o u p le of m in u te s.
p u ttin g
in ju n c tio n s o n
h im ru le s.
H e w ill
(P a tie n t w a lk s o u t- p a r e n ts co m e in a n d sit
b r e a k th e m d o w n ; yo u w ill n o t be a b le to sto p
d o w n .)
h im
at
th is
p o in t.
W ith
so m e
th e r a p y
he
72

s h o u ld
be
a b le
to
c o n tro l
h im self.
At
th e
T h . T h e n I ll ta lk to h im ; so m e d a y h e c a n p a y m e.
p re s e n t tim e h e is fo cu sin g e v e ry th in g on a
Mo. H e w a n ts to co m e th e n ?
b a ttle w ith y o u , w h ic h is n t so u n u s u a l a t th is
T h . I th in k he v ery m u c h w a n ts to com e. H e w a s
ag e w h e n h e is b re a k in g h is d e p e n d e n c y on
te llin g m e th a t h e w a s ta lk in g to a frie n d last
you.
n ig h t a n d said th ey (m e a n in g y o u ) w a n t m e to
Mo. W h a t k in d of ru le s, ex cu se m e, w h a t k in d of
see a p s y c h ia tris t. T h is o th e r k id sa id , Y ou
ru le s ? [A p p a r e n tly , sh e is q u ite d e fe n s iv e .]
k n o w y o u re v ery lu c k y , y o u r e v ery lu ck y you
T h . H e w o n t p a y a tte n tio n to ru le s.
ca n see so m e b o d y to ta lk t o .
Mo. T h e r e a r e n t a n y ru le s.
Fa.
T h . Y o u tell h im n o t to see th is g irl. I w o u ld advise

y o u I d o n t k n o w if y o u can do it to lay off
th a t
s itu a tio n
fo r
th e
tim e
b e in g .
H e to ld u s a b o u t it. T h e in te r e s tin g th in g is
th e fellow
he says sa id
it, h is m o th e r a n d
fa th e r, c a n t get a lo n g w ith h im .
D o n t
c o u n te n a n c e it a n d d o n t c o n d o n e it, b u t d o n t
a g re e d it w o u ld be b e tte r for h im to see o th e r
( T h e p a tie n t c a m e for a session th e next

w eek, a g a in acc o m p a n ie d by his p a re n ts . At
p e o p le . I to ld h im it w o u ld be o n ly se n sib le for
t h a t tim e I convinced th e p a r e n t s to co n tin u e
q u iz h im a b o u t it. W e ta lk e d a b o u t it, a n d he
h im n o t to re s tric t h im se lf to th is g irl. It is n t
in th e r a p y w ith me, b o th singly a n d to ge the r,
as se rio u s a s you th in k . H e a g re e d it w o u ld be
d u r i n g w h ic h
a good th in g if h e d id n o t re s tr ic t h im se lf to
v elo p m en tal re q u i r e m e n ts of adolescents a n d
o n e p e rso n . T h e basic th in g is he n eed s so m e
th e need to en c o u ra g e th e ir s o n s in d e p e n d e n t
b o d y to ta lk to. H e n eed s to c o m m u n ic a te w ith

so m e b o d y , to o p e n u p w ith so m e b o d y , b ecau se
h e s a v o lcan o in sid e , re a d y to b u st w id e o p e n .
I counseled th e m on th e d e
strivings. It b eca m e a p p a r e n t th a t th e chief

p r o b l e m in t h e f a m il y n e u r o s i s w a s th e
o u t. I to ld h im , I ca n see you a n y tim e you
m o t h e r s need to control a n d d o m i n a te bo th
h e r h u s b a n d a n d h e r c h ild re n to a p o in t th a t
co m e, if y ou call m e in a d v a n c e .
th ey h a d to obey w ith o u t q u e stio n to avoid h e r
W e w e re ta lk in g a b o u t th a t o u tsid e .
T h . A n d h e sa id to m e, W h a t d o you c h a r g e ? I
hysterical displays. T h e fa th e r w a s in tro d u ced

to a g r o u p w h o ch allen ged his passive y ielding
sa id , I c h a rg e a s lid in g scale, w h a t a p erso n
to his wife a n d en co u ra g e d his sta n d in g u p to
A n d if h e v e rb a liz e s, h e s n o t so lik ely to act
Fa.
co u ld a ffo rd to p a y . H e sa id , I d like to p a y
h e r an d ta k in g h e r s o n s side. T h e m o t h e r
fo r th is m y se lf o u t of m y a llo w a n c e . so I sa id ,
re c e iv e d a b o u t 4 0 s e s sio n s o f p s y c h o a n a lytically o rie n te d t h e r a p y a lo n g w ith a b o u t 10

sessions o f g r o u p th e r a p y . T h e boy him self
A ll r ig h t, w e ll w o rk o u t s o m e th in g . W e ll
w o rk o u t s o m e th in g b etw e e n th e tw o of u s,
w h a te v e r y o u ca n a ffo rd to p a y , b e c a u se a f te r all
y o u c a n t a ffo rd a h ig h fee a n d I do see som e
p e o p le h e re a t a lo w fee sc a le . It w o u ld be b e t
te r fo r h im to feel h e ca n h a n d le it by h im self, so
h e c a n sen d m e five b u c k s o r w h a te v e r it is.
Mo. T h a t s h is allo w a n c e .
benefited sufficiently from 5 m o r e sessions to

d is co n tin u e t h e r a p y greatly im pro v e d . O n fol
lo w -u p th e e n tire fam ily s tr u c tu r e an d r e l a
tio n sh ip b etw e en m e m b e rs o f th e fam ily had
ch an g ed re m a rk e d l y for th e b etter.)
Case 2
T h e follow ing illu strates the active, s u p p o r
tive first-session m a n a g e m e n t of a n a c u te e x
a cerb a tio n of a n x ie ty in a ch ron ic obsessivecom pulsive p a tie n t. In deciding to te r m i n a te
th e r a p y after a few sessions, I toyed w ith the
altern ativ e possibility of en g ag in g in a lo n g
te r m process, b u t felt th a t th e risks of e n h a n c

ing th e p a t i e n t s d ep en d e n c y on m e m i g h t be
too great. A ctually, the p a ti e n t herself e x
pressed an inab ility to c o n tin u e in p ro lo n g e d
th e r a p y . M y objective th e n w a s to b rin g h e r
ra p id ly to a n anx iety -free e q u il ib r iu m , offering
73
som e insig ht into h e r d y
h a v in g a lot o f fin a n c ia l tr o u b le . T h e r e w a s a
nam ics, w h ich h opefully could in tim e, if she

utilized it, hav e some reco nstru ctive effect.
lot of w o r ry a n d h ig h te n s io n in th e h o u se . I
T h e r e w as no illusion th a t th is brief tr e a tm e n t
w h e r e a s m y sis te r a n d b r o th e r d i d n t re a lly
h e r,
if possible,
suppose
I to o k
th is m o re o r less to h e a r t,
b eliev e in a ll th e c o m p la in ts , th e u su a l k in d s of
in te rlu d e w o uld forestall fu tu re attacks. H o w
th in g s th a t go o n . O n e tim e I w a s u p in m y
ever, it w a s felt th a t if th e p a tie n t could be
b e d ro o m a n d I w a s j u s t so rt of like p r a y in g to
tided over h e r im m e d ia te crisis, she m ig h t be
G o d th a t e v e ry th in g w o u ld w o rk o u t a n d it
helped to a b e tte r a d ju s tm e n t. Since tension
w o u ld be a ll r ig h t. I k n o w I w a s feelin g d e
w a s th e m o to r th a t released h e r obsessional
sy m p to m s, h elp in g h e r to le a r n to co ntro l te n
fia n c e a n d I k n o w h o w th is w o rk s, b u t I said
to m yself, W e ll, if I c a n t p r a y to G o d to
sion by re la x a tio n w a s th e tactic I decided to
m a k e e v e ry th in g all r ig h t, m a y b e if I say J e s u s
utilize.
C h r i s t o v e r a n d o v er a g a in it w i ll . W e ll, I
s ta rte d
Pt.
I called th e C o n s u lta tio n S erv ice a n d 1 sp o k e to

D r . G . a n d to ld h im w h a t I n ee d e d a n d he re c
to
rep eat
th a t
in
my
m in d
and
it
seem ed re p u lsiv e .
T h . J e s u s C h r is t?
o m m e n d e d yo u . H e sa id th a t yo u w e re th e p e r
P t.
son to tell m e yes o r n o . [ T h e p a tie n t sp e a k s
T h . T h e re p e titio n of J e s u s C h r is t, w a s it so rt of a
r a p id ly a n d se e m s u p s e t a n d p e r tu r b e d . I g e t
th e im p re ss io n th a t sh e n e e d s a g o o d d e a l o f
T h a t s it.
d e fia n t g e s tu re ?
P t.
I su p p o s e it w as. I d o n t q u ite u n d e r s ta n d it.
re a ssu ra n ce w h ic h m a y o r m a y n o t be o f h elp
W e ll, I c o u ld n t sto p r e p e a tin g th is th in g in
to her.}
m y m in d . It w o u ld ju s t go on a n d on a n d o n,
w h ic h n e v e r h a p p e n e d a c tu a lly b efo re. I d id n t
T h . Y ou m e a n , w h e th e r m y k in d of th e r a p y w o u ld
k n o w w h a t to d o. F in a lly , I to ld m y m o th e r
be o f v a lu e to y o u ?
Pt. T h a t s rig h t.
a b o u t it, a n d w e w e n t to o u r fa m ily d o c to r. I
T h . W e ll, su p p o s in g you give m e a n id e a o f y o u r
w a s 15 a t th e tim e. I a m 21 n o w . H e se n t m e
p ro b le m , a n d th e n I w ill tell yo u w h e th e r I can
to a p s y c h ia tris t. T h is g u y w a s a p sy c h ia tris t
be o f a n y p o ssib le h e lp to you.
a n d n e u ro lo g ist. N o w , w h e n I w e n t to h im , it
Pt. C a n you tr e a t m e? I h a v e o b se ssio n s th a t
w as
s h o rt
tim e.
m a tte r
of a few
f a r a s th a t goes. I to ld h im th e sa m e sto ry
T h . If y o u h a v e th e d e s ire for h e lp , th a t is u su a lly

[B ec a u se sh e is so
w h ic h I w ill tell you n o w th a t th e r e is so m e
u p se t, 1 d ecid e to re a ssu re h e r r a th e r th a n to
th in g th a t h a p p e n e d to m e w h e n I w a s 8 y e a rs
e x p lo r e w h a t sh e m e a n s b y o b se ss io n s. ]
o ld. I can re m e m b e r w h e n th is th in g first cam e
n in e -te n th s o f th e b a ttle .
Pt.
for a
m o n th s. H e d id a b s o lu te ly n o th in g for m e, a s
c ro w d in to m y m in d a n d u p se t m e.
W e ll, t h a t s w h a t
I a m . I a m re a lly obsessive,
o u t. I a m p o sitiv e a b o u t it. I a m te llin g th e

sa m e r o tte n sto ry . I h a te m y se lf fo r th is b e
v ery b ad ly .
T h . T e ll m e a b o u t it. H o w b ad is it?
c a u se it w a s j u s t a w a s te of e v e ry th in g . W e ll,
Pt.
f in a lly , a f te r a b o u t 5 m o n th s I re c a ll th a t it
W e ll
I w ill tell you th e sto ry . I get very u p se t
o v er it. ( T h e p a tie n t p a u s e s a n d is m a n ife s tly
s ta rte d
a n x io u s .)
w o r d s a n d I g ot back to b e in g m yself. J u s t
W hen
let
d o w n th is
r e p e a tin g
o f th e
b e in g m yself. P e rio d . [ 772^ o u tc r o p p in g o f th e
T h . T a k e y o u r tim e [m o re re a ss u ra n c e ].
Pt.
to
I w as 15, th is first ca m e o u t a n d it
o b se ssio n a l s y m p to m
a n x ie tie s ,
r e a lly b o th e re d m e. A w o rd ca m e to m y m in d ,
is a d e r iv a tiv e o f m a n y
so m e p e r h a p s u n c o n sc io u s, d a tin g
a n d I felt forced to r e p e a t it. (p a u se ) It is th e
b ack to h e r c h ild h o o d . T h e p a tie n t re co g n izes
r e p e a tin g of th e w o rd (p a u se).
th e c o n n e c tio n .]
T h . T h e re p e a tin g o f th e w o rd .
T h . D u r in g th is p e rio d th a t yo u w e re se ein g th e
Pt. Y es, you see I com e fro m a very re lig io u s

fam ily . I, m yself, a m n o t re lig io u s o r a n y th in g
p s y c h ia tris t w h a t h a p p e n e d ?
P t.
Yes.
1 w ent
to h im
on
and
off, a n d
th e n
like th a t. I d o n t k n o w if you k n o w w h a t I am
e v e n tu a lly he ju st to ld m e th a t he re a lly sp e
ta lk in g a b o u t. In th e fam ily th a t I cam e from
c ia liz e d in n e u ro lo g y a n d th e r e w a s n ot a d a r n
th e re w e re c o n s ta n t p r a y e r s . W e ll, a s a c h ild ,
th in g he co u ld do for m e. A n d if I c o u ld , I
w h e n I w a s a b o u t 15, I re m e m b e r m y f a th e r
w o u ld h a v e r a t h e r av o id ed th is. I w a s a ju n io r
74

in
h ig h sch o o l at th e tim e th a t
I w a s 15.
T h . It m u st h a v e u p se t you a good d e a l.
T o w a r d th e en d of th a t y e a r it m o re o r less
P t.
w ent aw ay and
T h . T h a t s 5 m o n th s ago.
I w o u ld fo rg e t a b o u t it. 1
w o u ld r a t h e r th in k th a t it h a d n o th in g to do
P t.
It d id , th is p a s t A p ril.
I h a v e sp o k e n to som e p e o p le since th e n b e
w ith m e a n d th a t I co u ld sta n d it. I w a s all
c a u s e m y h u s b a n d a n d I w a n t a la rg e fam ily
rig h t in m y s e n io r y e a r in h ig h school. I w as
n a tu r a lly . M y h u s b a n d a n d I w a n t to p la n on
all
r ig h t
in
my
fre s h m a n
year
in
college.
a fa m ily , a n d I d o n t w a n t to h av e c h ild re n b e
M a y b e it w o u ld s ta r t co m in g u p , b u t I could
c a u s e I w ill be su ffe rin g w o rse th e n . B ecau se,
so rt o f fig h t it d o w n . W h e n I w a s a s o p h o m o re
if it is a n a n x ie ty , o r w h a te v e r y o u call it,
in college, I w e n t a w a y to school.
w h e n I g e t it, re a lly get it, I a m m ise ra b le .
T h . Y ou w e re all r ig h t a s a fre s h m a n in college?
Y ou c a n t re m o v e it so m e tim e s ly in g th e re ; you
P t.
Yes. T h e n I w a n te d to go a w a y to school an d
ju s t d o n t k n o w w h a t it is. I t s lik e y o u r scared
live in a d o rm . It w a s a n ew e x p e rie n c e . G e t
o f s o m e th in g , b u t yo u d o n t k n o w w h a t you
tin g a w a y a n d , o f c o u rse , th e c h a n g e o f e n v i
a r e sc are d of. It is v ery h a r d to say . I h a d
ro n m e n t su d d e n ly . E v e ry th in g w a s g o in g a lo n g
sp o k e n to som e p e o p le a b o u t th e th in g th a t
w e ll, a lth o u g h
happened
it w a s n ew a n d I h a d n ev er
av o id ed e v e ry th in g a n d e v e ry b o d y . T o m e if I
b e tte r, th is th in g g ot h o ld o f m e. Y ou k n o w
am n o t feelin g g u ilty a n d it is n o t b o th e rin g
w h at I m ean?
m e, I a m fine. I re a liz e n o w th a t it is so m e
T h . Y o u m e a n th e o b se ssio n s s ta rte d a g a in ? W h e n
P t.
th in g th a t w ill be r e c u r rin g u n til I fin d o u t
w a s th a t? H o w lo n g a g o ?
w h a t it is th a t is n e e d e d , o r d e s tro y it, o r p u t it
T h is w a s w h e n I w a s 18. I t s n o t so m u ch th e
d o w n . I sp o k e to a few d o c to rs, b u t n o th in g
r e p e a tin g of th e w o rd , a c tu a lly , a lth o u g h th a t
ste a d y .
T h . A ny o th e r trie s a t p sy c h o th e ra p y ?
o c c u rre d .
T h . T h e sa m e w o rd , J e s u s C h r is t?
P t.
to m e in A p ril. I got p e trifie d . I
b een a w a y fro m h o m e. B u t b efo re I could get
P t.
J u s t th e o n e tim e th a t I to ld you a b o u t. I h a d a
Yes, b u t it c h a n g e d to a ll k in d s of sy m p to m s
g irl frie n d ta lk in g to m e once. I n e v e r to ld a n y
a c tu a lly .
sa y in g , J e s u s
b o d y a b o u t it b ecau se I a m d e a th ly a s h a m e d of
C h r i s t , b u t I k n o w w h e re all th is ca m e fro m .
it, a n d d e a th ly a s h a m e d th a t a n y o n e sh o u ld
I s ta rte d j u s t
w ith
I w ill go b a c k , b u t I ju s t w a n te d to ta k e it from
k n o w . A n y w a y , th a t b o th e rs m e a n a w fu l lot.
h e re . F in a lly , w h e n I w a s a s o p h o m o re , a t th e
S h e w a s te llin g m e a b o u t w h e n sh e w a s a w a y
en d o f m y so p h o m o re y e a r, I g ot h o m e a n d
on e tim e. S h e s tu tte r s . S h e h a d g o n e to a p e r
e v e ry th in g w a s fine. It d id n t b o th e r m e th a t
so n , w h o I b elieve is a p s y c h ia tris t, w h o ta u g h t
m u c h e ith e r th a t y e a r as m u c h as it d id th e
h y p n o sis to o th e r d o c to rs o r so m e th in g of th a t
first tim e. T h e n I b ecam e e n g a g e d . I w a s fine
so rt, a n d sh e w a s te llin g m e th e sto ry o f how
a n d I th o u g h t it w o u ld n t even b o th e r m e a n y
sh e w a s re g re sse d to e a r lie r tim e s of h e r life.
m o re . I g o t m a r rie d . M y h u s b a n d a n d I h av e a
S h e w a s re g re sse d to th e tim e w h e re sh e first
v ery
m a rria g e .
s ta rte d to s tu tte r . H e r m o th e r to o k a k nife to
[U p to th is p o i n t th e p a tie n t d o es n o t p r e s e n t
nice
m a r ria g e a
successful
o n e o f h e r b r o th e rs w h e n sh e w a s 2 y e a rs old,
too c o h e r e n t a sto ry . S h e se e m s so c o n c e rn e d
w h e n it h a p p e n e d th a t sh e s tu tte r e d . A fter she
a n d u p se t w ith h e r o b se ssio n a l s y m p to m th a t
fo u n d o u t a b o u t th a t, th e n sh e b e g an to ta lk .
sh e b yp a sses im p o r ta n t d e ta ils th a t I sh a ll e x
[T h is c o n v e n tio n a l n o tio n o f th e p a th o g e n ic ity
p lo r e la te r ./
o f b u r ie d m e m o r ie s , a n d th e ir n e e d to d is
T h . H o w old w e re y ou w h e n you g ot m a r rie d ?
g o rg e th e m f o r cu re, se n d s so m e p a tie n ts in
P t.
q u e s t o f th e r a p is ts w h o can su rg ic a lly d issect
N in e te e n . I m 21 n o w .
T h . Y o u h av e b een m a r rie d a lm o st 2 y e a rs?
in to
P t.
a b o u t th a t, th e n sh e b eg a n to ta lk . W e ll, from
A y e a r a n d 3 m o n th s. I w a s m a r rie d for 10
th e
u n c o n s c io u s .)
A fter
sh e fo u n d
out
m o n th s th is is w h y I a m h e re n o w th is p a st
w h a t I h ad re a d a b o u t h y p n o sis a n d th in g s like
A p ril I w a s h u m m in g in b ed , a n d , you see
th a t, I th o u g h t th a t m a y b e , m a y b e th is is o n e
a c tu a lly w h e n I a m o u t a n d activ e a n d e v e ry
w a y of g o in g b ack a n d fin d in g o u t w h y I h a d
th in g , a n d if th is s ta rts to b o th e r m e, I can ju s t
th is tro u b le . W h a t is it c o v e rin g u p ? I k n o w
get in v o lv ed in o th e r th in g s a n d so rt o f k eep it
th is m u ch a t le a s t. W h e n I w a s 8 y e a rs o ld , I
d e p re ss e d , k eep it d o w n . W h e n it ca m e to th e
h av e th re e b r o th e rs , a n d a n o ld e r b r o th e r, w h o
su rfa c e a g a in , th a t re a lly b o th e re d m e.
is 6 y e a rs o ld e r th a n I th e r e w a s a lot of sex
75

p lay b etw een th e tw o of u s. I w a s b ro u g h t u p
ro o m , b u t sh e ca m e in w ith m y a u n t, a n d I
in a v ery stric t h o m e. Sex w a s s o m e th in g th a t
w a s g o in g to tell h e r, b u t sh e w a s w ith m y
w a s n e v e r ta lk e d a b o u t, a n d so fo rth . T h e w ay
a u n t a n d I c o u ld n t. I looked a t h e r a n d sa id ,
I feel a b o u t it, I h av e n o t a b a d a d ju s tm e n t. I
"M o m m y ,
h av e h a d a v ery good a d ju s tm e n t in m a rria g e .
a u n t b u rs t o u t la u g h in g . I w o u ld b u rs t o u t
O f c o u rse , m y
I c a n t u n d e r s ta n d h o w o n e h a s a n y th in g to do
la u g h in g if it w a s a n y b o d y else. T h e y j u s t sh u t
it off. It w a s j u s t n o th in g . S o m e k in d of silly
m e m b e r fro m m y y o u n g c h ild h o o d life. T h is
b u sin e ss a n d th a t w a s th e e n d of it. W e ll, to
th in g is b o th e r in g m e. T h e r e w a s no a c tu a l in
th is d ay n o b o d y k n o w s a n y th in g a b o u t it e x
cep t th is d o c to r th a t I sp o k e to .
lik e m a s tu r b a tio n . H e w o u ld to u c h m e, a n d I
T h . Y o u r b r o th e r w a s 14 at th e tim e ?
w o u ld to u c h h im , a n d so fo rth . \ W h a t th e p a
P t.
Y es. W h e n th is w a s g o in g o n , h e w o u ld send
tie n t w a n ts is h y p n o s is to u p r o o t im p o r ta n t
m e o u t o f th e ro o m , a n d I n e v e r k n e w w h y . It
m e m o rie s.
T h is , in m y o p in io n , is n o t w h a t
w a s w h e n h e w o u ld re a c h a n o rg a s m a n d th e
w ill h e lp her. N a tu r a lly , sh e is n o t to ld th is
sp e rm w o u ld be co m in g o u t. O n e tim e I ask ed
sin c e it m a y d isc o u ra g e h e r to lea rn th a t th e
h im w h y , a n d h e let m e sta y , a n d I saw th e
te c h n iq u e th a t sh e b elieves w ill save h e r c a n n o t
sp e rm c o m in g o u t, a n d h e to ld m e, T h a t s
do so. L a te r , w h e n I h a v e a w o r k in g r e la tio n
w h a t m a k e s you p r e g n a n t . I b ec a m e , a s a
sh ip w ith her, I w ill be in a b e tte r p o s itio n to
c h ild of 9 a n d
a p p r is e h e r o f w h a t I b elieve ca n h e lp her.]
sp e rm . T h in g s th a t m y b r o th e r w o u ld to u c h I
T h . Y ou
rem em b er
th e
in c id e n t
to d a y
w as
q u ite
a f ra id
to
10, I b ec a m e v ery a fra id of

to u c h
for fe a r
I w o u ld
get
p r e g n a n t. S o m e tim e s I w a s sc a re d in m y m a r
a c u te ly ? Y o u w e re o n ly 8 y e a rs of ag e th e n . It
still b o th e rs y o u ?
rie d life. I ca n u n d e r s ta n d it ra tio n a lly , b u t I
1 r e m e m b e r ev ery sin g le th in g th a t h a p p e n e d .
do n o t w a n t to h a v e a p re g n a n c y , a n d I a m
m o re sc are d o f b e c o m in g p r e g n a n t ju s t fro m
T h . D o you r e m e m b e r if yo u felt se x u a l ex c ite m e n t
sp e rm th a n I th in k a n o rm a l p e rso n w o u ld be.
a t th e tim e ?
P t.
p r e g n a n t.
w ith th e o th e r. T h is is th e o n ly th in g I can r e
te rc o u rs e th a t to o k p la c e a t a ll, b u t th e re w a s
P t.
I am
I a m q u ite s u re o f th a t.
N o t m e.
T h . N ot you?
T h . D o you u se c o n tra c e p tiv e s?
P t.
P t.
W e ll, it is a fu n n y th in g . If I w e re to be t r u t h
Yes. I b ec a m e v ery a f ra id to to u c h a n y th in g
fu l, I d say th a t I k n e w th a t I lik ed it. B u t h e re
th a t m y b r o th e r to u c h e d . If I w o u ld , th e n I
is th e sto ry . Y ou see, w h e n w e first s ta r te d
w o u ld
th is w e n t o n fo r a v ery s h o rt tim e , b u t it
h an d s, an d w ash m y h ands.
w a s n t ju s t o n e tim e th a t it to o k p la c e b etw e e n
rid ic u lo u s , b u t I h a d to do it. If th a t is c o m p u l
th e tw o of u s w h e n it first s ta rte d , I k n ew
sio n , w ell, th e n th a t is c o m p u ls io n . I d o n t
ru n
and
w ash
my
hands, w ash my
It w a s g e ttin g
n o th in g a b o u t sex. I w a s j u s t a b o u t 8 y e a rs
k n o w w h a t it is. T h e n , o f c o u rse , I th in k th a t
o ld. I d i d n t even k n o w w h a t it w as. D u r in g
fro m th a t m a y b e yo u w o u ld d e te r m in e th a t I
th e tim e th a t th is w a s g o in g o n , a ll th e g irls
w a s to u c h y . T h a t d o e s n t b o th e r m e m u ch .
w e re g e ttin g to g e th e r a n d s ta rtin g to ta lk a b o u t
W hen
sex. T h e n I re a liz e d w h a t I w a s d o in g a n d th a t
p r a y e r b o o k a n d s ta r t to re a d . W h e n I w o u ld
w h a t I w a s d o in g w a s w ro n g . T h a t m a d e m e
co m e to th e en d o f th e se n te n c e , o r so m e th in g
I w a s y o u n g e r, I w o u ld p ick u p th e
lik e th a t, I w o u ld h a v e to sa y , J e s u s C h r i s t
feel d iffe re n t, (p a u se)

T h . It m a d e y ou feel g u ilty ?
o v er a n d o v er to m yself. It g ot to th e p o in t
P t.
w h e r e I c o u ld n t re a d w ith a n y b o d y , a lth o u g h
N o w , I w a s o n ly 8, b ut I r e m e m b e r on e tim e.
M a y b e it w a s e x tr a nice o r so m e th in g like
I d i d n t say a n y th in g . T h e n th is w o u ld com e to
th a t. It w a s th e su m m e rtim e in m y h o u se . I
m y m in d . As I g re w u p , I g u ess it su b sid e d a n d
w a n te d to tell m y m o th e r. I h a d to get th is
d id n t b o th e r m e, w ith th e h a n d w a s h in g an d
th in g o u t of m e. I can re m e m b e r g o in g to m y
th in g s
ro o m
A lw a y s d e a th ly
te e n a g e life I a lw a y s w a s a fra id I w a s g o in g to
a fra id th a t I w a s p r e g n a n t. E v en th o u g h , a s I
b eco m e p r e g n a n t. E v en as a c h ild . It o n ly w e n t
say , I k n e w I c o u ld n t be, b u t I w a s sc a re d th a t
on fo r a s h o rt p e rio d , a m a tte r o f m o n th s. I
I w as. I w a s sc a re d all of m y te e n a g e life th a t
d o n t re a lly re m e m b e r h o w lo n g . W e ll, it w as
an d
c ry in g
about
it.
lik e
th a t ,
a lth o u g h
all
th r o u g h
my
so m e d ay I w o u ld be p r e g n a n t fro m th is th in g .
d u r in g th is tim e th a t I s ta rte d to r e p e a t J e s u s
I re m e m b e r m y m o th e r ca m e u p s ta ir s to m y
C h r i s t to m yself. A n d ev er sin c e th a t tim e ,
76

th is th in g h a s j u s t b een g ro w in g a n d g ro w in g
w o rd s co m e u p in th e sa m e c o n te x t a s J e s u s
a n d g ro w in g . N o w it sto p s, n o w it fla re s u p ,
n o w it d o e s n t. T h e last tim e w a s in A p ril. It
C h r is t?
P t.
h a s n t b o th e re d m e for q u ite a w h ile . A lth o u g h

I co u ld fig h t it d o w n , I a m p u rp o s e ly n o t fig h t
b u t it d o e s n t b o th e r m e in th e le a s t a c tu a lly .
T h . T e ll
in g it d o w n fo r th e sim p le re a so n th a t I w a n t
to g et rid o f it b ecau se n a tu r a lly w e w a n t to
O n ly if I tr y to co v er it u p w ith a s w e a r w o rd ,
me
little
b it
m o re
about
o th e r
sy m p to m s . D o yo u get te n s io n d u r in g th e d a y ?
P t.
Do
yo u
m ean w hen
h a v e a fam ily . I k n o w th a t I c a n n o t m a k e a
r e g u la r d a y ?
d e c e n t m o th e r w ith th is so rt of a tta c k co m in g
T h . R e g u la r d a y .
u p o n m e. O n e o th e r th in g th a t b o th e rs m e I
P t.
g u ess th is is b ecau se I a m o v e rse n sitiv e to th e
I am
u p se t o r j u s t a
I k n o w I h a v e a lo t o f in fe rio ritie s . I ca n tell

yo u th a t m u c h . H e r e is a c u r io u s th in g . I d o n t
p r o b le m it is th a t w h e n w e to ld o u r fam ily
know
d o c to r, I w a s a f ra id , I a m n o w sc a re d th a t
s tr e n g th e n u p th r o u g h tim e o r n o t. A t o n e tim e
if
th is
m eans
th a t
your
eg o
does
ev ery b o d y k n o w s. I a m so a fra id th a t p eo p le
I felt lik e I w a s th e u g lie st th in g in th e w o rld . I
w ill find m e o u t. T h e p e o p le a r o u n d C o n
w o u ld w a lk d o w n th e h a lls th is m y p re ju d ic e
n e c tic u t, w h e re I live, a r e n o sy . I believe, I
c o m in g u p a n d if th e co lo red g irls w o u ld w a lk
th in k it n o w .
by m e, I w o u ld th in k , Y o u k n o w y o u a r e j u s t
T h . F in d o u t a b o u t y o u r o b se ssio n ?
th e u g lie st th in g in th e w o r ld . A n d y et, it
P t.
W h e n it d o e s n t b o th e r m e a n d I th in k th a t
d o e s n t
so m e o n e k n o w s, I ju s t la u g h it off. I th in k , So
b o th e re d m e since. I h a v e h a d th e o th e r tw o a t
w h a t, w h a t ca n I do a b o u t it. I c a n t h e lp it. It
ta c k s m o re o r less w h ic h h a v e b een j u s t a s b ad .
me
at
a ll
now , and
h a s n t
is o v e r a n d d o n e w ith . It is a silly th in g . In
A n d y et, w h e n I w a s a s e n io r in h ig h sch o o l, I
fact,
c o u ld n t c o m p e te in m y s o ro rity , w h ic h m u st
I ca n
re m e m b e r
a c tu a lly
la u g h in g
at
m y se lf in -b e tw e e n tim e s to th in k th a t I w o u ld
h a v e b e e n a sh o c k to m y ego. N o w it re a lly
d o s o m e th in g lik e th a t. A lth o u g h th a t b o th e rs
d o e s n t b o th e r m e a n y m o re . I h a v e tw o siste rs,
m e a lo t, sw a llo w in g so m e tim e s is a sy m p to m .
o n e is a y e a r o ld e r th a n I. I k n o w I w a s h eld in
Th.
S w a llo w in g ? T e ll m e a b o u t
P t.
It is j u s t n o th in g . A ll o f a s u d d e n I ju s t
th a t.
h e r sh a d o w .
c a n t
T h . I see. D id y o u h a v e a n y o th e r k in d s o f p r o b
sw a llo w . It d o e s n t b o th e r m e a lo t. I t is all of
lem s a s a c h ild ? D id yo u h a v e a n y tics o r
a su d d e n . I a m n o t d o in g it n o w . I a m ju s t
sp e ech p ro b le m s o f a n y k in d , in sta n c e s o f b e d
ta lk in g a b o u t th is w h o le th in g , p a r tic u la r ly th e
w e ttin g o r w a lk in g in y o u r sle e p ?
w o rd re p e a tin g .
h a v e fo c u s e d m o r e on th e c o m p e titiv e n e s s w ith
T h . T e ll m e a b o u t th is. W h a t o th e r w o rd besides
fo r m a tio n as p o s s ib le in th is in te r v ie w to h e lp
I d o n t a lw a y s sa y J e s u s C h r i s t . I c h a n g e
th e w o rd a ro u n d so th a t I d o n t h a v e to say
th a t
p a r tic u la r
w o rd .
[ / c o u ld
h e r sister, b u t I w a n te d to g e t as m u c h in
J e s u s C h r is t co m es o u t?
P t.
b o th e r
I w o u ld
say cocka-
d o o d le o r so m e th in g lik e th a t.
m e in d e s ig n in g a tr e a tm e n t p la n .]
P t.
I n e v e r w a lk e d in m y sle ep , n e v e r w e t m y bed.
I d o n t k n o w if th is h a s a n y th in g to d o w ith it,
b u t I o n ce a sk ed m y m o th e r, a lth o u g h I c e r
T h . C o c k a d o o d le ?
ta in ly d o n t re m e m b e r b a c k th a t f a r m yself. O f
P t.
I d o n t k n o w . J u s t a n y th in g in o r d e r to avoid
c o u rse , m y s is te r h a s a b a b y n o w , a n d I lik e
sa y in g th e w o rd th a t I a m th in k in g of. B u t
th e w a y sh e is b rin g in g h e r u p . S h e lets h e r do
so m e tim e s I w ill ju s t be d o in g a n y th in g a n d it
th in g s a s sh e com es of ag e a n d t h a t s h o w sh e
w ill com e o u t j u s t like th a t.
c o n tro ls h erself. I su p p o s e d ly n e v e r w e t m y
T h . W h e n it co m es o u t, it gives y o u a n x ie ty ?
p a n ts , a n d by a y e a r o r s o m e th in g lik e it I
P t.
n e v e r bed w e t. I ca n n e v e r re m e m b e r a n y o n e
O h , yes.
T h . A g re a t d e a l of a n x ie ty ?
tim e in m y life w h e re I d id b e d -w e ttin g . A s fa r
P t.
a s tics a re c o n c e rn e d , w h ic h m e a n s s w a llo w in g
N o t a lw a y s . B u t w h e n I a m feelin g fin e, a n d
a ll o f a su d d e n it com es o u t, I ju s t p r a y th a t it
o r so m e su c h fu n n y th in g , I d o n t k n o w h o w
is n t g o in g to com e to th e su rfa c e , I d o n t p ra y .
old I w a s , b u t you k n o w h o w yo u ca n click
I d id n t m e a n it th a t w a y . I j u s t get sc a re d a n d
y o u r th r o a t o r s o m e th in g . I u sed to do th a t,
tr y to av o id it. B ecause I k n o w h o w I ca n get
b u t n o t a lo t. N o t th a t it b o th e re d m e. I n e v e r
so inv o lv ed a n d en g u lfed in th is th in g .
g ot
T h . A ll rig h t. N o w , a p a r t fro m th is , do a n y o th e r
w o r rie d
about
it.
M aybe
y e s te rd a y
s o m e th in g it m ig h t h a v e h a p p e n e d .
or

T h . H o w a b o u t d e p r e s s io n s ? D o y o u g e t d e
P t.
77
P t.
c u rio u s a b o u t th e w h o le th in g a n d w h e n w e
T h e o n ly tim e 1 get d e p re ss e d is w h e n I g et th e
w e re little te llin g jo k e s . A t th e tim e I w a s ju s t
a tta c k . R ig h t n o w I m n o t d e p re ss e d . If m y
h u s b a n d w a n te d to go to a p a r ty a n d h a v e a
c u rio u s.
T h . Y o u r s e x u a l a d ju s tm e n t n o w , w o u ld yo u say it
g o o d tim e , I d go. W h e n I feel a ll r ig h t in b e
is a good o n e ?
tw e e n a tta c k s , I a m j u s t lik e a n y o th e r p e rso n .
P t.
S o m etim es I feel b lu e o n e d a y , b u t c e rta in ly
T h . W ith a c lim a x ?
n o t d e p ressed . If so m e b o d y c a lls a n d w a n ts to
P t.
go so m e p la ce, o k a y . B u t I d o get v ery , very

d o w n h e a r te d
w hen
th is th in g g ets m e.
B e
in th a t sen se. W h a t a m I g o in g to d o ? I c a n t
h a v in g co m p le te free d o m in sex. B u t a fte r a
T h . So th a t y o u a re u n in h ib ite d m o re o r less se x
u a lly ?
P t.
T h . D o you g et a n y h e a d a c h e s?
feel a b o u t it.
n e u ro tic
T h . H o w a b o u t w h e n y o u h a v e a few d r in k s ? D u r
sy m p to m , p re ss in g o n th e sid e s. I get a ll th is
in g th e tim e s w h e n yo u h av e a n x ie ty does alc o
know
th is
m eans
i t s
stu ff. I h a v e g o tte n th is p re ss in g feelin g ev er
h o l h e lp ?
sin ce th e a tta c k s s ta rte d , fro m th e tim e th is
P t.
s ta rte d w h e n I w a s a ch ild .
T h . H o w a b o u t tr a n q u iliz e r s ? H a v e y o u ta k e n an y
T h . T h is d e p re ss in g feelin g ?
P t.
I o n ce w e n t to a d o c to r w h o g av e m e a p ill.
to r to g et a p h y sic al c h e c k u p b e c a u se I w a s
T h e firs t p s y c h ia tris t w h o m I w e n t to w h e n I
g e ttin g so ex cited a n d so sc a re d in sid e th a t I
w a s 15 g a v e m e so m e p ills, b u t h e to ld m e
w o u ld a c tu a lly w o rk a fever u p in sid e m yself. I
r ig h t to m y face, h e sa id , Y o u k n o w y o u r c u re
c a n t e x p la in it. I g et so sc a re d a n d so p e trifie d
is n o t in th e b o ttle . W h ic h , o f c o u rse , I k n o w .
t h a t I d o n t k n o w w h a t to d o . W e ll, I k n o w
T h is last tim e , I sp o k e to th is o n e d o c to r I
w h e n I g et a fever. W h e n I g e t a r e a l fever, I
j u s t w e n t to h im
k n o w th a t I a m sick, b u t w h e n I g e t th is k in d
p r e s c r ip tio n
of a h o tn e s s o r so m e th in g . . . n o w
d o w n a n d I w o u ld fo rg et a b o u t it, so m e th in g
I ca n
once an d
w h ic h
h e sa id
he g av e m e a
w o u ld ca lm
me
r e la te th a t to s o m e th in g w h e n I re fe r back.
lik e th a t. I to o k th e p ill, a n d it d i d n t do a
W h e n I w a s 8 y e a rs o ld , I c a n re m e m b e r d u r
th in g , a n d I k n o w m y se lf th a t a p ill is n o t g o
in g th e sex p la y b etw e e n m y b r o th e r a n d I, I
in g to c u re m e.
T h . D o yo u k n o w w h ic h p ill h e g a v e y o u ?
so w a r m o r so h o t. N o w I d o n t k n o w if th e re
P t.
is a n y d ire c t c o rre la tio n b e tw e e n th e se . I d o n t
T h . S o u n d s lik e L ib r iu m .
even k n o w
if it is th a t w h ic h is c a u s in g it.
P t.
It w a s a g re e n a n d b la c k one.
Y es, it w a s L ib r iu m .
M a y b e it is co m p letely su b c o n sc io u s. B u t for
T h . It d i d n t h e lp ?
so m e re a so n I a lw a y s r e la te it to th a t. B u t it
P t.
m a y h av e n o th in g to d o w ith it.
It d id n t do a th in g . I t s all u p h e re p o i n t s to
h e a d ). [I g e t a b e tte r fe e lin g a b o u t h e r basic
T h . D o y ou r e la te th e fever to th a t in c id e n t w ith
str e n g th s. S h e h a s m a d e a g o o d s e x u a l a d ju s t
y o u r b r o th e r?
m e n t a n d h a s so m e u n d e r s ta n d in g o f h e r p r o b
N o , it w a s fro m m y b r o th e r se em in g to g et e x
lem .}
c ited o r s tim u la te d , o f c o u rse . W a r m th w a s
T h . H o w a b o u t d r e a m s ? D o y o u d r e a m a g re a t
j u s t p a r t o f th e se x u a l s tim u la tio n . I re m e m b e r
w o n d e rin g a b o u t it esp e c ia lly w h e n I h a n d le d
h is p en is.
T h . W h e n y o u h a n d le d h is p e n is , d id y o u h a v e a n y
feelin g s a b o u t th a t?
P t.
I d o n t d r in k .
m e d ic a tio n ?
P re ss in g n o t d e p re ss in g . I h a d to go to th e d o c
co u ld n e v e r u n d e r s ta n d w h y th e a ir a lw a y s felt
P t.
M y h u s b a n d a n d I h av e com e to a n a g re e m e n t.
W e b o th e n jo y w h a t w e d o , a n d t h a t s h o w w e
Yes. I k n o w w h e n I g et a h e a d a c h e a n d w h e n I
d o n t.
P t.
A ll th e tim e. Y es. W h e n w e firs t g ot m a r rie d ,
few m o n th s , it w a s fine.
b r e a k o u t. W h a t s th e u se o f g o in g on fro m
h e re . It is j u s t rid ic u lo u s , (p a u se )
Yes.
th e o n ly th in g I c o u ld n t g et o v er th e id e a of
ca u se , w h a t ca n I d o ? R ig h t n o w I a m a ll rig h t
P t.
In th e b e g in n in g , it d id n t sc a re m e. I w a s very
p re sse d ?
M e ? S e x u a lly ?
T h . D id it ex cite you o r sc a re you?
d e a l o r do yo u d r e a m v e ry little ?
P t.
In fact, I h a d a d r e a m th is m o rn in g . I h ave
been a little a n x io u s a b o u t c o m in g h e re . I h av e
d re a m s . C e r ta in o n e s h a v e sto o d o u t, b e c a u se I
k n e w so m e d a y I w o u ld be te llin g so m e b o d y m y
sto ry a n d
I sh o u ld re m e m b e r th e s e d re a m s.
T h e y a r e a b o u t th in g s , a n d I w ill p la c e m y
78
o ld e r sis te r d o in g th e m , a n d th e n I w ill p r o b a
w a s v e ry , v ery h u r t w h e n I w a s a b o u t 11 o r 12
bly w a n t to d o th e sa m e th in g . T h is m o rn in g I
o r 13. Y ou see, m y s is te r w a s a y e a r o ld e r th a n
h ad a d re a m a b o u t m y sis te r a n d I. N o w w h e n
m e, a n d sh e w o u ld go in a n d s ta r t ta lk in g to
w e w e re little , w e used to fig h t, a t least I d call
m y m o th e r a b o u t h e r b o y frie n d s a n d th in g s
it
my
lik e th a t. O n c e o r tw ic e w h e n I trie d to go in to
siste r, w h o is a y e a r o ld e r th a n I a m , h a d a n
th e k itc h e n , a n d ju s t get to g e th e r, th e tw o of
a cc id e n t w h e n sh e w a s a sm a ll c h ild , a n d so
u s, a n d s p e a k a n d tr y to ta lk to h e r, it w a s a l
th a t,
b ecau se
I d
r e tre a t.
G e o rg e tte ,
sh e w a s a lw a y s co d d led a n d e v e ry th in g w h e n
w a y s as if O h , y o u a re ju s t a k id ; y o u r b o y
sh e w a s a b o u t 3 y e a rs o ld . S h e b ro k e o n e leg,
frie n d s a r e n o th in g ; ju s t little p la y m a te s .
sh e b ro k e a n a r m , a n d th in g s lik e th a t. If w e h it
d o n t
h e r, she w a s g o in g to fall a p a r t. A n y w a y , it is
th e t r u th . I r e m e m b e r th a t w e used to fig h t an d
your
silly
little
H o w d id yo u r e la te to h im ?
P t.
I a lw a y s lik ed m y fa th e r. I a lw a y s lik ed m y
m o th e r, to o , b u t I co u ld n e v e r g et close to h er.
T h . Y ou c o u ld n t ta lk to y o u r f a th e r e ith e r?
th e tw o of u s w e re fig h tin g a n d she w a s h ittin g
P i.
N o . W e ll th a t is so m e th in g to th in k a b o u t for a
m e a n d re a lly h u r tin g m e, a n d yet I c o u ld n t
seco n d . I felt th a t I w a s in w ith m y fa th e r,
r e a lly h it h e r b ack . B u t I w a s h o ld in g b a c k all
so to s p e a k , a n d th a t w a s all rig h t. M y fa th e r
m y s tr e n g th , w h ic h is so m e th in g th a t a lw a y s
is w h e r e a ll th e re lig io n co m es to o u r fam ily .
h a p p e n e d w h e n w e w e re c h ild re n . [ T h e p a ti e n t
H e is a v ery re lig io u s p e rs o n , p se u d o -re lig io u s
c o n tin u e s to re fe r to h e r r e la tio n s h ip w ith h e r
p e rs o n . I t d e p e n d s on h o w y o u look a t it. H e is
s is te r as a so u rce o f k e e p in g h e r d o w n a n d
v ery w ell e d u c a te d , in c u ltu r e , b a c k g ro u n d ,
her.
A c tu a lly , h e r s ib lin g
riv a lry,
a n d th in g s lik e th a t.
n e v e r reso lved , in la te r se ssio n s tu r n e d o u t to be
[A t th is p o in t th e p a tie n t is s h o w n th e R o rsc h a c h
a co re p ro b le m .]
cards. ]
T h . A n d y ou h a v e a lw a y s h eld b a c k ?
[ I
w o u ld h a ve
T h . N o w I m g o in g to sh o w you so m e c a rd s a n d I
lik e d to h a v e g o n e in to h e r r e la tio n s h ip w ith
w a n t to a s k you to te ll m e w h a t yo u see in
h e r sis te r a t th is p o in t,
th e s e c a rd s. W h a t does th is o n e look like?
b u t I r e a liz e d th is
w o u ld h a v e c o n s u m e d th e re m a in in g m in u te s
P t.
o f th e sessio n . ]
T h . A ll rig h t. H o w a b o u t th is seco n d o n e ?
Yes.
P t.
A b u tte rfly , a c ra b , (p a u se)

It looks lik e tw o e le p h a n ts w ith th e ir n oses u p
a n d to g e th e r.
T h . W h a t a b o u t y o u r m o th e r a n d fa th e r? W h a t
k in d of p e o p le a r e th e y ?
M y m o th e r is a p e c u lia r p e rso n . M y fam ily is
P t.
th e h ig h - s tr u n g ty pe.
T h . T h is is th e th ird c a rd .
T h . H o w d id you r e la te to y o u r m o th e r w h e n you
P t.
No
Two
p e o p le
b e n d in g
over
and
to u c h in g
s o m e th in g to g e th e r. N o th in g else.
w e re a ch ild ?
P t.
about
a ll th is o th e r stuff. T h is m o rn in g I d r e a m t th a t
c r u s h in g
P t.
hear
th in g s . S o I k e p t e v e ry th in g to m yself.
w a s b la m e d fo r th in g s a n d a lw a y s g ot h it an d
P t.
to
T h . H o w a b o u t y o u r d a d ? W h a t so rt of m a n is h e ?
I w o u ld n e v e r let m y self go to re a lly h it h e r

b ack . In o th e r w o rd s, I w a s a lw a y s th e o n e th a t
w ant
M o th e r a n d I w e re n o t close. T h e re a so n th a t
T h . A n d n o w th e f o u rth c a rd .
I d id w h a t m y b r o th e r w a n te d m e to d o I
P t.
k n o w th is is b ecau se I g ot a lot o f love from
T h . T h e n e x t c a rd .
m y b r o th e r. I w o u ld say m y g r a n d m o th e r, w h o
P t.
A b e a r fu g . (p a u se) T h a t s all.
I m th in k in g of a g re a t b ig b u m b le b e e w e h a d
d id n o t live w ith u s, w h e n I w o u ld see h e r, I
in th e c a r th e o th e r d a y w ith a big f u rry co at
w o u ld feel r e a l tr u e love. N o w th e re is so m e
o n it.
th in g w ro n g w ith m y re la tio n s h ip w ith m y
T h . A f u rr y b u m b le b e e .
m o th e r a n d fa th e r. I co u ld n e v e r ta lk to m y
P t.
m o th e r. M y o ld e r sis te r w a s a lw a y s sa fer. T h is
I k n o w . 1 h a v e a lw a y s felt th a t w ay . I a m close
Y es, g ig a n tic w ith b ig w in g s. It also lo o k s like

a b u tte rfly .
T h . I b elieve th is is th e six th c a rd .
to m y s is te r n o w . It w a s n t u n til I g ot m a rrie d
P t.
th a t
T h . T h is is th e sev en th .
I co u ld a c tu a lly go o v er a n d
look m y
m o th e r s tr a ig h t in th e face, a n d j u s t sit th e re
a n d ta lk a n d h a v e a r e g u la r c o n v e rsa tio n as a
m o th e r a n d d a u g h te r sh o u ld . A s a te e n a g e r, I
P t.
T h a t looks like a sc a re d c at. (p a u se)

It j u s t
r e m in d s
m e o f c h e ru b s
c h u rc h o r so m e th in g .
T h . A n y th in g else h e re ?
in sid e o f a
79

P t.
A fter lo o k in g a t it, I ca n see w h e re th e re m ay
o r o u tsid e of th e fa m ily . Y ou d id n o th in g th a t
be tw o c h ild re n o r so m e th in g lik e th a t.
is p a r tic u la r ly d iffe re n t o r b a d . B u t y o u r r e a c
T h . T h is is th e e ig h th c a rd .
P t.
tio n to th e s e in c id e n ts w a s a b n o r m a l. P e r h a p s
in a
th e r e a s o n w h y yo u in te r p re te d th is a s su ch a
bio lo g y la b o r a to ry . ( P a tie n t te n ta tiv e ly tilts th e
h o r rib le a n d te r rib le th in g w a s th a t , p r io r to
c a rd .)
th e se x -p la y in c id e n t, yo u w e re a lr e a d y se n
T h is looks lik e a sk e leto n
I o n ce saw
T h . Y o u can h o ld it u p sid e d o w n if yo u w ish .
sitiz e d to b e in g b a d . A te r r ib le th in g , a b ad
P t.
p e rs o n , a h o r rib le p e r s o n .p a u s e ) . [I a m m a k
I see n o th in g else.
T h . T h is is th e n in th c ard .
in g a c tiv e e d u c a tio n a l e ff o r t s th a t , th o u g h
P t.
a im e d a t re a ssu ra n c e a re p r o b a b ly n o t g o in g to
T h is o n e so rt o f lo o k s lik e a v o lcan o .
in flu e n c e h e r u n d e r ly in g g u i lt fe e lin g s .
T h . H o ld it a n y w a y you w ish , (p a u se ) T h is is th e
P t.
Y et I
b e lie v e th is is w h a t sh e w a n ts to h e a r fr o m
last c ard .
m e .\
T h is in a w a y r e m in d s m e of th e w av es on th e
w a te r w h e re th e w a te r goes th r o u g h . T h is
P t.
looks like tw o c ra b s. T h e r e a r e o th e r u n d e rs e a
I w a n t to say o n e th in g . W h e n I w a s a k id , I
w a s a lw a y s to ld th a t I a m b a d a n d r o tte n a n d
no g o o d , a n d w h e n I w a s to ld t h a t , I a lm o st
fishes.
T h . N o w w e c a n ta lk a b it a b o u t y o u r p ro b le m . I
c o u ld n t ta k e it. If th e y w o u ld sa y , Y ou a re
get th e im p re ss io n th a t th e se x u a l e x p e rie n c e s
p r e tty o r nice o r a good g i r l, I w a s a lw a y s th e
w ith y o u r b r o th e r a t th e ag e of 8 in itia te d a
b a d , r o tte n , good for n o th in g . [ T h e p a tie n t is
good d eal o f g u ilt in you. N o t th a t yo u m ig h t
v e r y e m o tio n a l h ere. H e r fa c e is flu s h e d , h e r
n o t h av e felt g u ilty a b o u t y o u r feelin g s before,
fi s ts a re clen ch ed . T h e r e a re te a rs in h e r eyes.]
esp ecially to w a rd y o u r m o th e r a n d sis te r. \In
T h . T h is is e x a c tly th e so rt of th in g th a t I a m ta lk
a p p ra is in g h e r d y n a m ic s , it w o u ld a p p e a r th a t
in g a b o u t. T h a t s e x u a l e x p e rie n c e m a y h av e
th e p a tie n t h a s a n o v e r w h e lm in g , p u n i ti v e s u
b een m e re ly g ris t for th e m ill. T h e n y o u w e n t
p e r e g o th a t p u n is h e s h e r f o r h o stile fe e lin g s ,
a lo n g w ith th e re lig io u s e x e rc ise s a n d p ra y e rs .
p r o b a b ly to w a r d h e r sis te r a n d m o th e r . S h e
Y ou d id th is p r o b a b ly w ith a g re a t b u rd e n on
h a d to re p ress a g g ressio n to w a r d h e r s is te r be
ca u se h e r sis te r w a s w e a k . H e r o b se ssio n o f
y o u r soul.
P t.
d e fia n tly re p e a tin g J e s u s C h r i s t " se rv e s as an

o u tle t f o r a g g ressio n a n d as a w a y o f re s tr a in
in g h e r a g g ressio n .
A n x ie t y
T h . Y ou w e n t a lo n g tr y in g to a b so lv e y o u r g u ilt for
re su lts as even
m in im a l h o s tility co m e s th r o u g h .]
N ow
m a n y th in g s . B u t th e e x p e rie n c e p ro v e d to you
sex
th a t you d id a b a d th in g . T h a t m a d e y o u , in
p lay b etw e e n b r o th e rs a n d sis te rs is n o t too
y o u r th o u g h ts , a b a d p e rs o n . N o w w h y do you
u n c o m m o n even th o u g h you r a re ly h e a r a b o u t
it. [ T h is is an a tte m p t a t re a ssu ra n c e .]
P t.
th in k y o u p r a y e d ?
P t.
I k n o w , I le a rn e d a b o u t th a t a s I g re w u p .
T h . A ch ild h a s to d ev elo p som e id e a s a b o u t se x
I w a n te d to be fo rg iv en . I w a n te d G o d to fo r
give m e.
T h . W h e n you m a d e th ese p r o n o u n c e m e n ts , th ese
u a lity b efo re h e o r sh e g ro w s u p . S e x u a lity is
re lig io u s p ro n o u n c e m e n ts , th e y m a y h a v e b een
like w a lk in g . Y o u h a v e to le a r n it. O u r c u ltu re
is p ro h ib itiv e . S ex is re g a rd e d as h id e o u s , t e r r i
th o u g h t,
ble u n til o n e g ets m a r rie d . B u t lik e a n y o th e r
w h e n I k n o w th a t I a m su c h a h o r rib le , aw fu l
b o d ily fu n c tio n sex h a s a b e g in n in g e a rly in
a n d te r rib le p e r s o n . T h e p h r a s e J e s u s C h r is t
life. O b v io u sly , y o u r e x p e rie n c e s d id n t d o too

m u c h d a m a g e to y ou b ecau se yo u tell m e you
fu n c tio n w ell se x u a lly n o w . [M o r e re a ssu ra n ce
is g iv e n h e r, p lu s th e a tte m p t to g e t h e r to
fo c u s a w a y fr o m
P t.
I d id , I d id . I felt I d id n t d ese rv e to p r a y , th a t
I w a s a h y p o c rite .
sig n
of p u r ity .
H ow
B ut
co u ld
th e n
I p ra y
you
m ay
and
h av e
a c t holy
seem s to sy m b o liz e so m e th in g fo r you.

P t.
Y es, b u t w h e n I d say it, I felt h y p o c ritic a l;

th e n I d g et d e fia n t a n d sp it.
T h . It is p r o b a b le th a t re lig io n h a s m a n y m e a n in g s
an e v e n t sh e co n sid e rs ir
for you. W h a t y o u m a y h a v e felt w a s th a t o n ly
re p a ra b le, th e r e b y e s ta b lis h in g th e h o p e le ss
a te r r ib le p e rso n lik e y o u rse lf ac ts d e fia n t in
ness o f h e r c o n d itio n .]
p r a y e r . B u t th e r e is a so rt of h e a lth y co re to
B u t is n t it w ro n g ?
de fia n c e to o . Y ou w e re f ig h tin g b a c k . [ W h a t I
T h . Y o u c o n sid er it w ro n g . C h ild r e n in e a rly life
a m tr y in g to do w ith th e se te n ta tiv e in te r p r e ta
e x p lo re th e se x u a l a r e a . O fte n th e re is sex p lay
tio n s is to g iv e h e r so m e e x p la n a tio n f o r h e r
th a t goes o n a m o n g c h ild re n w ith in th e fam ily
s y m p to m s to s h o w h e r th a t th e y h a v e a m e a n
80

in g a n d fu n c tio n .
P t.
T h is m a y g e t h e r to c o n
w e re n o t sp o k e n in h e r fa m ily , in d e e d w e re
c e n tr a te in la te r se ssio n s on p o s s ib le so u rces o f
fo rb id d e n . H e r o u tb u r s ts w e re a n in d ic a tio n to
h e r co n flic t r a th e r th a n on h e r s y m p to m s , on
h e r th a t sh e w a s a h o r rib le p e rs o n . E x a c tly th e
h e r d e v a lu e d se lf-im a g e a n d th e n o tio n th a t sh e
s a m e th in g y o u h a v e , b u t u s in g a d iffe re n t k in d
is h o p e le s sly ill a n d b a d " because s h e c o m
of sy m b o l. T h e w o rd s u sed d o n t m e a n a th in g
m itte d a s e x u a l crim e . ]
in th e m se lv e s. I t s w h a t s b e h in d th e m . [S o m e
(e x c ite d ly ) Y o u a r e r ig h t. I d say , I ll show
tim e s th e u se o f an e x a m p le o f a case w ith
th e m . W h o d o th e y th in k th e y a r e . [I decide
p r o b le m s s im ila r to th e p a t i e n t s p r o b le m s r e in
to u tiliz e th e p a t ie n t's e m o tio n to o ffe r h e r
fo r c e s an in te r p r e ta tio n . ]
m o r e a c tiv e i n t e r p r e t a t io n s ,
r e a l iz in g
th a t
P t.
fe c t. B u t I a m s tr iv in g f o r a r a p id re la tio n
h y p n o sis to fin d o u t th in g s ?
s h i p .]
o b v io u s ly n o t g o in g to g iv e u p e a s ily in h e r
T h . A nd
w hy
s h o u ld n t you
be ag g ressiv e
re p re s se d m e m o r ie s . ]
p o s itio n ? N e g a te d a s a h u m a n b e in g ; a p erso n
T h . N o w , I d o n t th in k th a t y o u a r e g o in g to find
w h o c a n t act in h e r o w n r ig h t. Y ou m ay h av e
a n y d e e p r e m a rk a b le d isc o v e rie s o r se c re ts in
felt y ou w e r e n t su p p o s e d to be a n g r y , forced
y o u r p a s t. I re a lly do n o t, I believe th a t h y p
to be n a m b y -p a m b y , to ld th a t y o u w e re no
n o sis m ay b rin g you b ack to y o u r c h ild h o o d
good.
th a t
a n d h e lp yo u e x p e rie n c e so m e o f th e o rig in a l
got involved w ith th e w o rd J e s u s
fe a rs a n d a n x ie tie s . B u t a good m a n y o f y o u r
A nd
so m e h o w
th e n
th e
d e f ia n c e
cam e
C h r is t. P e r h a p s you felt th a t J e s u s C h r is t m u st
m e c h a n is m s se em to be o n th e su rfa c e . O n c e
k n o w w h a t a n a w fu l p e rso n yo u felt y o u rse lf to
yo u a b s o rb w h a t h a s frig h te n e d y o u , a ll th ese
be. T h e re f o r e y o u sh o u ld defy h im .
th in g s , a n d re a liz e h o w in c o n s e q u e n tia l th ese
O h , yes, yes. [ T h e p a tie n t is q u ite m o v e d , w ip
th in g s r e a lly a re , you m a y fin d y o u rse lf liv in g

in th e p r e s e n t, n o t fe a rfu l o f th e p a s t o r te r
in g tea rs f r o m h e r eyes. ]
rifie d by th e f u tu re . O n c e yo u firm u p y o u r
T h . It co m es o u t of y o u r d e p th s , o u t o f y o u r d e e p
e m o tio n s, w h ic h in d ic a te d to yo u w h a t a h o r r i
id e a s a b o u t w h a t is g o in g on in y o u , th e n ex t
b le, te r rib le , ev il, u g ly p e rs o n you w e re . B u t
ste p is u tiliz in g th is in sig h t in th e d ire c tio n of
y ou c o u ld n t c o u n te n a n c e th is . I t w e n t a g a in s t
c h a n g e . H e r e h y p n o sis m ay b e o f h e lp to you.
you
It m ay a lso be a b le to h e lp y o u c o n tro l y o u r
w a n te d to be. A fe a r d ev elo p ed th a t p eo p le
te n s io n a n d a n x ie ty w h e n e v e r th e s e p o p u p
w o u ld find o u t th a t y o u w e re re a lly a te r rib le
a g a in .
p e rso n .
o b se ssio n a l p a tie n ts to h e lp th e m c o n tr o l a n d
your ow n
P t.
[ T h e p a ti e n t is
q u e s t to d ig u p a n d e x te r m in a te d e te r m in in g
and
a n g r y w h e n y ou feel p u t in to such a te r rib le
P t.
D o c to r, yo u k n o w so m e th in g , I m b e g in n in g to
feel b e tte r , a lot b e tte r. D o yo u t h in k w e ll use
in s ig h t a t th is sta g e h a s la rg e ly a p la c e b o e f
id e a s of th e k in d
o f p e rso n
w ill
o fte n
u tiliz e
h y p n o s is
in
tu r n o f f " th e ir to r tu r e d r u m in a tio n s .[
W h a t frig h te n s m e m o re th a n a n y th in g else is
th a t ev ery b o d y w ill k n o w I a m b a d a n d h o r r i
[/
P t.
D r . W o lb e rg , I w a s sc a re d o f c o m in g h e re for
th e s im p le r e a s o n th a t I th o u g h t th a t I w o u ld
ble. (cries) B u t so m e tim e s I d o n t feel th is w ay .

T h . W h a t I d lik e to h a v e y o u do is to b e g in n o tic
leav e th is office a s I h a v e left too m a n y o r n o t
in g s itu a tio n s w h e r e yo u feel y o u rse lf to be a
h e a r a n y th in g b u t w h a t I w a n te d to h e a r. I
te r rib le p e rso n . D o es th is h a v e a n y th in g to do
m e a n it. Y o u j u s t c a n t im a g in e h o w I feel in
side.
w ith p e o p le o r situ a tio n s , o r d o es th is a ll com e

u p fro m th e in sid e a t tim e s w h e n y o u feel
T h . H o w do yo u feel in sid e ?
u n d e rm in e d . [ / a m a ssig n in g th e p a tie n t a ta sk
P t.
to
P t.
ke e p
h e r s e lf a le r te d f o r
so u rces
o f her
O h , If I c o u ld get rid o f th is th in g , it w o u ld be
th e g re a te s t th in g in th e w o rld . I so m u c h w a n t
s y m p to m s . ]
to h a v e a fa m ily a n d be a b le to be a m o th e r
B u t w h y a m I th is w a y ?
a n d a good w ife to m y h u s b a n d , a n d n o t th e
T h . T h e m e c h a n is m is p ro b a b ly a n e x tre m e ly co m
p le x
one.
It
ta k e s
m any,
m any
f o rm s .
w a y I w a s w h e re I c o u ld n t even cook d in n e r . I
w a s j u s t to o sc a re d to m ove. I h a v e a lw a y s h ad
re c e n tly h a d a g irl j u s t a b o u t y o u r ag e w h o
d e p re s s io n s , a n d a n y d o c to r I w e n t to , e s p e
w o u ld co m e u p w ith e x p o s tu la tio n s of fo u r-le t
c ia lly o n e I w e n t to w h e n I w a s 15, I w o u ld sit
te r s w e a r w o rd s th a t frig h te n e d h e r. T h is to
h e r e , a n d he w o u ld sit o v e r a t th e d esk a n d I
h e r w a s h o r rib le b e c a u se th e d i r ty w o rd s
w ill tell h im a sto ry . H e w o u ld p ra c tic a lly fall
81
a s le e p o n m e. I k n o w it is fu n n y a n d e v e ry
to r u n a w a y fro m th is im a g e b e c a u s e in y o u r
th in g , b u t it w o u ld h u r t m e so m u c h . I w o u ld
o p in io n it w a s su c h a h o r rib le th in g to look at.
w a lk o u t o f th e re b e in g th e sa m e h o p e le ss p e r
P t.
so n .
T h . Y ou a r e still y o u n g , a n d if y o u h a v e th e d e sire
No
h e lp , n o c h a n g e n o th in g .
I d id n t
k n o w w h a t is g o in g o n in sid e o f m e. W h e n it
to d o so, yo u s h o u ld be a b le to g et o v e r th is.
first cam e o n , I ju s t re a lly th o u g h t I w a s g o in g
T h e test I g av e y o u seem s to in d ic a te th a t you
o u t of m y m in d . Y o u d o n t k n o w w h a t is h a p
r e a lly a r e n o t to o b a d ly off, th a t y o u h av e
p e n in g to you.
f a i r ly g o o d p o te n t ia l s .
T h . W h a t I sa id , d o es it m a k e se n se to y o u ?
P t.
[E m p l o y i n g h e r e x
p o s u r e to th e R o rsc h a c h c a rd s as a re a ss u rin g
O h , yes. Y o u see, you a r e th e firs t p e rso n w h o
to o l a n d as p r o p to h e r to w o r k in g a t h e r p r o b
h a s ev er e x p la in e d it to m e, in w o rd s lik e th is.
lem ]
I a lw a y s
th o u g h t
w a s r o tte n ,
m ise ra b le ,
P t.
h a te d by e v e ry b o d y else, a lw a y s . I a lw a y s d id
a m o n g g irls . I w a s th e w o rst o n e th e re . (7 7 m
H o w lo n g w ill I h a v e to c o m e ? Y ou see i t s
h a r d for m e to tra v e l h e r e , a n d b esid es I c a n t
h a v e te r rib le in fe rio ritie s w h e n I w a s a girl
affo rd it.
T h . I t is h a r d to say h o w lo n g . S o m e tim e s it ta k e s
can o ffe r fe r tile fie ld s f o r e x p lo r a tio n la te r on
tim e to in te g r a te th in g s yo u le a r n . Y o u h ave
in v o lv in g h e r d esire to be a to m b o y a n d h e r in
to te d th is th in g a r o u n d for y e a rs a n d y e a rs a n d
fe r io r ity fe e lin g s a b o u t h e r f e m i n i n i t y .]
y e a rs. H o w lo n g w ill it be b efo re yo u co m
T h . A p p a r e n tly , you felt u n d e rm in e d w h e n you

w e re little . Y ou n e v e r seem
w arm
close
re la tio n s h ip
w ith
p le te ly d is c a rd it, I d o n t k n o w . B u t if you
to h a v e h a d a
h a v e th e r ig h t fo rm u la to w o rk o n , a n d if you
y o u r m o th e r.
a p p ly y o u rse lf, yo u w ill g r a d u a lly u n d e rm in e
A n d you h a d a f a th e r yo u c o u ld n t c o m m u n i
th is m isc o n c e p tio n of y o u rse lf. P e r h a p s w h a t
ca te w ith to o w ell. A n d you felt you h ad no
w e c a n d o is to h a v e a few m o re sessions
r ig h t to c o m p la in . Y ou c o u ld n t a ct n o rm a l
to g e th e r. I ll te a c h y o u se lf-re la x a tio n so you
w ith
ca n c o n tro l y o u r te n s io n a n d h e lp y o u r u n d e r
your
sis te r
e ith e r .
The
h e a lth y
th in g
w o u ld h a v e b een to fig h t b ack , to b e a t th e devil
sta n d in g b e tte r. A n d th e n w e w ill see w h a t
o u t of h e r w h e n sh e b e a t y o u , th e n k iss a n d
happens.
m a k e u p la te r. Y o u w e re a p p a r e n tly f ru s tra te d
P t.
C a n I get o v er th is ?
P t.
C a n I a sk a n o th e r q u e s tio n ? I to ld y o u th a t I
a n d h a m s tr u n g . Y ou c o u ld n t e x p re s s y o u rself,
h a v e a h o r rib le fe a r o f p e o p le k n o w in g th in g s
a n d , to b o o t, w h e n y o u w a n te d to p itc h in to
a b o u t m e. W e to ld o u r fa m ily d o c to r. T h e o n ly
h e r, y ou w e re c o n sid e re d to be a n evil, b a d ,
th in g th e fa m ily d o c to r w a s to ld , w h a t m y
h o r rib le p e rso n w h o d id te r rib le th in g s to a
m o th e r p r o b a b ly sa id w a s , M y d a u g h te r h a s
sis te r w h o w a s so fra il a n d w e a k . [A ctive in te r
J e s u s C h r i s t r u n n in g a r o u n d h e r m in d , a n d
p r e ta tio n s a re m a d e r e p e a tin g th e th in g s th e
so o n . H e se n t m e to so m e b o d y else. N o w ,
p a tie n t a lre a d y k n o w s , b u t w ith th e fo c u s on
w h e n I w a s w a itin g in th is p s y c h ia tr is ts office
h e r n e e d to re p ress h e r fr u s tr a tio n a n d ag
o n e tim e , I m et m y g ir lf r ie n d . S h e j u s t said
g re ssio n .]
h e llo a n d th a t w a s th e e n d o f it. S h e sa id ,
I w a s a lw a y s th e o n e w h o g ot h it even if w e
W h a t a r e you d o in g h e r e ? a n d I sa id , I
g o t in to fig h ts, a n d a f te rw a rd m y s is te r w o u ld
w a s j u s t g o in g to ta lk to h i m . I felt a w fu l th a t
tell m y m o th e r even if it w a s n t m y fa u lt. I w a s
sh e k n e w I w a s th e re . W h e n th is th in g b o th e rs
th e o n e w h o got h it a n d p u n is h e d a n d h a d to
m e,
say, I m s o r r y .
p e trifie d , w h e n I th in k p e o p le you k n o w k n o w
T h . So, th e re a g a in , th e n o rm a l im p u ls e w o u ld
I b eco m e p e trifie d , a n d
I re a lly
m ean
a b o u t it.
h av e b een to e x p re ss a g g re ss io n to g e t it o u t of
T h . T h is is p a r t o f th e p ro b le m , th e c o n s ta n t co n
y o u r sy stem , to sc rea m a t y o u r m o th e r , if n e c
c e rn w ith p e o p le w ill k n o w . T h e y w ill k n o w
e s sa ry to fig h t b ack w ith y o u r sis te r. So fa r as
w h a t a h o r r i b le p e rso n y o u a re . A g a in th is
se x u a l c u rio sity in c h ild h o o d , th e r e is n o th in g
is p r o b a b ly y o u r g u ilt feelin g sh o w in g in th e
so u n u s u a l a b o u t th is. B u t to yo u th e se w e re
fo rm o f a fe a r th a t p e o p le w ill see th e te rrib le
in d ices of h o w te r rib le yo u w e re . A n a w fu l
im a g e you see in y o u rself. R e m e m b e r you a re
p e rso n . Y o u m u st h a v e c a r te d th is im a g e of
th e o n e w h o is d e s ig n in g th is im ag e. \A g a in ,
y o u rse lf a r o u n d a ll y o u r life, a n d you h a v e had
a ctive, stro n g , a u th o r ita tiv e in te r p r e ta tio n s to

b o lste r h e r a g a in st a n x ie ty . I fe e l I h a v e a
82
P t.

w o r k in g r e la tio n s h ip w ith h er.] I m a fra id o u r
herself a n d on h e r re la tio n s h ip w ith h e r old er
tim e is u p . W o u ld you lik e to see m e a g a in ?
sister. H e r g uilt feelings for h e r re s e n tm e n t
O h , yes.
tow ard
T h . W h e n w o u ld y ou lik e to see m e?
P t.
I h a v e tw o m o re y e a rs of school befo re I fin ish .

I h a v e d ecid ed m ay b e n o t to go to school th is
co m in g y e a r a n d m ay b e w o rk th is se m ester.
T h . W e ll, th e n , s u p p o s in g I see yo u a few m o re
sister, an d
to w a r d
p r e s e n t life,
u p s u r g e s of
a n x ie ty w e re relieved bo th by h e r re la x in g e x
ercises a n d
by h e r re la tin g the u p s u r g e of
do
sy m p to m s to p rovocative co m petitive incidents
th e re a fte r. P e r h a p s a fte r a few tim e s y o u ll be
in h e r p re s e n t e n v iro n m e n t. A 5 -y ea r follow-
tim e s,
P t.
h e r m o t h e r an d
t r a n s f e r e n t i a l f i g u r e s in h e r
g r a d u a l l y lifte d . M o m e n t a r y
and
th e n
w e ll
d isc u ss
w hat
to
ab le to go o n by y o u rself. T h e n you can com e
u p indicated a significant ch a n g e in h e r self-
b ack if n e c e ssa ry for a n o c c a sio n a l session.
im age. A d r e a m she sent m e reflected this dif

ferent con ception of herself.
I know
m y h u s b a n d w a n ts to ta lk to you.
T h e r e a r e c e rta in th in g s th a t m y h u s b a n d does
n o t k n o w . H e sh o u ld k n o w . H e w a n ts to k n o w
L a s t n ig h t I h a d tw o d re a m s . In o n e I d re a m t
if I re a lly n eed it b ecau se he d o e s n t th in k
th a t I w a s in a fa sh io n sa lo n lo o k in g a t a fu ll-le n g th
th e r e is a n y th in g b a d a b o u t m e.
o y s te r- w h ite b e a v e r co a t b e in g s h o w n to m e on a
T h . O f co u rse , I ll be g la d to see h im if th is is n e c
e ssary .
P t.
A nd
live m o d el. T h e co at w a s a d u p lic a te o f o n e I h a d

seen y e s te rd a y on th e T V sh o w . In th e o th e r d r e a m
d o c to r,
a n o th e r
th in g ,
you
k n o w , th e
n a m e I u sed is n o t m y re a l n a m e .
I w a s in a v ery la rg e p riv a te h o m e a b o u t 10 m iles

fro m w h e re I live. T h e h o m e b elo n g e d to a lad y
T h . (la u g h in g ) I g u ess you felt so a s h a m e d of y o u r
p s y c h ia tris t, m y p s y c h ia tris t. S h e h a d given m e a
id e n tity th a t y ou d ecid ed to co n ceal y o u rse lf
p a r tia l p h y sic a l e x a m in a tio n (I liste n e d to m y h e a rt)
u n d e r a n a ssu m e d n a m e . W h ic h is p a r t o f th e
a lth o u g h I r e m e m b e r h o ld in g th e en d o f th e ste th o
p ro b le m , is n t it?
scope to m yself. T h e h o u se w a s full o f m a n y p eo p le,
Y es (sm ilin g ). W h e n sh a ll I com e b ack ?
all w a n tin g to see h e r, b u t th e y w e re in a p a r ty -lik e
P t.
T h . N e x t w eek a t th e sa m e tim e.
m ood,
P t.
k itc h e n , etc. S h e a n d I w e re ta lk in g a b o u t m y h a v
V e ry good (a rises). G o o d b y e.
T h . G o o d b y e , see you n e x t w eek.
t a l k in g ,
w a l k in g
a ro u n d ,
e a t in g
in
th e
ing a b a b y , w h ic h w a s fine w ith h e r. S h e a sk e d m e

to p le a se b rin g th e b a b y to h e r so th a t sh e m ay h av e
T h e p a tie n t r e t u r n e d for th r e e m ore sessions,
a p eek a t it a f te r it w a s b o rn . (I th in k I felt th e b a b y
d u r i n g w h ich w e m a d e a re la x in g ta p e * for
w o u ld be a g irl.)
p u rp o s es of re la x in g w ith h e r tensions, p u s h
ing obsessive th o u g h ts ou t of a tte n tio n , and
S h o rtly
reinforcing h e r insights. O u r focus soon co n
p re g n a n t .
cen tra ted
b ro u g h t
ing the
a n x ie ty
num ber
on h e r u n d e r m in e d conception of
* T h e te c h n iq u e of m a k in g a re la x in g ta p e will be found
in C h a p t e r 15.
after
th is
A te m p o r a r y
th e
p atien t
becam e
u p s u r g e of an x ie ty
h e r in for tw o m o re sessions. F o ll o w
b irth of h e r child, a brief p erio d of
w a s co ntro lled also w ith a lim ited
of sessions.
Case 3
Som e p a tie n ts a re no t suited for s h o r t-te rm
th e r a p y an d r e q u i r e a lo n g -term su p p o rtiv e
a p p r o a c h until sufficient m o tivation is d e
veloped for a m o re prod uctive ty pe of t r e a t
m ent. O ften such p a tie n ts seek a p a re n ta l ty pe
of r e l a t i o n s h i p w i t h th e t h e r a p i s t t h a t
ev entu ally , if th e th e r a p is t is n ot a w a r e of
w h a t is h a p p e n i n g n o r k n o w s h o w to deal
w ith the evolving s itu ta tio n , becomes a n in t e r
m in a b le sad om asoc histic e n c o u n te r t r a u m a t ic
83
to both p a tie n t an d th e r a p ist. T h e s e p a tie n ts
h a d a d r e a m a n d th e d r e a m to ld m e th a t I
frequ en tly refuse to accept a re fe rral to a clinic
w o u ld feel lik e a p r o s titu te if I sle p t w ith h im .
or a th e r a p is t ex perienced in d ealin g w ith th e ir
N o w th is is im p o r ta n t to m e, so th e n e x t d a y I
typ e of p ro b le m since t h e r a p y is no t w h a t they
a sk e d H a n s . W e g ot to ta lk in g a b o u t it, a n d
w a n t. T h i s is illustra ted in th e next initial in
h is first e x p e rie n c e s . I m ig h t a d d h e w a s fro m

C h ile , a G e r m a n w h o lived in C h ile . A ll o f th e
terview. T h e p a tie n t is a y o u n g single w o m a n

w h o asked for a n in terview t h r o u g h a lette r in
w o m e n he h a d sle p t w ith w e re p r o s titu te s . M y

su b c o n sc io u s m in d p ic k e d it u p . A n d b e c a u se I
w hich she co m p la in e d of tensio n a n d of h avin g

tr o u b l e d d r e a m s . A ta l l a t t r a c t i v e w o m a n
en tere d m y office at th e a p p o in t m e n t time,
w a s v ery w illin g to liste n to m y u n c o n sc io u s, I

fo u n d it v ery a c c u ra te .
T h . W e ll, w e m ay be a b le to ta lk a b o u t th is specific
so m e w h a t aggressively seatin g herself in the
q u a lity ,
c h a ir after w e in tro d u ce d ourselves.
w h e th e r i ts a m o re g e n e ra l q u a lity .
P t.
T h . W o u ld y ou lik e to tell m e a b o u t y o u r p ro b le m ?
P t.
W e ll, for m e in d iv id u a lly , I p u t it to u se all th e

tim e , {p a u se)
It d o e s n t m a tte r , e x c e p t th a t I th in k you need
T h . Is th a t so?
to k n o w w h a t y ou n eed to k n o w , a n d since I
P t.
d o n t k n o w y o u , I d o n t k n o w w h a t in f o rm a
T h . H o w ? D o you a s k y o u rse lf q u e s tio n s ? H o w do
tio n you w ish . [H e r in itia l re sp o n se s to th e in

te r v ie w a re c e r ta in ly u n u s u a l a n d stra n g e.]
O h yes, a lw a y s.
yo u do th is ?
P t.
T h . A ll rig h t. S u p p o se y ou give m e a g e n e ra l idea
A p ro b le m is th e r e , for e x a m p le . Y ou a r e in
th e m id d le a tte m p tin g to fin d a s o lu tio n . I find
o f th e p ro b le m , a n d th e n w e w ill decid e th e
th e b est w a y is to lie d o w n a n d re la x c o m
b est th in g th a t ca n be d o n e for y o u r p ro b le m .
p le te ly . A n d I u se a v ery f u n n y e x p re ss io n , I
T h e p ro b le m is th is. I h av e fo u n d th a t belief,
w ill to w ill th e w ill o f G o d , w h ic h m a k e s m e
j u s t b elief, ra ise s a tre m e n d o u s ro le in th e lives
re la x . W h ic h is v ery , v ery g o o d for m e. A n d in
o f h u m a n b ein g s. W h a t th e y believe in an d
th is
h o w th e y believ e; a n d I d o n t h a v e to tell you
w h ic h I su sp e c t is a fo rm o f h y p n o s is , th e a n
k in d
o f s ta te
o f su s p e n d e d
a n im a tio n ,
q u o te m ira c le c u re s u n q u o te , a n d th in g s o f th is
s w e r to th e p ro b le m w ill com e to m e.
n a tu r e . I d lik e v ery m u c h to k n o w h o w th is
T h . It w ill co m e to yo u a lm o st lik e in s p ir a tio n ?
o p e r a te s a n d h o w w e can tu r n th is to good
P t.
use. I d lik e to k n o w v ery im p o rta n tly h o w th e
T h . A k in d of feelin g . D o yo u g e t th e im p re ss io n
su b c o n scio u s m in d fu n c tio n s b e c a u se in m y e x
p e rie n c e th is is a p e rfe c t m e c h a n is m . It a lw a y s
N o t lik e a n in s p ir a tio n , b u t lik e a feeling.

th a t it co m es fro m th e o u ts id e w o rld ?
P t.
te lls th e p e rso n ex a c tly w h a t is r ig h t for th e in
N o , I do n o t. S o m e tim e s w h e n I d o n t like
w h a t s c o m in g o u t, I sto p it y o u see.
d iv id u a l. N o w is th is c o m m o n ? [A g a in , h e r
T h . W h a t co m es o u t?
q u e r ie s a re stra n g e , a n d I g e t th e im p re ss io n
P t.
th a t sh e is q u ite a sick p e r s o n . ]
O h , I d o n t k n o w , m a y b e I k in d of h a v e a
p ro p e n s ity of m a k in g o n e ch o ice, a n d a n o th e r
T h. H a v e y ou in y o u r e x p e rie n c e fo u n d th a t th is
P t.
M o r e g e n e ra l.
say.
P t.
T h . Y ou w o u ld r a t h e r h av e m e ask q u e stio n s .
P t.
to y o u rse lf o r
ca n be p u t to so m e c o n s tru c tiv e u se, a s you
y ou k n o w w h a t I m d o in g ? S o yo u a sk q u e s
P t.
i t s u n iq u e
T h . T h e n w e c a n d isc u ss it in te r m s o f w h e th e r it
E x a c tly w h a t is it you n eed to k n o w so th a t

tio n s an d I ll try to a n s w e r.
w h e th e r
o n e is p o k in g i t s n o se in.
I h a v e th e im
w o rk s fo r y o u ?
p re ss io n o f a d o u b le la y e r in m y m in d , of a
W o rk s c o n s iste n tly fo r m e.
th o u g h t c o m in g u p th r o u g h . T h is m ay be a n
T h . G ive m e a n e x a m p le of th a t.
a s so c ia tin g
P t.
Y es, I can give you a v ery c le a r e x a m p le of
had
th a t. I t s re a lly a v ery fu n n y o n e, to o . I w a s
F re u d a n d h is th e o rie s o r a n y th in g a b o u t h im .
g o in g w ith a y o u n g m a n th a t I liked v ery m uch

a n d I w a s tr y in g to m a k e u p m y m in d , d o I
issu e w ith
F r e u d , h o w e v e r.
I ve
th is s e n sa tio n lo n g b e fo re I ev er k n ew
I t s a p h y sic a l feelin g .
T h . I see. N o w I d lik e to h a v e yo u tell m e so m e
like h im e n o u g h to sle ep w ith h im o r d o n t I.
th in g a b o u t y o u r p ro b le m s , th e th in g s th a t
A nd
r e a lly b o th e r you a n d u p se t y o u . [ N o w th a t th e
se e m e d
to
need
h is
a f fe c tio n
and
w a r m th , a n d in th e m id d le o f th e d ecisio n I
p a tie n t is b e g in n in g to
ta lk
m o r e fr e e ly ,
84
P t.

b elieve 1 can be m o r e d e m a n d in g o f h e r to te ll
re m e m b e r th is , b u t m y m o th e r te lls m e, I r e
m e a b o u t h e r re a l p r o b le m s . ]
m e m b e r l a te r w h e n I h a d a r e a c tio n s im ila r to
Y o u m e a n as a n in d iv id u a l?
th a t. T h e firs t g irl I p la y e d w ith I th in k w as
T h . A s a p e rs o n , yes.
P t.
a b o u t 2 a n d m o th e r sa id if sh e d id n t w a tc h ,
T h a t is w h a t I w a n t to d o, 1 believe tw o m ain
I w o u ld co m e r u n n in g in to th e h o u se ju s t b lack
p ro b le m s.
afflicted w ith
a n d b lu e b ecau se if I w a n te d s o m e th in g a n d w e
v ery b ad feet, w h ic h th r o w s m y sp in e o u t of
w e re s h a r in g s o m e th in g o r it w a s m y tu r n o r
I am
u n f o rtu n a te ly
b a la n c e c o m p le te ly w h ic h k eep s m e a little
so m e th in g a n d M a r y d id n t lik e th e id e a , she
tire d all of th e tim e. I d e e p ly re se n t th is. It also
j u s t s im p ly b e a t m e u p . I still c a n t be p u t
m a k e s m e a little n e rv o u s a n d a lw a y s gives m e
a g a in s t a w a ll.
a co n scio u sn ess of b e in g
p r e tty w ell a d ju s te d to.
tied
to
m y body,
w h ic h in m y case is a v ery b a d th in g b ecau se
Th
H a v e yo u g o tte n a lo n g fa irly w ell a ll th r o u g h
b e in g ta ll a n d h a v e a sense o f b ein g d iffe re n t.
c h ild h o o d ?
T w o , I fin d it v ery d ifficu lt to believe th a t I m
P t.
N o , no.
a n a c c e p ta b le in d iv id u a l to o th e r p e o p le . N o w ,
Th
T e ll m e so m e th in g a b o u t th a t.
th e r e is n o b asis for th is, e x c e p t th a t I so m e
P t.
ta c t w ith o th e r p e o p le , h a s b e e n o n e o f s tr a in ,
th e s e a r e d eriv e d fro m th e feelin g itse lf a n d n ot
te n s io n , o f sh y n e ss a n d m a la d ju s tm e n t. N o w
I m re a c h in g th e p o in t w h e re th is is n o lo n g e r
tr u e . A s a m a tte r o f fact, a few y e a rs ag o I
T h is is a b lock th a t I w o u ld lik e v ery m u c h to
w e n t th r o u g h p r e tty th o r o u g h th e r a p y a n d got
get over.
q u ite a n u n d e r s ta n d in g of it.
T h . W h a t a b o u t y o u r se lf-co n fid e n ce? D o you feel
Th
O h , is th a t so?
c o n fid en t?
P t.
B u t it d o e s n t re liev e th e sh y n e ss, yo u see.
N o , I d o n t.
Th
W h o w e re yo u tr e a te d by?
T h . N o co n fid en ce a t a ll?
P t.
M y w h o le h is to ry a s a n in d iv id u a l, a n d in c o n
tim e s d o v ery foolish a n d clu m sy th in g s. B u t
T h . I see.
P t.
A n d in y o u r life s itu a tio n h a v e yo u a d ju s te d ?
I m v ery ta ll. A n d so I b eco m e co n scio u s a b o u t
fro m a n y th in g in h e r e n t in m e.
P t.
N o w , th e s e a r e th in g s I m
P t.
H e w a s a d o c to r a n d th e y p ro v id e d th is service
fo r stu d e n ts , a n d I w e n t th r o u g h th e w h o le
N o . I w o n t say e x a c tly n o co n fid en ce. I t s a

v ery fu n n y th in g . W h e n I m a lo n e , a n d w h en
b u sin e ss w ith th e R o rsc h a c h s a n d th e I Q tests
I m w o rk in g , a n d w h e n I m d o in g s o m e th in g I
a n d th in g s lik e th a t.
lik e to d o , I h av e a v ery b asic self-confidence. I
Th
th in k so m o re th a n m o st p e o p le . I k n o w I m
P t.
It w a s th e r a p y .
rig h t. I ve a c tu a lly m a d e very few m ista k e s in
Th
H o w m a n y tim e s a w eek d id y o u go?
m y life in te rm s of ju d g m e n t a n d in te rm s of
P t.
I w e n t tw ic e a w eek for 6 m o n th s.
w hat
It a lw a y s seem s to
Th
D id yo u fin d o u t m u c h a b o u t y o u rse lf?
so m e h o w w o rk o u t, b u t th a t d o e s n t m e a n th a t
P t.
N o th in g I d id n t k n o w before.
o th e r p e o p le w ill ac c e p t m y p e rs o n a lity . A n d
Th
I see, b u t it d id h e lp y o u ?
y ou see I w a n t to be acce p te d .
P t.
I w a n te d
to d o.
A n d d id yo u get a n y th e r a p y ?
I t h e lp e d b ec a u se I lik ed th e d o c to r, a n d I h a d
T h . I see. N o w to get b a c k to th e b u sin e ss a b o u t
th e sense th a t he lik ed m e, a n d th a t so m e o n e
y o u r b elief, th a t is, y o u r feelin g th a t y o u a r e
w h o is in te llig e n t a s w ell a s lik a b le w o u ld lik e

m e is s o m e th in g I n ee d e d very b ad ly .
n o t ac c e p ta b le .
P t.
I th in k I ca n give y o u th e re a s o n s for th is.
Th
th in k m a n a g e d to solve, b u t y o u ca n im a g in e
I see, y o u w e n t th r o u g h co lleg e, a n d w h a t do
yo u d o n o w ?
O n e , m y f a th e r is a p a r a n o ia c . T h is p ro b le m I
P t.
I m a se c re ta ry . T h is is a lo n g sa d sto ry , th is
b u sin e ss of m y o c c u p a tio n . I d o n t re a lly w o rk
h is possessiv e love, a n d m y re je c tio n of th is
v ery w ell fo r o th e r p eo p le.
o v e rd o m in a tio n a n d of h is h e a v y -h a n d e d w ay
o f h a n d lin g p e o p le a n d s u p e rs e n sitiv ity . So you
Th
Is th a t so? W h a t a r e y o u r g o a ls ?
reject it, a n d c o n s e q u e n tly it i s n t n ice to reject
P t.
T h is is th e w h o le p o in t. I b e g a n in th e a te r as
a n a c tre ss , a n d I m ig h t a d d I w a s a v ery good
fa th e r, so y o u d o n t like y o u rself. T w o , I d i d n t
actress.
lik e m y sis te r a r riv in g a t th e tim e sh e a rriv e d .

young
Th
O h , is th a t so?
p la y m a te s w e re very u n f o rtu n a te . N o w , I d o n t
P t.
B u t I a m to o ta ll a n d c o n s e q u e n tly I d i d n t get
T h re e ,
my
f ir s t
e x p e r ie n c e s
w ith

th e p a r ts I w a n te d . I c o u ld n t get th e m . T h e r e
85
P t.
w e re n o le a d in g m en for m e. T h e y d id n t e x
p la in th is to m e. N o o n e h e lp e d ; n o o n e to o k
th e tim e to say , L o o k , y o u re j u s t too ta ll,
I j u s t h a v e to k n o w p e o p le a lo n g tim e. T h e n
th e r e is n o p ro b le m . W h e n I feel ac c e p te d , I
h a v e n o d ifficu lty .
T h . W h a t a b o u t p h o b ia s ?
d o n t t r y . T h e y j u s t d id n t sa y a n y th in g , an d
P t.
let m e go o n a n d m y basic la c k o f co n fid en ce
T h . A n y th o u g h ts th a t com e in to y o u r m in d th a t
in c re a se d , y ou see, so th a t I h a d n o th in g left. I
tu r n e d to w r itin g , a n d I m v ery good a t th is.
N o n e th a t I ca n th in k of.
to r tu r e y o u o r b o th e r y o u ?
P t.
O n e , a n d th is is th e sto ry o f th e c a t-m o u s e s .
T h . I see.
T h . T e ll m e a b o u t th e c a t-m o u se s.
P t.
P t.
B u t I h a v e a te rrific block a g a in s t w r itin g . I
a n d it d i d n t w o rk v ery w ell. I m p a y in g off a
th is is th e ir r ita tin g p o in t. A s a c h ild I w a s
r a th e r
9 I w ro te a sto ry a b o u t a d o g a n d a little boy
m o u se s a r e d is to rte d c h ild re n . T h e y a re , as
w h o fo u n d th e d o g , a n d h e loved th e d o g , a n d
y o u n o tic e , p a r t m o u se a n d p a r t c a t. A n d so
he c o u ld n t k eep th e d o g . H e h a d r u n a w a y
th e firs t tim e I h a d th e d r e a m I se n sed w h a t it
fro m h o m e . A n d I r e m e m b e r h e w e n t d o w n to
w a s a n d I d i d n t lik e it, so I tu r n e d it in to a
c o m p lic a te d a n d rid ic u lo u s c h ild ish sto ry . A n d
T h . In th e d r e a m ?
m y fa th e r w h o th o u g h t he c o u ld w r ite , a n d
P t.
N o , n o a fte r, a n d so la te r m y su b c o n sc io u s
k e p t te llin g m e, a p p a r e n tly
h a p p e n e d . T h e sto ry is a v e ry b a d ly h a n d le d
I d islik e d w h a t
a b o r tio n I h a d , a n d I m e a n b a d ly h a n d le d , it
I t s th is re je c tio n y o u see. N o w I u n d e r s ta n d
w a s j u s t aw fu l.
h is ego c o u ld n t let h im say it w a s a ll r ig h t to a
T h . Is th a t so?
9 -y e a r-o ld ch ild . H e h a d to p ro v e h im se lf as
P t.
A n d so y o u see th e r e la tio n s h ip , a n d th is is th e
b e in g s tro n g e r a n d c ritic iz in g . It d o e s n t h elp
sto ry , a n d
th e re a c tio n .
u n d e r c e rta in
th is th in g
o c c a s io n a lly p o p s u p ,
t e m p e r a t u r e c o n d itio n s , a n d
so m e tim e s j u s t b efo re m y p e rio d w h e n th e re
r a t h e r r a p id ly . H o w old a r e y o u ?
a re cram p s and
T w e n ty -n in e .
p h y sic al feelin g a s d u r in g th e o p e ra tio n .
T h . E v er m a r rie d ?
I feel tig h t. It is th e sa m e
T h . I see. W a s th e o p e r a tio n d o n e by a p e rso n w h o
N o.
T h . H o w a b o u t te n s io n , d o y o u feel te n s e ?
P t.
fo r it. T h e c a t-
sh re d s. I n e v e r g o t o v er it q u ite .
T h . N o w , I m g o in g to a s k you a few q u e s tio n s
P t.
p e n a lity
p ro b a b ly co u ld h a v e a t o n e tim e , to re it to
T h . Is th a t so?
P t.
la rg e -s iz e d
w h im sic a l th in g I co u ld like.
th e r a ilro a d tra c k s o r so m e th in g . It w a s a very
P t.
T h e c a t-m o u se s . W e ll, I trie d to do so m e th in g ,
ca n tell y o u th is to o . I k n o w th e s e th in g s a n d
is c o m p e te n t a t a ll?
P t.
V e ry m u ch .
By a n e x c e lle n t d o c to r. T h e th in g th a t w e n t
w r o n g w a s th a t I h a d h a d se v era l sh o ts befo re
T h . A g o o d d e a l o f te n sio n ?
th e n in o r d e r to avoid th e o p e r a tio n itself. So
T h . W h a t a b o u t d e p re ss io n ?
th e fetu s h a d sh ifted , a n d th e d o c to r w h o d id
P t.
A w eek b efo re m y p e rio d ev ery m o n th . T h is is
th e
ch em ical. I feel th is c o m in g o n .
d id n t to u c h it so c o n s e q u e n tly tw o d a y s la te r on
o p e r a tio n
th o u g h t
it w a s a p o ly p a n d
T h . Yes. W h a t a b o u t p h y sic al sy m p to m s ?
a t r a in g o in g h o m e , I w e n t in to v io le n t la b o r
P t.
p a in s .
M y b ack , sp o n d y litis .
T h . A n y fa tig u e o r e x h a u s tio n ?
P t.
M ild a n e m ia also .
T h . A n y h e a d a c h e s?
P t.
P t.
No
T h . S to m a c h tro u b le ?
P t.
N o.
th a t
w as w hen
it a c tu a lly
P t.
Y es, w h ic h is th e u n f o rtu n a te p a r t you see. If I

h a d n o t, I th in k it w o u ld h a v e b een b e tte r.
T h . It lo o k ed lik e a c a t-m o u se ?
P t.
It d id n o t. It lo o k ed lik e a ch ic k e n h e a rt.
T h . L ik e a c h ic k e n h e a r t.
P t.
U h - h u h , e x a c tly .
T h . W o u ld y ou say you h a d a n y s e x u a l p ro b le m ?
T h . H o w m a n y m o n th s p r e g n a n t w e re y o u ?
P t.
S o m e in h ib itio n , u n le s s I k n o w th e m a n e x
P t.
tre m e ly w ell. I m ju s t n o t a c a s u a l p e rso n .
T h . W e ll, th a t is n t to o long.
T h . Yes.
oc
T h . D id y o u see th e fetu s?
V e ry seld o m .
T h . D iz z in e s s?
A nd
c u r r e d a n d th a t w a s j u s t a m essy m ess.
P t.
I d sa y 6 w eek s, a little o ver.

O h , no.
86
T h . W e ll, l e ts ta lk a b o u t th o se c a t-m o u se s a little
P t.
P t.
I d id th a t b e c a u se of i t s k in d of a tric k . I
m o re. G iv e m e a n id e a of w h a t th e d re a m s
s h o u ld n t h a v e d o n e it. A m o n g o th e r th in g s I
w e re .
w r ite a d v e rtis in g copy. I t s m y b u sin e ss to i n
T h e d r e a m s a ll h a v e th re e th in g s in c o m m o n
te re st p e o p le , so I u se tric k s b ecau se p e o p le a r e
h e a t th e se n sa tio n of b o d ily h e a t. T h a t s w h y
I h a v e th e m m o re o ften in s u m m e r. I t s very
a ttr a c te d by th is so rt o f w h im sic a l th in g .
T h . I see, it is n t re a lly a p ro b le m th e n .
h o t, w a te r , a th in g o f b e in g in w a te r o r n e a r
P t.
w a te r , o r s u r r o u n d e d by w a te r , a n d d is to rte d
T h . A ll r ig h t, fin e, n o w ?
a n im a ls , p e c u lia r a n im a ls , I m e a n . S om e of
P t.
th e m a r e v ery c h a r m in g a n d v ery w h im sic a l.

A n d in o n e I r e m e m b e r I h a d a b s o lu te ly to get
I t s a little u n p le a s a n t.
It i s n t a p ro b le m ;
th e y ll go a w a y .
T h . Y ou h a v e a n x ie ty in y o u r d r e a m s w ith th is
rid of th e a n im a ls . I h a d to k ill th e m , a n d it
w o k e m e u p b e c a u se I c o u ld n t.
It is n t re a lly a p ro b le m .
sy m b o l?
P t.
I d o n t k n o w if i t s a n x ie ty o r n o t. I t s j u s t a
T h . Y o u c o u ld n t?
fo rm o f te n s io n a n d a fo rm of a n x ie ty of b e in g
P t.
I j u s t c o u ld n t. I ju s t a b s o lu te ly c o u ld n t to u c h
forced to do s o m e th in g I d o n t w a n t to d o. A
th e a n im a ls.
v ery o b v io u s re a s o n . T h e a b o r tio n , it w a s very
T h . T h ese
c a t-m o u se s ,
are
th e r e
m any
in
th e
d ream or ju s t one?
P t.
p a in fu l a n d v ery u n p le a s a n t.
T h . T h is sy m b o l o n ly o c c u rre d a f te r th e a b o r tio n ?
O h , th ey c h a n g e ; th e y re n o t a lw a y s a cat-
P t.
m o u se . T h is is ju s t th e n a m e I ve given to th e
T h . A n d you feel v ery w ell sa tisfie d th a t th is is th e
c re a tu r e th a t evolved th r o u g h th is. T h e y can

be a n y th in g , b u t th e y a r e a lw a y s c o m b in a tio n s.
b asis of th is ?
P t.
T h . B u t th e c a t-m o u se s sy m b o l itself?
P t.
C a ll it a c a t-m o u se sy m b o l.
P t.
T in y , th e y re a lw a y s very sm a ll, th e y re a l
P t.
n ig h t.
L ik e a m o u se.
T h . O n ly d u r in g th e d ay .
P t.
T h e o rig in a l o n e w a s lik e a c a t a c a t s h e a d
a n d a m o u s e s body.
P t.
u n d e r s ta n d
w h im sy a n d
P t.
w ho
M y f a th e r is a v ery in te llig e n t m a n . A s a c h ild

h im
b e in g
v e ry
w o n d e rfu l
m a n a n d h e a d o re d c h ild re n . H e still does,
d u ll p e o p le .
b u t h e is a p a r a n o ia c . I d o n t m e a n a p a r a n o ia
T h . I see.
p e r s o n a lity , I m e a n a p sy c h o sis p a r a n o ia c . H e
T h is I ve d o n e , a n d w r itte n som e v ery c h a r m
is also a n alco h o lic.
in g little p ieces w h ic h I w ish I co u ld tu r n in to
T h . H o w d id h e r e la te to y o u ? W a s h e close?
so m e m o n ey if I co u ld .
P t.
T h . H o w d o y o u feel? D o you th in k a b o u t th ese

P t.
your
T h e y a re . It w o u ld be su c h a sto ry .
I re m e m b e r
h a v e a sen se o f h u m o r, a n d d o g -fish es a r e ju s t
P t.
b it a b o u t
T h . W h a t so rt of p e o p le a r e th e y ?
W e ll, th e c a t-m o u se s a r e p e o p le w ith w h im sy

ca n
N o w , te ll m e a little
m o th e r a n d y o u r fa th e r. A re th e y liv in g ?
W e ll, to a d o g -fish now .
w ho
B u t i t s lik e ly to be w a r m , a n d I ll be d ressed
a n d ly in g d o w n .
T h . OK.
T h . A d o g -fish n o w ?
and
O n ly th is. H o w e v e r, I n e v e r h a v e th is ex cep t
w h e n I m ta k in g a n a p . I d o n t h a v e th is a t
T h . A n d th e y w o u ld sh ift?
P t.
th is e x
N o , I ca n p u t m y se lf to sle ep in s ta n tly .
T h . G o o d , W h a t a b o u t n ig h tm a re s ?
T h . A n d th e c a t?
P t.
if y o u u n d e r s ta n d
b ig is it?
T h . T h e b o d y w h a t d o es it look lik e?
P t.
o v er,
T h . N o w , do y o u h a v e a n y in s o m n ia ?
w a y s little .
P t.
It clicked
p re ss io n . It felt rig h t.
T h . C a t-m o u s e sy m b o l, ca n you d esc rib e it? H o w

P t.
I ve n e v e r h a d it before. N e v e r.
A s a c h ild , v ery close. W e w e re v ery , very

close.
c a t-m o u se sy m b o ls a good d e a l?
T h . D id you re a lly love h im ?
N o , as a m a tte r o f fact I d o n t.
P t.
D e e p ly , I still do. T h is p r e s e n ts a p ro b le m .
T h . T h e y d o n t b o th e r you?
I ve b een u n a b le to solve it b e c a u s e h is w h o le
P t.
p e r s o n a lity s tr u c tu r e is so o b n o x io u s to m e th a t
N o.
T h . Y o u seem to be r a t h e r p re o c c u p ie d a b o u t th a t
in th e le tte r y o u se n t m e.
I h a v e h a d to sp lit it off. A n d to love th e m a n ,

th e
in d iv id u a l,
th e
th in g s
u n d e r n e a th ,
and
87
w h a t I k n o w is th e re a n d a v o id th e p e rs o n a lity
P t.
as
T h . N o w , I m g o in g to sh o w y o u th e R o rsc h a c h
if it
w e re
th e
p la g u e .
To
w a tc h
th e
d e g e n e ra tio n of a m in d a n d a h u m a n b e in g is
n o t a p le a s a n t th in g fo r a c h ild .
T h . I sh o u ld
P t.
say n o t, ev en a s
c a rd s r a th e r r a p id ly .
P t.
a c h ild
he w a s
P t.
I b e g an to p ick it u p a b o u t 9. T h a t s w h e n he
Th.
s ta rte d to d r in k . T h a t s w h e n a lot o f th e t r o u
P t.
It w ill ta k e ju s t a b o u t 5 m in u te s w ith m e. ( /
M o u n ta in s , c ra b , sea c ra b s , w o m a n p ra y in g ,
th e s e a r e th e m o st p r o n o u n c e d .
is sh e ?
T h . A ll r ig h t. T h is is th e seco n d o n e.
M y m o th e r is also tw o p e o p le . S h e is th e p e r
P t.
B e a rs , tw o little b e a rs, te d d y b e a rs , I a lw a y s
son she w a s 10 y e a rs ag o , a n d th e p e rso n sh e is
h a v e to th in k th is is a te m p le , th e w h ite p a r t in
now ;
th e c e n te r. A n d I a sso c ia te , th e o ra n g e p a r t
sh e
is w a s a v ery
sta b le
p e rs o n a
b e a u tifu l w o m a n .
w ith m e n s tr u a tio n blood.
T h . H o w did y ou get a lo n g w ith h e r ?

P t.
T h e la s t tim e it to o k m e 3 h o u rs .
h a n d h e r th e f i r s t c a rd .)
T h . H o w a b o u t y o u r m o th e r? W h a t so rt o f p erso n
P t.
O h , I ve h a d th a t (la u g h in g ).
T h . I k n o w . J u s t to give m e a n id ea.
d e g e n e r a tin g th e n .
ble b eg a n , a n d w e w e re n e v e r h a p p y since.
N one.
W o n d e r f u ll y ,
ju s t
w o n d e r f u lly .
T h . A ll rig h t. T h is is th e th ird c a rd .
O h,
we
P t.
sc ra p p e d a little b it, b u t w ith th a t k in d of a
O h , I r e m e m b e r th ese, th e s e a r e m y little c a n
n ib a l w o m e n . T h e y a r e c o o k in g , th e little g u y
fa m ily if w e get m a d , w e sa y s o m e th in g . I
w h o sits in th e tw o c o rn e rs h e re , {fo u rth card)
m e a n m o th e r th r e w p la te s a n d I sto m p e d o u t
T w o tire d b ird s s ittin g b ack to b ack . T h e y a re
o f th e h o u se , b u t it n e v e r m e a n t a n y th in g . I
v ery tire d , (fifth card) I a s so c ia te th a t w ith th e
m ean
th e re
w as never any
g ru d g e s h e ld
b e e r belly , a v e g e ta b le , a n d I c a n n o t tra c e it.
o v e rsh a d o w in g , lo n g te n s io n p e rio d s.
T h e to p is a s o ld ie r s h e lm e t. W o m e n chiefly
T h . D o y o u h a v e a n y b r o th e rs a n d siste rs?
w o m e n , p r o b a b ly n u r s in g o r a b le to n u r s e a n d
P t.
so m e h o w a sso c ia te d w ith c h ild re n in th is case.
I h a v e a y o u n g e r b r o th e r a n d y o u n g e r sister.
T h . H ow young?
T h . T h is is th e six th one.
P t.
P t.
M y y o u n g e r s is te r is 2 y e a rs y o u n g e r sh e is
m a r rie d a n d h a s tw o c h ild re n . M a r r ie d a m a n
w in g s.
j u s t like m y f a th e r w h o is also a n alco h o lic. So
T h . W h e r e do yo u see th e w in g s th e r e ?
sh e refu ses to sta y m a r rie d , a n d a s lo n g as
P t.
th e y re d iv o rced a n d live to g e th e r, life is fine.
of it. (se v e n th ca rd ) T h e s e a r e th e c h ild re n .

I m
bly is d u e to a b r a in in ju ry . S h e h a s b een sick
tio n s fro m b efo re . L ittle c h ild r e n , fa c in g o n e
a ll of h e r life. M y b r o th e r is 19, is se n sitiv e
a n o th e r , in k in d o f a b a lle t d a n c e r s po se , th is
and
w a y . (e ig h th ca rd ) T h is is th e m o st, I ca n ta k e
in te llig e n t, te r rib ly d e p re ss e d
and
in
by
th e
w a y , som e r e a c
th e co lo rs; i t s a w e ird c o m b in a tio n h e re , it h a s
th a t y ou re m e m b e r?
a k in d of offbeat lik e ja z z m u sic , th e o ra n g e
I d i d n t re m e m b e r a d a y w h e n I d i d n t h av e
a n d th e p in k . It h a s a w a te r y fe e lin g to m e.
an y .
T h ese
T h . W h a t fo rm d id th o se e m o tio n a l u p se ts ta k e ?
a re
th e
p o la r
b e a rs o v e r h e re , very
s tro n g ly sh a p e d . A n im a ls of so rts a r o u n d a
By e m o tio n a l u p se ts d o y o u m e a n ta n tr u m s o r
w h e e l,
o u tb re a k s ?
s o m e th in g . I m so rt of a ttr a c te d to th e a n im a l
so rt
of d is to rte d
p a tte r n .
I a lw a y s felt p u sh e d in to a c o r n e r a n d forced
T h . U h - h u h . T h is is th e n in th one.
off, a n d m y o n ly free d o m w a s w h e n I w a s by
P t.
is th e o n e
I d i d n t lik e.
B e cau se i t s
v io len ce a n d in se c ts, a n d th is is s o m e th in g I
m e n t p r io r to se ein g th e co lleg e d o c to r?
N one.
T h is
m essy , v ery m essy , b ec a u se it r e m in d s m e of
T h . A n d y o u r p re v io u s tr e a tm e n t, a n y so rt o f t r e a t
T h . T a k in g a n y m ed icin es o r tr a n q u iliz e r s ?
I n o ticed
w o rld .
O u tb r e a k s o r n e rv o u sn e ss. It w a s a re p re ssio n .
m y se lf a n d liv in g in d a y d r e a m s e s se n tia lly .
P t.
r e m e m b e rin g ,
it a p a r t m o re . T h is o n e I r e m e m b e r lik in g . I t s
T h . A s a c h ild d id you h a v e a n y e m o tio n a l u p se ts
P t.
T h e w h o le o u tsid e , th e f e a th e rs , a n d th e s h a p e
S h e a tte m p te d to c o m m it su ic id e . T h is p r o b a
h ib ite d . 1 sh o u ld say b a sic a lly ju s t a fin e boy.
P t.
N a v a h o ru g s , b e a r ru g s, I h a v e a s e n sa tio n of
d islik e .
T h . V io le n c e , insects.
P t.
W h e n p e o p le a r e r o u g h a n d v icio u s in a w ay .
88
T h . D o y ou see a n y th in g else th e r e ? . . . Y ou can
T h . Is th a t so. Y ou w o u ld a lso be v ery good in a n a
h o ld it a n y w a y yo u w ish . . . . A ll r ig h t, th is is
th e la s t on e.
P t.
ly z in g d re a m s , a n a ly z in g th e u n c o n sc io u s.
P t.
C h ild r e n th a t a r e lik e sea h o rse s , a n d a g a in

slig h tly h y ste ric a l m o d e rn a r t. I lik e th is one.
So i t s u n b e lie v a b le . A side fro m m yself, as lo n g

a s I d o n t th in k a b o u t it.
T h . So yo u d o h a v e th is fa c ility , b u t th is very
N o w I g et a n E iffel T o w e r im p re ss io n from
fa c ility ca n c re a te p ro b le m s for you.
th is im m e d ia te ly , w h ic h I a u to m a tic a lly sw itc h
P t.
o v er in to a p re fe rre d sy m b o l. A n d th is is th e
T h . Y o u re e x tre m e ly se n sitiv e , to o se n sitiv e. Y ou
feelin g I h av e. T h is o n e is g ood, so m e h o w ,
feel slig h ts , you get v ery te n s e , yo u a r e ju s t lik e
even th o u g h it seem s d is c o rd a n t a n d d isc o n
a w e a th e r v an e. Y ou j u s t sw in g w ith th e w in d ,
n ected . It h a s a c o h e re n c e of w a r m th a n d good
a n d b ec a u se of th a t , y o u m ay n eed so m e so rt of
feelin g th a t co m es so m e tim e s w ith good th in g s.
h e lp . N o w , I w o u ld th in k th a t y o u co u ld do
[T h e
th e
v ery w ell w ith t h e r a p y m a y b e n o t too in te n
in te n s ity o f fe e lin g in th e la st th re e ca rd s p o i n t
sive th e r a p y b u t se ein g so m e o n e a b o u t o nce
d is o r g a n iz a tio n
o f th o u g h t
and
to a s c h iz o p h r e n ifo r m - lik e te n d e n c y . ]
Y es, it does.
w eek ly .
T h . A g o o d feelin g ?
P t.
P t.
T h . S o m e b o d y th a t w o u ld s ta b iliz e you a n d w o u ld
P la y fu l is th e w o rd I w a n t.
T h . N o w , I h a v e a little b e tte r id e a of th e p ro b le m
e n a b le you to g et som e s ta b ility b e c a u se y o u re
th a n I d id b efo re. So v ery ra p id ly I m ju s t g o

in g to giv e y ou m y id eas, b u t I m a y n o t be
too m u c h lik e a w e a th e r v an e.
P t.
I k n o w , it w o u ld d riv e m e w ild , yo u see, a n d
a b s o lu te ly a c c u r a te a n d I w a n t y o u th e n to tell
t h a t s p a r t of th is w h o le th in g .
m e y o u r im p re ss io n s . \In p r e s e n tin g in te r p r e ta
tr a c k of th is id e a o f u sin g h y p n o s is a s a fo rm of
tio n s to th e p a ti e n t o r in g iv in g h e r a h y p o th
re s e a rc h ; n o w , I m n o t a d v e rs e to w o rk in g on
I ve g o tte n
esis o f th e p r o b le m , I m u s t be c a r e fu l th a t sh e
m yself. I d o n t m e a n to u se it a s a n easy w ay
d o es n o t re g a rd w h a t I sa y as an a tta c k , o r as
o u t. I w o rk a w fu lly h a r d for e v e ry th in g I ve
b e in g c r itic a l o f her. S h e h a s a lre a d y to ld m e
e v er h a d , a n d I d o n t m in d . I even e n jo y it, I
th a t w h a t sh e se e k s fr o m m e is a p p r o v a l a n d
h a v e a feelin g n o w o f g e ttin g so m e th in g t h a t s
s u p p o r t. ]
g o in g to m e a n e n o u g h to s te a d y m e d o w n .
T h . N o w , y ou a r e a n e x tre m e ly se n sitiv e a n d c r e a
T h . I m s u re th a t yo u co u ld u tiliz e h y p n o sis v ery
tive p e rso n . Y o u h av e a g re a t m a n y ta le n ts a n d
effectively.
th e a b ility to p erceiv e n u a n c e s a n d to a rriv e
P t.
v ery r a p id ly to in tu itiv e feelings. T h a t s b e
T h . A re y o u ?
ca u se you live v ery close to y o u r u n c o n sc io u s.
P t.
Y o u h a v e a r e m a rk a b le fa c ility in th a t d ire c
d o n t. Y ou ju s t seem to h a v e th is facility . F o r
I m v ery g o o d a t it, by th e w a y .
I ve d o n e a little b it o f it, j u s t e n o u g h , a n d if I
u se m y eyes it w o rk s lik e a c h a rm . I ju s t go
tio n . T h e r e a r e p e o p le w h o do a n d p e o p le w h o
r ig h t o u t.
T h . Y ou can c e r ta in ly u tilitz e y o u r facility in a
th a t re a so n m a n y of th e p h e n o m e n a th a t a re
very a p p r o p r ia te w a y . A s fa r a s y o u re c o n
o r d in a rily
c e rn e d , I d o n t th in k h y p n o s is is a b s o lu te ly
re p re sse d
and
are
n o t o rd in a rily
p erceiv ed a r e a v a ila b le to you. S o, yo u ca n b e
n e c e ssa ry . It w o u ld n t m a k e too m u c h d iffe r
co m e a w a r e of m a n y sy m b o ls th e a v e ra g e p e r
en ce as fa r a s y o u r g e ttin g so m e th in g b en eficial
son o v erlo o k s. Y o u can also be in flu e n ced by
P t.
J u s t to stu d y it o u t.
o u t o f th e r a p y .
y o u r u n c o n scio u s. Y ou th e n c a n p o se q u e s tio n s
P t.
to y o u r u n c o n sc io u s a n d g et th e a n s w e rs . N o w
T h . Y ou u n d e r s ta n d w h a t I m e a n ?
T h a t w a s n t th e p o in t. (la u g h in g )
th is is n o t a v e ra g e . I d say m o st p e o p le c a n n o t
P t.
d o th is.
T h . So w e re ta lk in g in tw o d iffe re n t fra m e s of re f
Y es, I k n o w w h a t you m e a n .
T h e n you see m y in te re s t in th is field b ecau se
e ren ces: h y p n o sis is o n e th in g a n d a lso yo u as
I m a w a r e o f th is. I ll tell y o u so m e th in g else
a p e rs o n
th a t m ig h t in te re s t you. If I ta lk to so m e o n e for
s o m e th in g m e a n in g fu l o u t o f o th e r k in d s of
2 h o u r s a n d let th e m ta lk to m e, I c a n tell you
th e r a p y . A s a m a tte r o f fact, I d o n t th in k h y p
in te r m s o f y o u r c a p a c ity
to get
w h ic h p a r e n t h a s c a u sed th e tr o u b le in th e p e r
n o sis w o u ld be th e b est th in g for y o u . Y ou a r e
s o n ju s t in stin c tiv e ly .
too im m e rs e d in y o u r u n c o n s c io u s n o w , a n d it
89
w o u ld be m u ch b e tte r for you to s ta b iliz e an d
ta n g e n ts . \ T h e p a tie n t is o b v io u s ly s e e k in g a
b u ild u p a little m o re re p re ssio n so th a t you
p r o lo n g e d
a re n o t b e in g b o m b a rd e d all th e tim e by y o u r
p r o b a b ly a ll sh e can u se a t th is tim e . S h e is
u n c o n sc io u s.
| M y fe e lin g is th a t th e p a tie n t
q u ite close to a s c h iz o p h r e n ic b re a k , in m y
w o u ld u tiliz e h y p n o s is to s tir u p too m a n y
o p in io n , b u t sh e s till h a s g o o d d efen ses, a n d
fa n ta s ie s
a n d in
th is
w ay
w o u ld fr ig h te n
m ig h t,
h erself. ]
co m e on a o n c e -a -w e e k b asis to ta lk th in g s
i f sh e is m o tiv a te d , b e n e fit f r o m
is
th e
to a h o s p ita l c lin ic w h e r e s h e c o u ld receive

g o o d th e r a p y . ]
T h . W e ll, give m e a n id e a of w h a t you can affo rd ,
o v er. Y o u ll feel a n a n c h o r a g e th e re . A n d in
th a t refe re n c e I m a y be a b le to re fe r you to
a p p r o x im a te ly .
Pt.
so m e b o d y w h o m ay be a b le to h e lp you.
T h a t I c o u ld m a k e , I co u ld m a n a g e th is.
T h . A ll r ig h t, I th in k I ca n fin d so m e b o d y for you
n a n c ia l b u sin e ss.
at o n e of th e clin ics. I sh a ll te le p h o n e h im th is
T h . T h a t s o n e of th e th in g s I m ig h t be a b le to h e lp
y o u w ith b y a r r a n g in g for th e r a p y in te r m s of
y o u r b u d g e t a n d in te rm s of y o u r o w n a b ility
to p a y w h a te v e r y ou c a n . T h e r e a r e p la c e s in
G e e , i t s so a w fu lly tig h t th a t even s o m e th in g

a s little a s $ 1 0 a w e e k w o u ld be too m u ch .
1 d o n t h a v e
a n d y ou see I m re a lly in a c o r n e r o n th is fi
a fte rn o o n a n d let y o u k n o w .
Pt.
A ll rig h t.
T h e p a tie n t w a s referred to th e h ead of a
I d o n t n eed th a t k in d o f h elp . I n eed a fa th e r,
clinic in the n e ig h b o r h o o d , w h o m I te lep h o n ed

a n d in fo rm ed a b o u t h e r p ro b le m . T h e clinic
D r . W o lb e rg . N o , th is is t r u e , I n e e d so m e
w a s w illin g to ta k e h er, b u t the p a tie n t n ever
b o d y th a t is v ery stro n g , a n d v ery sta b le a n d
accepted th e referral. A te le p h o n e call from me

to h e r w as n ev er r e tu rn e d .
th e city w h e re y ou ca n receive som e good h e lp .
Pt.
w h ic h
m ild n e u r o le p tic . 1 h a v e in m in d re fe rr in g h e r
in th e r a p y w ith so m e b o d y to w h o m you could
B e cau se th is co sts m o n ey a n d th is
r e la tio n s h ip ,
p r o p e r ty p e o f tr e a tm e n t a n d p e r h a p s so m e
Pt. W e ll, you k n o w th a t w a s p a r t of th e idea.

T h . N o w , I th in k th a t you p r o b a b ly w o u ld do w ell
Pt.
s u p p o r tiv e
w o n t la u g h a t m e w h e n I get off on o n e o f m y
CHAPTER 7
Choosing an Immediate Focus

h a v io ra l
M a n y p a tie n ts come to th e r a p y convinced
im p ro v e m e n t,
to
sim p le
su p p o r tiv e
som e p re c ip ita tin g factor in th e i r e n v iro n m en t.

A n alcoholic h u s b a n d , a dis a stro u s in v estm ent,
cessitate a seriou s look at u n d e rl y in g p e r

son ality factors th a t a re s t irr in g u p obstructiv e
a b ro k en love affair, a serious accident, these

a n d m a n y o th e r real o r e x a g g e ra te d calam ities
tr a n sferen ce a n d o th e r in terferences to change.

In p ractically all p a tie n ts som e im m e d ia te
m a y be bla m e d . W h a t p eop le u su a lly w a n t

from tr e a tm e n t is h elp in gettin g rid of pain fu l
stress situ atio n , u su a lly o ne w ith w h ich th e in

div idu al is u n a b le to cope, sp a r k s th e decision
o r d isab ling sy m p to m s th a t a re often ascribed
to get help. U s u a ll y th e p a tie n t considers

him self to be th e victim r a t h e r t h a n p e r p e t r a
to such offensive events. T h e sy m p to m s include
and
resistance
th a t th eir p ro b le m s w ere b ro u g h t a b o u t by
reed ucative tactics m a y
ne
to r of his identified tro u bles. T h i s , in some

cases, m a y be tr u e ; in m ost cases it is false. It
an x iety , d ep ressio n, p h ob ias, in s o m n ia, sexual

difficulties, obsessions, physical p ro b le m s for
w hich no o rg a n ic cause can be fou nd , a n d a
is necessary, therefore , in all p a tie n ts to a p
g re a t m a n y o th e r c o m p la in ts a n d afflictions.
p ra is e the d e g ree of p e rs o n a l p a rtic ip a tio n in
E ven th o u g h w e m a y be correct in o u r
a s s u m p t i o n t h a t th e b a sic t r o u b l e s re s id e
th e ir difficulties.
Since w e a re a c tu a lly d e a lin g w ith situation s
elsew h ere t h a n in e n v ir o n m e n ta l o r s y m p to
m atic co m p lain ts, to bypass the p a t i e n t s im
th a t
generate
te n s io n
and
a n x iety ,
it
is
e s s e n tia l to v ie w e n v i r o n m e n t a l in c i d e n t s
th r o u g h the lens of th e ir special m e a n i n g for
m e d iate con cern s is a serious m istak e. L a te r

w h en th e r e is firm evidence of th e u n d e rly in g
th e ind ivid ua l. W h a t m a y for one p e rs o n co n

stitute a n i n s u r m o u n t a b le difficulty m a y for
causes, for e x a m p le , faulty p e rs o n a lity o p e r
a n o t h e r be a bo on to a d ju s tm e n t. D u r i n g
W o r l d W a r II, for in stance, th e L o n d o n b o m b
ings for som e citizens w e re s h a t te r i n g a ssau lts
o n e m o t i o n a l w e l l - b e i n g ; for o t h e r s t h e y
b ro u g h t fo rth laten t p r o m p ti n g s of c o o p e r
atio n s o r unco nscio us conflict, a good in t e r

view er should be able to m a k e con nections b e
t w e e n t h e p r e c i p i t a t i n g e v e n ts o r e x i s t i n g
s y m p t o m s a n d t h e less a p p a r e n t d y n a m i c
sources of difficulty. T h e r e will th e n o ccur a
ch an g e in focus. T h i s shift, h o w ev er d esirab le
it m a y seem, is no t alw ay s necessary because
w e m a y find t h a t o u r objectives a r e re ached ,
an d th a t the p a tie n t achieves stab iliz atio n ,
w i t h o u t d e l v i n g in to c o r r o s iv e c o n flic ts o r
stirr in g u p ghosts of th e past. It is o nly w h e re
atio n , b ro th erlin e ss, a n d self-sacrifice th a t lent

a n e w an d m o r e co nstructiv e m e a n i n g to th e
i n d i v id u a ls existence. In d e e d , w a r t i m e w ith its
th r e a t to life m a r s h a ll e d a n in terest in survival
a n d s u b d u e d n e u ro tic m a l a d ju s tm e n t, w h ich
r e t u r n e d in pea cetim e to p la g u e th e ind iv idu al.
T h e u n d e r s ta n d in g of stress necessitates ac
k n o w le d g in g t h a t th e r e is no objective m e a s u r e
of it. O n e c a n n o t say th a t such a n d such a n e n
v ir o n m e n t is, for th e a v e rag e ad u lt, 7 0 p erc e n t
goals go bey on d s y m p to m relief or be hav ioral

im p ro v e m e n t t h a t w e will, in th e h o p e of
initiatin g som e d e e p e r p e rs o n a lity a lte ra tio n s,
delve into d y n a m ic p ro b le m areas. E ven w h e re
th e objective is m e re s y m p to m relief or b e
stressful a n d 30 p e rce n t n u r t u r a n t . N o m a t te r
90
CHO O SING AN IMMEDIATE FOCUS
91
how benevolent o r stressful th e en v iro n m e n t,

th e in dividual will i m p a r t to it a special m e a n
ing as it is filtered th r o u g h his con ceptu al n e t
w o rk . T h i s shad es his w o rld w ith a signifi
b rin g s p u n is h m e n t . T h e y a r e c o m m o n ly re
ferred to as lo s e rs. A p a ti e n t of m in e co n
sta n tly w o u ld involve him self w ith finan cial in
cance th a t is largely subjective. C o n c e p tu a l dis

t o r t i o n s p a r t i c u l a r l y t w i s t fe e lin g s t o w a r d
v estm ents th a t a lm o st in evitably w o u ld tu r n

o ut to be less th a n profitab le. H e w o u ld then
react w ith d ep res sio n , rag e, a n d s h atte re d self
o th e r h u m a n beings a n d especially t o w a r d th e
esteem . Yet no so o n er w o u ld he accu m u la te
self. A self-image th a t is h ateful o r in a d e q u a te
an y s u r p lu s of fu nds, th en he w o u ld a g a in
m a y p la g u e the individ ual th e r e m a i n d e r of his
p lu n g e into fanciful schem es th a t e nd ed in

d isaster. It w a s only after w e h a d ex po sed his
life an d causes h im to in t e r p r e t most h a p p e n

ings in relation to his feelings th a t he does not
h ave m uc h value. M o s t of w h a t h a p p e n s to
in n e r need to fail th a t he w o u ld recognize ho w

he b ro u g h t his tr o u b le s on him self. F o r a w hile
h im in life will be viewed as c o n firm in g his

o w n conviction th a t he is n ot m u c h good an d
it w a s w i t h t h e g r e a t e s t effo rt t h a t he
re s tra in e d h im se lf from in d u lg in g in w ildcat
t h a t n o th in g th a t he does will a m o u n t to
a n y th in g . Such a pervasive belief, of course,
g am bles. I felt th a t h a d he n ot needed to a n

sw e r to me, he still w o u ld hav e ta k e n im p o ssi
m akes n ea rly
ble risks.
any
o ccurren ce
p rod uctive
of
c onsiderable stress.
W i t h this as an in tro d u c tio n , it m a y be
C h a r a c t e r d is to rtio n s e n g e n d e re d by defects
asserted th a t th ere is such a th i n g as realistic
in d ev elo p m en t, such as e x tr e m e d e p en den cy ,

d e ta c h m e n t, ag g ressio n , m aso ch ism , p erfec
e n v iro n m e n ta l stress:
tio nism , o r com pu lsive a m b itio u sn e ss , a r e w h a t

u su a lly p re v e n t th e in d ivid ua l from fulfilling
1. T h e e n v ir o n m e n t m a y e x p o s e th e in d iv id u a l to
g ra v e th re a ts in th e fo rm o f g e n u in e d a n g e rs to life
a n d to se c u rity . E x a m p le s a r e e x p o s u re to d isa ste rs
su ch a s w a r , floods, sto rm s, a n d a c c id e n ts as w ell as
sev ere d e p riv a tio n of f u n d a m e n ta l n eed s for food,
sh e lte r, love, re c o g n itio n , a n d o th e r b io lo g ical a n d
social u rg e s e n g e n d e re d by a cru el o r b a r re n e n v i
him self a n d ta k i n g a d v a n ta g e of e n v ir o n m e n ta l
o p p o rtu n itie s . T h e y m a k e for th e c re a tio n of
a b n o r m a l goals a n d values t h a t m a y seriously
i n t e r f e r e w i t h a d j u s t m e n t a n d t h a t a c t as
sources of stress irrespective of th e en v iro n m e n t.
It is r a r e th e n
th a t e n v ir o n m e n ta l stress
2. T h e e n v ir o n m e n t m a y be p a r tia lly in im ica l,
a lo n e is the sole cu lp rit in a n y em o tio n a l p r o b

lem. In im ical, frig h te n in g , a n d d e s p e r a te s i tu a
th e in d iv id u a l n o t h a v in g th e re so u rc e s to rectify it.
tions do arise in th e lives of people, b u t the
T h e e n v iro n m e n t m ay be b e n e fic e n t e n o u g h , b u t th e
reaction s of the indiv idu al to h a p p e n in g s a re
in d iv id u a l, p e r h a p s th r o u g h e a rly fo rm a tiv e e x p e r i
w h a t d e te r m i n e th e ir p a th o lo g ic a l pote ntia l.
en ces,
U n d e r these c ir cu m stan c es m in o r e n v ir o n m e n
tal stress can ta x co pin g cap acities a n d b re ak
d o w n defenses so th a t a n e v e n tu a tin g a n x ie ty
will p ro m o te regressive devices like protective
p h o b ia s . It is, th erefore, essential th a t an y
p re c ip ita tin g incident th a t b rin g s a p a ti e n t into
ro n m e n t.
n ev er
d ev elo p ed
th e
a b ility
to
u se
th o se
re so u rc e s th a t w e re p o te n tia lly a v a ila b le .

3. T h e e n v ir o n m e n t m a y c o n ta in
a ll e le m e n ts
e s se n tia l f o r a g o o d a d ju s tm e n t, yet th e in d iv id u a l
m a y , a s h a s b een c ite d , be u n a b le to ta k e a d v a n ta g e
of it b ecau se o f a p e rs o n a lity s tr u c tu r e th a t m ak es
h im
e x p e rie n c e e s se n tia l n e e d s a s p ro v o c a tiv e of
d a n g e r. S u c h d efects m a y ca u se h im to p r o je c t o u t
in to th e e n v ir o n m e n t h is in n e r d issa tisfa c tio n s, a n d
he
m a \ a c tu a lly crea te c ir c u m sta n c e s th a t b rin g
th e r a p y be re g a r d e d as m erely o ne ele m e n t in
a n assem bly of etiological factors, th e m o st im
p o r t a n t v a ria b le bein g th e deg ree of flexibility
escape.
a n d in tegrity of the p e rs o n a lity stru c tu re . It is

this v a ria b le th a t d e te r m in e s a h a r m o n io u s in
te ra ctio n of forces th a t p o w e r in trap sy ch ic
Som e perso ns in v ariab ly re g a r d th e ir env i

ro n m e n t as on e in w hich th e i r assertiveness
m e c h a n ism s w h e n security a n d self-esteem are

th r e a te n e d by adv ersity fro m th e o u tsid e an d
u p o n h im s e lf th e v e r y h a z a r d s f r o m w h ic h h e se e k s
92
by c om m o n d ev elo p m en ta l crises th a t im pose

them selves from w ith in . By focusing on w h a t is
tion for its in fluence, good o r b ad, o n th e p a
re g a rd e d as a p re c ip ita tin g incid ent we m a y be
tient. A n u n d e r s ta n d in g of th e h o w a n d w h y of
its im p a c t m a y prove in v alu ab le. S o m etim es
able n ot only to in itiate re m e d ia b le e n v ir o n
th e in itia tin g factor m a y seem like a trivial
m e n ta l correction s but also to o p en a w in d o w
s p a r k to th e th e r a p is t , b u t a n e x p lo r a tio n of
th e p a t i e n t s p a s t h isto ry , his attitud es, a n d his
into h idd en p e rs o n a lity resources.

F r o m a p ractical v ie w p o in t th erefore, an y
e n v ir o n m e n ta l stress w a r r a n t s close e x a m i n a
values m a y reveal the e m o tio n a l explosive m i x

t u r e th a t a w a its d eto n atio n .
Focusing on Symptoms
Because
sy m p to m s
are
freq u en tly
by
p ro d u c t of stress, tension, a n d anxiety , it m ay

be helpful to e x a m in e th e ir d ev elo p m e n t a nd
Anxiety and Its Defenses

A vast a m o u n t of h u m a n p s y c h o p a th o lo g y is
m e a n i n g w ith in the m a t r i x of a d a p ta tio n . As
covered
long as a p e rs o n is ca p a b le of cop ing w ith his
c h a ra c te riz e d by a violent bio chem ical an d

n e u ro p h y s io lo g ical reactio n th a t d is r u p ts the
c u rr e n t life situ a tio n , as long as he c an gratify
by th e
g eneric te r m
anx iety.
It is
his most im p o r t a n t needs a n d dispose of o th e r s

th a t he is u n a b le to satisfy, as long as h e can
p hy sical, intellectu al, e m o tio n a l, a n d b e h a v
su sta in a sense of security a n d self-esteem, a n d
of a collapse o f a p e r s o n s h a b it u a l security
as long as he is able to m e d ia te tro u b le s th a t

vex h im , he will not ex pe rie nce stress b eyond
s t ru c tu r e an d his successful m e a n s of a d a p t a
tion. So u n c o m f o rta b le a r e its effects t h a t th e in
th e p o in t of a d a p tiv e b alan ce. W h e n , h ow ev er,
div id u al a tt e m p t s to escape from it t h r o u g h
this is not possible, th e th r e a t is registered as a
v a rio u s m a n e u v e rs. T h e s e a r e u su a lly self-de
state of tension, w ith altere d h o m e ostasis af
feating because th ose very m a n e u v e r s a re often
fecting the viscera, th e skeletal muscles, an d
regressive in n a t u r e t h a t is, they revive o u t

m o de d ch ild ish w a y s of d e a li n g w ith discom fort.
T h e y on ly f u r t h e r in terefere w ith assertive a n d
th e psychic a p p a r a t u s . T h e p erso n mobilizes

him self to cope w ith the stress a n d if he is suc
cessful, hom eostasis is resto red . W h e n a tte m p ts
at a d a p ta tio n keep failing, th e c o n tin u in g p r e s
ence of tension in t u r n sabotages the dev elo p
m e n t of m o re effective coping p a ttern s.
O v e rs tim u la tio n re sultin g fro m co n tin u ed
stress is b o u n d to register its effect on the
bodily in tegrity ( e x h a u stio n r e a c t io n ). B o m
b a r d m e n t of th e viscera w ith stim uli will tend
after a w h ile o rg a n ically to d is tu rb th e fu n c
tions of the v ario us o rg a n s a n d systems. T o
such e n su in g d is tu rb a n c e s Selye (19 50 ) h as
given th e n a m e disease of a d a p t a t i o n . As in
sidious as a re the physical effects of tension,
th e d ev elo p m en t of a c a stastro p h ic sense of
helplessness p ro d u c e s th e m o re d is tu rb in g p h e
ioral fu nction s of th e in divid ual. It is indicative
p ro d u ctiv e co o rd in atio n s.
W h e r e a n x ie ty is u n co n tro lle d , a n actu al
r e t u r n to in fantile he lplessness w ith co m plete
loss of m a s te ry m a y th r e a te n . R eality testin g
m a y totally d isin te g ra te , e n d in g in confusion,
d e p e rs o n a liz a tio n , a n in a b ility to locate the
lim b s in space, in c o o rd in a tio n , an d loss of c a
p acity to differe ntia te th e m e fro m th e no t
m e . T h i s th r e a t to in te g rity m a y in itiate
p a r e n t - i n v o k in g tactics r a n g i n g fro m q u iet
se a r c h in g for s u p p o r t to sc re a m in g , t a n t r u m s ,
be w ilde re d cries for help, a n d fain ting . Such
co m plete re la p se to infancy is ra r e , o c c u rrin g
only in in d iv id u a ls w ith fragile p e rs o n a lity
n o m e n o n of a nx iety . A n d it is often an x ie ty
stru c tu res.
A n x iety does not alw a y s h ave to be h a rm fu l.
th a t bring s th e p a tie n t to th e r a p y .
As a m a t te r of fact, som e a n x ie ty is a n a d a p
CHO O SIN G AN IMMEDIATE FOCUS
93
tive necessity; its release acts as a signal to
F ir st, th e re is a vast un d iffere n tiated , e x p lo
alert the ind iv idu al a n d to p r e p a r e h i m for
sive d is ch arg e of tension w h ic h d iso rg a n iz e s
em ergency action. S m all a m o u n t s of a n x ie ty

sp on sor so m atic an d visceral re actio ns th a t
th e physiological r h y t h m of every o rg a n an d
lead to attac k o r flight. A n x ie ty even facilitates
d u lar,
in fo rm atio n p rocessing in th e fo re brain. T h e
n it o u r i n a r y ,
p h y s i o lo g i c a l
tin u e d excitation s m a y p ro d u c e psy cho som atic

d is o rd e rs a n d u ltim a te ly even irre versible o r
and
b i o c h e m ic a l
pattern s
of
an x iety a re in n a te in th e o rg a n ism . Its p sy

chological in g red ien ts a re u n iq u e to th e e x p e r i
en ces a n d c o n d i t i o n i n g of t h e i n d i v i d u a l .
T h e s e , co n stitu tin g the security a p p a r a t u s , are
o rg anized to redu ce a n d to rem o ve t h r e a ts to
th e integrity a n d safety of th e individual.
T h e signal of an x iety , therefore, activates
tissue in th e body, in c lu d in g m u s c u la r, g l a n
card iovascular, gastro in testin al, ge
and
special
senses.
Long
co n
ganic changes. T h u s , w h a t starts o u t as a

g astric d is o rd e r m a y t u r n in to a sto m a c h ulcer;
bow el irrita b ility m a y becom e a colitis; h y p e r
te nsion m a y re s u lt in c a rd ia c illness, an d so on.
Second,
stro p h ic
th e r e
feelings
is a p re c ip ita tio n
of helplessness,
of c a ta
insecurity,
ad ap tiv e reserves s tim u la tin g som atic a n d p sy
a n d d e v alu a te d self-esteem. T h e victim often
ch o lo g ic a l
fo r a n
voices fears of fatal physical illness, like can cer
em ergency. T h e in dividu al le arn s to react to
or h e a r t disease o r b r a i n t u m o r , as i n t e r p r e t a
tions of th e p e c u lia r so m atic sen sation s o r
m ech a n ism s
to
prepare
m in im a l cues of a n x ie ty w ith a con structiv e d e

fensive reactio n th a t dispels th e a n x ie ty an d
p e r h a p s e lim in a tes its source. B u t w h e re the
defenses fa il to operate, a n x ie ty can reach a
sy m p to m s th a t a r e being released by anxiety.

T h i r d , th e r e is a w e a r in g d o w n of r e
pressio ns
to
th e
p o in t
w here
they
become
p itch w h ere it can not be d isp elled . So m atic
p a p e r th in in c e rta in areas. C o n s e q u e n tly , a
reactions of a diffuse, un differen tiated, a n d

destructive n a t u r e th en flood th e body. P s y
b r e a k t h r o u g h of re p u d ia te d th o u g h ts , feelings,
a n d im p u l s e s , o r d i n a r i l y c o n t r o l l a b l e , n o w
c h o lo g ic a l
becom e d iso rg an ize d .
m a y o ccur at r a n d o m . T h e s e o u tb u r s ts f u r th e r
Regressed, childish kind s of beh av ior, w h ic h

solve little to w a r d h a n d li n g a n a d u lt a nx iety
u n d e r m in e secu rity a n d p r o d u c e a fear of being
situa tion , m a y th e n em erge. B ecause th e in d i
F o u r t h , v a rio u s defenses a re m ob ilized , th eir

v ariety an d a d a p tiv e n e ss d e p e n d in g u p o n the
responses
vidual c a n n o t cope w ith intense an x ie ty , he

m a y w a n t som eone to tak e over for him .
W h a t g ene rally sh a tte rs th e defenses of th e
p e r s o n so t h a t h e r e s p o n d s w i t h g lo b a l
an x iety ? T h e p rovocative a g en t m a y be a n y e x
o ut of c on trol, of n ot k n o w in g w h a t to expect.
flexibility a n d m a t u r i ty of th e in div id ual. If

th ese strateg ies fail to co ntrol or d is sip a te th e
sense of te r r o r , th e n a f u r th e r set of m a n e u v e rs
is in itiated.
te rn a l d a n g e r o r in te rn a l conflict, recognized
Solution s for a n x ie ty will d e p e n d o n the
or un rec o g n ize d , th a t d iso rg a n iz e s th e in d i
source of th e a n x ie ty as well as th e s in g u la r
v id u a ls reality sense, crushes his secu rity and
p e rs o n a lity c o n fig u ratio n s of th e in dividu al.
self-esteem b eyond m e d ia tio n , an d fills h im

w ith a cata str o p h ic sense of helplessness to a
po in t w h e re he ca n n o t stabilize him self. It is
th e m ean in g to th e ind iv idu al of an ex perien ce
T h e specific ty p es of defense a r e chosen by

th e in div idu al for re a s o n s th a t a re not, at o u r
p re s e n t state of k no w led ge, fully k n o w n . T h e
follow ing factors a re p ro b a b le . (1) T h e in d i
v id u a ls u n iq u e ex periences a n d cond itio ning s
focus e m p h a s is on p ro b le m s a n d coping m e c h
a n is m s developed d u r i n g certain pe rio d s in his
o r a conflict th a t is the f u n d a m e n ta l criterio n

as to w h e th e r h e will re s p o n d w ith u n c o n
trollab le anxiety.
L et us proceed
w ith
e x a m i n a ti o n of the
physiological a n d psychological m a n ifestatio n s

of th e in d i v i d u a l s u f fe rin g fr o m e x t r e m e
life. F o r instan ce, as a child th e in d iv id u a ls

d ep en d en cy needs m a y no t have been satisfac
torily resolved, cau sin g h im to m e a s u r e his
anx iety since these m a y be chosen as a focus in

th erap y .
self-esteem chiefly in te r m s of ho w well loved

he w a s by his p a r e n t s (an d later th e ir in t e r
94
nalized im ages in his conscience). H e will be
ing h e r h o m e, except p e r h a p s in the presence
insecure w h e n c onfronted w ith circ um sta nce s

w h e re he m u s t ta k e a n in d e p e n d e n t stan d . (2)
of h e r m o th e r. T h e p h o b ia u ltim a te ly re s u lts in
h e r in c a p a c ita tio n , in terfe rin g w ith h e r liveli
C e r ta i n defenses a p p e a r in child ho od t h a t net
hood an d h e r c a p a city to estab lish n o r m a l r e l a
th e child a special g ain. S uch defenses, if su c
tio n sh ip s w ith people. She m a y , as a resu lt,
cessful, establish a p a tt e r n of b eh a v io r th a t
u n d e rg o a s h a t te ri n g of self-esteem, a n d h e r
feelings of in fe riority m a y stim u la te a f u r th e r
m a y be p u rs u e d la ter on. T h u s w h e re violent

an d aggressive d isp lays in tim id a te p a r e n t s into
yielding to the c h il d s d e m a n d s , he m a y ten d to
a tt e m p t to isolate herself fro m o th ers. H e r

hostility, w h ic h is u su a lly directed at h e r
have o u tb u r s ts of a n g e r a n d to in tim id a te
o th e rs as a p referred w a y of dea lin g w ith o p
p a r e n t on w h o m she is so helplessly d e p e n d e n t,
position. (3) U n reso lv ed childish fears, needs,

an d strivings, w ith persistence of arch aic co n
culty in ex p re s sin g o r even a c k n o w le d g in g h er

h a t e f u l fe e lin g s b e c a u s e t h e y t h r e a t e n h e r
cepts of reality,
will influence th e p a tt e r n s
sta n d in g w ith h e r m o th e r. T h u s , w h ile she has
ad o p ted in the face of stress. F e a rs of th e d a r k

o r of being alon e m ay r e t u r n w h e n e v e r stress is
em plo yed a defense to shield h e r fro m an x iety ,
excessive, w h e re these w ere manifest in c h ild

hood. (4) Defensive reactions a re often c o n d i
tioned by p a r e n t a l neu ro tic a ttitu d es a n d ill
nesses, w h ich th e in div idu al m a y tak e over
m a y becom e e x tr e m e , an d she m ay h ave diffi
she h a s suffered fro m gross difficulties in her

fu n ctio nal r e la tio n sh ip s w ith life a n d people.
T h e d e fe n s e a g a i n s t th e o r i g i n a l a n x i e t y
p lu n g e d h e r into difficulties as g re a t or g re a te r
th r o u g h the process of im itatio n . A m o t h e r s
t h a n the stress th a t in itially insp ired h e r re a c

tion.
t e r r o r o f l i g h t n i n g s t o r m s o r r e c o u r s e to
he ad ach es w h e n difficulties come u p m a y be
c u lt y fo r w h i c h
ad o p ted by h e r child.
T h e neu rotic individual th u s revives early
so u g h t a n d because th ey fr e q u e n tly a r e a n i m
m e d ia te focus in tr e a tm e n t, it m a y be p r o d u c
tec hn iqu es of a d a p ta tio n th a t o rig ina lly helped
tive to ela b o r a te on h ow a n d w h y th ey evolve.
solve the difficulties in his ch ildhood. Since

these tech n iq u e s h av e long outlived th e ir use
fulness, th ey create m a n y m o re p ro b lem s th a n
In g en era l, fou r levels of defense a r e e m

ployed as o u tlin e d in T a b l e 7 - 1 : (1) conscious
efforts at m a i n ta i n in g co n tro l by m a n i p u l a
th ey solve. N ev erth eless, the individual is a p t
tion of the e n v ir o n m e n t, (2) cha ractero log ic
to im p le m e n t th e m in a reflex m a n n e r , a lm o st
defenses a im e d at m a n i p u l a t i n g in te rp e r so n a l
as if th ey w e re th e most n a t u r a l of devices to
re latio n s, (3) repressive defenses th a t m a n i p u
em ploy u n d e r th e circum stances.

M a n y defensive responses to a n x ie ty th a t
a r e directed to w a r d th e re duc tion of a n x ie ty
late th e in tra p sy c h ic forces, a n d (4) regressive

defenses th a t re g u la te physiological m e c h a
nisms. T h e in d iv id u a l m a y stabilize at an y
level, w h ile r e ta in in g s y m p to m s a n d defenses
cha rac teristic of prev iou s levels. At different
times, as stress is alleviated or e x a g g e ra te d o r
as ego s tre n g th e n in g o r w e a k e n in g occurs,
th e r e m a y be shifts in the lines of defense,
eith e r u p o r d o w n . T h e m a n n e r in w h ic h these
m a y lead to a c rip p lin g of a p e r s o n s flexibility

an d adap tiven ess. T h e defensive te c h n iq u e of
th e p h o b ia illustra tes the destructive influence
th a t a m e c h a n ism of defense m a y yield. T h e
in hib ition of function c h aracteristic of p ho bic
states is calcu lated to isolate the in d ivid ual
from certain sources of d a n g e r o nto w h ich he
h a s projected his in n e r anxieties. F o r instance,
a w o m a n fearful of yielding to u n re s tra i n e d
sexual im pu lses m ay develop stro n g anx ieties
w hile w a lk in g outd oo rs. She m a y shield h erself
from such a n x ie ty attacks th r o u g h the s y m p
to m of a g o ra p h o b i a , th a t is, by av oid in g leav
B ecause defenses so often a r e sources of diffi

p s y c h o t h e r a p e u t i c h e l p is
four levels of defense a re em p lo y ed in a d a p t a

tion is as follows:
F i r s t - l e v e l d e fe n s e s : C o n t r o l m e c h a n i s m s
W h e n ten sion s a n d a n x ie ty a r e ex pe rien ced ,

th e first m a n e u v e r on the p a r t of an in d iv idu al
is to m a n i p u la t e th e e n v ir o n m e n t to fash ion it
95
TABLE 7-1. M echanism s of Defense

M A N IF E S T A T IO N S and S Y M P T O M S
T h re a ts to A daptation
A D A P T A T IO N
SY N D R O M E
1st Line of Defense
CONTROL
M E C H A N IS M S
2nd L ine of Defense

C H A R A C T E R O L O G IC
D EFEN SES
3rd Line of Defense

R E P R E S S IV E
D EFEN SES
SY N D RO M ES
tension
anxiety
physiological reactions
A nxiety states
Physical conditions arising
from m ental factors
(psychosom atic illness)
Rem oving self from sources of stress

Escape into bodily satisfactions & extroversion
W ish-fulfilling phantasies
Suppression, rationalization, philosophical credos, self-control, emo
tional outbursts, im pulsive behavior, thinking things th ro u g h
Alcoholic indulgence excessive alcohol intake
Sedation, narcotics drug overindulgence
Substance use disorders

(alcoholism , drug
dependence)
S T R IV IN G S of an IN T E R P E R S O N A L N A T U R E
1. Exaggerated dependency {religious fanaticism , etc.)
2. Submissive technics (passivity)
3. E xpiatory technics (m asochism , asceticism)
4. D om inating technics
5. Technics of aggression (sadism)
6. Technics of w ithdraw al (detachm ent)
S T R IV IN G S D IR E C T E D A T S E L F -IM A G E
1. N arcissistic strivings (grandiosity, perfectionism )
2. Pow er im pulses (com pulsive am bition)
Educational disorders, habit

disorders, w ork problem s,
m arital problem s, adjustm ent
disorders, conduct disorders,
sexual disorders and
perversions, delinquency,
crim inality, personality
disorders
P o sttrau m atic stress disorders

C onversion disorders
D issociative disorders
Phobic disorders
Com pulsive disorders
E F F O R T S D IR E C T E D at R E IN F O R C IN G R E P R E S S IO N
1. General: (a) reaction form ations, (b) accentuation of intellectual
controls w ith com pensations and sublim ations.
2. Inhibition o f function:
a. D isturbed apperception, attention, & thinking
b. D isturbed consciousness (fainting, increased sleep, stupor)
c. D isturbed m em ory (antegrade and retrograde am nesia)
d. Em otional dulling, indifference, or apathy (em otional inhibi
tions)
e. S ensory defects (h y p o e sth e sia a n aesth esia , am aurosis,
ageusia, etc.)
f. M otor paralysis (paresis, aphonia)
g. V isceral inhibitions (im potence, frig id ity, etc.)
3. D IS P L A C E M E N T & P H O B IC A V O ID A N C E (phobias
4. U N D O IN G & IS O L A T IO N (com pulsive acts
rituals)
&
B. R E L E A S E of R E P R E S S E D M A T E R IA L (direct o r symbolic)
1. Im pulsive break thro u g h w ith acting-out (excited episodes)
2. O bsessions, (excessive revery & dream like states)
3. D issociative states (so m n a m b u lism , fu g u e s, m u ltip le p e r
sonality)
4. Psychosom atic d iso rd e rs (sensory, som atic, v isceral; tics,
spasm s, convulsions)
5. S exu a l perversions (fetishism scoptophilia, etc.)
6. Internalization of hostility (depression)
7. Projection
O bsessive-compulsive disorders
C onversion disorders
4th Line of Defense

R E G R E S S IV E
D EFEN SES
A. R eturn to helpless dependency

B. R epudiation of and w ithdraw al from reality
1. D ereistic thinking; disorders of perception (illusions, hallucina
tions), disorders of m ental content (ideas o f reference, delu
sions)-, disorders of apperception and com prehension; disorders
of stream of m ental activity (increased or dim inished speech
productivity, irrelevance, incoherence, scattering, verbigeration,
neologisms)
2. Defects in m em ory, personal identification, orien tatio n , reten
tion, recall, thinking capacity, attention, insight, judgem ent
C. Excited acting-out (hostile, sexual, and o ther im pulses)
D. Internalization of hostility (depression, suicide)
to his needs, to escape from it, o r to c h a n g e his

m ode of th in k in g a b o u t it. T h u s he m a y avoid
certain activities o r places o r people. H e will
try to m a n a g e in som e different w a y w h a te v e r
he feels to be th e source of stress. H e m a y
N eurotic depression
P aran o id al reactions
Psychotic episodes
Schizophrenic disorders
P aran o id disorders
M anic-depressive disorders
Involutional psychoses
c h a n g e his j o b , his wife, his h a ir c u t, his nose

sh a p e , o r his domicile. O r he m a y try to
ch an g e ex istin g a ttitu d es, a tt e m p t in g to th in k
th in g s th r o u g h a n d to a rriv e at som e n e w in
tellectual fo r m u la tio n s a b o u t w h a t his life is all
96
ab o u t. In this re g a rd he m a y tr y to su p p ress
veloped ea rly in life, p r i m a r i ly in co pin g w ith
certa in th o u g h ts, to keep his m in d on m o re
th e p a r e n t a l figures w h o a r e th e first sou rce of

a c h il d s security. C e r ta i n c h a r a c t e r styles w ere
positive c h an n e ls, to exercise self-control, o r to

re a d self-help books th a t stim u la te h im to
th i n k th r o u g h a n ew p h ilo so p h y of life. H e
p ro m o te d by th e p a r e n t s , a n d th e child lea rn s
t h a t th e r e is a ce rta in m a n n e r in r e l a ti n g to
m a y develop different leisu re-tim e activities in
pe op le a n d events th a t h a s th e best c h a n c e of
q u est of satisfactions in a n ew ho bb y, a n ew
social activity, or different friends. H e m a y try
k eep in g h im free of a n x iety . L a t e r in life,

w h e n a n x ie ty is ex p erien ce d , th e r e is an u n w i t
to get outside h im self, or, j u s t th e opp osite,
tin g r e t u r n to th e m od e of life th a t w o rk ed
he m a y become m o r e a b so rb ed in bodily satis
m ost effectively in th e past.
factions such as eatin g o r d rin k in g . H e m ay
T h u s these m odes of defense m a y be te rm e d

m a n i p u l a t i n g o n e s i n t e r p e r s o n a l r e l a t i o n
d e a d e n his feelings w ith sedatives, s tim u la te

th e m w ith en erg iz ers, or d r o w n th e m in alco
hol. D a y d r e a m i n g of a w ish-fulfilling n a tu r e
s h i p s . If d e p e n d e n c y is cha ra c te ristic for a
m a y h elp in escap in g the p ain fu l realities of his
abjectly d e p e n d e n t. If d e ta c h m e n t is th e w a y in
w h ic h a p e rs o n h a n d le s u n t o w a r d exp erien ces,
daily troubles.
H is e m o tio n al e q u ilib r iu m m a y also shift, so
p erso n , th e n in tim e of stress he m a y becom e
th e n a serious tra g e d y will cause h im p a t h
t h a t h e p e rm its h im self e m o tio n a l o u tb u rsts ,

fits of crying o r la u g h in g , a n d im p ulsiv e o u t
ologically to isolate a n d w i t h d r a w
b re ak s designed to release tension.
m od e th a t is th e key to u n d e r s ta n d in g this
All these, a n d o th e r m a n e u v e rs like th em ,

are th e first a tt e m p t s to be m a d e w h e n a p e r
second level of defense.

It is typical of th e e x a g g e ra te d m a n e u v e rs of
son feels th e u n co m fo rta b le tension t h a t in

dicates a b r e a k d o w n in h om eosta tis. E very
th e second defense line th a t th e y get th e in d i

vid ual into in te rp e r s o n a l difficulties. If a h ig h
perso n alive at vario u s tim es e m p lo y s som e of
school p rin c ip a l is accused by his te a c h e rs of

b eing too co ntrollin g, th e p rin c ip a l m a y b e
these
en v iro n m en t-m an ip u latin g
dev ices.
P athological e x p lo ita tio n of c e rta in first-line
for long
period s. It is th e e x a g g e ra tio n of th e u sual
come th r e a te n e d . W h e n th r e a te n e d , he fears
and
th a t h e is lo sing co ntrol ov er his teac h ers a n d
d r u g s can cau se addictive d iso rd ers such as
reacts p e r h a p s by a sk in g th a t th ey s u b m it to
h im m o r e co m p le te lesson p l a n s an d th a t th ey
d e fe n s e s,
how ever nam ely,
a lc o h o l
alcoholism a n d d r u g ad dictio n. O t h e r first-line

d e fe n s e s, su c h a s a t t e m p t s a t i n t e l l e c t u a l
u n d e rs ta n d in g re g a r d in g th e basic n a t u r e of
o n e s conflicts a n d anxieties, m a y h elp pro v id e
som e degree of relief. O n th e o th e r h a n d , a hito r - m i s s a p p l i c a t i o n o f s e l f-h e l p m e a s u r e s ,
w ith o u t a w a re n e s s of th e n a t u r e of o n e s diffi
culties, m a y lead to n o th in g , n ecessitating the
use of the nex t line of defense.
S econ d-level defenses: C h aracterologic
defenses
In situ a tio n s of in creasin g th r e a t it is typical
sign o ut of th e
b u ild in g w h e n
leav ing for
lu nch . It is th is very co n tro l t h a t th e tea c h ers

objected to in th e first place, a n d the in t e r p e r
sonal conflict becom es ex a g g erate d .
E x a m p l e s of p a t h o l o g i c a l l y e x a g g e r a t e d
c h a ra c t e r d rives include m a n y k ind s of i n t e r
p e rs o n a l, v ocatio nal, a n d e d u c a tio n a l difficul
ties. T h e fo llo w ing a r e typical. E d u c a tio n a l
a n d w o r k d is o rd e rs m a y be s y m p to m a ti c of
such excessive d ep en d e n c y th a t on e is u n a b l e to
for a p erso n to ex p lo it in e x a g g e ra te d form his

n o r m a l c h a r a c t e r o l o g i c d ri v e s . A g g r e s s i o n ,
w it h d r a w a l , a n d a b n o r m a l self-image r e s t o r a
p u r s u e a n y i n d e p e n d e n t , a s s e r t i v e l i n e of
th o u g h t o r action. T h e w r it in g of a te r m p a p e r
o r th e m a k i n g o f a business call m a y r e p r e s e n t
th e exercise of p e rs o n a l resp o n sib ility ; a n i n d i
vid ual w ith a dev alu e d self-im age m a y n o t be
tio n a re ex am ple s.
Idiosy ncratic a d a p ta tio n s to stress a r e d e
able to p u r s u e such a n activity on h is o w n .

M a r i t a l p ro b le m s, so u b iq u i to u s in o u r society,

an d
parental
m is h a n d lin g
97
of th eir c h ild ren
m a y re p resen t the e x a g g e ra tio n

several c h a ra c t e r strivings.
of a n y
or
pressio ns of e m o tio n s ; a n d (4) a blo cking in

behavior.
T h e necessity of m a i n t a i n i n g rep ressio n can
D e lin q u e n c y an d c rim in a lity a r e sy n d ro m e s

re p re se n tin g th e excess of hostile aggression.
a b s o r b th e e n e rg y resou rces of th e ind ivid ual.

C o n s ta n t ly th r e a te n e d a r e b r e a k d o w n s in th e
S exual d iso rd ers often p o r t r a y th e n a t u r e of
repressive b a r r ie r s , a filtering of th e sealed-off
the in te rp e r so n a l d isord er.
H y p o c h o n d r ia c a l
c o m p o n e n ts in to consciousness, a n d a m o b i
p re o ccu p atio n s m a y depict th e fear of in ju ry ;
liza tion of a n x iety . T h e in d iv id u al m a y c o n
p sy c h o p a th s d e m o n s tra t e th e e x tr a v a g a n t c a ri
s eq u en tly be victim ized by a ceaseless stress
c a tu r e of m a n y in te rp e r so n a l needs; im m a t u r e ,
obsessive, schizoid pe rso n s h ave all, u n d e r the
rea ctio n, his physical system bein g in a p e r

p e tu a l u p r o a r . V u ln e r a b l e o r g a n system s m a y
th r e a t of a n x ie ty , p ressed th e ir life-styles to ex
becom e d iso rg a n iz e d w ith o u tb r e a k s of o rg a n ic
tr e m e lengths. U su ally , second-line defenses do

n o t w o r k effectively. R a t h e r t h e y p l u n g e
illness. At th e sam e tim e a sym bolic d is ch arg e

(id is p la c e m e n t o f affe c t) m a y o c c u r in a t
people into such in te rp e r s o n a l difficulties th a t
t e n u a t e d o r d is to rte d forms, w h ic h will pro v id e
conflict a n d stress a re h eig h te n e d r a t h e r th a n
so m e g ra tific atio n for th e re p u d i a te d drives. At

p h a se s w h e n rep ressed needs becom e p a r t i c u
reduced.
The
chronic
em p loy m ent
of d e
p end ency reaction s, for e x a m p le , is e v en tu a lly

resented by o th e r s on w h o m on e leans, serving
larly u rg e n t, or for som e re a s o n o r o t h e r a re
to alien a te th e p erso n from his sources of s u p
p revio usly q uiesc ent sexual drive s tirr in g d u r
p ort. R a t h e r th a n hav e his needs g ratified, he
ing adolescence) o r e x p e rie n tia lly (as w h e n an

in s u lt excites s lu m b e r i n g rag e a n d aggression),
drives o th e rs a w a y a n d is m o r e alone. T h e
em otiona lly p o o r get p o o re r if th e r e is a blind
re petition at th e sa m e p a tt e r n . B ecause of th e
u ltim a te ineffectiveness of th e second line of
defense, th e in d ivid ua l u su a lly goes o n to the
n ext level.
activated by physiological factors (such as a
a direct e xp re ssion
m a y o ccur follow ed by
re trib u tiv e re a ctio n s w h ic h will a p p e a s e guilt

feelings a n d serve to resto re repression s.
T h e u n d e r s ta n d in g of the rep ressive line of
defense can best be seen in tw o g ro u p in g s:
tho se efforts a im e d at rein fo rcin g re p ressio n
T h ird -level defenses: R ep re ssiv e m an eu vers
a n d th e d irect o r sym bolic release of rep re ssed

m a te ria l.
T h e th i r d level of defense consists of th e

m a n i p u la t io n of o n e s in tra p sych ic stru c tu r e . It
o r h eig h te n e d m o r a lity as a cover for p erverse
is a n a tt e m p t to gain peace by p u s h in g tro u b le s
sexual
F ir st, reaction fo rm a tio n s (such as ch astity

or
an tiso cial
desire)
may
becom e
ou t of o n e s m in d . In repression a b a r r i e r is set
p ath o lo g ically e x u b e r a n t in th e u r g e n t n eed to
u p to th e m o t o r d ischa rge of needs, im pu lses,

m em ories, ideas, o r a ttitu d es, a w a re n e s s of
w h ich will set off an xiety . T o avoid a n x iety ,
selected id eatio n al seg m en ts a r e sealed off
d e n y th e existence of forbid de n im pulses.

S econd, th e r e is a n in h ib itio n o f fu n ctio n ,
a long w ith an y asso ciatio n al m em o ries or

links, th e activatio n of w h ic h m a y cha llen g e
the repression. In this process th e r e m a y be (1)
a b lo c k i n g in t h e p e r c e p t i o n , p r o c e s s i n g ,
storage, a n d retriev al of ex periences; (2) a n in
hib ition o r d is to rtio n in th e fu nction s of in
in a tte n d s to c e rta in u p s e ttin g aspects of o n e s

in n e r o r o u te r w o rld . D is t u r b e d consciousness
m a y ta k e th e fo rm of faintin g, s tu p o r, o r e x
cessive needs for sleep. D is t u r b e d m e m o r y to
th e p o in t of a m n e s ia m a y develop. E m o tio n a l
d u llin g can be seen in a p e rs o n w h o exhib its
indifference o r a p a t h y as a defense a g a in s t be
ing involved in a p o te n tia lly th r e a te n i n g s i tu a
tion. S en so ry defects, m o to r p ara ly sis , an d
telligence, such as a tte n tio n , le a rn in g , d is c rim i

natio n , ju d g m e n t, reas o n in g , a n d im a g in a tio n ;
(3) a blocking in th e o p e ra tio n s a n d e x
d is tu rb e d a p p e r c e p t io n , a tt e n ti o n , c o n c e n t r a
tion, a n d th i n k in g o c cu rrin g as o ne selectively
98
even visceral in h ib itio n s m a y be conversion
s y m b o l i z a t i o n of f o r b i d d e n
reaction s th a t serve to block o u t th e direct
t h r o u g h obsessional th in k in g d r a i n s off e nerg y
i n n e r im p u l s e s
a w a re n e ss of a n an x ie ty -p ro v o k in g th o u g h t or
b u t p ro m o te s a n x ie ty in th e i r release. T h e in
deed. T h u s one m a y literally not be ab le to feel
div idu al m a y m u r d e r , r a p e , o r to r t u r e special
a frig h ten in g object, see a t h r e a te n i n g event, or
p eo p le in his fantasie s o r m a y ex p lo d e th e
ex perience a
w o rld w ith a to m b o m b s to his o w n d is m a y a n d

a n x io u s discom fort. H e m a y th e n n e u tr a li z e
his released im p u lses by e n g a g in g in c o m p u l
sexu ally
a ro u s in g s t im u lu s if
such a w a re n e ss w o u ld provoke u n d u e anxiety.

A n o th e r effort at reinforcing re p ressio n is
the d evelo pm ent of a p h o b ia . In p h o b ia fo r m a
sive ritu als, w h ic h on the surface m a k e no
tion th ere is a d is p la c e m e n t fro m a fearsom e
sense b ut w h ic h sym bolically a p p e a s e his guilt
in n e r drive to an e x te r n a l object th a t sy m
o r div ert his m in d from his p re o c c u p a tio n .
bolically comes to re p r e se n t this drive. T h u s a
Thus
fear of snakes in a w o m a n m a y conceal a n e x
h a n d w a s h in g as a clean sing ritual.

A th i r d m e a s u r e for lib e ra tin g re p r e sse d m a
terial is t h r o u g h d isso cia tive states, such as
a g g e rated b u t rep ressed in terest in th e m ale

sexual o rg an . A fear of heigh ts m a y be a cover
of a m u r d e r o u s im p u lse for w h ic h on e m ay
a n tic ip a te re tr ib u t o r y p u n is h m e n t.
F u r t h e r a tt e m p t s to g a in peace th r o u g h
repression a re th r o u g h u n d o in g an d isolation.
By these
m a n e u v e rs
the ind iv idu al,
alm o st
ev il th o u g h t s m a y in s p ire re p e a te d
so m n am b u lism ,
fugues, a n d
m u ltip le
per
sonality. Acted o u t a re th e rep re sse d im p ulses,

too t h r e a te n i n g to be in te g ra te d into o n e s c o n
scious activities, b u t not r e m e m b e r e d w h e n the
m agically, ro bs a forbidden im p u ls e of an y vi
u s u a l consciousness is restored.
P sych o so m a tic d iso rd ers m a y be a fo u r th ev
tality. W h e n he th in k s an a n g ry th o u g h t, he
idence of th e release of ten sion s th a t h ave not
qu ickly follows it w ith a th o u g h t th a t u n
made
d o e s the first th o u g h t. O r he does not feel
S ensory,
the th o u g h t, an d so he believes his sex ual or
reflect th e in n e r conflicts of an in d ivid ua l.

T ic s , sp a s m s a n d convulsions a r e often sy m
hostile im p ulses have no re al significance for

him .
T he release o f rep ressed m a te ria l th r o u g h
direct or sym bolic m e a n s is th e second fo rm by
th e ir
w ay
in to
so m a tic a n d
conscious
aw a re n e ss.
visceral ch an g e s m a y
bolic revelation s of in n e r psychic processes th a t

ca n n o t find d irect expression.
T h e fifth m e a n s a r e th e sexu al p e rve rsio n s,
w h ich repressive m a n e u v e rs a tt e m p t to m a i n
tain a psychic e q u ilib r iu m . As we h ave ju s t
such as fetishism , e x h ib itio n is m , a n d th e like,
noted, the first form of repressive m a n e u v e r

reinforces th e re pression itself. T h i s second
come u n co n tro llab le.

T h e use o f the s e lf as an o bject f o r ag
form allow s for a n in te rm itte n t direct o r s y m

bolic d ischarg e of th e rep ressed m a te ria l.
O n e such ty p e of release is sim ply a n i m p u l
sive b r e a k t h r o u g h of som e fo rb idd en w o rd or
th o u g h t o r im p ulse. O cc asio n ally an excited
g ressio n is a sixth m e th o d by w h ic h u n acce p ted

im p u lses g ain som e m e a s u r e of expression.
episode of acting ou t som e im p u ls e can be

noted in a pe rs o n w h o o th e rw ise relies heavily
on rep ressio n as his typical form of defense.
d epression , a feeling th a t o n e is a m iserab le

c re a tu re . T h e c o n tin u in g s elf-rec rim in atio n s
th a t th e d epressed p erso n in d u lg es served to
T h e fighting d r u n k m a y a c tu a lly be a sober

C a s p e r M ilq u e to a s t w hose rep ressio n s are
d is ch a rg e his hostility a lb eit in the w r o n g d i

rection. T h e r e m a y also be d a n g e r o u s ab uses
t e m p o ra r ily de a d e n e d by alcohol, p e r m it ti n g a
of the self, w ith accident p ro n e n e s s, m u tila tio n
hostile release.
O b se ssio n , t h a t
tendencies, an d even suicide.

is th e r e p e t i t i v e u se of
th a t d is c h a rg e erotic tensio n w h e n th es e be
A n g ry im p u lses o rig in ally directed at o th e rs

are rep resse d a n d th e n directed a g a in s t th e
self. T h e re s u lta n t cond itio n m a y be n e u ro tic
reveries an d d a y d re a m s , is a second m e a n s th a t
F in a lly , a defense m e c h a n is m th a t allow s for

releasin g rep ressed m a te ria l is p ro jec tio n . P r o
serves to d ra i n a w a y th e repressed m a te ria l. A
je c tio n is a m e a n s of r e p u d i a t i n g in n e r drives
CHO O SING AN IMMEDIATE FOCUS
99
th a t a r e painful an d a n x ie ty p ro v o k in g by a t
a re th e last in s tr u m e n ta l it y w ith w h ic h to es
tr ib u t in g th e m to o utside agencies a n d in f lu
ca p e the pain fu l d e m a n d s of reality. T h e r e m a y
ences. T h u s in n e r feelings of h ate, too d a n
be a r e t u r n to co m p lete ly h elpless d e pe nd enc y,
gerous to accept a n d m a n a g e , a r e e x te rn aliz ed
a r e p u d i a ti o n o f an d w i t h d r a w a l fro m reality,
in the conviction of being h a te d o r victim ized

by a n o p pre ssor. A varice m a y be concealed by
excited a c tin g -o u t im p u lses w ith o u t referen ce to

reality d e m a n d s, and d ep ressio n th a t has
a belief th a t on e is being exp lo ited. H o m o s e x
reach ed d elu sio nal a n d suicidal p r o p o r tio n s . In
ual drives m a y be credited to perso n s of the

s am e sex to w a r d w h o m the in div id ual is sex
this fo u r th level of defense th e ind iv idu al show s

evidence of psychotic fu nction ing . T h e r e m a y be
u a ll y a t t r a c t e d . T h e p r o j e c ti v e m e c h a n i s m
dereistic th in k in g , d iso rde rs of p e rc e p tio n (illu
serves th e p u rp o s e of objectifying a forb idd en

a n d repressed d a n g e r th a t will ju s tify certain
sions, h a llu cin a tio n s), d is o rd e rs of m e n ta l co n

te n t (ideas o f reference, d elu sio n s), d is o rd e rs of
m easu res, such as the e x pression of ag gression
a p p e rc e p t io n a n d c o m p r e h e n s io n , d is o rd e rs in
w ith o u t guilt.
In this w a y p u n is h m e n t a nd
self-blame a r e avoided. By p ro jectin g im p ulses

a n d desires on to the ou tsid e w o rld o ne m ay
insidiously gain acceptance for his o w n fo rb id
stream
of
m en tal
a c ti v it y
(increased
or
d im in ish e d speech p ro d u c tiv ity , irrelev ance, in

coherence, sc attering , n eologism s), a n d defects
in m e m o ry , p e rs o n a l identification, o rie n ta tio n ,
den drives. F o r e x am p le, insisting u p o n th e
re te n tio n , recall, t h i n k in g cap acity, a tte n tio n ,
fact th a t th e w o rld is sexu ally p reo cc u p ie d , a n d
insigh t, a n d ju d g m e n t . T h e r e is evidence th a t
finding p r u r i e n t e x a m p le s for this p o in t of
special sy n d ro m es, such as m a n ic-d ep ressive
view, a sexually fearful ind iv idu al m a y try to
p sy c h o sis a n d sch izo p h ren ia , h ave genetic c o m
lessen the severity of his o w n conscience th a t
p o n e n ts th a t b rin g o ut th e i r p e c u lia r c h a r a c
p u nish es h im for his sexual needs.
teristics in th e face of stressful experiences.

T h e s e fou r levels of defense m u s t no t be
re g a r d e d as a r b i t r a r y , static states. E a c h level
F ou rth -level defenses: R eg ressive defenses
n ever occurs in isolation. E a c h level is alw ay s
W h e n all o th e r m e a s u re s a r e failing to r e
m ix ed w ith m a n ife sta tio n s of o th e r defensive
store em o tio n al e q u il ib r iu m , psychotic states
levels.
Conclusion
O n ce w e h av e d e te rm in e d w h y at th is tim e
concern to th e p a tie n t, such as incidents in life
the p a tie n t h as p resen ted him self for th e r a p y

an d e x plo red w ith h im his ideas a b o u t his
situ ation in c lud ing w h a t he believes is b e h in d
th a t h ave p re c ip ita te d th e s y m p to m s for w hich

he seeks help. In focusing on p r e c ip ita tin g fac
to rs one m u s t g a u g e th e p a t i e n t s v u ln e ra b ility
to stress as well as th e virility of the stress fac
his troubles, an d w h a t he w a n ts to achieve

from tr e a tm e n t, we m a y th e n select a n i m
m ed iate focus an d o rg a n iz e o u r t r e a tm e n t s t r a
tegies. A too early c o n c e n tra tio n on the p a
ti e n ts p sy ch op ath olo gy a n d p ast c on dition ing s
th a t have created his conflicts a n d c i r c u m
scribed his g ro w th , h o w e v e r im p o r t a n t these
m ay be, will s u p p o r t regression and e n c o u ra g e
lon g -te rm lin g erin g in tr e a tm e n t. R a t h e r , we
sh ould begin to focus on w h a t is of im m e d ia te
to r itself. In focusing on sy m p to m s the t h e r a

pist shou ld view th e m as an assem b ly of re a c
ti on s to a n x ie ty as well as c o nsequ ences of
m e c h a n ism s of defense.
D u r i n g th e e x p lo r a tio n s it is im p o r t a n t to
c o n c e n tra te on p ro b le m solving, w h ile e x a m i n
ing, e n c o u ra g in g , an d h e lp in g the release of
w h a te v e r positive a d a p tiv e forces a r e p re s e n t in
th e p a tie n t, focusing on th e resistances th a t
100
block th e ir o p era tio n . In th e course of doing
P o w e rfu l resistance to t r e a t m e n t m a y m a k e a
this w e m a y be co nfron ted by th e p a tie n t w ith

his e arly fo rm ativ e experiences, b u t th ese a re
focus on d y n a m ic s essential. O b v io u sly , th e

th e r a p is t will d e lib erately hav e to select d y
ha n d le d in the context of e x p la in in g o b s tru c
n a m ic
tions to effective fun ctio ning in th e p resent.
p ed ie n tly , av o id in g or d e a lin g ta n g e n tia lly
A m p le o p p o rtu n itie s will be found la ter on to
w ith even n oticeab le conflicts th a t do n ot seem
sw itch
the focus to a re a s
related
to
som e
cen tral d y n a m ic th e m e by estab lishin g some

connection b etw e en it an d c u rr e n t p ro b le m s
a n d concerns shou ld this be dee m e d d esirab le .
aspects
th a t
he can
w o r k w ith
ex
offensive a n d w o u ld be difficult or im possible

to
h a n d le
th e r a p y .
in
th e b rie f p e rio d
allo tted
to
CHAPTER 8
Choosing a Dynamic Focus

A. Probing into the Past
L ittle tim e is av ailable in s h o r t-t e rm th e r a p y

to ex p lo re th e p ast. M u c h b e tter use can be
t h a t have been i n s tr u m e n ta l in la y in g do w n
m a d e of th e t r e a tm e n t h o u r by d ealin g w ith
th e fo u n d a tio n s of the p a t i e n t s c h a ra c t e r s t ru c
tu re. B ecause b e h a v io r reflects to a g r e a t e r o r
p e rtin e n t elem ents in th e h e re a n d no w . H o w

ever, w h e re the th e r a p is t can d e te r m in e i m p o r
lesser degree co n d itio n in g s set u p in the p a st, it

m a y be difficult to u n d e r s ta n d it fully w ith o u t
t a n t p a st events a n d contingencies th a t have

m olded the p e rs o n a lity o rg a n iz a tio n , this will
reference to w h a t h a s g on e on before. F r o m a
facilitate a b e tte r u n d e r s ta n d in g of the p a
is no t possible to devote m u c h effort in e x p lo r
t i e n t s illness a n d h e lp select a n a p p r o p r i a t e
ing th e p a st b ey o n d p ro v id in g the p a ti e n t w ith
d y n a m ic focus. E n o u g h d a ta m a y be av ailab le
from ta k in g a good h istory to m a k e a s s u m p
som e g uidelines to p u r s u e on his o w n after the
tions of ho w th e p ast has e n te re d into the

f o rm atio n of p e rs o n a lity d is to rtio n s th a t b u r
T h i s c h a p te r c on stitu tes a review of dev elo p

m e n t fro m a p sy ch o d y n a m ic perspective. It is
den p re s e n t-d a y a d a p ta tio n s . M o r e im m e d ia te
includ ed in this vo lum e as a n in tro d u c tio n to
clues m a y be g ain ed from th e tra n sfe re n c e th a t
th e m o r e clinically i m p o r t a n t c h a p te rs th a t fol
serves as a vital link to th e kinds of e a rly r e l a
low.
practic al p o in t of view in s h o r t-t e rm t h e r a p y it
fo rm a l th e r a p y perio d h a s ended.
tion sh ip s th a t existed in a c tu a lity o r fa n tasy
Transference
O f vital significance to p sy c h o th e ra p ists of
all p e rs u asio n s w a s F r e u d s crucial p e rcep tio n
th a t to a g r e a t e r o r lesser d eg ree p a tie n ts tend
to project o n to a u th o r it y figures th o u g h ts,
w ishes, a n d feelings identical to th ose form e rly
h a rb o r e d t o w a r d i m p o r t a n t p a st p ers o n ag es
recovering gratifica tio n s a n d resolving fears

t h r o u g h th e in s tr u m e n ta l it y of th e th e r a p is t,
w h o is e n d o w e d w ith p o w e r a n d a ttrib u te s
such as a n in fa n t h a r b o r s t o w a r d p a re n t a l
agencies. T h e r e m a y be e xh ibited also to w a r d
the th e r a p is t in tran sferen ce a host of a b e r r a n t
a ttitu d e s, such as rebelliousness, hostility, s u b
missiveness, a n d sex ual exc item e nt. Such feel
ings m a y also develop o u tsid e of th e t h e r a
(p aren ts, p a r e n t a l su bstitutes, siblings). R e a n i

m ated d u rin g th e r a p y a re tr a n sferen ce re a c
tions, w holly in a p p r o p r i a t e for th e p re s e n t, b ut
reactions th a t r e c a p itu la te a n tec e d e n t e m o peu tic s itu a tio n w ith a n y kin d of a n a u th o r it y
tion al situations. It is as if th e p a ti e n t seeks to o r sibling figure. T r a n s f e r e n c e is d iagn o stically
relive the p erio d s of in fancy a n d childh oo d, im p o r t a n t, since it is a la b o r a to r y revival of
101
102
m u ch of w h a t
w ent cn
in the in d iv id u a ls
childhood. It m a y e x p la in a good deal of c u r

rent
b ehavior
th at
on
th e
surface
see m s
ap is t a n d failing to resp o n d to the th e r a p e u tic

tec h n iq u es t h a t a re being used. T h e d etec
tion
an d
m a n a g e m e n t of tran sfe re n c e m ay,
illogical a n d m a la d a p tiv e . It m a y also co ntain
th erefo re, be cru cial a n d decisive a p a r t from
th e key to w h y th e p a tie n t is resistin g th e t h e r
h e lp in g to select a pivotal d y n a m ic focus.
Synthesizing Factors of Personality

Development
In o rd e r to u n d e r s ta n d h o w a n d w h y the
by v ario u s social scientists of th e incidence an d
p a st survives in the p rese n t a n d the mischief it

invokes, it is necessary briefly to s u m m a r i z e
p rev alence of em o tio n al p ro b le m s in different

p a r t s of the w o rld ; analy sis of reac tion s of in
some of th e c u rr e n t findings on p e rs o n a lity d e
div id uals to p sych otrop ic d ru g s ; accou nts by
velop m en t th a t come from th e biological an d

social fields. A tte m p ts a re co n stan tly being
eth ologists of a n im a l b eh av io r in a n a t u r a l set

ting; an d re s ea rc h findings of a n im a l ex p eri-
m a d e to brin g objectivity to the d a ta on d e
m e n to rs w h o have subjected h ig h e r m a m m a l s
velop m en t by s tu d y in g m a te ria l from a n u m b e r

of different sources. T h e s e include observatio ns
to a rtifa cts in u p b r i n g in g o r to m o tiv atio n al

conflicts.
by tra in e d w o rk e rs of n e w b o r n babies at h o s
O bjective a p p r a i s a l of this vast d a ta re q u ire s
pitals, institu tio ns, a n d d a y -care centers; ex
a m o r e a less precise ap p lic a tio n of th e scien

tific m e th o d . U n f o r t u n a te l y , inv estigators in
periences of teac h ers w ith ch ild re n at n u rs e ry

schools, k in d e r g a rte n s , and g ra d e schools; r e
po rts of p a re n ts d escribing th e beh av io r of
th eir offspring; studies o r recordings of plays,
a rt p ro d u c tio n s, d re a m s, fantasies, a n d s p o n
ta n e o u s v e rb a liz a tio n s of p r e s u m a b ly n o rm a l
children; psychological tests of child ren , espe
cially projective tests; investigations by social
w o rk ers, co rrectio nal w o rk e rs, an d p sy c h o l
o g ists of th e s o c io e c o n o m ic e n v i r o n m e n t ,
fam ily relation ship s, an d o th e r a re a s of p o te n
tial conflict a m o n g m a la d ju s te d , d e lin q u e n t,
an d crim in al y o u ng sters an d adu lts; s c ru tin y of
case records of child ren w ith severe em o tio n a l
p ro b lem s w h o have been hospitalized in m e n
tal in stitu tio ns; o b servations of p s y c h o t h e ra
pists tr e a tin g ch ild re n in th e i r p riv ate p r a c
tices o r in o u tp a t ie n t clinics; e x p lo r a tio n of
m em ories, d re a m s , and tran sferenc e p h e n o m
e n a th a t reflect childhood experiences of a d u lt
p a tie n ts receiving p sychoanalysis; field studies
of a n th r o p o lo g ists r e p o r tin g on th e customs,
the field of p e rs o n a lity re s e a rc h a r e h a n d i

ca p p e d by fo rm id ab le m etho do log ical p ro b le m s
in a tt e m p t in g to subject th e ir o b serv atio n s to
clinical research. M o r e o v e r, c u rr e n t th eo ries of
h u m a n b eh av io r a re so com p lex , th e ir in h e r e n t
te r m s so o p e ra tio n a lly indefinable, th e ir d e r i
vation s so diffuse, th eir im p lica tio n s so global
t h a t w e a r e u n a b le to e xp ose th e m read ily to
scientific e x p e rim e n t.
In
s p i te of th e s e s e e m in g l y
in su p e ra b le
obstacles, it h a s been possible to sc ru tinize

m a n y of the events associate d w ith th e d evelo p
m e n t of p e rs o n a lity a n d to e x a m in e a n d a n a
lyze this d a ta , m a k i n g a p p r o p r i a t e co n n e c
tions, d isc e rn in g c o m b in atio n s, a n d o th e rw ise
sy n th esizin g th e m a te ria l in a co nstructiv e
w a y . O u t of th is s y n t h e s i s a n u m b e r of
p ro p o s itio n s h av e em erged th a t m a y clarify
pa tho lo gica l evolvem ents on w hich th e t h e r a
pist m a y w ish to focus.
folkways, creative artistic exp ressio ns, modes

of c h ild r e a r i n g , a n d f a m il y s t r u c t u r e of
a m o rp h o u s
va rio u s c u ltu ra l gro u p s; d e m o g r a p h ic surveys
a d u lt c a p a b le
1.
T h e ta s k of h u m a n g ro w th is to tr a n s f o rm a n
c r e a tu r e ,
th e
in fa n t,
of liv in g a d a p tiv e ly
in to
a civilized
in a co m p lex
103
CHO O SIN G A DYNAM IC FOCUS: PROBING THE PAST

social
fram ew ork.
T o w ard
this
end
the
child
cu ltiv ates r e s t r a i n t s o n his biological im p u l s e s , a c
p e r s o n a l i t y o p e r a t i o n s t h e i n d i v i d u a l sa tisfies even
t h e m o st e l e m e n t a l of his needs.
q u i r e s skills in i n t e r p e r s o n a l r e l a t i o n s h i p s , evolves
9. D i s t u r b e d o r n e u r o t i c b e h a v i o r r e p r e s e n t s a
v a l u e s t h a t a r e c o n s o n a n t w i t h t h e society in w h i c h
c o llap s e in t h e i n d i v i d u a l s c a p a c itie s for a d j u s t
he lives, a n d perfe cts t e c h n i q u e s t h a t a l l o w h i m to
m e n t . T h i s co llap s e is s p o n s o r e d by a p e r s o n a l i t y
fulfill h i m s e l f creatively w i t h i n t h e b o u n d s of h is p o
s t r u c t u r e t h a t c a n n o t s u s t a i n t h e i n d i v i d u a l in th e
tentials.
face of his i n n e r conflicts a n d t h e e x t e r n a l d e m a n d s .

of de
I n h e r e n t in every n e u r o s i s is a n a t t e m p t a t a d a p t a
v e l o p m e n t a l l a w s for in stan c e, l a w s of m a t u r a t i o n
t i o n t h a t strives to r e s t o r e t h e p e r s o n to so m e k in d
c o m m o n to t h e e n t i r e species, l a w s p e c u l i a r to t h e
of h o m e o sta tic
c u l t u r a l a n d s u b c u l t u r a l g r o u p of w h i c h t h e i n d i
p e d i e n c e s t h a t a r e e x p lo ite d a r e u l t i m a t e l y d e s t r u c
2. G r o w t h
is g o v e r n e d
by
num ber
balan ce.
U n f o rtu n a te ly , the e x
v id u a l is a p a r t , a n d , finally , l a w s u n i q u e to him self,
tive to a d j u s t m e n t , c r i p p l i n g t h e i n d i v i d u a l in his
p a r c e ls of his p e r s o n a l e x p e r i e n c e t h a t w ill m a k e his
d ealings w ith the w orld.
d e v e l o p m e n t u n l i k e t h a t of a n y o t h e r i n d iv id u a l.
10. T h e first few y e a r s of life a r e t h e m o s t cru cial
3. W h i l e g r o w t h is b r o a d l y s i m i l a r in all h u m a n
in p e r s o n a l i t y d e v e l o p m e n t , e s t a b l is h i n g t h i n k i n g ,
in f a n ts a n d c h i l d r e n , t h e r e is g r e a t d iffe rence in i n
feeling, a n d b e h a v i o r a l p a t t e r n s t h a t will in flu en ce
div id u al styles a n d t h e r a t e of g r o w t h .
t h e i n d i v i d u a l t h e r e m a i n d e r of t h e life. W h e r e e x
4. D e v e l o p m e n t m a y c o n v e n i e n t l y be d ivid ed into
p e r i e n c e s w i t h t h e p a r e n t a n d w i t h t h e e a r l y en v i
a n u m b e r of stages of g r o w t h c o r r e s p o n d i n g r o u g h l y
r o n m e n t a r e h a r m o n i o u s , t h e ch ild is e n c o u r a g e d to
w i t h c e r t a i n a g e levels. W h i l e t h e r e is s o m e v a r i a
evolve a sy s tem o f se c u rity t h a t r e g a r d s t h e w o r l d as
tio n in t i m i n g a n d r a t e , t h e a v e r a g e in d iv id u a l a p
a b o u n t i fu l p la c e a n d to d e v e lo p a se lf-esteem t h a t
pears
p r o m o te s a s se r tiv e n e ss a n d se lf-confide nce. T h e
to
f o l lo w
th ese
stages
w ith
su rp risin g
s e q u e n t i a l r e g u l a ri t y .
ch ild w ill be c o n v in ced o f h i s c a p a c it i e s to love a n d
5. T h e v a r i o u s sta ges a r e c h a r a c t e r i z e d by spe ci
to b e loved, a n d this will f o rm t h e f o u n d a t i o n of a
fic need s t h a t m u s t be p r o p i t i a t e d , c o m m o n stres ses
h e a l t h y p e r s o n a l i t y . O n t h e o t h e r h a n d , w h e r e the
t h a t m u s t be reso lved, a n d special skills t h a t m u s t be
ch ild h a s b een d e p r i v e d o f p r o p e r s t i m u l a t i o n a n d
d evelop ed . A h e a l t h y p e r s o n a l i t y s t r u c t u r e d evelop s
c a r e , o r w h e r e h e h a s b een rejected , o v e r p ro t e c te d ,
on t h e b asis of t h e a d e q u a c y w i t h w h i c h th e s e n eeds
i m p r o p e r l y d i s c ip lin e d , o r u n d u l y i n t i m id a t e d , the
a r e su p p l i e d , stres ses m a s te r e d , a n d skills l e a r n e d at
w o r l d will c o n s t it u t e for h i m a p la c e of m e n a c e . A
p r o g res siv e ag e levels.
p e r s o n a l i t y o r g a n i z a t i o n s t r u c t u r e d o n t h e b ed ro ck
6. Difficu lties m a y a r ise at each sta ge of g r o w t h
of su c h u n w h o l e s o m e c o n d i t i o n i n g s is b o u n d to be
t h a t e n g e n d e r a p a r t i a l o r c o m p l e t e f a ilu re in t h e
u nsubstantial
sa tis faction of needs, t h e s o l u tio n of c u r r e n t c o n
i n d i v id u a t io n ,
flicts,
r e s e n tm e n t,
and
the
learning
of
skills.
Such
failu res
h a n d i c a p t h e i n d i v i d u a l in a d a p t i n g to t h e m o r e
and
shaky.
I n c o m p le te se p a ra tio n -
e x a g g e r a te d d e p e n d e n c y ,
g u ilt,
sa d o m a so c h is tic
in te n s e
im p u ls e s ,
im
p a ir e d in d e p e n d e n c e , a d a m a g e d se n se o f id e n tity
e l a b o r a t e d e m a n d s a n d r e q u i r e m e n t s t h a t co n s t it u t e
a n d se lf-im a g e , d e ta c h m e n t, a n d a h o s t o f c o m
th e su c ceedin g stages of g r o w t h .
p e n s a to r y
7. W h e re e sse n tia l p e r s o n a lity q u a litie s ch a ra c
m e c h a n is m s
i n te r fe r e
w ith
a p ro p er
a d a p ta tio n .
teristic o f m a tu r ity a re n o t evo lv e d , th e in d iv id u a l

w ill be b u r d e n e d u n th re sid u a l c h ild h o o d n eeds, a t
titu d e s, a n d w a y s o f h a n d lin g stress. T h e s e a n a c h
r o n i s m s t e n d to clash w i t h t h e d e m a n d s of a h e a l t h y
biological a n d social a d j u s t m e n t . P r i m i t i v e striv in g s
a n d c o n c e p tio n s of t h e w o r l d , e a r l y fears a n d guilt
feelings, a n d def en se s a g a i n s t th e s e u s u a l ly su rviv e
P sy ch o p ath o lo g y becomes m ore u n d e r

s ta n d a b le w h e n view ed a g a in s t th e b a c k d ro p
of p e r s o n a l i t y d e v e l o p m e n t . D e v e l o p m e n t a l
studies, as h a s been in dicated above, sho w th a t
p e rs o n a lity s tre n g th o r w e a k n e ss is m o r e or
b r o a d fab ric t h a t covers ev ery facet of m a n s i n t e r n a l
less d e te r m in e d by th e exp erien ces d u r i n g

child ho od . T h e child will te n d to identify w ith
the cha rac teristics of th ose w h o m h e ad m ires,
a n d to evolve a n id ealized im ag e of him self
(ego ideal) fashio ned after th e person o r p e r
sons h e ven erates. If, in the first few y ea rs of
life, th e indiv id ual h a s developed a feeling of
a n d e x t e r n a l a d j u s t m e n t . T h r o u g h t h e m e d i u m of
security, a sense of reality, a good m e a s u r e of
in t h e i r p r i s t i n e fo rm t h o u g h t h e y a r e n o t a l w a y s
m anifest. T h e y t e n d to c o n t a m i n a t e a n a d u l t t y p e of
i n t e g r a t io n .
8. P e r s o n a l i t y , evolving as it d oes f ro m a b l e n d of
h e r e d ity a n d e x p e r ie n c e , is n o t m e r e l y a r e p o s i t o r y
of special ab ilities, a t t i t u d e s , a n d beliefs.
It is a
104
a s s e r ti v e n e s s , p o s itiv e s e lf-e s te e m , a n d c a
tive security system, d isto rte d co ncep tio ns of
pacities for self-control, he will p r o b a b l y be

a b le to e n d u r e c o n s i d e r a b l e e n v i r o n m e n t a l
reality,
h a rd s h ip s th e r e a fte r a n d
still evolve in to a
h e a lth y ad ult. O n th e o th e r h a n d , e a rly u n f a

vo rab le d ev elop m ent h a n d ic a p s th e child in
m a n a g i n g even th e u su al vicissitudes t h a t are
im perfect social co ntro l over bodily
f u n c t i o n s , v i t i a t e d sen s e of a s s e r ti v e n e s s ,
s t u n t e d i n d e p e n d e n c e , i m p a i r e d s e lf-e s te e m ,
in a d e q u a te f r u s tr a tio n to lera n c e, im p r o p e r m a
stery of sexual a n d hostile im pu lses, in c o m
plete id entificatio n w ith m e m b e rs of o n e s ow n
c o m m o n to g ro w in g up . T h i s does n ot m e a n
sex, deficient g r o u p identification, fau lty in
th a t all child ren w ith a good p e rs o n a l s u b
te g ra tio n of p re v a ilin g social values, a n d i m
s tru c tu r e will
ad u lts since a n overly h a r s h e n v ir o n m e n t can
p a ir e d acc eptanc e of o n e s social role. P re s s u re

of e a rly unsatisfied needs, a n tic ip a tio n of th e
i n h i b i t d e v e l o p m e n t a t a n y p h a s e in th e
g ro w th process. N o r does it im p ly th a t a child
sa m e kin d s of tu r m o i l th a t existed in child ho od

o r th e ac tu a l setting u p of cond ition s th a t
w ith a n in a d e q u a te p e rs o n a lity s tru c tu r e m a y

no t in the face of favo rab le circum stanc es o ver
p revailed in o n e s e a rly life, a n d survival of

a n a c h ro n is tic defenses, s y m p to m s, a n d th e ir
sym bolic ex tensio ns, all a r e in c o r p o ra te d into
inevitably em e rg e as h e a lth y
come severe early im p e d im e n ts in g r o w th and

m a t u r e to satisfactory ad u lth o o d . W e r e w e to
th e p e rs o n a lity s tru c tu re . C o m p u ls iv e in n a
subscribe to the pessimistic p h ilo so p h y th a t all
tu re , they p e r m e a te every p h a se of th o u g h t,
early
per
feeling, an d action ; they g o vern th e r a n d o m
m a n e n t, we w o u ld blin d ourselves to th e ef
a n d p u rp o s e fu l activities of th e in div idu al,

forcing h im to co nfo rm w ith th e m in a m e r c i
less w ay.
p sy c h ic
dam age
is i r r e p a r a b l y
ficacy of p s y c h o th e ra p y th a t is p re d icated on
th e a ss u m p tio n th a t it is possible t h r o u g h th e
em otion ally corrective e xp erienc e p ro v id e d by
tr e a tm e n t to o vercom e m a n y ch ildh oo d p e r
W h il e th e p e rs o n a lity s t ru c tu r e is tr e m e n
dously co m plex a n d is u n d e r s ta n d a b l y different
sonality disto rtions.

P ers o n a lity tr a its in a d u lt life, ho w ev er, a re
in every h u m a n being by v ir tu e of distinctive

c o n stitu tio n a l m a k e u p a n d u n iq u e c o n d itio n
never an exact red u p lic a tio n of child ho od striv
ings, ce rta in co m m o n in g re d ie n ts m a y be o b
ings. E a r ly c on dition ing s a r e te m p e re d by e x
served in all p e rs o n s in o u r cu ltu re. A m o n g
periences in later life th a t te n d to modify, n e u

tralize, o r reinforce them . M o r e o v e r, th o u g h
th ese a r e (1) aspects of n u c le a r conflicts th a t

accrue in th e course of p e rs o n a lity d evelo p
b ehav ior is influenced by p a tt e r n s rooted in the
m e n t, (2) in te ra c tin g m a n ife sta tio n s of u n r e
past, responses vary w idely in different s i tu a

tions in acc ord ance w ith th e ir sym bolic signifi
cance and the p re v a ilin g social role playe d by
th e perso n at th e time. T h e s u n d r y v a ria tio n s
of p e rs o n a lity strivings in o p e ra tio n a re in
finite. I n c o r p o ra te d a re a ttitu d es, values, an d
p a tt e r n s of b e h a v io r th a t issue o ut of a defec
solved childish p r o m p ti n g s ,
ti on s of c h a r a c t e r drives,
d ep en d en cy , ag g ressio n ,
p end ence, d e ta c h m e n t, a n d
d evalue d self-image. T h e s e
a n d (3) re v e r b e r a
such as excessive
com pulsive in d e
m a n ife sta tio n s of a
a r e rich sources of
p ro b le m s th a t su p p ly i m p o r t a n t a re a s of d y
n a m ic focus.
Possible Assumptions Based on the Past

A n u n d e r s ta n d in g of h ow the past life (see
T a b l e 8 -1 on p e rs o n a lity d ev elo pm ent) of a
p a tie n t h a s influenced th e ex istin g p s y c h o p a thology is t h u s of in estim a ble v alu e in d y n a m ic

(C o n td ,p . 108)

TABLE 8-1. Personality D evelopm ent
(See follow ing chart* for corresponding num bers
(1 ) H e r e d ita r y a n d c o n s titu tio n a l e le m e n ts a re th e b u ild in g b lo cks o f p e r s o n a lity . A lo n g w ith
in tr a u te r in e in flu e n c e s th e y d e te r m in e s e n s itiv ity a n d a c tiv ity p a tte r n s a n d th u s re g u la te
th e c h a ra c te r o f la te r c o n d itio n in g s. U n d e r th e p r o m p tin g s o f m a tu r a tio n , n ee d s e m e r g e
a n d sk ills evo lve w ith s u r p r is in g re g u la rity . E n v ir o n m e n ta l fa c to r s , n e v e r th e le ss , m a y
m o d ify th ese p r e n a ta l fo r c e s a n d fa s h io n th e lin e s a lo n g w h ic h th e p e r s o n a lity s tr u c tu r e is
o rg a n ize d .
(2 ) P e rs o n a lity evo lves o u t o f th e c o n d itio n in g s a n d e x p e r ie n c e s o f th e in d iv id u a l in h is rela
tio n sh ip s
w ith
th e
w o rld .
B a sic
needs
m ust
be g r a tifie d
and
a p p r o p r ia te
c o p in g
m e c h a n is m s evo lved , th e c o n s u m m a tio n o f w h ic h , a t a n y a g e level, i f in a d e q u a te w ill

r e ta r d a n d i f sa tis fa c to ry w ill e x p e d ite su ccessive sta g e s o f g r o w th .
T h e so c ia l m ilie u ,
re fle c te d in th e d isc ip lin e s a n d v a lu e s sp o n s o re d b y th e fa m i l y , d e sig n s th e sp e c ific o u tle ts

f o r a n d m o d e s o f e x p r e ss io n o f th e e m e r g in g needs.
(3 ) P e rs o n a lity m a tu r a tio n is c o n tin g e n t on e x e c u tio n o f v ita l ta s k s th a t m u s t be su c c e ssfu lly
fu l f i ll e d a t th e d iffe r e n t age levels.
(4 ) W h a t in h ib its o r d isto r ts g r o w th a re d e p r iv in g e x p e r ie n c e s th a t block th e p r o p e r sa tisfa c
tio n o f n eed s. A n u n w h o le s o m e m ilie u te n d s to fo s te r d e s tr u c tiv e p a tte r n s th a t c ru sh se
c u r ity , u n d e r m in e se lf-e ste e m a n d in te rfe r e w ith th e d e v e lo p m e n t o f e s s e n tia l s k ills a n d
va lu e s th a t a re c o n s o n a n t w ith th e r e q u ir e m e n ts o f a d a p ta tio n .
(5) A t a n y age le v e l co lla p se in a d a p ta tio n m a y be s p o n s o r e d w h e n basic n e e d s a re v itia te d ,
a n d se c u rity a n d se lf-e ste e m a re s h a tte r e d w ith no h o p e o f im m e d ia te re p a ra tio n . I f th e
re se rv o ir o f d e fe n se s is s u ffic ie n tly fle x ib le , c o n sid e ra b le co n flic t m a y be e n d u r e d . O n the
o th e r h a n d , w h e re th e p e r s o n a lity u n d e r p in n in g s a re u n s ta b le , even m in im a l co n flic t m a y
ta x c o p in g ca p a cities. A c o m b in a tio n o f s y m p to m s issu e f r o m th e fa ilu r e to so lv e co n flicts,
a n d in c lu d e , in th e m a in , th e v a r io u s m a n ife s ta tio n s o f a n x ie ty , d e fe n se s a g a in st a n x ie ty , as
w e ll as tech n ics o f c o u n te r a c tin g or s o lv in g th e c o n flic tu a l situ a tio n itself.
W h ile th e
e la b o r a te d s y m p to m s a re u n iq u e f o r e v e r y in d iv id u a l, b e in g in flu e n c e d b y th e sp e cific
e x p e rie n c e s o f th e p e r s o n , a n d b y th e s in g u la r m e c h a n is m s o f d e fe n se he h a s f o u n d su c cess
f u l in p a s t d e a lin g w ith stress, d e fin ite g r o u p in g s o f s y m p to m s a p p e a r w ith su ffic ie n t f r e
q u e n c y to c o n s titu te fa m il i a r s y n d r o m e s . S y m p to m a tic e v id e n c e s o f a f a i l in g a d ju s tm e n t
m a y p e r s is t f r o m o n e age level to th e n e x t, a ccretio n s o f su c c e e d in g d iffic u ltie s b e in g a d d e d
to o r s u b s titu tin g f o r p r o b le m s e x is tin g a t p r e c e e d in g age levels.
(6) R e sid u e s o f d e fe c tiv e re a rin g c o n ta m in a te a d ju s tm e n t b y in flu e n c in g d is o r g a n iz in g rela
tio n s h ip s w ith o th e r in d iv id u a ls. C o n flic t is th u s in c o n s ta n t g e n e r a tio n . T h e sp e c ific d e
p o s its o f d e fe c t d is p la y th e m s e lv e s in lu x u r ia n t fo r m s , th e c u m u la tiv e p r o d u c t o f p a th o
lo g ica l a ccru a ls f r o m o n e age le v e l to th e n e x t.
(7 ) A w a r e n e s s o f fo r m a tiv e e x p e r ie n c e s a n d e la b o r a te d d e fe n s e s m a y be d im m e d b y re p ressio n .
F o r g e ttin g o r r e p u d ia tin g th e m d o es n o t p r o te c t th e in d iv id u a l a g a in s t th e ir fo r a y s in to h is
co n scio u s life in d ire c t o r d e r iv a tiv e fo r m . E a r ly c o n flic ts m a y be re v iv e d sy m b o lic a lly in
d re a m s, th ro u g h th e use o f p s y c h o to m im e tic d ru g s, as a r e su lt o f an o v e r p o w e r in g e m o
tio n a l crisis, d u r in g an in te n se r e la tio n s h ip w ith a p e r s o n a g e w h o re p re s e n ts a p a r e n ta l or
sib lin g fig u r e , o r b y a tra n s fe re n c e n e u r o sis in s p ir e d in th e c o u r se o f p s y c h o th e r a p e u tic
tre a tm e n t.
* F r o m L . R . W o lb e r g , P s y c h o th e r a p y a n d th e B e h a v io r a l S c ie n c e s ( N e w Y o rk , G r u n e & S tr a t to n ,
1 9 6 6 ), p p . 6 2 - 6 3 . R e p r i n te d w ith p e r m is s io n .
TABLE 8-1, cont'd: Building Blocks of Personality

I.
H E R E D IT A R Y E L E M E N T S ( n e u r o p h y s i o l o g i c a l b i o c h e m i c a l , )
I I . I N T R A U T E R I N E IN F L U E N C E S ( M e t a b o l i c , p o s t u r a l , in f e c t i o u s )
1
S en sitivity a n d Activity P o te n tia ls
M A T U R A T IO N A L C O M P O N E N T S AND E X P E R I E N T I A L C O N D IT I O N I N G S
YEAR
1
(In fa n c y )
(2 ) N E E D S
(3 ) T A S K S T O
A C H IE V E
(4 ) B A S I C T R A U M A S
In te n s e a n d u rg e n t d e m a n d s fo r o ra l
s a tis fa c tio n ( n u t r i t i o n a n d s u c k in g
p le a s u r e ); s e n s o ry s tim u la tio n (o p tic ,
a u d i t o r y , ta c tile , k in e s th e tic ) ; lo v e a n d
a p p r o v a l.
F e e lin g s o f s e c u rity a n d
tr u s t .
S e p a r a t i o n o f s e lf fro m
n o n s e lf.
C o o rd in a tio n ; a m b u la
t io n . S y m b o liz a tio n .
In te r f e r e n c e w ith n u t r i t io n ( a c u te o r
c h r o n ic illn e s s , g a s t r o i n t e s t i n a l u p s e ts ,
a lle r g ie s ). In te r fe r e n c e w ith s u c k in g
p l e a s u r e , s e n s o r y s t im u l a t i o n , love a n d
a p p r o v a l ( s e p a r a ti o n fro m , d e a th of, o r
re je c tio n b y m o th e r) .
F a u l t y w e a n in g .
2 -3
(E a rly
C h il d
hood)
In v e s tig a tiv e a n d e x p l o r a t o r y n e e d s ;
g e n ita l m a n ip u la tio n .
B e g in n in g s triv in g s fo r in d e p e n d e n c e a n d
m a s te r y ; a g g re s s iv e a s s e rtiv e n e s s .
F e e lin g s o f a u to n o m y ;
i n c o r p o r a tio n o f d is c i
p lin e s ; t o le r a n c e o f fr u s
t r a t i o n . S o c ia l o u tle ts fo r
a g g r e s s io n . S elfc o n fid e n c e .
H a b it t r a i n i n g (to o la x o r to o se v e re
d is c ip lin e s , a s in r e la t io n to to ile t tr a i n i n g ) .
In te r fe r e n c e w ith in d e p e n d e n c e a n d
m a s te r y (o v e rp ro te c tio n ) .
F a u l t y h a n d l i n g o f ra g e a n d a g g r e s s io n
(to o se v e re r e s tr ic tio n s o r e x c e ssiv e
p e r m is s iv e n e s s ) .
T o o g r e a t o r to o little e m p h a s is by p a r e n t
o n r ig h ts o f o t h e r m e m b e r s o f fa m ily .
I n te r f e r e n c e w ith in v e s tig a tiv e a n d
e x p l o r a t o r y a c tiv itie s . I n te r f e r e n c e w ith
g e n ita l m a n ip u la tio n .
U n c o n s c io u s e n c o u r a g e m e n t o f re b e llio n
by p a r e n t , a l t e r n a t i n g w ith e x c essiv e
p u n is h m e n t.
3 -5
(C h ild
hood)
N e e d fo r e x tr a f a m ilia l g r o u p c o n ta c ts a n d
fo r c o o p e ra tiv e p la y .
K e en in te re s t in sex , g e n ita l d iffe re n c e s ,
a n d b i r t h p ro c esses.
S e x u a l id e n tific a tio n .
O e d ip a l re s o lu tio n .
P ro b le m s re la te d to e n t r y in to n u r s e r y
school a n d k in d e rg a rte n .
In te r f e r e n c e w ith in te re s t in s e x u a lity ;
m a s t u r b a to r y i n tim id a tio n .
P re c o c io u s o r e x c e ssiv e s e x u a l
s tim u la tio n . S e d u c tiv e p a r e n t .
M o t h e r to o d o m in a n t; f a th e r to o p a s s iv e
o r a b s e n t.
5 -1 1
(L a te
C h il d
hood)
N e e d fo r in te lle c tu a l g r o w th a n d
u n d e r s ta n d in g .
N e e d fo r f u r th e r so cial c o n ta c ts a n d for
o rg a n iz e d te a m p la y .
N e e d to b e lo n g to a g r o u p , c lu b , o r g a n g .
G r o u p id e n tific a tio n .
P ro b le m s re la te d to e n tr y in to g r a d e
s c h o o l ( i m p r o p e r s c h o o l a n d te a c h e r s : fe a r
o f r e li n q u i s h i n g d e p e n d e n c y ).
N e ig h b o r h o o d s tre s s e s .
E x p o s u r e to r a c ia l a n d r e lig io u s
p re ju d ic e s .
1 1 -1 5
(E a r ly
A d o le s
ce n ce )
In te n s e s e x u a l fe e lin g s a n d in te r e s ts fo r
w h ic h a so cial o u tle t is n e c e s s a ry
( r e c r e a tio n a l p r o g r a m s , e s p e c ia lly so cial
d a n c in g .)
N e e d to p ra c tic e s k ills fo r s u cc essfu l
p a r ti c ip a t io n in g ro u p s .
S o c ia liz a tio n o f sex

d riv e s . R e s o lu tio n o f
p a r e n t a l a m b iv a le n c e .
C o n flic t b e tw e e n n e e d fo r a n d d e f ia n c e of
p a re n ts.
C o n flic t in r e la tio n to s e x u a l d e m a n d s
a n d s o c ia l re s tr ic tio n s ; m a s t u r b a to r y
c o n flic ts .
T o o la x s e x u a l e n v ir o n m e n t. P o o r
s u p e r v is io n a n d d is c ip lin e . L a c k of
co h e s iv e n e s s in h o m e .
1 5 -2 1
(L a te
A d o le s
ce n ce )
G r a d u a l e m a n c ip a tio n fro m p a r e n ts .
N e e d to m a k e a v o c a tio n a l ch o ic e .
G r o w i n g s e n s e o f re s p o n s ib ility . C o u r t s h ip ;
m a rria g e .
R e s o lu tio n of
dependency.
A s s u m p tio n o f
h e te ro s e x u a l ro le .
C o n flic t b e tw e e n d e p e n d e n c e a n d
in d e p e n d e n c e .
C o n ti n u i n g s e x u a l co n flic t.
S e v e re e c o n o m ic p ro b le m s .
2 1 -4 0
( A d u lt
hood)
G o o d s e x u a l, m a r i t a l , fa m ily , a n d w o r k
a d ju s tm e n t.
C o m m u n ity p a r ti c ip a t io n .
P ro d u c tiv e w o r k ro le
a n d e c o n o m ic in d e p e n
dence. M a rria g e ; p a r e n t
hood. C o m m u n ity r e
s p o n s ib ilitie s . C r e a tiv e
s e lf-fu lfillm e n t.
E x t r a o r d i n a r y fa m ily s tre s s e s .
E c o n o m ic h a r d s h ip s . N a t u r a l d is a s te rs .
Illn e s s , a n d a c c id e n ts .
R a c ia l a n d r e lig io u s d is c r im in a tio n s .
4 0 -6 5
(M id d le
A ge)
A c c e p ta n c e o f a s lo w e r life p a c e ,
p h y s ic a lly a n d c o m p e titiv e ly .
N e e d fo r n e w in te re s ts , h o b b ie s , a n d
c o m m u n ity a c tiv itie s .
M o b i li z a t i o n o f o n e s
to ta l re s o u rc e s to w a r d
a c h ie v e m e n t o f p e r s o n a l
h a p p in e s s , fa m ily
in t e g r a ti o n , a n d so cial
w e lfa re .
M e n o p a u s a l a n d c lim a c te r ic c h a n g e s .
C o n flic ts in r e la tio n to s e p a r a t i o n fro m
c h i l d r e n , u n fu lfille d a m b i t i o n s , s e x u a l
d e c lin a tio n , a n d , in w o m e n , c e s s a tio n o f
c h ild b e a rin g .
A c c e p ta n c e o f p h y s ic a l, s e x u a l, a n d
m e m o ry re c e s s io n .
N e e d to e n g a g e in so cial a c tiv itie s , to
c u ltiv a te n e w fr ie n d s , to d e v e lo p c o m m u n ity
in te r e s ts a n d h o b b ie s .
C o n tin u e d w o r k ,
in te r p e r s o n a l a n d so cial
a c tiv itie s to th e lim it o f
o n e s p h y s ic a l c a p a c itie s .
C o n flic ts in r e la tio n to lo n e lin e s s , d e a th

o f f r ie n d s a n d m a te , in c re a s e d le is u r e tim e ,
re ti r e m e n t , f a ilin g w o r k , p h y s ic a l a n d
s e x u a l a c tiv itie s . Illn e s s .
F e a r fu l a n t i c i p a ti o n o f d e a th .
6 5 on
(O ld A ge)
TABLE 8-1, cont'd: Building Blocks of Personality

I. H E R E D IT A R Y E L E M E N T S ( n e u r o p h y s i o l o g i c a l , b i o c h e m i c a l , )
II. I N T R A U T E R I N E I N F L U E N C E S ( m e t a b o l i c , p o s t u r a l , i n f e c t i o u s )
4
S en sitivity a n d Activity P o te n tia ls
M A T U R A T IO N A L C O M P O N E N T S AND E X P E R I E N T I A L C O N D IT I O N I N G S
(5 ) S Y M P T O M S O F
A D A P T IV E B R E A K D O W N
(6 ) S U R V IV IN G
P E R S O N A L IT Y D IS T O R T IO N S
l D iffu s e a n x ie ty re a c tio n s .
2 . P s y c h o s o m a tic d is o rd e r s : a n o r e x i a ,
v o m itin g , c o lic , d i a r r h e a , b r e a t h i n g a n d
c ir c u la to r y d is o rd e r s .
3 . R a g e r e a c tio n s s c r e a m in g , c r y in g .
4. W i t h d r a w a l r e a c t i o n s d u lln e s s , a p a t h y
s tu p o r .
In s e c u rity ; m i s tr u s t; d e p r e s s iv e n e s s .
P re o c c u p a tio n w ith o r a l a c tiv itie s . S e a r c h
fo r a n id e a liz e d p a r e n t a l fig u r e o r for
n i r v a n a . P r o p e n s ity fo r a d d ic tio n s . A lte re d
b o d y im a g e ; a u s titic re a c tio n s ;
d e p e r s o n a liz a tio n .
4+
1 . A n x ie ty , p h o b ic a n d c o m p u ls iv e -lik e
re a c tio n s . P s y c h o p h y s io lo g ic a l re a c tio n s :
(a ) g a s tr o in te s tin a l d i s o r d e r s fe ed in g
d iffic u ltie s lik e a n o r e x ia ;
c o n s tip a tio n , d i a r r h e a .
(b ) s p e e c h d is o r d e r s s ta m m e r in g .
(c) b o w e l a n d b la d d e r d i s o r d e r s
s o ilin g , e n u r e s is .
2. P e rs o n a lity d is o rd e r s : (a ) ra g e re a c tio n s ,
(b ) w i t h d r a w a l r e a c tio n s , (c) ex c e ssiv e
d e p e n d e n c v , (d ) d i s tu r b e d id e n tity .
L a c k o f s e lf-c o n fid e n c e . S tu b b o r n n e s s .
I n a b ility to c o n tr o l im p u ls e s a n d e m o tio n s .
F r u s t r a t i o n in to le ra n c e .
P re o c c u p a tio n w ith a n a l a c tiv itie s .
P a r a n o id a l id e a s; fe a r o f a u t h o r i t y .
C o m p u ls iv e n e s s . F e e lin g s o f s h a m e .
4+
1. P s y c h o n e u r o tic re a c tio n s : (a ) a n x ie tv
s ta te s , (b ) p h o b ic r e a c tio n s , (c)
p s y c h o p h y s io lo g ic re a c tio n s :
g a s tr o in te s tin a l d is o r d e r s , sp ee ch
d is o r d e r s , b la d d e r d is o r d e r s , s k in
d is o r d e r s , t its .
2 . P e r s o n a lity d is o r d e r s (a s a b o v e ).
3. P r i m a r y b e h a v io r d is o rd e r s .
P e r s is tin g o e d ip a l c o n flic ts ; in a b i l i ty to
id e n tify w ith p e r s o n s o f o w n sex .
2 + to
4+
1. P s y c h o n e u r o tic re a c tio n s : (a ) a n x ie ty
s ta te s a n d a n x ie ty re a c tio n s , (b ) p h o b ic
re a c tio n s , (c) c o n v e rs io n h y s te r ia , (d )
c o m p u ls io n n e u r o s is , (e) p s y c h o s o m a tic
d is o rd e r s : g a s t r o i n t e s t i n a l , b la d d e r,
s p e e c h , s k in , h e a r i n g a n d v isu a l
d is o rd e r s , tics, m u s c le s p a s m s , n a ilb itin g . c o m p u ls iv e o r a b s e n t
m a s tu r b a tio n .
2 . P e r s o n a lity d is o r d e r s (a s a b o v e ).
3. P r i m a r y b e h a v io r d i s o r d e r s le a r n in g
d is a b ilitie s .
4 . J u v e n ile s c h iz o p h r e n ia .
In a b ility to a c c e p t a p r o p e r ro le .
D i s t u r b e d r e la t io n s w ith o th e r s . P ro b le m s
in c o m p e titiv e n e s s a n d c o o p e ra tio n .
0 to
2+
a s a b o v e , p lu s
S c h iz o p h re n ia
S e x u a l a c tin g - o u t. E x c e s s iv e ly h o s tile
a t t i t u d e s to w a r d a u t h o r i t y . P ro b le m s in
i d e n tity . Is o la tio n .
0 to
2+
a s ab o v e
E x c e s s iv e d e p e n d e n c e .
D e v a lu e d s e lf-im a g e .
C o n fu s io n r e g a r d i n g s o c ia l ro le . S e x u a l
in h ib itio n s .
0 to
2+
A lc o h o lis m
D r u g a d d ic tio n
M a n ic - d e p re s s iv e p s y c h o s is
R e in fo rc e m e n t o f e x is te n t p e r s o n a lity
d is tu r b a n c e s .
0 to
1+
I n v o lu tio n a l m e la n c h o lia
as above
0 to
1+
A r te rio s c le r o tic a n d S e n ile p sy c h o se s
as above
0 to
2+
(7 )
R E P R E S S IO N
108
s h o r t-te rm t h e r a p y . W h il e little tim e is a v a il

able to exp lo re th e p ast, as h a s been m e n
tioned, certain a s s u m p tio n s m a y be possible
from the sy m p to m pictu re, a good histo ry ,
d re a m s , a n d p a r t ic u l a r ly tra n sferen ce m a n
ifestations. T h e
im p ac t of th e p a st m a y be
t o w a r d a n y c o m p e tito r w h o m she e q u a te s w ith

th e p re f e rre d a n d privileged y o u n g e r child in
h e r fam ily w h o displaced h e r as th e favorite.
M ech a n ism s d e v e lo p e d in e a rly ch ild h o o d
th a t have in su red a g ra tifica tio n o f needs w ill
con tin u e to be in d u lg ed to a g re a te r o r lesser
s u m m a riz e d u n d e r seven h eadin gs.

U n p ro p itia te d ea rly needs co n sta n tly o b
degree in a d u lt life. T h u s a child in tim id a te d
tru de th em selves on th e in d ivid u a l, p ro p e llin g
re s p o n d s w ith g re a t hostility a n d , in a d efian t
him to w a rd d irect or sym b o lic actions to sa tisfy
m a n n e r , covertly c o n tin u es his practice. L a t e r

th e m a n ife sta tio n of h ostility seem s to be a
these needs. A m a n d ep riv ed d u r i n g infancy of

a d e q u a t e su ckin g p le a s u re m a y co n stan tly be
by his p a r e n t s to avoid m a s t u r b a t o r y activities
ov er-in d u lg in g him self w ith food a n d alcohol
cond itio n p re r e q u is i te for a n y k in d of sexual

e xp ressio n, sex u a l sadism being th e u ltim a te
o utcom e. A n o th e r y o u n g ste r m a y h a v e been
to the
en jo ined by o v e rs c ru p u lo u s p a r e n t s to p e rf o rm
physical
m eticulou sly on all occasions, on th e th r e a t of

th e ir c o n d e m n a tio n o r loss of love. H e n c e fo rth
obsessed w ith a need for m o u th stim u la tio n ,
w om an,
p o in t of obesity a n d
restricted
alcoholism .
as a c h il d
in
activity a n d assertive beh av io r o n th e basis th a t

she w a s a girl, m a y c o n tin u e to envy m e n an d
th eir possession of th e e m b le m of m ascu lin ity,
in du lg enc e of th e tr a it of p erfection ism m a y be

com e a n essen tial factor in his e x p e rie n c in g
th e penis. A ccordingly, she will a tt e m p t to p a t
an y d eg ree of positive self-esteem . A p a m p e r e d
tern h e r life a lo n g lines c o m m o n ly p u rs u e d by
child w ho se t e m p e r t a n t r u m s co m p elled his
m ales, m a s cu lin ity bein g e q u a te d in h e r m in d

w ith freedom a n d assertiveness. W i t h dogged
persistence she will d e n y fem in in e interests,
p a r e n t s a n d siblings to give in to h is w h im s ,
a n d she m a y even clothe herself in m a s c u lin e

like attire , cro p p in g h e r h a i r after the style of
men.
satisfactions. Sensitive to th e slightest rejection,
D efenses e vo lv ed in ch ild h o o d m a y ca rry

o v e r in to a d u lt life w ith an a s to n is h in g
persisten ce. A boy, ov erp ro tecte d a n d sexually
o v e r s t i m u l a t e d by a d o t i n g m o t h e r , m a y
vigorously detach him self fro m her. W h e n he
grow s u p, h e m a y c o n tin u e to avoid contact
w ith w o m en ; a n y a tt e m p t s at sexual p la y m a y
resu lt in in cestuous guilt to a p o in t w h e r e h e is
u n a b le to function. A child rig oro usly an d p r e
m a tu re ly toilet tr a in e d m a y re g a r d his bowel
persists in self-oriented, selfish d e m a n d s on th e

w o rld to s u p p l y h im w ith gratificatio ns an d
he c o nstrues a n y casu aln ess t o w a r d h im as a
designed p e rs o n a l inju ry . T h i s m obilizes ra g e
an d releases coercive b e h a v io r to force p eo p le
to yield to his d e m a n d s .
T h e in d iv id u a l w ill r e p e titiv e ly se t up a n d
a tte m p t to live th rou gh e a rly d estru c tiv e situ a
tion s th a t he has fa ile d to m a ster as a child. A
y o u n g w o m a n rep etitiv ely involves h erself in
co m petitive re la tio n s h ip s w ith older, m o re a t
tractive, m o r e gifted w o m e n in a n a tt e m p t to
su b d u e th e m . T h e feelings she e xp erienc es a n d
activities as disa g reea b le a n d filthy. O v e r

c l e a n lin e s s , o v e r o r d e r l i n e s s , o v e r m e t i c u l o u s
th e situ a tio n s she creates p a ra lle l closely the

riv alry e x p erien ce w ith h e r o lder sister w h o m
she could n ever v a n q u is h . A child is severely
ness ensu e a n d b u r d e n his a d u lt a d ju s tm e n t. A

y o u n g e r sibling m a y c a rr y over into a d u lt life
th e conviction th a t he is sm all a n d ineffectual
in re latio n to a n y perso n m o r e o r less u n c o n
sciously identified as his o ld er sibling. T h i s
will p ro m o te w ith d r a w a l tendencies o r p rovoke
h im to prove him self by fighting a n d p u sh in g
him self beyond his h a b it u a l capacities. A n
old er sibling m a y c o n tin u e to h a r b o r h a tr e d
rejected a n d p hy sically m a l tr e a te d by a n alco

h o lic f a t h e r . W h e n sh e m a t u r e s , s h e is
p assio n ate ly a tt ra c t e d to d e tac h ed , sadistic, an d
p s y ch o p ath ic m e n , w h o se affection she d e s p e r
ately tries to w in . A m a n in p sy ch o an aly sis d e
velops p a r a n o i d a l attitu d e s a n d feelings t o w a r d
th e a n a ly s t, im a g in in g th a t th e a n a ly s t w ishes
to h u m i li a te a n d to r t u r e h im . T h e s e a r e t r a n s
ference m a n ife sta tio n s reflective of th e sam e
109

kinds of feelings he h a d t o w a r d his fa th e r d u r
respect oth ers. A boy w h o se fa th e r is passive
ing th e o edip al period.

T he in d ivid u a l often
u n w ittin g ly ex h ib its
a n d deta c h ed identifies w ith a stro n g a g

gressive m o th e r, e m u l a ti n g h e r m a n n e r a n d i n
the sam e k in d o f d estru ctive a ttitu d e s a n d be
terests to th e p o in t of a v oid in g m as c u lin e a t
h avior p a tte rn s th a t he b itte r ly p ro te sts w e re
titu d es a n d goals. A y o u n g s te r w h o w a s dis
m an ifested
c rim in a te d a g a in s t by his a g e m a te s because of
w o m a n re a r e d by a p e tu l a n t, a rg u m e n ta t iv e
his race m a y , fro m th e b eg in n in g of his ex-
m o th e r m ay en g a g e in th e sa m e k ind of b e
tr a fa m ilia l contacts, develop a c o n te m p t for his
h av io r w ith h e r o w n c h ild re n , to tally u n a w a r e
kinfolk a n d a fear of g ro u p s . A girl victim ized
of the co m p ulsiv e n a t u r e of h e r p a tt e r n . A m a n
victim ized d u r i n g his ch ildh oo d by a h y p o
by p r o p e r a n d g e n tle p a r e n t s w h o ca n n o t
chondriacal
to w a rd
him
father
by
may
h is p a re n ts.
h im self
becom e
sta n d scenes is sh a m e d in to a b a n d o n in g an y
d e m o n s tr a t io n of an g er. S he c o n tin u e s to d is
obsessionally c o n cern ed w ith physical illness
p la y a b la n d , forgiving m a n n e r d esp ite ex
follow ing m a r ria g e . T h r o u g h in sid iou s id e n

tification a son m a y becom e a n alcoholic like
p lo ita tio n a n d in tim id a tio n .

T h e in d ivid u a l m a y te n d to revive ch ild h o o d
his m a le p a r e n t , a d a u g h te r th e victim o f m i
sy m p to m s in th e fa ce o f stress. V o m itin g , colic,
g ra in e like h e r m o th e r; th e e x a m p le s of such
a n d d i a r r h e a , w h ic h w e re m a n ife sta tio n s of
identification a r e endless.
T h e in d ivid u a l m a y f a il to d evelo p certain
stress d u r i n g o n e s e arly infancy, m a y be m o b i

lized by la te r episodes of tensio n to th e e m b a r
m atu re p e rs o n a lity featu res. A child severely
ra s s m e n t a n d d is m a y of the p ers o n . F e a r of th e
neglected and rejected d u r i n g infancy comes
d a r k a n d of a n im a ls , w h ic h te r ro riz e d the in d i
into a d u lt life w ith p a th o lo g ical feelings of i m

p e n d in g doom , a co n c e p tu a liz a tio n of him self
vidual in ea rly c h ild ho od , m a y o v e rw h e lm h im

in a d u lt life w h e n a n x ie ty ta x e s his ex isten t ca
as in h u m a n a n d
pacities.
in significant, ten den cies to
d e p e rs o n a liz a tio n , a n d a n in ability to love or
Nuclear Conflicts
T a b l e 8 - 2 s u m m a r i z e s th e chief conflicts,
w h ich we call n u c le a r conflicts, im bed ded in
the psyche of each p erso n , p ro d u c ts of th e
inevitable clash of m a t u r i n g needs a n d reality
restrictions, the m a s te ry of w h ich co nstitutes
one of the p r i m a r y tasks of psychosocial d e
velo pm ent. It m u s t be e m p h a s iz e d th a t these
conflicts a re univ ersal q u alita tiv ely , th o u g h
q u a n tita tiv e ly differing in all p e rs o n s as a
re sult of c o n s t itu tio n a l-c o n d itio n in g v a ria tio n s
a n d the inte grity of th e ex istin g defenses.
T h e earliest n u c le a r conflicts a re o rg a n iz e d
in rela tio n sh ip to the p a re n ts. F o r in stance, th e
an d th e relief of ten sion . At th e sam e tim e th e

absence of m o t h e r becom es linked to dis
com fort, distress, an d p a in . D u r i n g th e last
p a r t of th e first y e a r the child reacts w ith w h a t
is p ro b a b l y a p ri m o r d i a l ty p e of a n x ie ty to
se p a r a tio n from th e m o t h e r, a n d w ith ra g e at
h e r tu r n i n g a w a y fro m h im t o w a r d a n y b o d y
else, child o r a d u lt. T h i s b len d ed g ratificatio nd e p riv a tio n im ag e of m o t h e r is p r o b a b l y the
p re c u r s e r of la te r a m b iv alen cies, p o w e rin g
sibling riv alry a n d th e riv alries d u r i n g the
oed ipal p erio d. It also gives rise to m o tiv atio n s
to co ntrol, a p p e a se , an d w in favors from
in f a n ts association of th e presence of m o th e r
w ith satisfaction of his needs (h u n g e r , th irst,
m o t h e r a n d m o t h e r figures, to v a n q u is h , e lim i
n a te , o r d e stro y co m p e tito rs for h e r in terest
freedom from discom fort an d p a in , d e m a n d for

stim u la tio n ) re su lts in h e r b eco m in g affiliated
w ith gratification of these needs, w ith p le a s u re
a n d a tte n tio n , a n d to p u n is h m o t h e r a n d
m o t h e r figures for actual or fancied d e p r i v a
ti o n s .
The
m other
sym bol
becomes
sy m -
110
H A N D B O O K O F SHO RT-TERM PSYCH O TH ERAPY

T A B LE 8-2. N u cle a r C o n flicts*
R esidual
M an ife statio n s
(repressed o r
Ages
0 - 3 mo.
C o n flictu a l E lem ents

C o n s ta n t freedom from distre ss and pain
L eg en d s
I m ust be ev e rlastin g ly h a p p y an d com
fo rta b le; in stead I su ffe r.
op p o sed by realistic en v iro n m en tal
su p p ressed )
S earch for n irv a n a.
D em a n d for magic.
restrictio n s.
4 m o .- l yr.
1 -2 yrs.
N eed for o ra l, sensory, an d affectionate
I w a n t to be fed, loved, s tim u la te d , and
A m bivalence to w ard
gratifica tio n opp o sed by realistic d e p riv a
kept free from p ain at all tim es; but
m o th er figures.
tions.
m o th er d enies m e th is g ra tific a tio n .
S e p a ra tio n an x iety .
S elf-a ctu aliza tio n op p o sed by essential

restrictive disciplines.
1 w a n t to do w h at I w a n t to d o w h en I
w a n t to d o it, b u t I w ill be p u n ish ed and
Im p u lsiv e aggressiveness.
G u ilt feelings.
told I am b a d .
3 -5
P ow er im pulses op p o sed by sense of h e lp

lessness.
O e d ip a l desires op p o sed by re taliato ry
fears.
I w a n t to be big an d stro n g , b u t I know I

am w eak and little .
I w an t to possess my m o th er (fath er) for
myself, but 1 can n o t co m p ete w ith my
In ferio rity feelings.

C a s tra tio n fears.
C o m p u lsiv e striv in g s for
m ascu lin ity .
fa th er (m o th e r).
6-11
1 2 -1 5
D em and for to tal g ro u p acceptance opposed
1 w an t everybody to like, ad m ire, an d ac
by m anifestations of aloofness and u n
cept m e, but th e re a re som e people w ho
friendliness.
are ag ain st m e an d reject m e .
S exual im pulses opposed by guilt and fear

of punishm ent.
I feel a need for sex u al stim u latio n , but

th is is w ro n g and not a c cep ta b le.
F e a r of rejection by the
g ro u p .
F e a r of lack o f m alen ess

in m en and fem ale
n ess in w om en.
16-21
Independence strivings opposed by de

pendency.
I need to be a gro w n , in d ep en d en t person,
C o n tin u in g dependency.
but I d o n t w an t th e resp o n sib ility . I

w ould like to be a ch ild , b ut th is w ould
m ake me feel like a n o th in g .
* From L. R. Wolberg, an d J . Kildahl, T h e D ynam ics o f P ersonality (New York, G r u n e & Stratton, 1970), p. 56. Re
printed by permission.
bolically link ed to la te r sou rces of g ratific a tio n
z o n e o f con sciou s a w a r e n e s s . W h e n e v e r h a b i
o r d e p riv a tio n . M o r e o v e r , if a d is r u p t i o n of
h o m e o s ta tic e q u i l i b r i u m o ccurs at a n y tim e
la te r on in life o r if for a n y re a s o n a n x ie ty
tu a l co p in g m e c h a n is m s fail th e in d iv id u a l an d
he e x p e rie n c e s a n x ie ty , h e m a y feel th e h e l p
lessness a n d m a n ife st th e b e h a v io r o f a n in fa n t,
a n d h e m a y seek o u t, a g a in s t all logic, a
m o t h e r fig u re o r h e r sy m b olic s u b s titu te (such
as food in co m p u lsiv e e a tin g activities). It is lit
tle w o n d e r th a t m o th e rs, a n d th e i r la te r r e p r e
sentatives (p ro tecto rs, a u th o r it ie s ) , co m e to
possess sym bolic re w a rd (p le a su re ) v alu es
alo n g w ith sy m b o lic a b a n d o n m e n t (p a in ,
a n x ie ty ) p o ten tials. T h i s conflict, dee ply i m
b edd ed in th e unco nscio us, acts as co m p o st for
e r u p t s w i t h a s h a t t e r i n g o f th e s e n s e of
m a s te ry , th e p rim o rd ia l an x ie ty im p rin ts
m a y be revived, a ctiv a tin g s e p a r a ti o n fears
an d m o t h e r-i n v o k in g ten den c ie s a lo n g lines
p u rs u e d by the in div idu al as an infant.
T h e g ratificatio n -d ep riv atio n , se p aratio n a n x ie ty con stellation s, laid d o w n d u r i n g p h ases
of d e v e lo p m e n t e a rly in th e perio d of co n c e p
tu a liz a tio n , will tend to o p e ra te ou tsid e the

the fertilization
of a host of derivative a t
titudes, im pulses, a n d drives th a t re m a in w ith

the individual t h r o u g h o u t his existence. O t h e r
conflicts develop in the c h il d s rela tio n sh ip s
w ith th e w o rld , as noted in T a b l e 8 - 2 , th a t are
su p erim p o se d o n the conflicts associated w ith
the d e m a n d for m agic an d for th e co n sta n t
presence of th e m o th e r figure.
T h e actual experiences of in fan ts d u r i n g the
even
in s h o r t - t e r m
111
t h e r a p y e s p e c i a ll y in
d re a m s , tr an sferen ce, a c tin g -o u t b eh av io r, a n d

certain s y m p to m s to observe ho w a n i m p o r
ta n t n u c le a r conflict is c o n ti n u in g to d is tu rb
the p re s e n t a d ju s tm e n t of the pa tien t.
T h e o p e ra tio n of a n u c le a r conflict is e x e m
plified in a p e rs o n w h o h a b it u a ll y relies on a l
cohol as a m e a n s of e scap in g ten sion an d
first years of life, th e degree of need g ra tific a
an xiety. F e elin g s a b o u t d ep riv a tio n s in life are

avoided t h r o u g h th e t r a n q u il iz i n g effects of a l
tions th ey achieve, th e relative freedom from
cohol. At th e sa m e tim e the p erson rea s su res
d ep riv atio n , th eir le a r n in g to to le ra te som e

fr u str a tio n and to accept te m p o r a r y se p a r a tio n
him self, at least as long as h e d rin k s, t h a t a
from th e ir m o th e rs provide th e m w ith co p in g
k eep h im free of p a in .
devices to c o n t r o l t h e i r n u c l e a r c o n flic ts,

w h ich, nonetheless, irrespective of h o w satisfy
ing an d w h o leso m e th eir u p b r i n g in g m a y have
been,
a re still o p erativ e
(albeit successfully
repressed), w a itin g to b r e a k o u t in la ter life

should th e psychological hom eostasis collapse.
N u c le a r conflicts, to re p e a t, a re in h e r e n t in
n u r t u r i n g age nt is availab le to h im th a t will

A n o th e r e x a m p l e of a n u c le a r conflict is evi
denced in a te e n a g e r w h o establishes p s e u d o i n
d e p e n d e n c e t h r o u g h in v a ria b ly do ing th e o p
posite of w h a t his p a r e n t s ask. A re q u e s t to
w e a r a g reen sh irt im m e d ia te ly establishes in
h im an intensely felt desire to w e a r a red shirt.
of the
H i s o w n fears th a t h e will su ccu m b to his

d esire to be d e p e n d e n t on his p a r e n t s d rive him
c h a ra c te r of the en v iro n m e n t. T h i s is not to
to exert his in d ep en d e n ce, little re aliz in g th a t
the
g ro w in g - u p
process
irrespective
say th a t a d ep riv in g or destructive e n v ir o n m e n t
he is still not free because he is n o w im
will not e x ag g erate the effect of conflict or keep
p riso n e d by his o w n needs to be op p o sitio n a l.

A n d m u c h la ter in life, w h e n a su p erv iso r says
it alive beyond th e tim e w h e n it sh ou ld have

subsided; a w ho lesom e e n v ir o n m e n t will tend
to keep in check o p e ra tio n s of conflict, h e lp in g
to resolve it satisfactorily. N u cle a r conflicts are
in p a r t o rdain ed b y b iological elem en ts a n d in
do it this w a y , he m a y still be b o u n d u p in
his need to resist, irrespective of the m e rits of
d o in g a task on e w a y or a n o th e r .
T h e c u rr e n t inab ility of m a n y p e rs o n s to
p a r t are aspects o f the cu ltu re. W e sh o u ld ex
get in v olved m a y be a m a n ife sta tio n of several
p e c t th e ir a p p e a ra n c e in m in o r o r m a jo r
degree in all person s. T h e ir im p o rta n ce is con
n u c le a r conflicts. T o re m a in on e step rem oved
tain ed in the fa c t th at th ey g iv e rise to reaction
ta t o r r a t h e r t h a n a p la y e r m a y be skillfully r a
tio nalized by say in g th a t one does not h ave the
tendencies that, w e ld e d into the p e rso n a lity

stru ctu re, m ay la ter in terfere w ith a p r o p e r
from p a rtic ip a tio n in a cause o r to be a spec
a d aptation . O f clinical con sequen ce, too, is

th eir tendency to stir from d o r m a n c y into o pe n
expression w h e n an x iety b re a k s d o w n th e r a m
tim e, o r th a t th e cause does n ot ju s tify th e ef

fort, o r th a t the c a n d id a te is all too h u m a n , or
th a t th e political p la tfo rm is just so m u ch
w in d o w dressin g. B ut b e h in d these reaso ns
p a rts of the existent defensive fortifications.

T h e e x p o su r e of re pressed n u c le a r conflicts
th a t so u n d good, th e real rea so n m a y be o n e s

sense of helplessn ess a n d th e s u b s e q u e n t de
th a t a re cre atin g p ro b le m s con stitutes a task of

dy na m ic ally o rie n te d th e r a p y , the object being
to d e te rm in e the d isto rtio ns th ey p ro d u c e in
sp a ir a b o u t fin d in g m agical solutions. O r one

m a y not becom e involved because of fear of not
being to tally accepted by a n y g r o u p o r p a rty
the c h a ra c te r stru c tu r e , th e i r affiliation w ith

c u rr e n t conflicts, an d the subversive role th ey
p lay in s y m p to m form atio n. It m ay be possible
t h a t on e jo in s; so it m a y be less p ain fu l not to

expose oneself to such a possible rejection. T h e
n u c le a r conflict is h a n d le d by avoidance.
112
Conclusion
E ven th o u g h tim e does n ot p e rm it a n e x te n
sive p ro b in g of th e past, a n u n d e r s ta n d in g of
c u r r e n t conflicts, a n d th e subversive role th ey

play in in itia tin g a n d su s ta in in g sy m p to m s.
how
p e rs o n a lity vu ln erab ilities m a y be
H a v in g g ra s p e d the significance of h o w th e
p a st h a s e n te re d into p r o m o ti n g a d ju s tm e n t
im p o r t a n t for som e p a tie n ts in s h o r t-te rm t h e r
p ro b le m s in th e p re s e n t, m a n y p a tie n ts becom e
apy. D re a m s and transference p h e n o m e n a

often yield d a t a r e g a r d in g p a st c o nd itio nin gs
o w n after fo r m a l t h e r a p y h a s te r m in a te d . Such
th e
p ro d u ced
past
has
en tered
in t o
and
has
m o tiv ate d to e x p lo re th ese co nn ectio ns o n th e ir
a n d m a y expose som e n u c le a r conflicts t h a t can
h o m e w o r k m a y facilitate a s tre n g th e n i n g of
serve as a focus in th e r a p y . T h e object h e re is
defenses a n d u ltim a te ly act as a m e a n s of p osi

tively influen cin g p e rs o n a lity g ro w th .
to d e te r m in e th e d istortion s th ey p ro d u c e in
th e c h a ra c te r stru c tu r e , th e i r affiliation w ith
CHAPTER 9

B. Some Common Dynamic Themes
By th e ir effect on th e p e rs o n a lity s t ru c tu r e
k in d in a d e q u a te s e p a r a tio n - in d iv id u a tio n .
the de velo pm en tal vicissitudes set forth in the

last c h a p te r a re res p o n sib le for a host of
A n d peop le a r e a p t to b la m e th e i r tr o u b le s on
sym p to m s, cop ing m e ch a n ism s, an d defenses
c o rr u p tio n , in fla tion , c o m m u n is m , c a p ita lism ,
th a t provide m a n y d y n a m ic th em es on w hich
o r th e a to m b o m b . M o s t p eop le, h ow ev er,

s o m e h o w m u d d l e th r o u g h , w o r k in g ou t th e ir
we m a y focus. B ecause it is difficult for som e
th e w o rld : th e revolt of yo u th , g o v e rn m e n ta l
p a tie n ts to c o n ce p tu a lize th ese th em es, it m a y

be e x ped ie n t to simplify p e rs o n a lity o p e ra tio n s
tr o u b le s in o ne w a y o r a n o th e r .
an d disto rtio ns by p ic tu rin g th e m as p ro d u c ts

of the o p e ra tio n of five p o w erfu l m o to rs: e x
cessive d ep end ency , r e s e n tm e n t, redu ced in d e
plete a n d d e p e n d e n c y needs too in ten se th a t so
p endence,
dev alued
self-image,
and
It is only
w h e re s e p a r a ti o n - in d i v id u a t io n is too in c o m
d e ta c h
lu tio n s will not be found.

P e o p le w ith p o w e rfu l d e p e n d e n c y n eed s will
often cast a b o u t for in d iv id u a ls w h o d e m o n
s tra te stro n g e r q u a litie s t h a n they them selves
ment.
possess. W h e n a s w im m e r tires, he looks a b o u t

for s o m e th in g o r so m eo n e o n w h o m to lean or
Dependency
w ith w h ic h to g ra p p le . A d e p e n d e n t p e rs o n
O ften at th e core of p ro b le m s is th e first m o

tor, excessive dep en d en cy needs, th a t h a d not
c an be likened to a tire d s w im m e r , a n d he*

w a n t s to find so m eo ne o r s o m e th in g w h o can
do for h im w h a t h e feels he c a n n o t d o for
himself.
W hat
he g e n e ra lly
looks for is a
b e e n a d e q u a t e l y re s o lv e d in c h i l d h o o d . A
h e a lth y b alanc e b etw een d ep en d e n c y a n d in d e
p e rfe c t p a r e n t , a n ideal t h a t exists o nly in his
p end ence is essential for em o tio n a l w ell-being.

W h e r e it does n ot exist, p ro b le m s ensue. M o s t
o w n fancy. A ctu ally , t h e r e a r e no perfect

p a r e n t a l figures w h o a r e a b le o r w illin g to
likely th e av erag e p e r s o n s c h ild ho od y e a rn in g s

for n u r t u r e a n d affection w e re n ot o p tim a lly
met, leaving a residu e of u n m e t needs th a t tend
to e x p r e s s t h e m s e l v e s in t e n s e l y w h e n t h e
p ressures of life m o u n t. O r d e p e n d en cy w a s
p athologically e n co u rag ed by a m o t h e r w h o
utilized the child as a vehicle for h e r o w n
unfulfilled d e m a n d s , h a m p e r i n g th e c h il d s
g ro w th an d strivings for ind ep en d e n ce. U n re
so lved depen den cy is a u b iq u ito u s fo u n ta in -
m o t h e r o r fa th e r a n o t h e r ad u lt. So o u r d e
p e n d e n t p erso n is c o n tin u a lly being f r u s tr a te d
because his h o p es a n d ex p e c ta tio n s a re no t m e t
by so m eo ne else. A m a n w h o w ed s exp ectin g
h ead o f troubles. It stem s fr o m w h a t is p e rh a p s

the m ost com m on conflict bu rd en in g hum an
a n all-giving m o t h e r figu re for a wife is b o u n d

to be d is a p p o in te d . F u r t h e r , if he does find a
p e rs o n w h o fits in w ith his design an d w h o
* T h e generic he is employed to designate both males

and females. T h ere are, however, some distinctive roles
played and effects scored for males and females, which will
be differentiated as much as possible.
113
114
treats h im like a helpless individual, he will

begin to feel th a t he is being sw allow ed up,
blacks, C h ic a n o s , J e w s , C o m m u n is t s , c a p i
talists, an d so on. Self-hate com plicates his
th a t he is losing his in dividuality, th a t he is
e x is te n c e
tr a p p e d . C o n se q u e n tly , he will w a n t to escape
d ep ression . H a t r e d directed o u tw a r d an d th e n
from the re la tio n sh ip . Also, as he senses his

being
t u r n e d in resu lts in m aso ch ism , in the fo rm of

m a j o r an d m i n o r se lf-p u n ish m e n ts. T h e s e m a y
passive like a child. A nd this is frig h ten in g be

c au se he k n o w s th a t he is no t being m a n ly ; he
r a n g e from fouling u p a business deal to

inab ility to accept success, to d a n g e r o u s ac
may
cident p ro n en es s, to physical illness, to foolish,

o u tr a g e o u s, o r e m b a r r a s s in g behavior.
d epen den cy,
actually
he
will
have
feel th a t
h o m o s ex u al
he
is
d o u b ts an d
f e a r s since m a s c u l i n i t y is a s s o c ia te d
activity a n d in dependence.
w ith
W e will call his first m a n e u v e r his de

p en d en cy m otor, w h ich begins to o p e ra te e sp e
b e c a u s e it s p o n s o r s te n s i o n
and
Low Independence
cially at tim es w h e n he is u n d e r p ressure. As

he searches for th e elem en t missing in his p sy
N o w o u r m a n has tw o m o to rs going m ost of
chological diet, n a m e ly a p a re n ta l figure, he
th e tim e w h e n u n d e r p re s su re: the d ep en d e n c y
will most a ssu re dly be disillusioned. W o m e n
m o to r a n d th e re s e n tm e n t m o to r, w ith a c
c o m p a n y in g kickbacks of guilt a n d m asoch ism .
a re no less victim ized by d e pe nd enc y t h a n are

men. A nd th e ir reactio ns a re q u ite sim ila r in
th a t they a re a p t to re g a rd both m ales a n d fe
m ales on w h o m th ey get d e p e n d e n t as p o te n
T h e p ic tu re is not com plete, ho w ev er, w ith o u t

a th i r d m o to r, lo w in depen den ce, w h ich is an
tial n u r t u r i n g m o t h e r figures. T h e y a re also no
L o w in d ep en d e n ce is a feeling th a t on e c a n n o t
g ain, by his o w n reaso n o r s t re n g th , the d e s i r a
less subject to the con seq uen ces of th e o th e r

m o to rs th a t we shall describe.
in v a ria b le
c o u n te r p a r t
of high
d e pen den ce.
ble p rizes of o u r c u lt u re w h e th e r th ey be love

a n d ju s tic e o r w in e , w o m e n , a n d song. A s p i n
off of low in d e p en d e n ce is a feeling of infe
Resentment
riority , a lack of proficiency on achie ving d e

sirab le goals.
P a r t an d p arcel of inferiority
A second m o to r th a t inevitably acco m p anies

the first is the resen tm en t m otor. R e se n tm e n t
feelings is th e u n c e rta in ty a b o u t being m a n ly

a n d m asculin e. S elf-doubts a b o u t o n e s sexual
inv ariab ly fires off because eith er one m u s t find
in te g rity a re to r tu ro u s ; th e u su al sequel is to
try to c o m p e n s a te by b eing the q u in tessen ce of
e v ery th in g m ascu line: overly aggressive, overly
co m petitive, a n d overly d o m i n a ti n g . Pro v in g
him self w ith w o m e n m a y lead to saty riasis a n d
a perfect p a r e n t w h o will ta k e care of h im or

he feels tr a p p e d w h en som eone does take care
of h im a n d he senses his o w n passivity an d
helplessness. R e se n tm e n t breeds guilt because
peo ple j u s t a r e not supp osed to be hateful.
E ven guilt does not alw ay s keep th e hostility
hid den . S o m etim es w h e n o u r m a n h as h a d too
m u c h to d rin k o r w h e n he is very fru stra te d
ab o u t som ethin g, his h a te feelings leak o r p o u r
out. T h a t in itself can be te r rib ly u p settin g be
cause he m a y fear he is g etting out of control;
D o n J u a n i s m . O u r m a n m a y h ave fantasies
a n d im ages in his m in d of stro n g m e n (often
sym bolized by th e ir possessing large penises)
a n d m a y be p a r t ic u l a r ly a ttra c te d to t h e m b e
cause of th eir s tren g th . B ut his a w a r e n e s s of
h ow m u c h he th in k s a b o u t m en m a y c ause h im
o r th e m ere a w a re n e s s of his in n e r a n g ry co n
dition can m a k e h im despise himself. Sad ism
an d sadistic b eh av io r m a y be directed at the
object of his d e p en d en cy w h o he believes is
to w o n d e r if he is h o m o s e x u a l an d to fear th e
very th in g s th a t he ad m ire s. H e m a y a c tu a lly
on occasion be sex ually a ttra c te d to id ealized
m ale figures, a n d he m a y fan ta siz e i n c o r p o r a t
ing th e ir penises into himself.
tr a p p in g h im o r w h o fails to live up to e x p e c
tations. It m a y be d ra in e d off on scapegoats:
Interesting ly , lo w -in d e p e n d e n c e feelings in

w o m e n lead to th e sa m e self-doubt an d c o m
115
CHO O SING A DYNAM IC FOCUS: SOME CO M M O N THEMES

p ensation s as in m en. Such w o m e n will tr y to
an d be d e p e n d e n t. H o w e v e r, giving in to such
re p a i r the fancied d a m a g e to them selves by ac
a desire speeds u p all his m o to rs a n d m ak es
q u ir in g a nd actin g as if th ey h av e th e sym bols

of m ascu lin ity (e.g., by sw a g g e rin g a n d w e a r
h im
ing m ale a p p a r e l )
drive; he co m p etes w ith a n y stro n g figure on
th a t
in o u r
cu ltu re a re
feel even
w orse.
He
p u rs u e s j u s t
the
reverse course fro m his o rig in a l d ep en d e n c y
eq u ate d w ith ind ep en de n ce . T h e y will c om p ete

w ith and try to v a n q u is h an d even figuratively
whom
he
m ig h t
castrate males. In its e x a g g e ra te d form , th ey
adolescent
w ill act t o w a r d o t h e r fe m a le s as if th e y
them selves a re males, d o m i n a ti n g a n d ho-
w h a te v e r his p a r e n t s say. A n d he m a y c o m
m o sexually seducing them .
ing all th e c u ltu ra l sym bols of being a w o r th y

p e rs o n , such as being perfectionistic, c o m p u l
Devalued Self-image
co m p en sato ry
who
to
lean.
disagrees on
He
show s
p rin c ip le w ith
p e n s a te for his dev alue d self-image by e x p lo it
sively a m b itio u s,
mercilessly,
By now in o u r illu s tratio n we h av e a fully
o p e ra tin g fo u rth m otor, a d eva lu ed self-im age.
want
t h e p s e u d o i n d e p e n d e n c e r e m i n i s c e n t o f th e
and
d ri v e s
and
he
p o w e r driv en.
may
m ay
These
preo ccu p y
o rg a n iz e
him
his
life
a r o u n d th em . O n e fa ilu re m e a n s m o r e to h im
W it h th e c o n sta n t re v e r b e ra tin g of his first

th ree m otors, o u r m a n is n o w feeling spiteful
th a n tw e n ty successes, since it is an affirm atio n

of his lowly status.
T h e s e difficulties a re c o m p o u n d e d by the
to w ard
w a y th ey in te ra c t w ith o u r m a n s sexual needs.
h im s e lf.
H e feels h e is m i s e r a b l y
in c o m p e t e n t , u n d e s i r a b l e , a n d u n w o r t h y .
E v e ry w h e re he sees evidence of his in sign ifi
cance: he is not tall eno u g h , he h a s developed
W hen
o n e s d e p e n d e n c y
needs
are
b e in g
gratified, th e r e is often a pervasive feeling of

w ell-being th a t floods o n e s w h o le body. U p o n
a p a u n c h , w o m e n do not seem to p ay a tte n tio n
a w a k e n in g follow ing s u rg ery , for e x a m p le , the
to h im , his h a i r is th in n in g , his jo b is not
confident, sm ilin g face of a n u rs e can suffuse a

m a n w ith g ratefu l, loving feelings, at least p a rt
o u ts ta n d in g ; his car, his house, his w ife

n o th in g is perfect. H e m ay even th i n k his penis
is of in a d e q u a te p ro p o rtio n s . H e feels like a
d a m a g e d p erso n. T h e s e feelings to r m e n t him ,
of w h ich m a y be sexual. T h e sexual feeling is

no t th a t of a d u lt m ale to a d u lt fem ale but
r a t h e r th a t of a helpless child to w a r d a w a r m
m o th e r. Such a feeling is t a n t a m o u n t to a n in
an'* he vows to prove th a t he is not as devalued

as he feels. H e com m its him self to th e ta s k of
cestuous su rg e a n d m a y b ri n g w ith it g reat
being all-p o w e rfu l, a m b itio u s, perfect so as to
conflict a n d guilt. S h o u ld th is d ep en d en cy be
repair
he
the n a tu r e of a h u s b a n d s c o n tin u in g r e l a ti o n
im ag ines he can surely respect himself. If he

can live w ith o u t a single m isstep, all will be
sh ip to his wife, he m a y be u n a b le to function
well. H e tries to boost h im self on his o w n to

the po int w h e re o th ers will have to a p p ro v e of
him . H e m a y only d a y d r e a m all this, o r he
m ay, if events a r e fortuitous, accom plish m a n y
of his o v erco m p en sato ry goals.
If he climbs hig h, he will most likely resent
in a m o t h e r - s o n rela tio n sh ip . O n th e o th e r
his
devalued
self-im age.
Then
those below w h o n o w lean on h im an d m a k e

d e m a n d s on him . T o th ose w h o ex hibit w e a k
ness, he will sho w his an g er. W h il e he m a y be
able to be giving on his o w n te r m s, a n u n e x
p e c te d a p p e a l fr o m s o m e o n e else w ill be
re g ard ed as a v u lg a r im po sitio n. H e actu a lly
w a n ts for him self som eone on w h o m to lean
sexually w ith h e r since h e is v irtu a lly involved

h a n d , if th e n u r t u r i n g figure is a m a n , h o
m o sex u al fears an d feelings m a y arise w ith
e q u a tio n s of the h o s t s p en is w ith a n ip p le . F o r
w o m e n the d e p e n d e n c y situ a tio n does j u s t the
reverse. A n u r t u r i n g m o t h e r figure calls u p in
h e r fears a n d feelings of h o m o s e x u a lity w hich
m a y or m a y no t be acted o u t in passive h o
m o s ex u a lity w ith y e a rn in g s for th e breast.
M o r e o v e r, low feelings of in d e p e n d e n c e m ay,
as h a s been in dicated , in s p ire ideas of defective
m ascu lin ity in m ales w ith im p u lse s to identify
w ith muscle m en . F a n ta s ie s of h o m o s ex u a lity
116
o r direct a ctin g-ou t of h o m o s e x u a l im pu lses
p lu n g e s in a g a in . By n ow his first m o to r of d e
m a y follow. In w o m e n feelings of defective in
p e n d e n c y is really d riv in g him . A n d if h e is
dep en d en ce
may
in sp ire
of the
d e s p e r a te e n o u g h , he m a y a tta c h h im self all
fantasies of possessing a
over a g a in to a figure w h o holds o ut som e
penis, th e sym bol in o u r c u ltu re of p o w e r an d
p ro m is e of b eing th e perfect p a re n t. T h e n the
ind epende nce.
n e u ro tic cycle is on its w a y again . T h e fifth
fem inin e role an d
S a d is m
rejection
and
m a so c h ism
may
also be acted ou t in sexual activities in both

m en an d w om en.
m o to r of d e ta c h m e n t h a s a g ain revived the

first, second, th ird , a n d fo u r th m otors.
T h e re v e r b e ra tin g of all these m a c h in e s calls
T h e s e drives, th ese five m o to rs, a re never
for s tre n u o u s efforts on th e p a r t of o u r subject.

It all b egan w ith the d e p e n d en cy m o to r, w hich
e n tirely q u iescent. In th e a v e ra g e perso n th e re

is in v a ria b ly som e fuel to keep th e m going.
th en activated the re s e n tm e n t m o to r (together
T h e r e is n o one w h o se d e p e n d e n c y needs w ere
w ith its c o m p o n e n ts of aggression, guilt an d
perfectly m e t e a rly in life. T h i s h u n g e r lives

on, a n d w ith this h u n g e r, the m e c h a n is m of
m asochism ). T h i s th r e w into g e a r the th ird

m o to r of low ind ep en d e n ce, w h ich in tu r n
fueled the fo u r th m o to r of self-devaluation w ith
its o v erco m p en satio n s an d sex ualization s.
d ep en d en cy is co n tin u a lly o perative. In o u r

c u ltu re , in this g e n e ra tio n , the u n m e t d e
p en d e n c y needs sets in m o tio n the successive
m o to rs just described. As lo ng as fuel is a v a il
ab le a n d th e speed of th e m o to rs can be co n
Detachment
trolled, th e ind ivid ua l m a y m a n a g e to keep g o

ing, s w itch in g on on e o r th e o th e r m o to rs an d
W h e r e can a m a n t u r n n ext to g a in some
t u r n i n g th e m off if they t h r e a te n to c a rr y h im
sense of c o m p o s u re ? H e often t u r n s to the fifth

m o to r, detach m en t. D e ta c h m e n t is an a tt e m p t
a w ay . T o som e ex tent all p eo p le a re victim s of

th e five m o to rs d e scrib e d to a m in o r d eg ree
at escaping from lifes messy p ro blem s. O u r
at least.
m a n by n o w is fed u p w ith th e ra t race an d
D e p e n d e n c y in evitab ly b re ed s re s e n tm e n t in
o u r c u ltu re . If o utlets for th e re s e n tm e n t are
w a n ts to get ou t. H e says, N o m o re c o m m it
tees, no m o re p arties, no m o re responsibilities,
not a vailable a n d if c o m p e n s a tio n s for a d e
no m o re ex tr a s of a n y kin d, no m o re involve
valued self-im age c a n n o t be p u r s u e d in o th e r
m ent
w o rd s, if th e individ ual c a n n o t read ily sw itch

from on e en g in e to a n o t h e r th e n the conflict
w ith
p e o p le .
He
w a n ts
an
is la n d
fortress, o r at least a castle w ith a m o a t a r o u n d

it, a n d he w o u ld pull u p th e d r a w b r i d g e and
a n d stress reac h p r o p o r tio n s w h e re on e feels
say no to e v e ry th in g a n d everyone. H e is sure

th a t th is is th e solution; he decides no t to b e
com e rich an d fam ous.
B u t it does n ot w o rk. P eople need people.
cata stro p h ic a lly o v e rw h e lm e d . W h e n th e te n

sion m o u n t s excessively an d th e r e seems to be
no w a y of escape, a n x ie ty strik e s w h ic h is th e
feeling th a t o ne is o v e rw h e lm e d a n d lost.
Life is not satisfying alone. O u r m a n finds

loneliness to be a w o rse state th a n w h a t he w as
e n d u r i n g before. H e realizes th a t pe op le co n
O p e r a ti o n s to defend a g a in s t th e a n x ie ty will
be institu te d, b u t the defense is often ineffective
o r m o re b u rd e n s o m e t h a n th e con ditio n it w a s
s titu te one of lifes richest g ratifications. So, he
d esig n ated to com bat.
Case History
T h e p a t i e n t , R o g e r, w a s a m a n in h is m id 3 0 s
g e n t l e m a n p r e s e n t e d h i m s e l f w i t h a n e x p r e s s i o n of
w h o s e wife t e l e p h o n e d m y s e c r e ta r y for a n a p p o i n t -
depression
m ent.
sa id , s t a r t e d w h i l e d isc u ssin g s e e m i n g ly c a s u a l m a t -
At the
initial
in terv ie w
a w ell-groom ed
and
bew ilderm ent.
The
problem ,
he
117
CHO O SING A DYNAM IC FOCUS: SOME COM M O N THEMES

ters w i t h his best f rien d a n d p a r t n e r d u r i n g a l u n c h
C o n t i n u i n g his sto r y , R o g e r sa id t h a t w ild , u n
h o u r . H e w a s o v e r w h e l m e d w i t h a feeling of p a n i c ,
p r o v o k e d fe elings of p a n i c w e r e n o t co n f in ed to his
w i t h violent h e a r t p a l p i t a t i o n s a n d c h o k i n g s e n s a
w o r k . E v e n at h o m e , his h a b i t u a l h a v e n of co m fo rt
tion s, w h ic h forced h i m to e x c u s e h i m s e l f o n the
a n d sa fe ty, h e e x p e r i e n c e d b o u t s o f a n x i e t y , w h i c h
b asis of a s u d d e n i n d isp o s itio n . B a ck at w o r k , h e
b u r s t fo rt h a t i r r e g u l a r in te r v a ls. H i s sleep, too, w a s
of d a n g e r e n
i n t e r r u p t e d by n i g h t m a r i s h fears, w h i c h forced h i m
v elop ed h i m a c o n f o u n d i n g a g o n i z i n g s e n sa tio n ,
to seek r efu g e in h is w i f e s bed. A p e r v a siv e sense of
th e s o u rce o f w h i c h e lu d e d all a t t e m p t s a t u n d e r
h e lp le s sn e s s s o on c o m p l i c a t e d R o g e r s life. F e a r of
recov ered
partly,
but
a sensation
sta n d in g . U p o n r e t u r n i n g h o m e , h e p o u r e d h im se lf
b e i n g a l o n e a n d f ear of t h e d a r k d ev elo p ed . O t h e r
t w o e x t r a j i g g e r s of w h isk e y . H i s f ear slo w ly v a n
f e a r s t h e n o c c u r r e d , s u c h as f e a r of h e ig h ts , of o p e n
ished so t h a t a t d i n n e r t i m e he h a d a l m o s t c o m
w i n d o w s , of c r o w d s , a n d of s u b w a y s a n d buses. In
pletely recov ered his c o m p o s u r e . T h e n e x t m o r n i n g ,
t h e p r e s e n c e o f h is wife, h o w e v e r , th e s e f ears s u b
h o w e v e r , h e a p p r o a c h e d his w o r k w i t h a sense of
sided o r d i s a p p e a r e d . R o g e r c o n s e q u e n t l y a r r a n g e d
fo re b o d in g , a feeling t h a t b e c a m e s tr o n g e r a n d
m a t t e r s so t h a t h is wife w a s a v a i l a b l e as often as
poss ible. F o r a w h i l e sh e se em ed to re l i s h t h is n e w
s t r o n g e r as th e d a y s a n d w e e k s p as sed.
closeness, for sh e h a d r e s e n t e d w h a t sh e h a d c o m
p l a i n e d a b o u t for a lo n g t i m e h is co ld n ess a n d
R og er h a d obviously e x perienc ed a n a n x ie ty
a ttack th e source of w h ic h b e cam e so m e w h a t
cle a re r as h e c o ntinu ed his story.
d e t a c h m e n t f r o m h er.
W h a t a p p a r e n t l y h a d h a p p e n e d w a s th a t
not being ab le to escape fro m th e a n x ie t y - p r o
T h e m o st u p s e t ti n g t h i n g to R o g e r w a s t h e d i s
v ok in g s itu atio n at w o rk , a n d bein g u n a b le to
cover y t h a t his s y m p t o m s b e c a m e m o st v iolen t w h i l e
develop a d e q u a t e first-line defenses to control
at w o r k . H e fo u n d h i m s e l f c o n s t a n t l y ob sessed at
o r n e u tr a li z e h is a n x iety , R o g e r w a s r e t r e a t in g
t h e office w i t h w a y s o f r e t u r n i n g h o m e to his wife.

b u t even
to a n d so u g h t safety in a d e p e n d e n t r e l a ti o n
sh ip w ith his wife (second-line defenses, see p.
a n t i c i p a t i n g r e t u r n i n g to his d esk o n M o n d a y w a s
96) th a t p a ra lle le d t h a t of a sm all child w ith a
W e e k e n d s b r o u g h t t e m p o r a r y su rcea se;
e n o u g h to fill h i m w i t h f o r e b o d in g . H e w a s u n a b l e
to av oid c o m i n g late m o r n in g s , a n d , m o r e a n d m o r e
often he ex cu s ed h im se lf f ro m a p p e a r i n g a t w o r k on
t h e b asis o f a c u r r e n t p h ysic al illness. B e cau se he
re a liz e d fully h o w his w o r k w a s d e t e r i o r a t i n g , he
m o th e r. V a r i o u s fears of th e d a r k a n d of being
a lo n e w e re in dicative of his ch ildlike h e lp le ss
ness. T h i s k in d of a d a p t a t i o n obviously h a d to
fail.
w a s no t s u r p r i s e d w h e n h is frien d to o k h i m to ta s k
for h is deficiency. F o r c i n g h i m s e l f to go to w o r k b e
came
e a s ie r
af te r
Roger
had
consum ed
se vera l
Not
lo n g
a f t e r th is,
Roger continued,
he de
v elo p ed fa n t a s i e s of g e t t i n g into a c c id e n ts a n d h a v
d r i n k s , b u t he fo u n d t h a t h e r e q u i r e d m o r e a n d
in g his b o d y c u t u p a n d m u t i l a t e d . W h e n R o g e r
m o r e alcoh ol d u r i n g the d a y to s u b d u e his te n s io n .
confid ed to his wife t h a t he w a s g r e a t l y u p s e t by
At n i g h t h e n e e d e d b a r b i t u r a t e s e d a t i o n to i n s u r e
th e s e o c c u r r i n g f an tasies , sh e e n j o i n e d h i m to c o n
e ven m i n i m a l sleep.
su lt a d o c to r . H e r ejected t h is ad vice, c o n t e n d i n g
t h a t h e w a s m e r e l y o v e r w o r k e d , a n d h e p r o m i s e d to
T h e surm ise th a t I m a d e at this p o in t w a s

th a t so m ethin g in the w o rk s itu atio n w a s tr ig
gering off his an xiety . I felt th a t R og er h a d a t
tem p ted to gain surcease from a n x ie ty by i m
p lem e n tin g m e c h a n ism s of co ntrol (first-line
defenses, see p. 94) such as try in g to avoid the
stress situa tion s of w o rk a n d d e a d e n in g his
feelings w ith alcohol a n d sedatives. T h e s e ges
tures seemed n ot too successful since he w a s
obliged to re m a in in the w o r k situ a tio n no
m a tte r ho w m u c h he w a n te d to avoid it.
t a k e a w i n t e r v a c tio n , w h i c h h e w a s s u r e w o u l d r e
s t o r e his m e n t a l c alm . F e a r f u l t h o u g h t s c o n t i n u e d to
p l a g u e R o g e r. H e b e c a m e f ri g h t e n e d w h e n e v e r he
h e a r d sto ries of v iolence, a n d he a v o id e d r e a d i n g
n e w a c c o u n t s of su ic id e s o r m u r d e r s . S o o n h e w a s
o bse ss ed w i t h t h o u g h t s of p o i n t e d objects. Kniv es
te r rif ie d h i m so t h a t h e in sisted t h a t h is wife co nceal
t h e m f r o m h im .
T h e r e t u r n to a childish d e p e n d e n t position
a p p a r e n t l y m ob iliz ed fears t h a t in too close a s
sociation w ith a m o t h e r figu re he w o u ld be
118

In a tt e m p t i n g to m a k e a te n tativ e diag no sis
subjected to m u ltila tio n an d destru ction . S e x

ual feelings to w a r d his wife w e re e q u a te d w ith
of R o g e r s c o nd itio n at th is p oint, I w a s co n
fo rb idd en
th e
fro n te d w ith the c o n te m p o r a r y c o n tra d ic tio n s
p e n a lty w a s bloody m u tila tio n . F a n ta s ie s of a c
t h a t p lag u e o u r a tt e m p t s at classification. All
cidents an d b loodshed could be reflections of
e m o tio n al difficulties sp re a d them selves over a
R o g e r s c a stra tio n fears. T h e rep e titio n of th e
w id e p ath o lo g ic al a re a , involving every aspect

of th e p e r s o n s f u n c tio n in g intellectual, e m o
in cestuous feelings for w h ich
o edip al d r a m a t h u s could follow a s h a t te r i n g of

R o g e r s repressive system. A tte m p ti n g to r e i n
fo rce r e p r e s s i o n by r e p r e s s i v e ( t h i r d - l i n e
defenses, see p. 76), R o g e r em ployed p h o b ia
f o rm atio n
striving
to
rem ov e
h im self from
tio nal, physical, a n d b eh av io ra l. Based as th ey

a re on p re s e n tin g c o m p la in ts a n d sy m p to m s,
system s of nosology often lose sight of th e fact
th a t th e e n tire h u m a n being is em b r a c e d
sym bols of m u tila tio n such as knives a n d o th e r
in a n y
cu ttin g in s tru m e n ts .
classification into w h ich a p a ti e n t fits th e n m ay
em o tio n a l
u p h e a v a l. T h e
particular
d e p e n d m erely u p o n th e relative e m p h a s is th e
W hen
asked
if h e
had
other
sym ptom s
or
fan tasies , R o g e r, in a n e m b a r r a s s e d w a y , confided

t h a t in t h e p r e se n c e of forceful o r s t r o n g m e n , h e e x
d iagn ostic a g en t (i.e., the th e r a p is t ) o r the p a

tient p u ts u p o n selected sy m p to m s.
T h i s m a y be illu strated in the case of R oger.
p e r ie n c e d a p e c u l i a r fear, w h i c h he trie d to concea l.
H is
S o m e t i m e s he w a s a w a r e of a d e s ire to t h r o w his
ritab ility , explosiveness, a n x ie ty , d ep ression ,

p sy c h o so m a tic sy m p to m s, p h o b ias , a n d o b
sessive th o u g h ts. In a d d itio n , he exh ib ited a
a r m s a r o u n d m e n a n d to kiss t h e m in a filial w ay.

T h is
im pulse
d isturbed
Roger
greatly,
as did
f a n ta s ie s of n u d e m e n w i t h h u g e g e n i t a l o r g a n s . H i s
se x u a l life c o n t i n u e d to d e t e r i o r a t e . W h i l e he h a d
c o m p la in ts
w e re
tho se
of ten sio n,
ir
c h a r a c t e r d is tu r b a n c e in such m a n ife sta tio n s as
n e v e r b een a n a r d e n t lover, he h a d p r i d e d h im self
ex c ess iv e
o n h is p o ten cy . H i s se x ual p o w e r s n o w se em ed to be
W e r e R og er chiefly co ncerned w ith his p h y s i
d i s a p p e a r i n g , w h e n he a p p r o a c h e d his wife, he w a s
cal a il m e n t s his h ea d a ch es, d yspe psia, list

lessness, fatigue, failing h e a lt h , o r im p o te n c e
im p o t e n t o r h a d p r e m a t u r e e ja c u la tio n s . T h i s upset
subm issiveness
and
dependency.
f u n ctio n well se x u a lly . T o d i s p r o v e this, he forced
w e w o u ld be inclined to re g a r d h im as a p e r
son suffering fro m physical d is o rd ers of p sy
h i m s e l f c o m p u ls iv e ly to a t t e m p t i n t e r c o u rs e , on ly to
chological o rig in , th a t is, a ty p e of so m a to fo rm
be
d iso rd er.
R o g e r a n d c r e a t e d fears t h a t he ne v e r a g a i n w o u l d
rew arded
by
fu rth er
failures.
A nticipatory
a n x i e t y soon m a d e se x u a l r e l a t i o n s a s o u rce of p a i n ,
a n d w h e n his wife su gg e sted t h a t th ey a b s t a i n , he
a g r e e d , b u t he w a s f rig h t e n e d t h a t sh e w o u l d leave
h i m for a n o t h e r m a n .
T h e fear R o ger m anifested of stro n g males,

the desire to act in an affectionate w a y w ith
th em , the te r r o r of h o m o s ex u al a ss a u lts by
n u d e m en w ith hu ge g en ital o rg a n s w ere, if we
follow o u r previou s line of reas o n in g , the
p ro d u c ts of his fear of a tta c k by fath e r figures
irate at his a p p r o p r i a t i o n of the m a t e r n a l o b
ject. A d is in te g ratio n of R o g e r s sexual life w as
inevitable because he w a s re la tin g to his wife
not as a h u s b a n d but as a child. A b a n d o n m e n t
of a m ale role w ith his wife w as, therefore,
necessary to avoid anx iety. W h ile serving as a
sp u r io u s protective device, his sexual in hib itio n
obviously fu r th e r u n d e r m in e d his self-esteem.
S h o u ld
h is a n x i e t y a t t a c k s h a v e
caused h im g re a te st co n cern an d w e re he to
h ave focused his a tte n tio n o n his a n x ie ty , we
m ig h t classify h i m as a n x ie ty d i s o r d e r . In the
event his d e p res sio n w a s of p ri m e in terest, a
d i a g n o s i s of p s y c h o n e u r o t i c o r r e a c t iv e
d e p r e s s io n m ig h t be e n te r ta in e d . If e m p h a s is
h a d been p u t on his obsessive concern w ith
b loody a m p u t a t i o n s , d e ath , a n d po in ted objects,
he m ig h t be called an obsessive d i s o r d e r . H is
fear of heights, su b w a y s, buses, a n d cro w d s an d
of solitude an d th e d a r k a re th ose often fo un d in
p h o b i c d i s o r d e r s . F i n a l l y , h a d h is s u b
m i s s i v e n e s s , p a s s iv it y , a n d o t h e r c h a r a c t e r
defects been considered his most significant
p ro b le m , he m ig h t be labeled as a p e rs o n a lity
d is o r d e r . T h e m a tte r of diag n o sis, th e n ,
w o u ld be essentially a m a t t e r of w h a t seemed
im m e d ia te ly i m p o r t a n t. A ctu ally, we m ig h t say
119
CHO O SING A DYNAM IC FOCUS: SOME CO M M O N THEMES

th a t R og er suffered from a m ixed p s y c h o n e u
rotic d iso rd e r w ith anx iety , depressive, psy-
ch a n g e his job to one th a t d id not im po se too
chophysiologic, obsessive, phobic, a n d d istorted
g re a t resp o n sib ility on him . H e w o u ld be e n

c o u ra g e d to try to d etac h him self m o re from
p e r s o n a l i t y e le m e n ts . T h i s d i a g n o s t i c p o t
p o u rr i is not s u r p ris in g w h e n w e con sider th a t
o n th e basis of th e c u s to m a ry distan ces th a t he
every in dividual w h ose h o m eo stasis h a s b ro ken
erected
d o w n e xploits d y n a m i s m ch a ra cteristics of all
g u id a n c e an d r e a s s u ra n c e m a y m a k e it possible
levels of defense in a d d itio n to d isp la y in g

m a n i f e s t a t i o n s , p s y c h o l o g ic a l a n d p h y s i o
for R o g er to r e t u r n to his o w n b e d ro o m a n d to
logical, of ho m eostatic im b a la n c e a n d a d a p ta -
en a b le h im to fun ction w ith o u t anx iety.
his wife a n d slowly to begin fu n c tio n in g ag ain

b e tw e e n
h im self a n d
o th ers.
Active
ass u m e th e reserve w ith his wife th a t w ould

O n a n o th e r level, the th e r a p is t m ig h t utilize
tional collapse.
b e h a v io r m odification m e th o d s to desensitize
R o g e r w a s as ked w h a t he believed h ad
the p a tie n t to his an xieties as well as to in
p r e c i p i t a t e d his a n x i e t y o r i g in a ll y , he w a s u n s u r e ,
stitu te assertive t r a in i n g to p ro m o te g re a te r
b u t he h a z a r d e d t h a t it m ig h t h a v e been r e l a t e d to a
self-sufficiency a n d ind ep en d e n ce. A p p ro a c h e s
c h a n g e in h is p o s itio n at w o r k . N o t lo n g af ter his
such as these u n d e r s ta n d a b l y w o u ld n ot correct
W hen
t e n t h w e d d i n g a n n i v e r s a r y , a t ag e 33, R o g e r w a s
p r o m o te d to se n i o r m e m b e r of th e firm . H i s elatio n
at th is w a s sh o rt-liv e d as h e b e c a m e c on s ciou s of a
sudden
depressed
feeling,
w hich
progressively
d e e p e n e d . I n e r t i a , b o r e d o m , a n d w i t h d r a w a l fro m
his o r d i n a r y s o u rces of p l e a s u r e follo w ed. E v e n his
an y basic c h a r a c t e r p ro b le m s th a t lay a t the

h e a r t of R o g e r s distress. Yet th ey m ig h t m a k e
it possible for h im to get a lo n g p e r h a p s as well
as he h a d ever d on e p r i o r to th e o u tb r e a k of
his neurosis.
w o r k , to w h i c h he h a d felt h im se lf d evo ted , b e c a m e
Since m y a p p r o a c h w a s a d y n a m ic form of
a ch ore. A l w a y s e a g e r to c o o p e r a t e , he e x p e r i e n c e d ,
s h o r t-t e rm t h e r a p y a im e d at som e p e rs o n a lity

rectification, I p roceeded to e x p lo re as c o m
d u r i n g w o r k h o u r s , a v a g u e d r e a d o f s o m e th i n g
a b o u t to h a p p e n w h i c h he cou ld n ot def ine.
He
co uld not u n d e r s t a n d w h y h e w o u l d r eact to a p r o

m o t i o n t h a t he w a n t e d by g e t t i n g upset.
Sho uld
th e r a p is t
not
be
in terested
in
p letely as I could his p a s t life th r o u g h in t e r

v iew in g a n d to p ro b e for m o r e un con sciou s
m o tiv a tio n a l e le m e n ts t h r o u g h e x p lo r a tio n of
d r e a m s a n d fan tasie s a n d t h r o u g h observatio n
of th e transference.
p u rs u in g the p a t i e n t s s y m p to m s f u r th e r to d e
te r m i n e th eir orig in in early p ast e xpe rie nce or
R o g e r w a s t h e y o u n g e r of t w o b r o t h e r s . H e w a s
in unconscious conflict, in o th e r w o rd s, a v o id
r e a r e d by a d o m i n e e r i n g m o t h e r w h o w a s resentfu l
ing a d y n a m ic a p p r o a c h , a n a b b re v ia te d a p
p ro ac h aim ed at sy m p to m re d u c tio n m igh t
o f h e r r o le as h o u s e w i fe , w h i c h h a d h a l t e d a success
n ow be selected w ith o u t f u r th e r p ro b in g into
love life w i t h h e r h u s b a n d , sh e t r a n s f e r r e d h e r affec
history.
F irst, an effort m ay be m a d e to tr e a t his
sy m p to m s t h r o u g h m ed ica m en ts, like sedatives
or tr a n q u il iz e rs for a n xie ty a n d e n erg iz ers for
ful c a r e e r as a f a sh io n d e s ig n e r. U n h a p p y in h er
tio n to h e r y o u n g e r son , m i n i s t e r i n g to his every
w h i m a n d s m o t h e r i n g h i m w i t h clo y in g a d u l a t i o n .
R o g e r s
brother,
George,
bitterly
c o n tes ted
this
s i t u a t i o n , b u t g e t t i n g n o w h e r e , h e su bje cted his si b

lin g to c ru el r e p r i s a l . R o g e r s f a t h e r , r eco ilin g f ro m
depression. R o g er m ay be enjoined to slow

d ow n in his activities a n d to d etac h h im se lf as
th e no t
to o well con cea le d
re m o v e d
h i m s e l f f ro m t h e f am ily as m u c h as h e
much as possible. H e m ig h t be re q u es ted to

take a vacation, e ng age in h obbies an d re c r e a
co u ld m a n a g e a n d h a d very little c o n t a c t w i t h his
h o s tility of h is wife,
sons.
tions in o rd e r to divert his m ind off his difficul

ties.
A n o th e r w a y of h a n d li n g th e p ro b le m m igh t
be to assu m e th e source of th e difficulty to be
R o g e r s w o rk s itu atio n a n d to get h im to
T h e d y n a m ic s in R o g e r s case b ecam e a p
p a r e n t d u r i n g t h e r a p y . Basic to his p ro b le m
w a s a d is tu rb ed r e l a ti o n s h ip w ith his p a re n ts,
p a r t ic u l a r ly his m o th e r. T h e yielding of her
120
u n m a r r ie d p rofessional statu s to a s s u m e th e
liked for h is f a i rn e s s a n d a m i a b i l i t y . A t college h e
role of housew ife a p p a r e n t l y h a d created in th e
w a s r e t i r i n g , b u t h e h a d a n u m b e r of f rie n d s w h o
m o th e r re s e n tm e n t to w a rd h e r h u s b a n d and
s o u g h t his c o m p a n i o n s h i p b e c a u s e h e w a s so easy to
rejection
get
of h e r
c hild re n.
T h is
in s p ire d
reaction fo r m a ti o n in th e form of o v e r p r o
tection, p a r t ic u l a r ly to w a r d h e r y o u n g e r child,
R oger.
F r u s tr a t e d
a n d unfulfilled, she used
R o g e r as a targ e t for h e r o w n needs a n d a m b i

tions w ith the fo llow ing effects: (a) in R og er,
e n c o u ra g e m e n t
of o verd ep en d e n c e
an d
pas
sivity, stra n g lin g of assertiveness a n d in d e

pendence, an d s tim u la tio n of excessive sexual
feelings to w a r d th e m o th e r a n d (b) in G e o rg e ,
hostility d isplay ed directly to w a rd R o g e r as
a ggression, a n d (c) in h e r h u s b a n d , d e ta c h
m ent.
along
w ith.
su p e rf ic ia l, a n d
H is
ro m an tic
attachm ents
w ere
t h e y o u n g w o m e n he s q u i r e d to
p a r t i e s a d m i t t e d t h a t he w a s a t t r a c t i v e b u t c o m
p l a i n e d t h a t it w a s difficult to get to k n o w h im .
A d o p tin g d e ta c h m e n t as a defense a g a in s t a
d e p e n d e n t in v olv em en t, a n d c o m p lian ce as a
m e a n s of a v o idin g physical h u r t , R o g e r evolved
a c h a ra c t e r s t ru c tu r e th a t en a b le d h im to fu n c
tion at h o m e a n d at school, a lt h o u g h a t th e e x
p ense of co m p letely g ratify in g
r e la tio n sh ip s
w ith people.
U p o n l e a v in g college, h e e n t e r e d a b u sin e ss firm ,
a r r a n g e m e n t s for this h a v i n g b een m a d e b y his
O v e r p r o t e c t e d by his m a t e r n a l p a r e n t , neglected
f a t h e r . H e resisted for t w o y e a r s t h e e x h o r t a t i o n s of
by his f a t h e r , a n d a b u s e d by his b r o t h e r , R o g e r took
his m o t h e r to m a r r y t h e d a u g h t e r of o n e o f h e r best
refu g e in t h e r e l a t i o n s h i p offered h i m by his m o t h e r .
frien d s ; b u t fin ally h e s u c c u m b e d , a n d he se em ed
H i s d e p e n d e n c y on h e r n u r t u r e d s u b m is siv e n e s s a n d
satisfie d a n d h a p p y in his choice. T h e y o u n g co up le
p assiv ity , w i t h a l t e r n a t i v e striv in g s of reb ellio u sn es s
lived in h a r m o n y , a n d he w a s c o n s i d e r e d b y his
a n d fierce r e s e n t m e n t w h i c h h e r e p r e s s e d b ecause
g r o u p to be a n ideal e x a m p l e of a n a t t e n t i v e h u s
t h e y t h r e a t e n e d t h e se cu rity he m a n a g e d to derive
b a n d a n d , a f t e r h is so n w a s b o r n , of a devo ted
t h r o u g h c o m p l i a n t b e h a v io r . R o g e r b o th c h e r ish e d
f a t h e r . H i s s te a d fa s t a p p l i c a t i o n to h is w o r k soon
and
elevated
loath ed
the
crushing
attentiveness
of h is
h is
p o s itio n ,
u n til
he
became
a junior
m o t h e r . T o w a r d his f a t h e r a n d b r o t h e r h e felt a
m e m b e r o f t h e firm . H i s bes t f rie n d a n d co n f id a n t
s m o t h e r i n g fear, w h i c h he m a s k e d u n d e r a clo ak of
was
a d m i r a t i o n a n d co m p lia n c e .
R o g e r b o r e t h e g r e a t e s t r esp ec t a n d a d m i r a t i o n .
one
of t h e
se n i o r
m em bers,
tow ard
whom
T h e w i th d r a w a l of his fa th e r m a d e it dif
H is w o rk a n d m a r it a l life, w h ich w e re m o re
ficult for R o g er to achieve th e identification
or less a r r a n g e d for h im by his p a re n ts , t u r n e d
w ith a m ascu lin e object necessary for a virile

conception of himself. R o g e r t u r n e d to his
m o t h e r for p rotectio n. H e revolted, how ever,
ag ain st too g reat d e p e n d en cy on h er, fearin g
th a t excessive closeness w o u ld rob h im of
assertiveness a n d th a t his a ro u s e d sexual feel
ings w o uld b rin g on h im d is a p p ro v a l fro m his
out to be successful since he w a s able to e m

ploy in th e m his c o m p lia n c e a n d d e ta c h m e n t
m ech a n ism s. T o w a r d his best friend a n d o th e r
sen io r firm m e m b e r s R o g er related passively as
he h a d rela ted p rev iou sly t o w a r d his fath er
a n d b ro th e r. T o w a r d his wife he e x pressed
con ven tion al devotion, k eep in g him self suffi
m o t h e r as well as p u n is h m e n t from his fath e r

a n d b ro th e r. R e p u d ia t in g com petitiveness w ith
the o th e r m ale m e m b e rs of th e family, he a t
ciently d is ta n t to avoid th e t r a p of a te m p ti n g
d e p e n d e n t r e l a ti o n s h ip th a t w o u ld th r e a te n the
in d e p e n d e n t assertive role he w a s stru g g lin g to
te m p te d to w in th e ir a p p ro v a l by a subm issive,
in g r a ti a ti n g attitud e.
m a in ta in .
T h e o n l y d i s t r e s s i n g e l e m e n t in R o g e r s life w a s
D u r i n g a do les cen ce R o g e r e m e r g e d as a q u iet,
his failin g h e a l t h . C o n s t a n t l y f a t i g u e d , he evid en ced
d e t a c h e d lad , ne v e r p e r m i t t i n g h im se lf to be d r a w n
a pallor
i n to ver y i n t i m a t e r e l a t i o n s h i p s .
H e w as an ex
licitous i n q u i r i e s . D y s p e p t i c a t t a c k s a n d se vere m i
cellen t a n d c o n s c ie n tio u s s t u d e n t, a n d he w a s well
g r a i n o u s h e a d a c h e s i n c a p a c i t a t e d h i m f ro m t i m e to
and
listlessn ess t h a t
inspired
m a n y so
CHO O SIN G A DYNAM IC FOCUS: SOME CO M M O N THEMES

tim e. In a d d i t i o n to his p hy sic al s y m p t o m s w a s a
perv asiv e te n s io n , w h i c h co uld be relieved o n ly by
121
rea so n s of b oth statu s a n d econom ics, actu a lly

bein g p u t in a p o sitio n of p a r i ty w ith his friend
r e c r e a t i o n a l a n d social d istractio n s.
violated his defense of passivity, c o m p lian ce,

a n d s u b o r d in a ti o n a n d th r e a te n e d h im w ith
I n n e r co nflict b e tw e e n d e p e n d e n c y , s u b
missiveness, co m p liance, d e ta c h m e n t, a n d a g
th e very h u r t he h a d a n tic ip a te d as a child in

r e la tio n s h ip to his fa th e r a n d b ro th e r. T o ac
g re s s io n , h o w e v e r , c o n s t a n t l y c o m p r o m i s e d
cept th e p ro m o ti o n m e a n t t h a t h e w o u ld be
R o g e r s a d ju s tm e n t, p r o d u c in g a d is ru p ti o n of
h om eostasis w ith tension a n d psy cho som atic
c h a lle n g in g of a n d p e r h a p s t r i m p h a n t over
sym ptom s. H is failing h e a lth , fatigue, p a llo r,
fears of in ju ry a n d d e stru c tio n at th e h a n d s of
listlessness, dysp eptic attack s, a n d m i g ra i n o u s
a p o w e rfu l an d p u n itiv e force he could n e ith e r
h ead aches w ere evidences of a d a p tiv e i m b a l

ance. W h a t in sp ired this im b a la n c e w a s a n in
con tro l n o r v a n q u is h . Yet R o g e r s d esire for
vasion of his capacity to d etac h, p ro d u ce d by

th e d e m a n d s m a d e on h im by his wife a n d a s
m a d e it im p ossible for h im to give u p th a t
f a th e r a n d b r o t h e r figures. T h i s to u c h e d off
a d v a n c e m e n t,
in s p ire d by realistic concerns,
w h ic h he con sidered his due. Since he w as
sociates. In a d d itio n , his subm issive a n d c o m

p lia n t beh avio r, w hile p ro tectin g h im from
a w a r e n e ith e r of h o w fearfully he re g a r d e d a u
im ag ined h u r t , e n g en d ered in h im o v e r p o w e r
childish a ttitu d e s , he w a s n o n p lu s se d by his
ing hostility, w h ich p ro b a b l y d ra in e d itself off
reactions.
t h o r ity n o r of h o w he w a s o p e r a t in g w ith
th r o u g h his a u to m a tic ne rv o u s system p r o d u c

ing physical sy m p tom s.
A dream
se ssion
As
m ight
b e ex p e c te d ,
R o g e r s affa bility
and
n eeds to p lease w o n for h i m t h e p r a i s e of his s u p e r i
revealed d u rin g o n e p sy c h o th e ra p y
w ill
illu strate
som e
of
our
p a t i e n t s
m a n e u v e r s t h a t b e c a m e o p e r a t i v e a n d a p p a r e n t in
therapy.
o rs a t w o r k , a n d he w a s a d v a n c e d a n d finally of
fered a se n i o r p ositio n.
P t.
I h a d a d r e a m last n i g h t t h a t u p se t m e. I a m in
bed
w om an,
big
w onderful
I feel c o m p le te ly loved a n d accep te d.
u al feeling t h a t u p se t m e. [H e re R o g e r s y m b o
lize s in d re a m str u c tu r e h is d e p e n d e n c y im
cam e m ore an d m ore ac c e n tu a te d un til finally

he no lo nger w a s ab le to m a r s h a l f u r th e r
defenses. C o lla p se in a d a p ta tio n w ith he lp less
tive self-fulfillment, R o g er w a s ab le to m a k e a
to lera ble a d ju s tm e n t even w ith his psych oso
m atic sy m pto m s. T h e p re c ip a tin g factor th a t
h a d b ro u g h t a b o u t the u n d e r m in i n g of R o g e r s
capacities for a d a p ta tio n w a s his p ro m o tio n to
senior m e m b e rs h ip in th e firm . W h il e R og er
h a d a r d e n t l y d e s i r e d t h i s p r o m o t i o n , for
big
aw o k e from the d r e a m w ith a strong h om osex
H is le gitim ate desires for ad v a n c e m e n t, h o w

ever, enjoined him to accept. H is conflict be
As long as h e h a d been able to satisfy to a

re ason ab le d eg ree his needs for security, a ss e r
tion, satisfaction in w o rk a n d play , a n d c r e a
this
n eg ress. S h e str o k e s a n d to u c h e s m e all over ,

and
escaped the c a ta s tr o p h e th a t finally stru ck him .
ness an d ex pec tatio ns of in ju ry a n n o u n c e d

th e m s e l v e s in a n a n x i e t y a t t a c k d u r i n g
lun cheo n w ith his friend.
w ith
b r e a sts . S h e s m y wife, b u t s h e c h a n g e s in to a
H a d R o g e r at this p o in t refused to accept

senior m e m b e rs h ip in the firm , he m ig h t have
p u ls e s , h is re p u lsio n a g a in st h is d e p e n d e n c y ,
h is in c e s tu o u s d esire, a n d th e re s u lta n t h o
m o s e x u a l re sid u e.]
T h . Yes, w h a t d o y o u m a k e o f t h i s ?
P t.
I d o n t k n o w . T h e w o m a n w a s c o m f o r t i n g a n d
se ductive.
I a l w a y s like b i g - b r e a s t e d w o m e n .
E x c i ti n g . B u t m y wife i s n t as sta ck ed as I d
like h e r , o r as she w a s in t h e d r e a m , (p a u se)
T h . H o w a b o u t t h e n eg ress ?
P t.
I n e v e r liked t h e idea of s l e e p i n g w i t h a co lored

w o m a n . M a k e s m e feel cr e e p y . C o l o r e d p e o p le
m a k e m e feel cre e p y . I k n o w I s h o u l d n t feel
t h a t w ay . L a s t t i m e I w a s h e r e I n oticed you
h a d a t a n like y o u h a d been in t h e sun . I sa id,
M aybe
h e s go t
negro
blood.
I know
s h o u l d n t c a r e if y o u d i d o r no t, b u t t h e idea
sc are d m e for so m e r e a s o n .
122
and u n m ascu lin e
T h . S o u n d s like the w o m a n in y o u r d r e a m w a s
p a r t l y me.
in
[ T h is in te r p r e ta tio n w a s p r o ffe r e d
th e h o p e o f s tir r in g u p s o m e te n sio n
sh it
h a t e myse lf.
I am
to
n o t h i n g a n d I d like to be a s o m e b o d y , b u t I
(p a u se ) T h e id ea sc are s me. W h y s h o u l d I
T h . A p p a r e n t l y it sc are s y o u to be a s o m e b o d y .
w a n t you to m a k e love to m e ? (p a u s e ) By G o d ,
W h e n yo u w e r e p r o m o t e d , y o u s t a r t e d g e t t i n g
c a n t.
fa c ilita te a sso cia tio n s.]

Pt.
\m o to r th re e ], I feel like a
[m o to r f o u r j a n d
m a y b e I w a n t y o u to m o t h e r m e, be giving,
k in d .
u p se t.
P t.
W h y s h o u l d I? I s u p p o s e I feel like I m s t e p
T h . H o w do y o u feel a b o u t m e?
ping
P t.
e n o u g h . T h e w h o l e t h i n g p u z z l e s a n d f ri g h t e n s
I w a n t yo u to be p erfect like a G o d ; to be a c
out
of m y d e p t h .
I m
not
m an
me.
c e p t i n g a n d loving ; to be w ise a n d str o n g . I

r e a l i z e I m d e p e n d e n t \m o to r o n e], I resen t m y
T h . So w h a t d o you d o ?
n eed to be d e p e n d e n t o n y o u
P t.
[m o to r tw o ] .
L ike
I a m c o n s t a n t l y r u n n i n g a w a y [m o to r fiv e ] , I
W h e n you s h o w a n y w e a k n e s s , I a m fu rio u s. I
get so a n g r y a t p eop le. I d o n t w a n t to see a n y
feel g uilty a n d u pse t a b o u t m y feelings. I feel
b od y. I m so u p se t a b o u t myse lf. I t r y n o t to
like killing a n y b o d y w h o c o n t r o l s me. I k n o w I
feel. B u t I c a n t se em to m a k e it on m y o w n .
m u s t face res p o n s i b i li t y , b u t I feel to o w e a k
[ T h e r e in s titu tin g o f m o to r o n e ]
FIG . 9-1. Personality M echanism s*
THE FIVE M OTORS
M OTOR ONE
HIGH DEPENDENCE
"I want you to be perfect, like a God; to be
accepting and loving; to be wise and
strong."
M OTOR TWO
RESENTMENT
HOSTILITY
"I resent my need to be dependent on
you. When you show any weakness, I am
furious. I feel guilty and upset about my
feelings. I feel like killing anybody who
controls me."
M OTOR THREE
LOW INDEPENDENCE
M OTOR FOUR
DEVALUED SELF-IMAGE
"I feel like a shit and hate myself. I am a
nothing and I'd like to a somebody, but I
can't."
"I know I must face responsibility, but I

feel too weak, and unm asculine." (In fe
males: "If I were a man, I would be strong
and independent.")
M OTOR FIVE
DETACHMENT
"I am constantly running away. I get so
angry at people. I don't want to see any
body. I'm so upset about myself. I try not
to feel."
* F r o m L . R . W o lb e r g a n d J . K ild a h l, T h e D y n a m ic s o f P e r s o n a lity (N e w Y o r k , G r u n e & S tr a t to n , 1 9 7 0 ), p . 2 1 5 .

R e p r i n te d b y p e rm is s io n .
CHO O SIN G A DYNAM IC FOCUS: SOME CO M M O N THEMES
123
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124
T h e p a tie n t in th e session w as m anifestly
in te r m s of his h a b itu a l p e rs o n a lity responses,
g ro p in g w ith his passiv e-d e p e n d en t strivings

(m o to r one), his ra g e (m o to r tw o ), his feelings
c on nec ting t h e m w ith his ex periences in g r o w

in g u p an d re la tin g th e m to the in cid ents le a d
of low in d ep en d e n ce (m o to r th ree), his d e

valued self-image (m o to r fo u r ), his d e ta c h m e n t
in g to the collapse in his hom eostasis, en a b le d

R o g e r to a p p r o a c h a different re la tio n s h ip
(m o to r fiv e ), to g e th e r w ith c o n co m ita n t u n r e
w ith me. T h i s oc curred a b o u t the tw e n ti e th
solved incestuous drives a n d u n e x p re s se d h o
session an d acted as a n u cle u s for different feel

ings t o w a r d him self. N o t o n ly w a s hom eo stasis
resto red w ith cessation of his sy m p to m s, b u t he
m osexu al im pulses. M a n y aspects of R o g e r s

p e rs o n a lity p ro b le m w ere bein g projected onto
his th e r a p is t in tr ansference.
T h e s e p a tt e r n s a r e delin eate d in F ig u r e 9 - 1 .
In te r p r e t a ti o n o f the p a t i e n t s reac tion s to me
also w a s ab le to accept his post as a senio r

m e m b e r of th e firm w ith subjective a n d objec
tive s t re n g th e n i n g of his ego.
Conclusion
C o m m o n p s y c h o d y n a m i c s a r e s h a r e d by
p e o p le
in
our
cu ltu re.
They
in c l u d e
th e
self-image also leads to c o m p e n s a to r y m e a s u re s
ravages of h ig h d e pen de ncy , re s e n tm e n t a n d
s u c h as p e r f e c t i o n i s m , . a m b i t i o u s n e s s , a n d
p o w e r drives. A nd d e ta c h m e n t often provokes
hostility, lo w ind ep end e n ce, a d e v alu a ted self-
o ne to a b a n d o n o n e s isolation a n d p lu n g e into
im age, a n d d e ta c h m e n t. It is the d egree of

in ten sity of th ese drives th a t d e te r m in e th e ir
co m pu lsiv e g reg ario u sn ess. A n y a n d all of

th ese drives m a y becom e sexu alized, so th a t
o n e s sexual im p u lses becom e linked to feelings
path og enicity . O ffshoots fro m re s e n tm e n t in

clude aggression, p e r h a p s to the p o in t of
sadism , an d also guilt re s u ltin g from th e h a t e
ful feelings, even ev e n tu a tin g in m a sochism .
H ig h d e p en d e n c y is associate d w ith passivity
and
a f e m i n i n e id e n t i f i c a t i o n .
F e e l i n g s of
hostility s p o n s o r guilt, m aso ch ism , a ggression,

a n d sadism . L o w in d ep e n d e n c e p r o m p ts the
o v e rc o m p e n sa to ry strivings of co m pulsive a g
gressiveness a n d com petitiveness, m a k i n g for a
n e u ro tic m a sculine identification. A devalue d
of in cestuo us passivity o r co m p etitive d o m i n a

tion w ith co n se q u e n t fears of re ta lia tio n or
w ith m asoch istic o r sadistic im pulses. W h e n
these drives fail to m a i n t a i n ho m eo stasis a n d
conflict is un reso lved , th e n a n x ie ty res u lts a n d
v a rio u s levels of defense m e c h a n ism s o p e ra te to
cope w ith th e an x ie ty . A g re a t m a n y d y n a m ic
th em es e v e n tu a te (see F i g u r e 9 - 2 ) a n d offer
them selves as possible foci for e x p lo ratio n .
CHAPTER 10

C. Presenting Interpretations
T h e most effective focus is o ne th a t deals

w ith a basic repetitive conflict, th e m anifest
form of w h ich is b eing exp ressed t h r o u g h the
good deal of h e r hostility in th e t h e r a p e u ti c

session, she m a y be w illin g to cancel h e r d i
im m ed iate co m p la in t factor. As a n e x a m p le ,
vorce p la n s a n d settle for h a lf a loaf r a t h e r

t h a n n o n e . T h e r e c o n c i l i a t i o n is e x e c u t e d
consider a crisis s itu atio n involving a wife, the
t h r o u g h a s u p p r e s s io n of h e r hostility, w h ich
m o th e r of tw o sm all c h ild ren , w h o insists on a

divorce because of c o n tin u in g d is e n c h a n tm e n t
finds a n ou tlet t h r o u g h sexu al frigidity an d
w ith h e r m a r ria g e . T h e divorce decision a p
h a n d , shou ld th e th e r a p is t recog nize th e core
p e a rs to be th e te r m in a l e r u p t io n of y ears of
conflict t h a t is m o tiv a tin g h e r idea of divorce,
d is a p p o in t m e n t in h e r h u s b a n d s failu re to live
u p to h e r ideal of w h a t a m a n sho uld be like.
t h e r e is a c h a n c e th a t th e p a t i e n t m a y be
h elp e d to a n a w a r e n e s s of h e r m erciless in
After w e cut t h r o u g h endless c o m p lain ts, it be

cam e a p p a r e n t t h a t the s t a n d a r d a g a in s t w hic h
v olvem ent w ith h e r fa th e r a n d th e d estructive

u n re a s o n a b le n e s s of h e r fantasies of w h a t an
she m e asu res h e r h u s b a n d is h e r fath er, w h o m

she w o rsh ip s as th e e p ito m e of success a n d
ideal m a r r ia g e is like. S h e m a y th e n allow

h erse lf to e x a m i n e th e re al v irtu es of h e r h u s
m asculinity. T h is id e a liz a tio n actu a lly has
b a n d a n d the tr u e a d v a n ta g e s of h e r e x isting
little basis in fact, b eing th e r e m n a n t of a n u n
m a r ria g e .
resolved oedipal conflict. Be this as it m a y , it
A d y n a m ic focus sh o u ld , the re fore, be p r o s

pecte d in the co u rse of e x p lo r in g th e im m e d ia te
has th w a r t e d h e r a bility to m a k e a p r o p e r a d
j u s t m e n t to h e r m a r r ia g e , a n d n ow w ith th e
various physical
sym p to m s.
On
th e o th e r
c o m p la in t factor. S u ch a focus is often arriv e d
decision of a divorce th e in teg rity of h e r fam ily
at
is being th r e a te n e d . She comes to t h e r a p y at

the u rg in g of h e r la w y e r w h o realizes th a t she
e m p a th ic , skilled, a n d ex p e rie n c ed th e t h e r a
pist, th e m o r e likely he will be to e x p lo r e th e
is too u pset at p re s e n t to m a k e re a s o n a b le deci

sions.
A th e r a p is t w h o m in im iz es th e im p o rt a n c e
a ctu a l o p e ra tiv e dy n a m ic s. H o w e v e r, no m a t
te r h o w firm ly convinced he is in his i m
of d y n a m ic conflicts m a y a tt e m p t to achieve th e
goal of crisis resolu tio n by in v ok in g logic or
a p p e a ls to co m m o n sense. H e m a y suggest
w ays of p a tc h in g th in g s u p , in sistin g th a t for
the sake of th e child ren a fath er, ho w e v e r
in a d e q u a te , is b etter t h a n no fath er. H e m ay,
u p o n con su ltin g w ith th e h u s b a n d , p o in t out
v ario u s co m p ro m ises the h u s b a n d can m ak e,
an d after th e wife h as v erb ally disg org ed a
in t u i t i v e l y
(B in d er,
1977).
The
m ore
m e d ia te a ss u m p tio n s , h e realiz es th a t th ese a re

b e i n g p r e d i c a t e d on i n c o m p l e t e d a t a . H e
k n o w s th a t his p a ti e n t m a y delib e rately w i t h
ho ld im p o r t a n t in fo rm a tio n , o r t h o u g h th e p a
tie n t m a y rec o g n ize ce rta in conflicts she is still
oblivious to th e i r significance o r com p letely
u n a w a r e of th e i r existence. W h a t e v e r ten tative
th eories com e to th e t h e r a p i s t s m in d , he will
co n tin u e to check a n d to revise th e m as f u r th e r
in f o rm a tio n unfolds. In te rv ie w s w ith relatives
125
126
a n d friends a re ex tre m ely v a lu a b le since th ey

m a y open facets of p ro b le m s not evident in th e
ing course for th e m o m e n ta r y jo y th a t followed

a n o u tb u r s t of aggression.
co nversations w ith th e p a tie n t. M o r e o v e r, once

th e p a tie n t d u r i n g the first en c o u n te r h a s d i
a m p le evidence of th e futility of focusing on th e
vulged d a ta , late r interview s will h elp uncover
E x p erie n ce
w ith
th e
ad d ictio n s
p rovide
dis to rtio n s
d y n a m ic s of a d a n g e r o u s a n d w h a t a p p e a r s on
th e surface to be a d is a g re e a b le w ay of b e h a v
th a t will force th e th e r a p is t to revise his thesis

a n d con cen tra te on a different focus from the
does not nullify th e need to persist in m a k
o ne th a t o rigin ally seem ed so obvious.

N o m a t te r h ow a stu te th e th e r a p is t has been
ing careful i n t e r p r e ta ti o n s in the h o p e of

e v e n tu a lly e ro d in g re sistanc e to th e voice of
in ex po sin g a tr u ly m o m e n to u s focus, the p a

t i e n t s reaction s will d e te r m in e w h e th e r th e e x
reaso n.
W e m a y expect th a t a p a ti e n t in need of
ratio n a liz a tio n s,
p rojections,
an d
ing. B ut, th a t som e p a tie n ts d is reg ard logic
po su re t u r n s o u t to be fruitful o r not. F o r ex
h e lp will c o m m u n ic a te sufficiently to su p p ly
a m p le , even th o u g h a n u n d e rly in g p ro b le m is
essential m a t e r i a l fro m w h ic h a focus m a y be
c a u s i n g h a v o c in a p e r s o n s life a n d is
responsible for th e crisis th a t bring s th e perso n
e x tr a p o la te d .
to th e r a p y , this does not im ply th a t the p a tie n t

will elect to do a n y th i n g a b o u t it. Its em o tio n al
am ong
m e a n in g m a y be so i m p o r t a n t to th e p a tie n t,
th e subversive p le a s u re s a n d seco nd ary gains
so g reat, th a t suffering a n d m isery a re easily
U n d e r s t a n d a b ly ,
th e r e will
be
differences in e m p h a s is a m o n g th e r a p ists, even

th o s e
who
have
re c e iv e d
sim ilar
the oretica l g ro u n d in g . T h e av ailab le m a te ria l

is u su a lly sufficiently rich to en a b le th e r a p ists
to e m p a t h iz e w ith aspects th a t sy n c h ro n ize
accepted as con dition s for th e in du lg ence of

destructive drives even w h e r e th e p a tie n t has
w ith th e ir needs, in tu itio n s , ideas, a n d biases.

Since all p eo p le s h a r e ce rta in conflicts th a t
a re basic in o u r c u ltu re , som e of th ese can co n
full insight in to th e p ro b le m , recognizes its
stitu te the d y n a m i c focus a r o u n d w h ich in t e r
genetic roots, an d realizes th e com plication s
p re ta tio n s a r e m ade. T h u s m an ifestatio n s of

the stru g g le over se p a r a tio n -in d iv id u a tio n fol
th a t inevitably in dem n ify the indulgence. I r e

call one p a tie n t w ho se y e a rn in g for revenge on
a yo u n g er sibling p ro d u ce d a repetitive series
lo w in g th e ideas of M a n n (1973), p ersistence
figures to w a r d w h o m re ta lia to ry hostilities an d
of oedip al fantasies as exem plified in the w o rk

of Sifneos (1972), a n d residu es of psychic
m as o ch ism such as described by L e w in (1970)
violence b ro u g h t forth p u n is h m e n t by e m
ployees, colleagues, a n d friends. A series of
a r e som e of the core conflicts th a t m a y be ex

plo red a n d in te rp re te d . Se nsitiz ing o neself to
ab uses c u lm in a te d in a d is a stro u s incident in

w h ich a physical a ssa u lt on a fellow em ployee
resu lted in th e p a t i e n t s d ischarge from a
p ro m isin g executive position. T h i s h a p p e n in g
w as so w idely publicized in th e in d u s try th a t
ind ica tion s of such conflicts as th ey come

t h r o u g h in th e p a t i e n t s c o m m u n ic a tio n s , the
th e r a p is t m a y rep e a te d ly co nfro n t th e p a tie n t
w ith evidence of h o w he is b ein g victim ized by
t h e o p e r a t i o n s of specific i n n e r s a b o t e u r s .
T h e r e is scarcely a pe rs o n in w h o m o ne m a y
of c o m p e t it iv e
en co u n te rs
w ith
su rro g a te
the p a tie n t w a s u n a b le to secure a n o th e r jo b .

D u r i n g th e r a p y th e p a tie n t w a s co nfro nted
w ith the m e a n i n g of his beh av io r a n d p a r t i c u
larly his revenge an d m asochistic motives; he
read ily recognized an d accepted th eir validity.
T h i s did not in th e least d eter his acting ou t on
a n y occasion w h e n he could vent his rag e on a
sibling figure. At the en d of o u r brief tr e a tm e n t
p erio d , it w a s re c o m m e n d e d th a t he go into
lo n g -te rm t h e r a p y , w h ich he b lu n tly refused to
do. H e seemed reconciled to p u r s u e a d a m a g
no t, if on e searches assidiously e n o u g h , find in

dicatio ns of in com ple te s e p a r a ti o n - in d i v id u a
tion, fr a g m e n ts of th e o ed ip al struggle, an d
su rges of guilt a n d m aso ch ism . It is essential,
ho w e v e r, to sh ow h ow these a re in tim a te ly
connected w ith th e a n x ieties, needs, and
defenses of each p a ti e n t an d h o w th ey u lti
m a te ly have b r o u g h t a b o u t th e sy m p to m s an d
b eh a v io ra l difficulties for w h ich the p a tie n t
seeks help.
CHO O SIN G A DYNAM IC FOCUS: PRESENTING INTERPRETATIONS

Lest we o v ere m p h a siz e the p o w e r of insight
in b rin g in g a b o u t c han ge, we m u s t stress th a t
p ro b le m s
in itiate
e m o tio n a l
127
difficulties
an d
c reate resistan ce to p s y c h o t h e r a p y first, high
to a larg e e x te n t the choice of a focus will
levels of d e p e n d e n c y (the p ro d u c t of i n a d e q u a te
d ep e n d on th e t h e r a p i s t s seeing the p re s e n tin g
s e p a r a tio n -in d iv id u a tio n ), second, a h y p e r t r o
p ro b le m of the p a tie n t th r o u g h th e lens of his
p h ie d sadistic conscience, a n d , th ird , d e v a lu a te d
theoretical convictions. A F r e u d i a n , J u n g i a n ,
self-esteem.
A d lerian , K lein ian , H o rn e y ite , S u lliv an ian ,
o th e r , th ey cre ate needs to fasten o n to a n d to
E x istentialist, o r b e h a v io r th e r a p is t will focus

on different aspects a n d will o rg a n iz e a t r e a t
d i s t r u s t a u t h o r i t y , to t o r m e n t a n d p u n i s h
oneself m asochistically, a n d to w allo w in a
m e n t p la n in acco rdan ce w ith p e rs o n a l ideo l

ogies. W h ile the focus, because of this, will
sw a m p of hopeless feelings of in feriority an d

ineffectuality. T h e y fr e q u e n tly sa bo tag e a t h e r
vary, th ere is co nsid erab le evidence th a t h o w
a p i s t s m ost skilled tr e a t m e n t inte rve ntion s,

a n d , w h e n they m an ifest them selves, unless
th e focus is im p le m e n te d a n d th e q u a lity of the

re la tio n sh ip w ith th e p a tie n t a re at least as i m
p o rt a n t factors in th e cure, if no t m o re so, th a n
th e prescience of the th e r a p is t a n d the in s ig h t
ful bone of d y n a m ic w isd o m he gives the p a
C o e x istin g an d
reinforcin g each
d e a lt w ith d e lib e ra te ly a n d firm ly, th e t r e a t

m e n t process will usu ally reach a n u n h a p p y
end. D e d icated as he m a y be to th e i r re s o lu
tion , th e m ost th e th e r a p is t m a y be ab le to do
tient to chew on. T h a t im p la n t a ti o n s of insight

som etim es do a lter th e b a la n c e b etw ee n the
is to p o in t ou t evidences of o p e ra tio n of these

s a bo teurs, to d elin eate th e ir o rig in in ea rly life
repressed
ex perience, to in dicate th e ir destru ctive im p act

on th e a c h ie v e m en t of re a s o n a b le a d a p tiv e
and
r e p r e s s i v e fo rces c a n n o t be
d isp uted . H o w m u c h th e benefits a re d u e to

this factor a n d h ow m u c h a r e th e p ro d u c t of
the placebo effect of insight, how ever, is dif
ficult to say. W h e r e a th e r a p is t is firm ly co n
vinced of the validity of the focus he h a s chosen
an d he convinces his p a ti e n t th a t n e u ro tic
de m on s w ith in can be con trolled t h r o u g h a c
goals, to w a r n t h a t th ey m a y m a k e a sh am b le s
o ut of th e p re s e n t tr e a t m e n t effort, a n d to e n
co u ra g e th e p a ti e n t to recognize his perso n a l
resp on sib ility in p e r p e t u a ti n g th e i r o p e ratio n .
T h e ten ac iou s hold they can h ave on a p a tie n t
is illu strate d by this fr a g m e n t of a n interview .
c e p ti n g a n d a c ti n g u p o n t h e i n s i g h t s
presented, ten sion a n d a n x ie ty m a y be suffi
T h e p a tie n t, a w rit e r, 42 y ea rs of age, w h o

m a d e a sk im p y living as a n ed ito r in a p u b li s h
ciently lifted to relieve s y m p to m s a n d to p r o

mote pro du ctiv e a d a p ta tio n . E v en sp u r io u s
ing h ouse ca m e to th e r a p y for d ep ressio n a n d

for h e lp in w o r k in g o n a novel th a t h a d defied
insights if accepted m a y in th is w a y serve a

useful p urpo se. W i t h o u t q u estio n , n e v e rth e
c o m p l e t i o n for y e a r s . A n g e r , g u i l t , s h a m e
less, th e closer one comes in a p p r o x i m a t i n g
w h e n e v e r he c o m p a r e d h im se lf w ith his m o re
some of th e sources of th e p a t i e n t s c u rr e n t
troubles, the g re a t e r the likelihood th a t signifi
cant benefits will follow.
successful colleagues. H e w a s in a c u sto m a rily

fr u str a te d , d e s p o n d e n t m o od w h e n he c o m
p la in ed :
In this respect for som e y ears I h ave e m

ployed a schem e th a t I have found v a lu a b le in
P t.
w o rk in g w ith patie nts. T h i s consists of s t u d y

ing w h a t resistences arise d u r i n g the im p le
m en ta tio n of th e tech niqu es th a t I h a p p e n to
be em p lo y in g at the time. T h e resistances will
yield d a ta on the existing d y n a m ic conflicts,
the most obstructive of w h ich is th e n chosen as
a focus.
E x p erie n ce w ith large n u m b e r s of p a tie n ts
convinces th a t th re e co m m o n d ev e lo p m en tal
a n d a host of o th e r e m o tio n s b u b b le d over
I j u s t c a n t get m y ass m o v i n g o n a n y t h i n g . I
sit d o w n a n d m y m i n d goes b l a n k . S t a r i n g a t a
b l a n k piece of p a p e r for h o u r s , I fin ally give
up.
T h . T h i s m u s t be t e r r i b l y f r u s t r a t i n g to you.
P t.
(a n g r ily ) F r u s t r a t i n g is a m ild w o r d , do cto r. I

can kill m y se lf for being su c h a shit.
T h . Y o u re a l l y t h i n k yo u a r e a s h i t ?
P t.
(a n g r ily ) N o t o n ly do I t h i n k I a m a sh it, I am
a sh it, a n d n o b o d y can co n v in ce m e t h a t I m
not.
128
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FIG. 10-1. Outline of Personality O perations
by p e r m is s io n .
12
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T h . F r a n k l y , F r e d , I m n o t even g o in g to try. B u t
y o u m u s t h a v e h a d s o m e h o p e for yourse lf,
o t h e r w i s e y o u n e v e r w o u l d h a v e c o m e h ere.
Pt.
I f ig u re d y o u c o u ld get m e o u t o f this, b u t I
k n o w i t s n o use. F v e a l w a y s b e e n a tail e n d e r .
i m p re s s io n t h a t y o u ve go t a n i n v e s tm e n t in
h o l d i n g on to t h e i m p r e s s io n yo u a r e a shit.
W h a t d o yo u t h i n k y ou get o u t of t h is?
N o t h i n g , a b s o l u te ly n o t h i n g .
W hy
should
In th e co n d u c t of b rief tr e a tm e n t on e m a y
no t h av e to d eal w ith th e u n d e r l y in g conflicts
such as th ose above as lon g as the p a tie n t is
m o vin g alo n g a n d m a k in g p ro g re ss. I t is on ly
w h en th e ra p y is b o g g ed d o w n th a t sou rces o f
T h . (confronting the patient) Y o u k n o w , I get t h e
Pt.
129
n eed th is?
T h . Y o u tell m e. [In his upbringing the patient

was exposed to a rejecting father who de
manded perfection from his son. The father
was never satisfied with the even better than
average marks his son obtained at school and
compared him unfavorably with boys in the
neighborhood who were prom inent in athletics
and received commendations fo r their school
work. It seemed to me that the paternal introject was operating in the patient long after
he left home, carrying on the same belittling
activities that had plagued his existence when
he was growing up. ]
P t. (pause) T h e r e is n o r e a s o n , (pause)
T h . Y o u k n o w I get t h e i m p r e s s io n t h a t y ou a r e
doing the sam e jo b on yourself now th at your
f a t h e r d id on you w h e n y o u w e r e a boy. I t s
like y o u ve got h i m in y o u r h e a d . [In the first
part of the session the patient had talked about

the unreasonableness of his father and his own
inability to please his father.]
P t. I a m s u r e I do, b u t k n o w i n g t h is d o e s n t h elp.
T h . C o u l d it be t h a t if y ou m a k e y o u r se lf h elp less
s o m e b o d y will co m e a l o n g a n d h e l p yo u o u t ?
[I was convinced the patient was trying to

foster a dependent relationship with me, one in
which I would carry him to success that defied
his own efforts. ]
P t. Y o u m e a n , y o u ?
T h . I s n t t h a t w h a t you said a t t h e b e g i n n i n g , t h a t
y ou c a m e to m e to get y o u o u t o f t h i s t h i n g ?
Yo u see if I let y o u get d e p e n d e n t o n m e it
w o u l d n t re a lly solve y o u r p r o b l e m . W h a t I
w a n t to d o is h e l p you h e l p yourse lf. T h i s will
s t r e n g t h e n you.
resistan ce m u st be u ncovered. T h e s e as ha s
been ind icated , a r e u su a lly ro o ted in th e im
m a t u r e n e e d s a n d d e fe n s e s o f d e p e n d e n t ,
m asochistic, self-d ev alu atin g p r o m p ti n g s . At
som e
p o in t
an
e x p la n a tio n
of w h e r e
such
p ro m p ti n g s o rig in a te d a n d h o w they a r e no w
o p e r a t in g will h ave to be given th e p a tie n t.
T h i s e x p la n a tio n m a y at first fall on d e a f ears,
b u t as th e th e r a p is t c onsistently d e m o n s tra t e s
th e ir existence fro m th e p a t i e n t s re actio n s a n d
p a tt e r n s , th e p a ti e n t m a y e v en tu a lly g ra s p
th e ir significance. T h e desire to m a k e oneself
d e p e n d e n t a n d th e destructiv eness o f this i m
pulse, th e c on ne ctio n of suffering a n d s y m p
to m s w ith a pervasiv e desire for p u n is h m e n t ,
th e m asochistic need to a p p e a s e a sadistic co n
science th a t derives fro m a bad p a r e n t a l introject, th e o p e r a t io n of a d e valu e d self-image,
w ith the subversive gain s th a t a ccru e fro m vic
tim iz in g oneself, m u s t be re p e a te d at every o p
p o rt u n it y , co n fr o n tin g th e p a ti e n t w ith q u e s
ti on s as to w h y he needs to c o n tin u e to sp o n so r
such activities.
S o m etim es a g e n e ra l o u tlin e of d y n a m ic s
(such as a r e de tailed in C h a p t e r 9) m a y be of
fered the p a ti e n t w ith th e object of e ith e r s t ir
rin g u p som e a n x ie ty o r res istan ce o r of p r o
viding th e p a t i e n t w ith a n in t e r p r e ta ti o n th a t
f o s te rs a b e t t e r u n d e r s t a n d i n g
of h im s e lf.
W h il e the d elin e a te d drives a n d defenses a re

p r o b a b l y t y p i c a l in o u r c u l t u r e of b o th
n o r m a l a n d n e u ro tic ind ivid u als, th e specific
m o des of o p e r a t io n a n d the k in d s of sy m p to m s
a n d m a l a d ju s tm e n ts th a t exist a r e u n i q u e for
e ach in d iv id u a l. E v e ry p e rs o n h a s a t h u m b ,
b u t p a t t e r n s of t h u m b p r i n t s a r e all different.
T h e th e r a p is t , e m p lo y in g a b lu e p r in t such as
y o u c a n t get o u t o f t h is t h i n g t h is self
s a b o tag e. ( The patient responds with a dubi
F ig u r e 1 0 - 1 , m a y try to fit each p a t i e n t s

p ro b le m s into it a n d th e n choose for focus
w h a te v e r asp ects a r e most im p o r t a n t a t th e
m o m e n t. F o r e x a m p le , th e p a ti e n t m a y d u r i n g
ous expression on his face and then quickly tries

to change the subject.)
a session c o m p l a in of a severe h e a d a c h e a n d
th e r e a fte r p ro ceed to bea t h im self m a s o c h is
Pt. B u t if I c a n t h e l p m yself, w h a t t h e n ?
T h . F r o m w h a t I see t h e r e i s n t a n y r e a s o n w h y
130
ineffectual. T h e th e r a p is t sho uld th en search to
p ro d u c e d his b re a k d o w n . H e is very m u c h like

a m a n w ith b a c k p a in w h o credits his sci
see h o w this tr e n d affiliates itself w ith guilt

feelings an d w h a t im m ed iate situ atio n insp ired
a t i c a to one incident of lifting a w e ig h t th a t

w a s too heavy, o blivious of the fact th a t for
tically, b la m in g him self for being w e a k an d
such feelings. T h e th e r a p is t m a y discover th a t
m o n th s or y ears he has, th r o u g h faulty p o s tu re
w h a t is beh ind th e guilt is a n g e r in th e p a tie n t
a n d lack of exercise, been a c c u m u la tin g w e a k
at his wife for not living u p to his e x p e ctatio n s
a n d stra in e d muscles.
in executing h e r h o u seh o ld duties. F u r t h e r

p ro b in g m a y reveal a n g e r at th e th e r a p is t for
su s tain ed by a defense of perfectionism , for as
not d oing m o r e for th e p a tie n t. Such t r a n s
far back as he c a n re m e m b e r , will h av e to p e r
ference m an ifestatio n s m a y e n ab le th e t h e r a
fo rm flawlessly even in tin y a n d m o st in c o n
pist to m a k e a co nnection w ith th e p a t i e n t s
seq u e n tia l a re a s of ach ie v em ent. T o p e rf o rm

less th a n perfect is t a n t a m o u n t w ith failu re an d
m o t h e r to w a r d w h o m th ere h as existed since
T h u s a p a ti e n t w h o se self-image is being
child ho od a good deal of a n g e r for h e r neglect

a n d rejection. T h i s will o pen u p a discussion of
signals in fe riority an d a sh a tte re d identity. T h e
th e p a t i e n t s excessive d ep en d e n c y needs an d
a c tu a lly be im p ossib le of fu lfillm ent. At a

ce rta in p o in t w h e n he c a n n o t face u p to d e
th e ine sc apa ble hostility, low ind ep en d e n ce,

a n d d e v a lu e d se lf-e s te e m t h a t d e p e n d e n c y
merciless d e m a n d s he m a k e s on him self m a y
m a n d s in som e tr u ly i m p o r t a n t s itu a tio n , his
be e s
fa ilu re will act like a s p a r k in a n explosive m i x
tablish ed betw e en th e p a t i e n t s hostility tu r n e d

in w a r d an d the m ig ra in e h ea d a c h e s for w h ich
tu re . T h e e v e n tu a tin g s y m p to m s t h a t finally
b ri n g h im in to tr e a t m e n t a r e d ep re ssio n a n d in
th e r a p y w a s so u g h t in th e first place. T h e
th e r a p is t shou ld in this w a y ta k e a d v a n ta g e of
so m n ia. It will r e q u i r e little a c u m e n for a t h e r a

pist to spot th e perfectionistic tr e n d s a r o u n d
every o p p o r t u n it y to show the p a tie n t th e i n
w h ic h the p a ti e n t fash ion s his existence. B u t to
t e r r e l a t i o n s h i p b e tw e e n h is v a r i o u s d ri v e s ,
a r g u e h im
tra its,' a n d sy m p to m s, ke ep in g in m in d th a t
c o u n te r th e b a r r a g e of ra tio n a l iz a t io n s evolved
w hile a ce rta in tr e n d m a y e n co m p a ss th e p a
over a lifetime a r e difficult, if n ot im possible,
ti e n ts chief concern at th e m o m e n t, it never
tasks. W e m ay , nevertheless, a tt e m p t to w o rk
w ith cognitive t h e r a p y a n d select perfection ism
brings
ab out.
An
association
m ay
occurs in isolation. It is re la te d in tim a te ly to

o th e r in tra p sy ch ic forces even th o u g h the co n
nection m ay not be im m e d iately clear.
o ut of his perfe ctio nism a n d to
as a focus, p o in t in g ou t th e d is to rtio n s in logic

th a t go vern th e p a t i e n t s th i n k in g process. N o t
A n individual can m a k e a re a s o n a b le a d ju s t
all t h e r a p is t s h av e th e skill a n d s t a m i n a to do
m e n t for a long tim e even w ith a v u ln e ra b le

c h a ra c t e r stru c tu re . H is p e rs o n a lity m oto rs,
defective as they m ay have been, still o p e ra te
h a rm o n io u s ly ; v a rio u s balan ces a n d c o u n te r
this, n o r do w e yet have sufficient d a ta to testify

to th e efficacy of this a p p r o a c h in m ost cases.
balances m a i n ta i n the psychological e q u il ib

riu m . T h e n because of th e im po sitio n of a n e x
W h a t w o u ld
seem in dic ated
is to review
w ith th e p a ti e n t th e full im p licatio n s of his

perfectio nism , its re la tio n s h ip to his defective
self-image, th e sources of self-d evalu ation in
in co m p lete s e p a r a ti o n -in d i v id u a t io n , the o p e r
te r n a l crisis situ ation o r because of stresses a s

sociated w ith in n e r needs a n d e x te r n a l d e
m a n d s , an xiety , d ep ression , p h o b ias , an d o th er
sy m p to m s a p p e a r . T h e p a ti e n t m a y consider
t h a t his a d ju s tm e n t p ri o r to th e presen ce of
atio n s of m as o ch ism , a n d so fo rth. O b vio usly ,

th e th e r a p is t m u s t have evidence to ju stify
these co nnections, but even th o u g h h e p re s e n ts
a n o u tlin e to th e p a tie n t of possibilities a n d
som e p re c ip ita tin g factor w as satisfactory if not

ideal, w ith no a w a re n e s s of ho w his te n u o u s
p e r s o n a l i t y i n t e r a c t i o n s h a v e b e en s p o n
stim u la te s th e p a ti e n t to m a k e con nection s for

him self, he m a y be able to p e n e tr a te som e of
th e p a t i e n t s defenses. G iv in g the p a tie n t some
sorin g vario u s sy m p to m s a n d u ltim ately had
idea a b o u t p e rs o n a lity d e v e lo p m e n t m a y, as I
131

have indicated, be occasionally helpful, esp e
d e p e n d e n c e ? M i n d y ou, y o u m a y n o t s h o w all
cially w h e re insufficient tim e is a v a ilab le in

th e r a p y to p in p o i n t the precise p ath o lo g y . P a
of t h e t h i n g s t h a t I sha ll p o i n t o u t to y ou, b u t
tients a re usu ally e n th u s iastic at first at h av in g
you.
received som e clarification, a n d th ey m a y even

ack no w led ge th a t segm ents of the p re s en ted
ou tline relate to them selves. T h e y then seem to
lose th e significance of w h a t h a s been revealed
to them . H o w e v e r, in m y ex perien ce la te r on
t r y to f ig u re o u t w h i c h o f th e s e d o a p p l y to
N o w , m o st p e o p l e w i t h s t r o n g feelings of
d e p e n d e n c e will a t t e m p t to find p e r s o n s w h o
a r e s t r o n g e r t h a n th ey a r e , w h o can d o for
th em
w hat
they
feel
they
cannot
do
for
th em se lv e s. It is a l m o s t as if t h e y a r e s e a rc h in g
for id e a liz e d p a r e n t s , n o t t h e s a m e k i n d of
in follow -up, m a n y have b ro u g h t u p p e r t in e n t
p a r e n t s t h e y h a d , b ut m u c h b e t t e r ones. W h a t
details of the ou tlin e a n d h av e confided t h a t it

stim u lated th i n k in g a b o u t them selves. T h u s in
does th i s d o to t h e i n d i v i d u a l ? F i rs t , u s u a l ly he
th e case of R o g e r described in th e last c h a p te r , I
o u t as id e a liz e d p a r e n t a l f ig u re s b ecau s e they
beco m es d i s a p p o i n t e d in t h e p e o p l e h e picks
n e v e r co m e u p to h is e x p e c t a t i o n s . H e feels
gave h im th e follow ing g e n e ral in t e rp re ta ti o n :
c h e a t e d . F o r i n sta n c e , if a m a n w e d s a w o m a n
T h . I believe 1 h a v e a fair id ea of w h a t is g o i n g on
w ith you, b u t I d like to st a rt fro m t h e b e g i n
n in g . I s h o u l d like to give you a p i c t u r e of
w h a t h a p p e n s to t h e a v e r a g e p e r s o n in the
g row ing-up
process .
From
t h is p i c t u r e
y ou
m a y be a b l e to u n d e r s t a n d w h e r e yo u fit a n d
w h a t h a s h a p p e n e d to yo u. Y o u see, a child at
b i r t h c o m es into t h e w o r l d h elp les s a n d d e
pendent.
H e need s a g r e a t d eal of affe ction,
care, a n d s t i m u l a t i o n . H e also need s to receive

th e p r o p e r d isc ip lin e to p r o t e c t h im . In th is
m e d i u m of loving a n d u n d e r s t a n d i n g c a r e a n d
d iscip lin e, w h e r e he is given a n o p p o r t u n i t y to
g r o w , to develop, to e x p l o r e , a n d to e x p r e ss
him self, his i n d e p e n d e n c e g r a d u a l l y in crease s
and
his d e p e n d e n c e g r a d u a l l y decreases,
so
t h a t at a d u l t h o o d t h e r e is a h e a l t h y b a l a n c e b e
t w e e n facto rs of d e p e n d e n c e a n d i n d e p e n d e n c e .
L e t us say th ey a r e e q u a l l y b a l a n c e d in th e
a v e r a g e a d u l t ; a c e r t a i n a m o u n t of d e p e n d e n c e
b e in g q u i t e n o r m a l , b u t not so m u c h t h a t it
cripples the person. N o rm a lly the dependence
level m a y t e m p o r a r i l y go u p w h e n a p e r s o n
gets sick o r in secu re, a n d his i n d e p e n d e n c e will
tem p o rarily
recede.
But
t h i s s h i f t is o n l y
w i t h i n a n a r r o w r a n g e . H o w e v e r , as a r esu lt of
b ad o r d e p r i v i n g e x p e r i e n c e s in ch ild h o o d , a n d
fro m y o u r histo ry , th is se em s to h a v e h a p p e n e d
to y ou to so m e e x te n t [the p a t i e n t s fa t h e r a
sa le sm a n w a s a w a y a g o o d d e a l o f th e tim e a n d
h is o ld er b ro th e r b r u ta lly in tim id a te d h im ] ,
t h e d e p e n d e n c e level n e v e r goes d o w n suffi
ciently a n d t h e i n d e p e n d e n c e level stays low.
N o w w h a t h a p p e n s w h e n a p e r s o n in a d u l t life
h a s excessive d e p e n d e n c y a n d a low level o f i n
w h o h e ex p ects will be a k i n d , giving, p r o t e c

tive, m o t h e r fig u re, he will b eco m e in f u ri a t e d
w h e n she fails h i m o n a n y c o u n t . S eco n d, he
fin ds t h a t w h e n he does r e l a t e h i m s e l f to a p e r
son o n t o w h o m h e p ro jects p a r e n t a l q u a litie s,
he b eg in s to feel h elp les s w i t h i n him self, he
feels t r a p p e d , he h a s a d e s ire to es c a p e from
t h e r e l a t i o n s h i p . T h i r d , t h e feeling of b e in g d e
p e n d e n t , m a k e s h i m feel p as sive like a child.
T h i s is of ten asso ciated in his m i n d w i t h being
n o n m a s c u l i n e ; it c r e a t e s fears of his b e c o m in g
h o m o s e x u a l a n d r e l a t i n g h i m s e l f passiv ely to
o t h e r m e n . T h i s role, in o u r c u l t u r e , is m o r e
a c c e p ta b le to w o m e n ,
b u t t h e y to o f ear e x
cessive passiv ity , a n d t h e y m a y , in r e l a t i o n to

m o t h e r figure s, feel as if th ey a r e b r e a s t - s e e k
ing a n d h o m o s e x u a l .
So h e r e he h a s a d e p e n d e n c y m o t o r t h a t is
c o n stan tly
o p eratin g ,
m ak in g
him
forage
a r o u n d for a p a r e n t a l im age. I n e v ita b ly th ey

d i s a p p o i n t h i m . ( A t th is p o i n t th e p a tie n t in
te r r u p te d a n d d e s c rib e d h o w d is a p p o in te d he
w a s in h is w ife , h o w in e ffe c tiv e sh e w a s, h o w
u n a b le sh e p r o v e d h e r s e lf to be in ta k in g care
o f h im .
th e n
W e d isc u sse d th is f o r a m in u te a n d
c o n tin u e d .)
In
addition
to
the
de
p e n d e n c y m o t o r , t h e p e r s o n h a s a se cond m o
to r r u n n i n g , a r e s e n t m e n t m o t o r , w h i c h o p e r
ate s c o n s t a n t l y o n t h e b asis t h a t h e is e i t h e r
trapped
in
dependency,
or
cannot
find
an
id ealized p a r e n t a l fig ure, o r b e c a u s e h e feels o r

acts p as sive a n d helpless. T h i s r e s e n t m e n t p r o
m o te s t r e m e n d o u s g u ilt feelings. A fter all, in
o u r c u l t u r e o n e is no t s u p p o s e d to hate. But
th e h a t e feelings so m e ti m e s d o t r ic k le o u t in
132

sp ite of this, a n d o n special occasio n s t h e y g u s h
d a m a g e d . F e e l i n g s of s e l f- d e v a l u a t i o n give rise
o ut, like w h e n t h e p e r s o n d r i n k s a little to o
to a ho st of c o m p e n s a t o r y d riv es, like b e in g
m u c h . (The patient laughs here and says this is
p erfe ctio nis tic,
exactly what happens to him.) If t h e h a t e feel
d r i v e n . As lo n g as h e c a n do t h i n g s perfe ctly
ings
and
do
come
out,
the
person
may
g et
o perate
overly a m b i t i o u s ,
w ithout
fla w ,
he
and
w ill
power
r esp ec t
f ri g h t e n e d o n t h e b asis t h a t he is lo sing c o n
h im self. O r , if h e is b r i g h t e n o u g h a n d his e n
trol. T h e very id ea of h a t i n g m a y be so u p s e t
v i r o n m e n t fav o ra b le , h e m a y b oo st h i m s e l f into
t i n g to h i m t h a t he p u s h e s t h i s i m p u l s e o u t of
a success ful p o sitio n o f p o w e r , o p e r a t e like a
his m i n d , w i t h r e s u l t i n g te n s io n , d e p r e ss io n ,
strong au th o rity a n d g a th e r aro u n d him self a
p h y sic al s y m p t o m s of v a r i o u s k i n d s , a n d self-
g r o u p o f s y c o p h a n t s w h o will w o r s h i p h i m as
h a t e . T h e h a t e i m p u l s e h a v i n g been bl ocked is
t h e id e a liz e d a u t h o r i t y , w h o m in t u r n t h e i n d i
t u r n e d b a c k on t h e self. T h i s is w h a t w e call
v id u a l m a y r e s e n t a n d e n v y w h i l e a c c e p ti n g
m a s o c h i s m , t h e w e a r i n g o f a h a i r s h i r t , th e
t h e i r p l a u d i t s . H e will feel e x p l o i t e d b y those
c o n s t a n t s e l f - p u n i s h m e n t as a re s u l t o f feed
w h o e l ev ate h i m
b ack of r e s e n t m e n t . T h e r e s e n t m e n t m a c h i n e
p r i e s t . W h y , he m a y a s k h im self, c a n t I
go es
ru nning
find so m e b o d y s t r o n g w h o m / ca n d e p e n d o n ?
As if t h is w e r e n t e n o u g h , a t h i r d m o t o r gets
s h i p , b u t t h i s role e n t a i l s su c h conflict for h i m
on
good
de al
of the
tim e
al o n g s id e t h e d e p e n d e n c y m o t o r.
g o in g a l o n g
w ith
the oth er
to t h e p o s i t i o n
of a h ig h
W h a t h e seeks a c t u a l l y is a d e p e n d e n t r e l a t i o n
H igh de
t h a t he goes in to fierce c o m p e t i t i v e n e s s w i t h
p e n d e n c e m e a n s low in d e p e n d e n c e . A p e r s o n
tw o .
a n y a u t h o r i t y o n w h o m h e m i g h t w a n t to be
w i t h low fe elings of i n d e p e n d e n c e suffers t e r
dependent.
r ib ly becau s e he does n o t feel sufficient u n t o
So h e r e w e h a v e o u r d e p e n d e n c y o p e r a t i n g
h im self; h e does n o t feel c o m p e t e n t . H e feels
first; se co n d , r e s e n t m e n t , a g g r e s s i o n , g uilt, a n d
n o n m a s c u l i n e , passive, h elp les s, d e p e n d e n t . It
m a s o c h i s m ; t h i r d , d r iv es for in d e p e n d e n c e ; a n d
is h a r d to live w i t h suc h feelings, so h e m a y try
f o u r t h , s e lf- d e v a lu a tio n a n d m a n e u v e r s to o v e r
to c o m p e n s a te by b e in g o v e rly ag g ressiv e,
come
o verly c o m p e titiv e , a n d ov erly m a s c u lin e . T h i s
t i o n i s m , o v e r a m b i t io u s n e s s , a n d p o w e r s t r i v
m a y c r e a t e m u c h t r o u b le for t h e p e r s o n b e
ings, in f a n t a s y o r in reality .
ca u s e he m a y try to o h a r d to m a k e u p for his
t h is
through
such
te c h n ic s as p erfe c
T o c o m p l i c a t e m a t t e r s , s o m e of th ese drives
feelings of loss of m a s c u l in i t y . H e m a y h av e
get s e x u a l i z e d .
f a n ta s ie s
w h e n o n e r e la te s to a p e r s o n t h e w a y a child o r
of becom ing
strong,
handsom e,
In d e p e n d e n c y , for in stan c e,
ov erly activ e se x u al m ale, a n d , w h e n h e sees
i n f a n t r e l a t e s to a p a r e n t , t h e r e m a y be e x p e r i
su ch a figu re, he w a n t s to id entify w i t h him .
en ced a p o w e r f u l su ffu sion of good feeling t h a t
T h i s m a y c r e a t e in h im d es ires for a n d fears of
m a y b u b b l e o v er in to s e x u a l feeling. T h e r e is
h o m o s e x u a l it y , w h i c h m a y te r rif y so m e m e n
p r o b a b l y a g r e a t deal of s e x u a l i ty in all in f a n ts
w h o d o n o t re a lly w a n t to be h o m o s e x u a l .
in a very diffuse f o rm , p r e c u r s o r s of a d u l t se x
I n t e re s t i n g l y , in w o m e n a l o w - i n d e p e n d e n c e
u a lity . A n d w h e n a p e r s o n r e v e r ts e m o t i o n a l l y
level is c o m p e n s a t e d for by h e r c o m p e t i n g w i t h
b ack to t h e d e p e n d e n c y o f in fan cy , he m a y
m e n , w a n t i n g to be like a m a n , a c t i n g like a
r e e x p e r i e n c e diffu se se x u a l feelings t o w a r d th e
m a n , a n d r e s e n t i n g b e in g a w o m a n . H o m o s e x
p a r e n t a l figure . If a m a n r e la te s d e p e n d e n t l y to
u al
a w o m a n , h e m a y s u s t a i n t o w a r d h e r a k i n d of
im p u l s e s a n d fears also m a y s o m e tim e s
e m e r g e as a re s u l t of r e p u d i a t i o n o f fem in in ity .
A
consequence
of
low
feelings
of
inde
i n c e s t u o u s feeling. T h e s e x u a l i ty will be n o t as
a n a d u l t , b u t as a n i n f a n t to a m o t h e r , a n d t h e
p e n d e n c e is a d e v a l u e d se lf-im age, w h i c h s ta rts
feelings
t h e f o u rt h m o t o r g oing. T h e p e r s o n b eg in s to
t r e m e n d o u s gu ilt, f ear a n d p e r h a p s a n i n a b ility
d es p ise him self, to feel h e is w e a k , ug ly, a n d
to fu n c tio n se x u a lly . If th e p a r e n t a l f ig u re h a p
c o n t e m p t i b l e . H e will pick o u t a n y p e r s o n a l
p e n s to be a m a n i n ste a d of a w o m a n , t h e p e r
evidence for th is t h a t he can find, like st a tu r e ,
so n
c o m p l e x i o n , p h y s i o g n o m y , a n d so o n.
m other,
If he
h a p p e n s to h a v e a sligh t h a n d i c a p , like a p h y s
ical d e f o rm i t y o r a sm a ll p e n is , he will focus on
this
as
evidence
that
he
is
irretrievably
m ay
for
still
and
her
may
relate
be
accom panied
to h i m
em erging
by
like t o w a r d
sexual
feelings
will
[ / / the p a
tient is a woman with sexual problems, the
parallel situation of a female child with a
s t i m u l a t e fears o f h o m o s e x u a l i t y .

parental substitute may be brought up. A
woman may repeat her emotions of childhood
when she sought to be loved and protected by a
mother. In body closeness she may experience
a desire to fondle and be fondled, which will
stir up sexual feelings and homosexual fears.}
133
no t a v a i l a b l e to h i m to sa tisfy h is diffe rent

d r iv es a n d if h e c a n n o t r e a d i l y s w itc h f ro m o ne
to t h e o t h e r , h e m a y b e c o m e exces sively ten se
a n d u pse t. I f his te n s io n b u i l d s u p to o m u c h ,
or
if he
experiences
great
tro u b le
in his
life s i t u a t i o n , o r in t h e e v e n t self e s te e m is
In s e x u a l i z i n g d r iv e s for i n d e p e n d e n c e a n d a g
c r u s h e d fo r a n y r e a s o n , h e m a y d ev elo p a
gressiveness, o n e m a y id en tify w i t h a n d seek
c a t a s t r o p h i c feeling of h e lp le s sn e s s a n d e x p e c t a
o u t p o w e r f u l m a s c u l in e fig u res w i t h w h o m to
t i o n s o f b e i n g h u r t . (The patien t here excitedly
fr a t e r n i z e a n d affiliate. T h i s m a y a g a i n w h i p
blurted out that he felt so shamed by his defeat

at work that he wanted to atom bomb the
w orld. H e became angry and weak and
frigh ten ed. H e w anted to g e t aw ay from
everything and everyone. Yet he fe lt so helpless,
he wanted to be taken care of like a child. He
then felt hopeless and depressed. I commented
that his motors had been thrown out of gear by
the incident at work and this had precipitated
excessive tension and anxiety.)
up homosexual
im p ulses . W h e r e agg ressiv e-
sa distic a n d se lf-pu nitiv e m a s o c h is tic im p u l s e s

exist, th e s e m a y , for c o m p l i c a t e d r e a s o n s , also
be fused w i t h se x u a l i m p u l s e s , m a s o c h i s m b e
co m i n g a c o n d itio n for se xu al r elease. So h e r e
w e h av e t h e d e p e n d e n c e m o t o r , a n d t h e re se n tm e n t-a g g re ssio n -g u ilt-m a so c h ism m otor, and
t h e i n d e p e n d e n c e m o t o r , a n d t h e s e lf-d ev alu
ation m otor, w ith the various com pensations
a n d s e x u a l i z a t i o n s . W e h a v e a ver y b u s y p e r
W hen
te n s io n
gets
to o g r e a t ,
and
there
son on o u r h a n d s . (At this point the patient
se em s to be n o h o p e , a n x i e t y m a y hit. A n d the
revealed that he had become impotent with his

wife and had experienced homosexual feelings
and fears that were upsetting him because they
were so foreign to his morals. What I said was
making sense to him.)
p e r s o n w ill b u ild u p defenses to c op e w i t h his
I n t h e face of all th i s t r o u b le , h o w d o so m e
T h e s e defen se s o ften d o n o t w o r k . S o m e , like
a n x i e t y , s o m e o f w h i c h m a y suc ceed a n d so m e
m a y no t. F o r i n sta n c e , excessive d r i n k i n g m a y
be o n e w a y o f m a n a g i n g a n x i e t y . F e a r s , c o m
p u lsio n s , p h y sic al s y m p t o m s a r e o t h e r w ay s.
p e o p le g a i n p e a c e ? By a fifth m o t o r , t h a t of
p h o b i a s , m a y c o m p l i c a t e t h e p e r s o n s life a n d
d e t a c h m e n t . D e t a c h m e n t is a defense o n e m a y
make
tr y to u se as a w a y o f e s c a p i n g lifes m essy
t h o u g h w a y s a r e s o u g h t to d e a l w i t h a n x i e t y
p r o b l e m s . H e r e o n e w i t h d r a w s f ro m r e l a t i o n
th e s e p r o v e to be self-defeating.
it
m ore
difficult t h a n
before.
Even
sh ips, iso lates him self, r u n s a w a y f ro m th in g s.
N o w , w e a r e n o t s u r e yet h o w th i s g e n e r a l
B y r e m o v i n g h i m s e l f f ro m p e o p le , t h e i n d i
o u t l i n e a p p l i e s to you . I a m s u r e s o m e of it
v id u a l t r ie s to h e a l hi m self. B u t t h is does n o t
does, as y o u y o u r s e l f h a v e c o m m e n t e d . S o m e of
u s u a l ly w o r k b ecau s e af ter a w h i l e a p e r so n
it m a y n o t. W h a t I w a n t y o u to d o is to t h i n k
gets terrified by his isolation a n d in a b i l i t y to
a b o u t it, o b se rv e y o u r s e l f in y o u r a c tio n s a n d
feel. P e o p l e c a n n o t f u n ctio n w i t h o u t peo ple.
relations
T h e y m a y succeed for a s h o r t tim e , b u t t h e n
W h i l e k n o w i n g w h e r e y o u fit w ill n o t sto p the
th ey
m o t o r s f r o m r u n n i n g , a t least w e will have
realize
they
are
drifting
aw ay
from
to
people an d
see w h e r e y o u fit.
th in g s; t h e y a r e d e p r i v i n g th e m s e lv e s of lifes
so m e id ea as to w i t h w h a t w e a r e dealin g .
prim e
T h e n w e ll b e t t e r be a b l e to f i g u r e o u t a p l a n
satis factions.
C om pulsively, then,
the
d e t a c h e d p e r s o n m a y tr y to r e e n t e r t h e liv in g a t
c o n c e r n i n g w h a t to do.
m o s p h e r e b y b e c o m in g g r e g a r io u s . H e m a y , in
d e s p e r a t i o n , p u s h h im se lf i n t o a d e p e n d e n c y
si t u a t i o n w i t h a p a r e n t a l f i g u re as a w a y o u t of
his d i l e m m a . A n d t h is w ill s t a r t t h e w h o l e n e u
ro tic cycle all ov er a g a i n .
Y o u c a n see t h a t t h e p e r s o n k eep s g e ttin g
c a u g h t in a w e b f ro m w h i c h t h e r e is no escape.
As lo n g as he h a s e n o u g h fuel a v a i l a b l e to feed
his v a r i o u s m o t o r s a n d k eep t h e m r u n n i n g , he
ca n go o n for a perio d . B u t if o p p o r t u n i t i e s a r e
So m etim es I d r a w a sketch on a b la n k p a p e r
s h o w i n g h i g h d e p e n d e n c e , lo w d e p e n
d e n c e , d eva lue d self-im a g e , re s e n tm e n tg u ilt-m aso ch ism , and d e ta c h m e n t, and
re p e a t th e sto ry of th e i r in te rre la tio n s h ip . I
th e n ask th e p a ti e n t to figure o ut a n d study
aspects th a t a p p ly to h im . If a g e n e ra l d e sc rip
tion of d y n a m ic s is given th e p a tie n t, a lo n g the
134
lines indicated above, a little insight m a y be in

culcated th a t can serve as a fu lcru m for g re a te r
self-u nd erstan d ing . T h e insight m a y be te m p o
ra r ily re a s su rin g at first; th e n it seem ingly is
forgotten w ith a re surgen ce of sym pto m s. A
review of w h a t h a s occu rred to s tim u late a n a t
ta ck of a n x ie ty m a y consolidate the in sig h t an d

solidify b ette r co ntrol. A n im p o r t a n t tool h ere
is self-observation, w h ich the th e r a p is t should
tr y to en c o u ra g e an d w h ich will h e lp th e
w o r k in g - th r o u g h process, w ith o u t w hich
insig ht can h ave little effect.
Conclusion
In d y n a m ic s h o r t-t e rm th e r a p y th e most
productive focus is often on som e aspect of a
tendencies. T h e s e m an ife statio n s will be espe
n u c le a r conflict. Since the p a tie n t u su ally d e
cially p r o m in e n t d u r i n g pe rio d s of resistan ce to

te c h n iq u e s th a t th e th e r a p is t is im p le m e n tin g .
fe n d s h i m s e l f a g a i n s t r e v e a l i n g s i g n if i c a n t
unconscious con ten t, th e th e r a p is t will have to
to w h a t lies b e h in d the p a t i e n t s inab ility or
arriv e at it by o bserving its manifest d e riv a

tives. T h e s e m a y be hig hly disguised a n d s y m
bolized. H o w e v e r, a sensitive a n d astu te t h e r a
pist will be ab le to detect vital u n d e r c u r r e n t
forces from the p a t i e n t s verbal a n d no n v e rb al
behavior, from periodic tra nsferenc e displays,
and from d re a m s , fantasie s an d actin g-out
A ccordingly, th e th e r a p is t sh ou ld a le r t him self

refusal to re s p o n d to tr e a t m e n t in terventions.
A g e n e ral o u tlin e of d y n a m ic s p re s en ted to th e
p a ti e n t w ith th e object of s tirr in g u p som e te n
sion in th e in terv iew an d hence e x p ed itin g e x
p lo r a tio n s, o r of w o rk in g t o w a r d fitting the p a
t i e n t s special p ro b le m s an d m e c h a n ism s into
th e ou tline, is so m etim es helpful.
CHAPTER 11
Techniques in Short-term Therapy

P s y c h o t h e r a p y a s it is p r a c t i c e d t o d a y is n o
lo n g er
it s
a hom ogeneous
m ain stream
branches
of
sciences.
every
are
th e
T h is
o p eratio n .
trib u ta rie s
bio lo g ical
is
because
co n stitu en t
of th e
E n te rin g
from
and
b eh av io ral
behavior
hum an
v ario u s
em braces
b ein g
from
m i g h t be in o r d e r . T h e n th e r e a r e th o s e w h o
p r e f e r a n i n t r a p s y c h i c e x p l a n a t i o n , s e e i n g it a s
a th in k in g d iso rd er th a t
p ro cess,
tio n ,
prim itive,
w ith
excessive
m en t, an d
provokes p rim a ry -
irratio n al,
w ishful
condensation,
idea
d isp lace
th e d isto rte d use of sy m b o ls. T h e
p h y sio lo g ic a l m a k e u p to s p i r i t u a l p r o m p ti n g s .
r e s u l t is a n i n t e r f e r e n c e w i t h p r o p e r e m o t i o n a l
In T a b l e 1 1 - I
m o d u latio n . T h is
t h e v a r i o u s l i n k s in t h e b e h a v
io ra l c h a i n a r e d e l i n e a t e d , a s w e ll as th e fields
v ie w p o in t so m e tim es sp o n
sors a p sy c h o a n a ly tic a p p ro a c h . O n th e in te r
of in terest these e m b ra c e , a n d th e th e ra p e u tic
p e r s o n a l level c e r t a i n a u t h o r i t i e s c r e d it t h e d i s
m o d a litie s r e la te d to e a c h lin k to w h ic h c e r ta in
ease
sy n d r o m e s a r e often assig n ed . T a k e as a n e x
defenses th a t en co u ra g e d e ta c h m e n t, distru st,
a m p le th e s y n d ro m e of sc h iz o p h re n ia .
and
S c h i z o p h r e n i a is a d i s e a s e t h a t is v a r i a n t l y
a ttrib u te d
to
m any
causes.
T here
are
those
to
th e
m isch ief
e x trao rd in ary
apy,
group
oriented
of
regressive,
dependency.
th e ra p y ,
th erapy
and
w ould
archaic
F am ily
th er
p sy choanalytically
fit
in
here.
Social
w h o r e g a r d it a s a b i o c h e m i c a l a f f l i c t i o n , t h e
forces a r e c o n s id e re d b y s o m e to be th e p r i m e
product
c u lp rits,
of
defects
in
th e
fu n ctio n
of
the
in sp irin g
th e
p atien t
to
assum e
n e u ro tra n s m itte r d o p am in e, w h ich , o p e ra tin g
a n o m a l o u s so cial ro le s t e r m i n a t i n g in a l i e n a
in e x c e s s , a f f e c t s t h e m e s o l i m b i c , i n f u n d i b u l a r ,
tio n
and
M illieu
n ig ral
p ath w ay s.
U nder
these
circu m
and
sta n c e s p h a r m a c o t h e r a p y w o u ld a p p e a r to be
th erap y ,
th e
utilized
preferred
approach,
neuroleptics,
for e x
a m p l e , b e in g e m p l o y e d to b lo c k th e a c t i o n of
th ere
dop am in e.
eso teric
O th ers
regard
sch izo p h ren ia
as a
d ev iatio n s
in
ta sk
p erform ance.
t h e r a p y , c a s e w o r k , c o u n s e lin g , social
and
w ith
are
re h a b ilita tiv e
therapy
th ese
in
factors
p ro fessio n als
sp iritu al
who
co u ld
m ind.
prefer
e x p la n a tio n ,
be
F in ally ,
a
m ore
v iew in g
neu ro p h y sio lo g ical d iso rd er, c h a ra c te riz e d by a
sch izo p h ren ia as a u n iq u e a n d sin g u lar m ode
l a c k o f left c e r e b r a l d o m i n a n c e a n d d e f e c t i v e
of
c e re b ro lim b ic fu n c tio n in g th a t s p o n s o r a b n o r
E x iste n tia l th e r a p y a n d a c ro p of p h ilo so p h ical
p erceiv in g
and
ex p erien cin g
reality .
m a li t i e s in l i n e a r c o g n itiv e a b ility . A d h e r e n t s
approaches,
of this v ie w p o in t m ig h t c o n s id e r c e r ta in fo rm s
from
of so m a tic th e r a p y su ita b le u n d e r so m e c ir c u m
a d v o c a te s w h o seek to in flu e n c e th is e lu siv e d i
sta n ces,
m e n s io n .
fo rm s
ECT,
of
for
instan c e,
relaxation
as w ell a s so m e
therapy.
Some
ascrib e
s c h iz o p h r e n ia to fa u lty le a r n i n g a n d c o n d i t i o n
ing, c o n s id e rin g
th e
consequence
it a d e v e l o p m e n t a l
of
severe
fa m ily
use
of th e
child
w ith
projective
who
co m m u n icate
conflictual
m any
E astern
D ifferen t
th u s accord
d eriv in g
th e ir
system s of th o u g h t,
w ith
approaches
m u ltip le
to
su b stan ce
have
th eir
treatm en t
w a y s of re g a rd in g
th e disease. A c tu a lly , s c h iz o p h r e n ia e m b r a c e s
p roblem ,
all o f th e b o d ily s y s te m s , a n d n o o n e e tio lo g ic a l
p athology
facto r can be co n s id e re d exclusively d o m in a n t.
p aren ts
A n d a n y o f t h e m a n y m o d a l i t i e s s i n g l y o r in
d o u b le - b in d ''
c o m b i n a t i o n m a y in so m e c a s e s r e g is te r a b e n e
by
th e m e s. A b e h a v io ra l a p p r o a c h , c o n s e q u e n tly ,
f i c i a l effe c t.
135
136
TABLE 11-1. The Biological and Behavioral Links of Behavior*

T H E B E H A V IO R
C H A IN
Biochemical links
RELATED
F IE L D S
Biochemistry
T H E R A P E U T IC M O D A L IT IE S
P harm acotherapy
SYNDROM ES
Schizophrenia (neuroleptics)
M an ia (lithium )
M ajo r depressions
(antidepressants)
A nxiety states (anxiolytics)
H yperkinetic syndrom es of
childhood
N europhysiological
N europhysiology
links
Biofeedback
Som atic therapy
R elaxation th erap y (m editation,
relaxing hypnosis)
Em otive release
Developm entalconditioning links
D evelopm ental theory

L earning theory
Behavior therapy
Cognitive th erap y
Persuasion
Suggestive hypnosis
T ension states (relaxation,

biofeedback, em otive release)
Suicidal depressions (E C T )
Physical conditions arising from
m ental factors (biofeedback)
Phobic reactions (behavior
therapy)
H ab it disorders (hypnosis)
Behavior disorders (behavior
therapy)
Obsessive-compulsive disorders
(behavior th erap y , persuasion,
cognitive therapy)
A djustm ent reactions
D evelopm ental delays
Intrapsychic links
Psychoanalysis
Psychoanalysis
Personality disorders
C ognitive theory
H ypnoanalysis
N eurotic disorders
Existential analysis
G uided im agery
Interpersonal links
D ynam ic theory
Psychoanalytically oriented therapy
Personality disorders
Role theory
G roup therapy
N eurotic D isorders
G ro u p dynam ics
M arital therapy
Social psychology
Fam ily therapy
M a rita l problem s
F am ily problem s
Psychodram a
Experiential therapy
B orderline personality
D ru g abuse and dependence
T ransactio n al analysis
Cognitive learning
Social links
Sociology
A nthropology
Economics
S piritual links
M ilieu therapy
Social casework
S ituational problem s
Psychoses in remission
C ounseling
Political science
Social therapy
R ecreational therapy
Theology
Religious therapy
R eactive depression
Philosophy
E astern philosophical systems

Existential therapy
Anxiety states
M etapsychiatry
A ddictions
Behavior is a complex entity composed of a chain of interrelated biochemical, neurophysiological, developmentalconditioning, intrapsychic, interpersonal, social, and spiritual links Difficulties in one link will by feedback influence all
other links in the chain. Distinctive fields of interest and special theories related to each link inspire a num ber of thera
peutic modalities that are preferred approaches in certain syndromes even though through feedback interventions
bracketed to other links may also be effective.
137
TECHNIQUES IN SHORT-TERM THERAPY

By the sam e token, p ractically every n e u
d icate o u r u n d e r s ta n d in g a n d e m p a t h y a n d to
rotic o r b eha v io ral d is o rd e r m a y be cau sally
keep h im focused on i m p o r t a n t content. Sec
associated w ith m u ltip le links in th e be hav ioral
o nd, w e h e lp h i m arr iv e at som e p r e l im in a r y
chain. T h e y too m a y be a p p ro a c h e d w ith a v a
u n d e r s ta n d in g s of w h a t his difficulty is all

a b o u t. T h i r d , w e select a m e th o d th a t is t a r
riety of tech n iq u es th a t c o rre sp o n d to different

links. T h i s is the r a t io n a l e of eclecticism,
w hich in s h o r t-t e rm t h e r a p y is a prefe rred
mode of o p era tio n .
T h e fact th a t we have so m a n y different a p
geted on th a t link th a t is c re a tin g greate st diffi

culty for th a t p a t i e n t b ioch em ical, b e h a v
ioral, in trap sy c h ic, in te rp e r s o n a l, o r social.
F o u r t h , w e try to sho w h im h o w he h im self is
p ro ach es to the sa m e em o tio n a l p ro b le m c a n in
n ot an in n o c en t b y s ta n d e r a n d th a t he, in a
itself be confusing. Because th e r e is so little

tim e availab le in brief t h e r a p y , we will w a n t to
m a j o r o r m i n o r w a y , is involved in b rin g in g
his tr o u b le s on himself. F ifth , w e deal w ith
select th e on e m eth o d o r co m b in a tio n of m e t h
a n y resistances th a t he develops th a t block (a)
ods th a t is most ap p lic a b le to the specific diffi
an
culty. In this respect w e can console ourselves

in a m in o r w ay . N o m a t te r w h a t te c h n iq u e we
em ploy, if we a r e skilled in its use, h av e faith
p ro du ctiv e use of th e te c h n iq u e s w e em ploy,
in its validity, an d c o m m u n ic a te this faith to

the pa tien t, a n d if the p a tie n t accepts th e tech
u n d erstan d in g
o f h is p r o b l e m ,
(b) h is
a n d (c) th e a p p lic a tio n of his tr e a t m e n t to w a r d

b eh av io ra l correction. S ix th , w e tr y to ac
q u a i n t h im w ith som e of th e p e rs o n a lity d is to r
n iq u e an d ab so rb s o u r faith, it will influence
tions th a t he carries a r o u n d w ith h im t h a t can

c reate tr o u b le for h im in th e f u t u r e h ow they
h im in some positive w ay. In resolving a diffi
developed, h o w th ey o p e r a t e n ow , a n d how
culty related to o ne d is tu rb e d link in his be
they m a y sh o w u p after he leaves th e r a p y .
hav io ral ch ain , this will in fluence by feedback

o th e r links. T h u s , if we p resc rib e n eu ro lep tic s
A n d , seventh w e give h im som e h o m e w o r k th a t
for a sch izo p h ren ic w ith a d is tu rb i n g th in k in g

diso rder, th e im p a c t on his b ioch em istry will
m a y m in im iz e o r p re v e n t p ro b le m s from o ccu r
register itself positively in v a ry in g degrees on

his neu ro p h y sio lo g y , his g en e ra l b eha v io r, his
i n t r a p s y c h i c m e c h a n i s m s , his i n t e r p e r s o n a l
is a im ed at s t re n g th e n i n g h im se lf so th a t he
r in g la te r on. W i t h i n this b ro a d f r a m e w o r k
th e r e are, of course, w id e differences on how
relatio ns, his social attitud es, a n d p e r h a p s even
t h e r a p is t s w ith v a ry in g th eo retical o r ie n ta tio n s

will o p erate . By a n d larg e, h ow e v e r, p sy
c h o th e r a p is ts w ith a d e q u a t e t r a in i n g sh ou ld
his ph iloso ph ical outlook. A p p ly in g beh av io r
a n tic ip a te satisfactory resu lts w ith the g re a t
th e r a p y to a ph ob ic will in its correction in flu

ence o th e r aspects from th e bio chem ical factors
m a jo rity of th e i r patients.
to sp iritu a l essences. W o r k i n g w ith m o da lities

th a t a re directed at th e in tra p sy c h ic s tru c tu r e
in a pe rs o n ality d is o rd e r th r o u g h p s y c h o a n a l
t e c h n iq u e s a r e ind icated by th e needs o f th e

p a ti e n t an d t h a t a r e w ith in the scope of o n e s
ysis or cognitive t h e r a p y , w e m a y find th a t all

o th e r links in the b eha vio ral c h ain a r e affected
in a gratifyin g w ay. T h i s global response,
how ever, does n ot in th e least absolve us from
try in g to select the best m e th o d w ith in o u r
r a n g e of skills th a t is m ost a tt u n e d to th e p a
ti e n ts u n iq u e le a r n in g ap titu d es .
Be this as it m ay, th e r e a r e som e g en e ra l
principles th a t a re ap p lic a b le to m ost pa tien ts.
F irst, we sta rt th e r a p y by allo w in g the p a tie n t
to u n b u r d e n him self verbally, to tell his story
u n in t e r r u p t e d ly , in te rp o la tin g c o m m e n ts to in
E m p l o y in g w h a te v e r te c h n iq u e s o r g r o u p of
t r a i n i n g a n d e xp erien ce, th e th e r a p is t m a y be
ab le to achieve th e goals ag re ed on in a ra p id
a n d effective w ay. W h e r e th e th e r a p is t h as be
come a w a r e of th e u n d e rl y in g d y n a m ic s, it
m a y be necessary to m e n tio n at least some
salien t aspects an d to enjo in the p a tie n t to
w o r k on th ese by him self after t h e r a p y has
ended. O n the o th e r h a n d , th e th e r a p is t m a y
not be able to achieve d esired goals unless in
te rfering d y n a m ic influences th a t function as
resistance a r e d e a lt w ith d u r i n g the tr e a tm e n t
period because th e p a tie n t is blocked by the
resistance a g a in s t m a k i n g progress.
138
In lon g -term th e r a p y a d y n a m ic th e m e th a t
stitu tes a v a lu a b le m e a n s of h e lp in g a p a tie n t
e x p la in s the p a t i e n t s p e rs o n a lity o p e ra tio n s

a n d resistances g ra d u a l ly reveals itself th r o u g h
to face a n d , if m o tiv atio n is presen t, to a lt e r his

rep etitiv e self-defeating b eh avio r. P o in te d i n
a leisurely stu dy of the p a t i e n t s verb aliza tio n s,

b eha vio ra l proclivities, d re a m s , fantasies, a n d
te r p r e t a tio n s of th e d y n a m ic s u n d e rly in g egosyn ton ic sy m p to m s, traits, a n d b e h a v io r only
tra nsferen ce pro jections. N o such casual in d u l

gence is possible in s h o r t-te rm tr e a tm e n t. P iec
too fr e q u e n tly resu lt in d en ial an d an x iety , for

m a la d a p tiv e as they are, n e u ro tic conflicts a n d
ing to g e th e r d a ta from th e p a t i e n t s history,
needs a r e w elded into th e p a t i e n t s h a b it u a l

cop in g m odes a n d yield florid gra tificatio ns
g en era l d e m e a n o r, in te rp e r so n a l exploits, asso

ciations, an d th e few fantasie s an d d r e a m s th a t
a re available, a n d c o rr e la tin g these w ith re a c
tions to th e r a p y an d to the th e r a p ist, as well as
to a n y brief psychological tests th a t m a y have
been given (e.g., m a n - w o m a n d r a w in g s and
e x p o su re to R orsc h a ch cards), the th e r a p is t
c o m p a r e d to w h ich th e p le a s u re s of h e a lth y
p a tt e r n s pale. W h a t is th e best w a y of d e a lin g
w ith such o b stru c tio n s? A p ith y e p ig r a m in th e
K o ra n co n te n d s th a t G o d is w ith th ose w h o
p e rs e v e re . T h i s c e rta in ly a p p lie s to th e u n
d a u n te d th e r a p is t w h o in th e face of o b stin a te
will be able to m a k e some a s s u m p tio n s a b o u t
resistance do ggedly w o rk s a g a in s t it. In lo n g
the p a t i e n t s dy n a m ic s. T h e s e will be a guide
te r m
in co nfro n tatio n s a n d in te rp re tiv e w o rk.
sistances to a reco gn ition of o n e s d y n a m ic s

an d m a n a g i n g s t u b b o rn o p p o sitio n a l re ac tio n s
As has been a m p ly illu s tra te d in the p ast

c h ap te rs, a n u m b e r of d y n a m ic them es, p re s e n t
in the g re a t m a jo rity of people in o u r cultu re,
therapy
th e ta s k of de alin g w ith
re
to th e r e l in q u i s h in g of destru ctive b e h a v io r
have been rep e a te d ly observed th a t can guide
c o n su m e a bu lk of th e tim e devoted to t h e r a p y
a n d can ta x th e e n d u r a n c e of th e m ost reso lute
in b rin g in g some basic p ro b le m s to light d u r

ing th e r a p y , rec og nizing th a t m a n y c o n fig u ra
tions exist th a t a r e u n iq u e for each individual.
t h e r a p i s t . In s h o r t - t e r m t h e r a p y t h e t a s k
w o u ld seem tc be d o u b ly com plicated since
th e r e is only lim ited tim e to p ro secu te the
A m o n g fa m iliar th em es th a t have been d e
search for conflictual th e m e s a n d to resolve
scribed a re th ose relate d to inco m p lete s e p a r a
resistan ce to th e ir disclosure a n d rectification.
tio n -in d iv id u a tio n , residu al guilt feelings and

needs for self-p u n ish m en t, a n d devalued self
U n d e r s t a n d a b ly , o ne c a n n o t d u p lic a te in 10
esteem. It is r a r e th a t one sees any p a ti e n t in

th e r a p y w h o does not possess an a b u n d a n t
s h a r e of th ese leitmotifs, a lth o u g h th e w ay s
th a t th ey m anifest them selves in the c h a ra c te r
s tru c tu r e an d the k ind s of sy m p to m s th ey
sp o n so r a re distinctively idiosyncratic.
W o r k i n g w ith the op erativ e d y n a m ic s co n
sessions w h a t could be achie ved w ith skillfully

conducted t h e r a p y in 100. Yet, e x p erien ce
b ears ou t th e valu e of b rin g in g to th e p a t i e n t s
atte n tio n a g lim p se of his o p e ra tiv e d y n a m ic s
a n d d e m o n s tr a t in g to h im his respo nsib ility in
b rin g in g a b o u t th e d isasters th a t he h a s h i t h
erto credited to destiny a n d m isfo rtu ne.
Confrontation
O n e tec h n iq u e th a t h a s been advocated by
som e s h o r t-te rm th e r a p is ts to cut th r o u g h
re sistance to u n d e r s ta n d in g o n e s dy n am ics is
t h a t of c o n f r o n t a t i o n . T h i s is s o m e t i m e s
utilized to get at u n d e rly in g tren d s by p r o
v oking an x iety or negative feelings. U su a lly
the p a tie n t will re s p o n d to th e t h e r a p i s t s

challenges of his beh av io r w ith a n g e r th a t m a y
be p ro m p tl y su p p re ssed . W h a t will a p p e a r
instead a re disa vo w al, pro test, self-justifica
tion , a n d self-abasem ent, lay in g the b la m e for
o n e s b e h a v io r o n m alev o le n t c ir cu m stan ces o r
139

the dereliction of others. N eg ativ e tra n sferen ce
a w a y so th a t he can to r m e n t him self w ith
r a p i d l y p r e c i p i t a t e s o u t. O p p o r t u n i t i e s a r e
th u s rich for in te rp re ta tio n of feelings ab ou t
he
an d reaction s to the th e r a p is t. T h i s te c h n iq u e
forces h im to d o a n d h o w th e d is p a rity creates
is d ra m a ti c an d often effective in p a tie n ts w ith

good ego s tren g th . H o w e v e r, it can d ras tica lly
difficulties. T h e c o n tr a st b e tw e e n a h e a lth y c o n
h u r t th e t h e r a p e u ti c re la tio n s h ip in a good
actio ns a n d th e p a t i e n t s e x istin g sadistic c o n
n u m b e r of p a tie n ts if im p le m e n te d too e a rly in
science th a t viciously to r m e n t s a n d p u n is h e s is
po in ted out. It becomes essential for th e p a tie n t
th e r a p y before p ro p e r r a p p o r t h as been es
lon elin ess. T h e p a tie n t is he lped to see w h a t

w an ts
to
do
and
w h a t h is c o n s c ie n c e
science th a t g u id es w h ile in h ib itin g destructiv e
ta blished. T h e p a tie n t is a p t to r e g a r d th e
to recognize t h a t a n in t e m p e r a te a n d merciless
t h e r a p i s t s actions a n d m a n n e r as a r b i tr a r y ,
un ju stifiab le, re c r im in a to r y , m alicious, and
c o n s c i e n c e is t h e c o m m o n e n e m y a g a i n s t
w h ic h th e th e r a p is t is his e g o s stro n g a l l y . N o
reflective of the t h e r a p i s t s ina bility to u n d e r
im m e d ia te in te r p r e ta ti o n s a r e m a d e of specific
stan d him o r to e m p a t h iz e w ith his suffering

an d situ ation . It tak es a g re a t deal of skill to
conflicts. T h e initial co n fr o n ta tio n s a re co n

fined to th e p a t i e n t s need for s e lf-p u n ish m e n t
select th ose w h o a re suited for c o n fro n ta tio n
a n d his m asochistic respo nses to a n g e r .
and
to titr a te th e degree of forcefulness of
T h i s focalization, it seem s to me, is used as
challenges to th e p a t i e n t s existing streng ths.

E x p erie n ced th e r a p is ts a r e c a p a b le of d oin g
an e x p ed ie n t to p ro v id e th e p a ti e n t w ith a
this even in th e first interv iew w ith som e p a
energies.
tients, but the av erag e th e r a p is t will be c o m

pen sated for his efforts w ith an e x tr a o r d i n a r y
n u m b e r of d ro p o u t s from tr e a tm e n t. In most
defense, the th e r a p is t m a y not be too far off if

its existence is p o in te d o u t th a t is, of course,
p a tie n ts
w ho
c o m e for h e l p
a m in im a lly
p rovocative p o s t u re will be indicated at first;
single insight in to w h ich h e c an converge his

S in c e
m aso ch ism
is
com m on
if th e p a tie n t p re s e n ts even slight evidences of

its o p e ra tio n . O bv iou sly, m a s o c h ism is not the
the th e r a p ist shou ld w o rk t o w a r d th e e s ta b lis h
o nly basis for sy m p to m s, a n d th e th e r a p is t

sh o u ld not be side trac ke d by usin g th e e x p la
ing of a good w o rk in g re la tio n s h ip before b a t
n atio n of m a s o c h ism as a stra te g y for b re a k in g
terin g a w a y at th e p a t i e n t s defenses th r o u g h
u p the p a t i e n t s resistance. T h e th e r a p is t will
stro n g co nfro ntation s.

Selection of fruitful a re a s for c o n fro n ta tio n
a d d itio n a l re a s o n s for som e of th e p a t i e n t s
w h e n it is do ne is im p o rt a n t. Since m ost p a
tients possess a n overly p rim itiv e a n d severe
sym p tom s.
O t h e r e x p la n a tio n s th a n m a s o c h ism m a y be
conscience (superego) th a t p rov ok es gu ilt, feel

ings of w ickedness, a n d m asochistic beh avior,
offered by t h e r a p is t s tr a in e d in specific schools

of psychology or p sy c h iatry . O n e un iversal
u su ally discover, if a search is m a d e for th e m ,
th ese patho lo gical zones prov id e a p ro du ctiv e
basic cause is p resen ted for all types of e m o
a re a for atta ck a n d discussion. Som e th e r a p is ts

e m p l o y a t e c h n i q u e t h a t i n t e r p r e t s th e
tio n al illness, a n d this single etiological factor
sy m p to m s of th e p a tie n t, no m a t te r w h a t th ey
m a y be (for e x a m p le , an x iety , d epression ,
w o rry , o u tb u r s ts of a n g e r, co nversion re a c
tions, com pu lsion s, p ho b ias, in s o m n ia , a n o r e x
ia, etc.), as m a n ifestatio n s of s e lf-p u n ish m en t,
the co nsequ ences of a guilty conscience (L e w in ,
1970). E ach s y m p to m is d elin eate d as serving
b oth self-to rm e n tin g needs a n d p rovocative
is to r tu r e d to fit in w ith e v e ry s y m p to m a n d
b eh a v io ra l m a n ifestatio n . T h u s , the p a tie n t
m a y be daz zled by b rillia n t e x p la n a tio n s of the
m a lfu n c tio n s of p re g e n ita l splitting , o r of the
O e d ip u s c o m p le x , o r
im age, o r of subversive
tioned anx iety , o r of
th eo rie s a r o u n d w h ic h
of th e devalued selfa rc h e ty p e s, or of c o n d i
an y of th e countless
c u r r e n t psychologically
a i m s t o w a r d o th e r s . E v e n a n i n d i v i d u a l s
d istu rb ed c h a ra c te r p a tt e r n s a re reduced to the
ideologies a r e o rg a n iz e d . W h il e such single e x

p la n a t io n s m a y not be a c cu ra te, they ce rtain ly
a r e con ven ien t a n d th ey m a y be te m p o r a r ily ef
masochistic need to suffer a n d drive pe op le
fective, especially w h e n d o g m a tic a lly stated.
140
O n e of th e a d v a n ta g e s of d o g m a is th a t it
m ak es critical t h i n k in g u nne cessary . A nd some
p a tie n ts a re on ly too e ag er to h a n d over th eir
m in d s to the th e r a p is t w h o will do th e ir t h i n k
ing for t h e m th a t is, un til th e tr e a tm e n t ends,
W h il e aggressive co n fro n ta tio n u n d e r these

c irc u m stan ce s m a y p ro ve p ro fita b le in som e
p a tie n ts w ith good ego stre n g th , it m a y n o t be
a p p lic a b le to sicker p a ti e n ts unless th e co n
fr o n ta tio n s a re to n e d d o w n to a p o in t w h e re
after w h ich th e p a tie n t will begin to re c o n
th e y a r e executed in a n e m p a t h ic r e a s s u ri n g
stitute his o w n fr a m e of reference a n d e n

thusiastic ally rec rea te th e con d ition s th a t got
h im into tr o u b le in th e first place.
w a y . E v en th e n it m a y be necessary to w ait
u ntil a good w o r k in g re la tio n s h ip h as been es
tab lis h e d , a n d th e n o nly after it becomes
T h i s does not m e a n th a t w e should th r o w

the bab y ou t w ith the b ath . Som e of th e
a p p a r e n t th a t m asochistic m a n e u v e rs a re o b
viously being e m p lo y ed by th e p a ti e n t in the
th eo ries an d e x p la n a tio n s m a y be helpful m ore

th a n te m p o r a r ily w h e n a p p lie d to certa in kinds
i n t e r e s t s of r e s i s t a n c e Y o u se e m to
p u n is h in g yo u rse lf by refusing to get w e ll.
of sy m p to m s a n d p e rs o n a lity p rob lem s. Ac

cident p ro ne ness, obsessional self-to rm e nt, su i
T h e p h r a s in g of q u e stio n s can be crucially

im p o r t a n t in h e lp i n g a p a ti e n t ex p lo re a n d
com e to g rip s w ith d e te r m i n in g p ro b lem s. F o r
cidal tendencies, a n d h y p o c h o n d ria c a l preo ccu

p atio ns, for e x am p le, m a y be indications of a
g eneralized m aso chism . A n e x p la n a tio n such
as th e follow ing m a y be offered: Y ou feel
a n g ry at w h a t y o u r p a r e n t s did to you as a
be
ex a m p le , th e p a ti e n t states, I w ish I h a d a
fa th e r w h o w a s like y o u . T h e th e r a p is t m a y
re p ly v a ria n tly alo n g th e follow ing lines: (1)
A n d I w o u ld like to hav e a d a u g h te r (son)
child. B ut you also feel gu ilty for y o u r a n g e r
like y o u . (2) In w h a t w a y did y o u r o w n
a n d th o ug hts. So you p u n is h yourself for these
fa th e r d is a p p o in t y o u ? (3) Y ou m u s t be very
a n g ry at y o u r f a t h e r . (4) R e a c h in g o u t for
th o u g h ts an d
feelings.
Y o u r sy m p to m s an d
y o u r b eh avio r seem to m e to be th e re su lts of

y o u r p u n is h in g yourself. N o w w h a t a re you
a n o th e r fa th e r figure is n t g oin g to h e lp you
going to do a b o u t w h a t you a re do ing to y o u r
m u c h . Y o u ve got to le a r n to stan d on y o u r
be:
o w n f e e t . (5) Y o u r s a y i n g t h a t is a
m a n ifesta tio n of y o u r c o n tin u in g d e p e n d e n c y .
W h e n e v e r you t o r tu r e yourself w ith u p settin g

th o u g h ts, o r you get d epressed , o r you have
(6) W h a t is th e r e a b o u t m e th a t m a k e s you
say t h a t ? (7) Y ou d o n t k n o w m e well
s y m p t o m s ( e n u m e r a t e th e s e ) a s k y o u rs e lf,
W h y a m I p u n is h in g m y se lf? T e ll yourself,
e n o u g h to be su r e of w a n t i n g m e as a f a t h e r .
(8) W h a t do you th i n k w o u ld have h a p p e n e d
I ve p u n is h ed myself en o u g h so j u s t stop i t !
to you if I h a d been y o u r f a t h e r ? E a c h of
S h o u ld these e x p la n a tio n s a n d in jun ctio ns fail

to p ro d u c e results, som e th e r a p ists resort to
s tro n g e r challenges a n d co nfron tatio ns.
th ese re spo nses will elicit c e rta in im p o r t a n t
self?
M ore
d ir e c t
s u g g e s tio n s
may
re actio ns in th e p a tie n t a n d will in fluence th e

re latio n sh ip .
Interpretive Activities
As
th erap y
moves
on
during
th e
first
sessions, the p a t i e n t s responses to in t e r p r e t a

tion will becom e a p p a r e n t . If th ere is rejection
of i n t e r p r e t a t i o n s , lack o f te n s io n a f t e r a
c h a llen g in g in t e rp re ta ti o n is m ad e, or b iz a r re
responses, p a r a n o i d tendencies, o r a cting -o ut
w ith o u t insight occur follow ing in te rp re ta tio n s,
th e p a ti e n t is p ro b a b l y not a m e n a b le to d y
n a m ic s h o r t- t e r m t h e r a p y . In m ost cases, h o w
ever, it will be possible to m a k e i n t e r p r e ta ti o n s
a n d to h e lp th e p a tie n t a c q u ir e a n u n d e r s t a n d
in g of p ro b le m s a n d defenses.
T h e in te r p r e ta ti o n of resistan ce is indicated
from th e very s ta rt of its a p p e a r a n c e , p a r t i c u
141
larly w h e re it tak es th e fo rm of in terfe rin g

w ith th e w o r k in g re latio n sh ip . S h o u ld a n e g a
tive transfe ren ce a p p e a r e ith e r in d r e a m s o r in
th e p a t i e n t s b ehav ior, th e th e r a p is t m u s t i m
m ed iately deal w ith it in as e x p e d ie n t a w a y as
possible.
F o r e x am p le, the resp on se of a p a tie n t after
th e second h y p n o tic session d u r i n g w h ich a r e
bility th a t she w o u ld reject th e ta p e a n d its

co ntents, even refusing to listen to it.
I felt I h a d a sufficiently good re la tio n s h ip to
offer an im m e d ia te a n d re p e a te d in t e rp re ta ti o n
of resistance a n d negative tran sferenc e. T h i s
did h e lp co nso lida te th e w o r k in g re latio n sh ip .
T h e p a ti e n t c o n tin u e d liste nin g to th e tap e,
laxing cassette ta p e w as m a d e for h e r w a s i r r i

tatio n an d a n g e r at li stenin g to th e tap e. U p o n
a n d she d erived a good deal of benefit fro m it.

U n le ss th e p a ti e n t is hig h ly m o tiv ated a nd
th e th e r a p is t h a s been ab le to estab lish an
u rg in g h e r to tell me h e r reactio n s to th e tap e,
early
she stated the following.
a n x ie ty too soon by focusing on an d i n t e r p r e t
P t.
W h e n 1 t r ie d l i ste n in g to t h e t a p e , I f o u nd m y
m ind
w a n d e r i n g . W h e n yo u sa y, Y o u a r e
tired
and
d ro w sy ,
tired
and
drow sy
are
a n t o n y m s . T i r e d m e a n s n o t r e l a x e d . W h e n you
sa y, E v e n y o u r leg m usc le s a r e r e l a x e d , w h y
firm
w o r k in g
re la tio n s h ip ,
p ro v o k in g
ing defenses will ten d to drive th e p a ti e n t out

of th e r a p y . I n t e r p r e t a ti o n s sh o u ld be b alanc ed
ag a in s t th e s ta te of th e p a t i e n t s w illing ness to
ex p lo re p ro b l e m s a n d th e q u a li ty of th e pat i e n t - t h e r a p i s t rela tio n sh ip . C o n s ta n t e x a m i
relief, s i t u a t i o n a l c o n tr o l, self-esteem , self-su g
n a tio n a n d use of th e tra n sfe re n c e to p o in t ou t

h a b it u a l p a t t e r n s of the p a ti e n t a n d th e origin
g e s t io n s ) I sa y t h e fo u r asses. I r e s e n t e d you.
in p a st re la tio n s h ip s m a y be helpful. U n lik e
I w a n t to a p o l o g i z e for m y feelings. I a m s u r
fo rm al an alysis, tr a n sferen ce n eu ro sis shou ld
p r ised a t m y self for l i k in g you . W h e n you said
be avoided, an d deepest c h a r a c t e r p ro b le m s r e
last t im e y ou m i g h t p r e s c r i b e a d r u g for m y
m a i n u n e x p lo r e d since to m a n a g e th e m w o uld
e v e n ? W h e n y o u sa y t h e f o u r S s ( s y m p t o m
d e p r e s s io n , e m o t i o n a l l y I felt you w a n t e d to
kill m e, to i m m o b i li z e m e w i t h m ed icin e. In
t h e t a p e y o u sa y, Y o u a r e filled w i t h n eg ativ e
th o u g h ts
that
we
m ust
n eu tralize,
w hat
th o u g h t s ? A t t h e e n d y o u say Y o u will r e l a x
o r fall a s l e e p . T h e y a r e i n c o m p a t i b l e . I said
re q u i r e m o r e tim e t h a n is av ailab le in th e sho rt

sp a n devoted to tr e a tm e n t.
T o in t e rp re t un co nscio us o r p a rtia lly co n
scious im p u lses p r e m a tu r e ly is w o rse t h a n use
less. T h e r e a r e th e r a p is ts w h o d iv in in g th e
p e r m e a b l e , u n r e a c h a b l e . I felt th is w a y also
conflicts of a p a ti e n t at th e first in terv iew b o m

b a r d h im w ith in t e r p r e ta ti o n s th a t a r e p r e
a b o u t m y m o t h e r a n d f a th e r. Y o u sa y, You
su m e d to p u t th e p a ti e n t ex p e d itio u sly on th e
will i m a g i n e a b eau tifu l r e l a x e d s c e n e . I c a n t
ro a d to cure. A ctually , a n a s tu te d y n a m ic a lly

o rie n te d in te rv ie w e r m a y be ab le to in du ce a
to m yself a b o u t y ou, H e is so g o d d a m i m
fig u re o u t if I s h o u l d j u s t see s o m e t h i n g o r be
in it p e r s o n a l l y sittin g , ly ing , o r sleepin g.
T h e scene I se ttled o n w a s t h e b a n k o f a river
w i t h a b o a t s u n l i g h t on t h e r iv e r reflected it
on t h e w a t e r . Y e s t e rd a y I p o p u l a t e d t h e w a t e r
w i t h a s w im . Also I t h o u g h t t h is w a s all n o n
sense. I tr ie d to o p en m y eyes, b u t m y lids
w e r e so he a v y th ey w o u l d n t o p e n . Y o u say,
E v e n if you a r e con scio us, t h e su g g e stio n s
will be effective. I a m conscious. T h e w h o l e
t h i n g gives m e a fear of e m p t i n e s s . T h i s is
w h a t I felt w i t h m y p a r e n t s . I h av e g u ilt in
r e l a t i o n to m y p a r e n t s . W i t h m y m o t h e r , I r e
j e c te d h e r m u c h o f m y life. 1 t h i n k I id en tified
w i t h m y f a th e r. I to ok o n his s y m p t o m s .
H e r reaction prov id ed th e basis for o u r d is

cussion of h e r tran sferen ce to m e a n d th e possi
p a ti e n t to disgo rg e a good deal of m a t e r i a l r e

lated to ea rly drives, in clu d in g sexual a n d a g
gressive im p u lses a n d fan tasies, to sho w th e
p a ti e n t h o w th ese a r e affiliated w ith p re s e n t
drives a n d sy m p to m s, a n d to d e m o n s tr a t e som e
tr a n s f e r e n c e m a n i f e s t a t i o n s t h a t re f le c t a
ca rry o v e r of childish d is to rtio n s into o n e s con
t e m p o r a r y r e l a t i o n s h i p s . T h e s e d is c lo s u r e s ,
d r a m a ti c as th e y seem an d p e r h a p s are, have
an effect in th e g reat m a jo rity of cases th a t is
d iam e tric a lly o p p o site to t h a t w h ic h is h op ed
for. T h e in t e r p r e ta ti o n s fall on d e a f ears.
N o t lo ng a go I a tte n d e d a conference on
s h o r t-t e rm t h e r a p y w h e re , to m y asto n ish m e n t,
som e tr a in e d a n a ly s ts in ta l k in g a b o u t w h a t
142
they did w ere naively p racticin g w h a t F re u d

him self c o n d em n e d
in
his
1910
paper
tak es th e fo rm of an im o sity to w a r d the t h e r a
on
pist a n d a b r u p t te r m i n a ti o n of tr e a tm e n t. F o r
W ild P sy c h o a n a ly sis (S ta n d a rd E d itio n ,

Vol. 2, pp . 2 2 5 - 2 2 6 ) by co n fro n tin g th e p a
e x am p le, a y o u n g w o m a n of 28 cam e to t h e r
a p y because of an x iety a tta c k s an d a dull p a r a
lyzing d ep ressio n. O n e of h e r chief co ncerns
tient w ith aspects of his unconscious d u r i n g th e

first in terview . If k no w ledg e a b o u t th e u n c o n
scious, w ro te F r e u d , w ere as im p o r t a n t for
w a s h e r 2 -y ea r-o ld child w h o m she feared she

w a s neglecting so m u c h th a t he w ou ld not s u r
th e p a tie n t as peo ple inex perienced in p sy c h o
vive. T h e d isasters she envisioned ra n g e d from
analy sis im ag ine, listening to lectures o r r e a d

ing books w o u ld be en o u g h to cure h im . Such
accidental leth al p o is o n in g to a fatal accident.

A repetitiv e n ig h t m a r e relate d to h e r child fall
m easu res, h ow ev er, have as m u ch influence on
ing o u t of a w in d o w in sp ite of h e r efforts to
th e sy m p to m s of n erv ou s illness as a d is tr i b u
tion of m e n u - c a rd s in a tim e of fam in e h as
save him . H e r s y m p to m s sta rte d sho rtly after

the b ir th of h e r child a n d cau sed h e r to give up
u p o n h u n g e r . M a n y years ago in m y p ristine

e n th u s ia s m w ith deep hy pnosis, I a tt e m p t e d to
uncover in th e tr a n c e som e o f th e f u n d a m e n ta l
a n excellent position in a firm for w h ic h she

h a d w o rk e d since g r a d u a t i n g from college. It
core conflicts of patie nts, e n jo in in g th e m to r e
does not r e q u i r e a g re a t deal of im a g in a tio n to

con stru ct a h y p oth esis of w h a t w a s g o in g on
m e m b e r the revelations th a t they them selves

w ith g reat em o tio n divulged, only to discover
d y n a m ic ally . A reckless th e r a p is t m ig h t reveal
th a t the effect on the p a t i e n t s b eh a v io r w a s
h e r child d e a d so th a t she can be lib erated back

to a n i n d e p e n d e n t life a n d t h a t sh e u n
b a r r e n a n d bleak. I learn ed t h a t a m u c h b etter

tactic w a s to safeg u ard the in fo rm atio n for m y
o w n priv ate e n lig h te n m e n t a n d not w aste tim e
convincing p a tie n ts of m y brillian ce as a p sy
chological detective. O n ce I h a d established a
good w o rk in g r e la tio n s h ip w ith m y p a tie n ts
(a nd it re q u ire d m o re t h a n o ne session), I
to th e p a ti e n t th a t p a r t of h e r w o u ld like to see
d o u b ted ly resen ts h e r ro le as a w o m a n , w hich

re s e n tm e n t sta rte d in h e r e a rly to m b o y d ays
a n d accou nts for h e r p re s e n t sexual frigidity.
T h i s in trig u in g e x p la n a tio n , ho w e v e r tr u e it
m a y be, w o u ld in all p r o b a b ility set off sp as m s
could p rov ide ntly guide th e m w ith p r o p e r in
of r e n e w e d a n x ie ty a n d increase the p a t i e n t s
d e s p a ir a n d hopelessness. O n th e o th e r h a n d ,
terv iew ing te c h n iq u e s t o w a r d co m in g u p o n th e
sho uld th e th e r a p is t be ass u re d th a t a t h e r a
essential co nnections of th e ir presen t topical

beh a v io r w ith f u n d a m e n ta l intrap sy ch ic d e
p eu tic allian ce h as been s ta rte d , h e m igh t

in stead em p lo y a pro jective te c h n iq u e in t e r
te r m in a n ts . T h e y w o u ld th e n tell me w h a t I
h a d previously h o p ed I could sm uggle into
th e ir m ind s in a flash. E ssen tially , I w a s d oin g
w h a t F re u d in 1913 h a d re c o m m e n d e d in his
p a p e r O n t h e B e g i n n i n g of T r e a t m e n t
(S ta n d a rd E d itio n, Vol. 12, p p. 1 3 9 -1 4 2 ) , th a t
is, to w a it u ntil the p a tie n t evinced som e
p re tin g s o m e w h a t as follows:
p reconscious a w a re n e s s of his conflicts.

T h e r e a re, of course, w ays a skillful a n d e x
perienced th e r a p is t can in a ro u n d a b o u t , c a re
is little s t i m u l a t i n g
fully p h ra s e d , a n d e m p a th ic w a y allu d e to th e
essential d y n a m ic s by projective tech niqu es
such as th ose described by A rle n e W o lb e r g
(1973) in h e r book T he B o rd erlin e P atien t. In
this m a n n e r one m a y avoid a n escalation of the
p a t i e n t s a n x ie ty o r a h a r d e n i n g of resistance,
w hich so often in p r e m a tu r e in te rp re ta tio n s
T h . I can
understand
how
u p s e t yo u m u s t
be.
W o m e n do t a k e a k i n d of a b e a t i n g in o u r so
ciety. T h e r e a r e q u i t e a n u m b e r of intelligent
e d u c a t e d w o m e n w h o w h e n t h e y g et m a r r i e d
r e s e n t giv in g u p t h e i r c a r e e r s . A fter all, t h e r e
in
w ashing
d ish e s a n d
p u s h i n g a m o p . S o m e o f t h e s e w o m e n fa n t a s y
a n es c a p e f ro m t h is t r a p ( s m ilin g a t t h is p o i n t
as if j o k i n g ) by i m a g i n i n g t h a t t h e i r h u s b a n d s
will in o n e w a y o r a n o t h e r d r o p d e a d , t h u s
free in g t h e m a g a i n . B ut th ey r e a lly d o n t w a n t
their
husbands
d ead .
They
love t h e i r
hus
b a n d s . B u t t h is is t h e w a y t h e h u m a n b r a i n
works:
it o p e r a t e s by p e c u l i a r sy m b o l s a n d
f a n ta sie s t h a t do no t m e a n t h e y will l i te ra lly be

c a r r i e d ou t.
143
W h a t th e th e r a p is t is d o in g is em p lo y in g an
e x a m p le ro u g h ly a n d ta n g e n tia lly re la te d to
the p a t i e n t s p ro b le m , b u t u sin g a n o th e r p e r
son as the targ et. If she is re a d y to identify
w ith th e e x a m p le , the p a ti e n t will begin w o r k
ing on it as it ap p lie s to h e r a n d h e r r e l a ti o n
R eco gn izing th e d e p th of th e p ro b le m a n d th e
im possibility of a lte rin g the d ep en d e n c y need
in
b rie f t h e r a p e u ti c
effort,
th e
th e r a p is t
focuses on a lle v ia tin g th e s e p a r a ti o n an x ie ty

w ith ego s u p p o r ts . H e b rin g s th e p a ti e n t to an
a w a re n e s s of th e orig in s a n d th e d estructive be
sh ip w ith h e r o w n h u s b a n d a n d h e r child. If
not, she will p a ss it by as irrele van t. In the fo r
h a v io ra l resid u es of his sym biotic needs an d
m e r instance, w h e n th e p a ti e n t op en s u p , th e
fight off th e u rg e for fu tu re e n ta n g le m e n ts w ith

rejecting w o m e n .
th e r a p is t m a y g ra d u a lly be m o re a n d m o r e d i
through
cognitive a p p ro a c h e s
h e lp s h im
to
rect in his in te rp re ta tio n s , ti tr a ti n g th ese to the
D e riv a tiv e con flicts a r e closer to a w a re n e s s
p a t i e n t s level of tole ran ce of a n x ie ty w h ile b e

ing sure to preserve th e w o rk in g rela tio n sh ip .
th a n n u c le a r conflicts, an d the p a tie n t h as

b e tte r control over th em . E x a m p l e : A p a tie n t
In the latter in stance, th a t is, w h e re th e p a tie n t

avoids the in te rp re ta tio n , th e th e r a p is t will
w h o h as been u n a b le to achieve pa ssin g g ra d e s

a t college sees h erse lf as a lo s e r. H e r h isto ry
d ro p the subject an d w ait for a m o re strategic

m o m en t w h e n th e p a tie n t show s g re a te r
reveals a series of failures in a c h ie v e m en t an d
a w a re n e ss before e n g a g in g in c h allen g in g i n
terpretiv e w o rk again. In the case of th e y o u n g
w o m a n j u s t cited, m y in t e rp re ta ti o n w a s c o m
pletely
ig nored,
bu t
tw o
sessions late r
she
b r o u g h t u p fantasies a b o u t th e d e a th of h e r
h u s b a n d , a n d w e w e re ab le to discuss h e r feel
ings an d to m a k e good p ro g ress fro m th a t
po int on.
In p re s e n tin g in t e r p r e ta ti o n s the th e r a p is t
should search for a re a s w h e re e x p la n a tio n s
will be most p ro du ctiv e an d w h e re th e most
resistances to g ettin g well reside. A m o n g these
are n u clea r conflicts, derivative conflicts, n e g a
tive transference; a n d s u n d r y o th e r resistances.
N u c le a r
co n flic ts
freq u en tly
p e r s is t
in in te rp e r s o n a l re la tio n sh ip s . It becomes a p
p a r e n t th a t th e r e is o p erativ e a fear of success
w h ic h is e q u a te d w ith b ein g aggressive and
d estru ctiv e to w a rd o th ers. T h e th e ra p is t
pred icts th a t th is fear of success m a y sp o n s o r a
failu re in th e r a p y . W i t h o u t p ro b i n g th e o rig in s
of h e r aversion t o w a r d ag gressio n, the t h e r a
pist focuses on th e v ario u s m a n ifestatio n s of
th e need to fail an d t h r o u g h desen sitiz atio n
a n d o th e r b eh a v io ra l te c h n iq u e s h elps th e p a
tien t to m a s te r anx ieties re la te d to a com ing
school e x a m in a tio n . U til iz i n g th e p a t i e n t s suc
cessful passin g as a fu lcru m , the th e r a p is t
h elps the p a tie n t evolve w a y s of co p in g w ith
fu tu re challenges.
N e g a tiv e transference will block a n y p r o d u c
th r o u g h o u t the life of th e p ers o n a n d a re

responsible for sy m p to m s a n d b eh av io ra l diffi
tive th e r a p e u tic effort. T h i s focus is p e r h a p s

t h e m o s t i m p o r t a n t o f a ll a r e a s . W h e n
culties. E x a m p le : A p atie n t w h o se m o t h e r died

d u r i n g his infancy an d w h o w a s raised by a
m a n i f e s t a t i o n s o f n e g a ti v e t r a n s f e r e n c e a p
p e a r , its re s o lu tio n becomes a p r i m a r y task.
succession of relatives h as since ch ildh oo d been

in co n stan t search for a loving, giving, m a
E x a m p l e : A p a ti e n t after the second session

becomes hig hly defensive a n d a rg u m e n ta t iv e
tern al figure. H e m in im izes re la tio n sh ip s w ith

w o m e n w h o a r e a c c e p t i n g b u t seek s o u t
liaisons w ith un stab le, rejecting females w ith
w h o m he acts ou t the th e m e of e n te r in g a
perfect id ealized u n io n , on ly to e x p erie n c e r e
jection , h u m ilia tio n , feelings of a b a n d o n m e n t,
a n d s e p a ra tio n anxiety. A c u r r e n t crisis caused
c h a lle n g in g a lm o st every in te r p r e ta ti o n the

th e r a p is t m ak es. It is a p p a r e n t th a t h e w ishes
to avoid e sta b lish in g a w o r k in g r e la tio n s h ip
w ith th e th e r a p is t. T h e th e r a p is t, reco gn izing
th a t th e p a ti e n t is u n re s p o n siv e a n d o b s tru c
tive, c o nfro n ts th e p a tie n t w ith his be hav ior. A
section of th e inte rview follows:
by discovery of infidelity on th e p a r t of th e
y o u n g w o m a n w ith w h o m he h as h a d a r e l a
tion sh ip for a y e a r h as b ro u g h t h im to t h e r a p y .
T h . I no tice t h a t y o u c o n s t a n t ly d i s a g r e e w i t h w h a t
I say.
144
Pt.
N o , sh o u l d I t a k e for g r a n t e d e v e r y t h i n g , like
profession, th e th e r a p is t c on fron ts h im w ith his
g osp e l?
m asochistic need.
T h . I t s
in t e r e s t i n g
that
you
say
gospel.
Your
f a t h e r , y o u told m e, is a m i n iste r .
P t.
T h . I r e a l i z e t h a t , as y o u h a v e told m e, d o c to r s
A r e y o u t r y i n g to tell m e t h a t I m a c t i n g as if
m a k e m ista k e s . B u t I get t h e i m p r e s s io n t h a t
you are m y father?
in y o u r cas e, w i t h so m a n y m ed ical a n d n e u
T h . A re you?
P t.
ro lo g ic al ch ecks, t h e r e is little c h a n c e you h a v e
(lo n g p a u s e )
I d o n t t h i n k
so,
bu t
(p a u se)
c a n c e r of t h e b r a i n . M o r e i m p o r t a n t t h a n t h is
m a y b e y o u re r i g h t. I w a s a n a th e is t ever since
is w h y y o u h a v e to t o r t u r e y o u r s e l f w i t h t h is
I w a s 6 y e a r s old.
idea o r w i t h o t h e r fears. L i k e all t h e o t h e r
T h . Yo u m e a n f ig h tin g t h e g osp e l?
Pt.
c a n c e rs y o u t h o u g h t y o u w o u l d d ev elo p in t h e
(la u g h s ) W h a t y ou a r e t r y i n g to d o h e r e is
h a r d l y religio n.
p a s t a n d d i d n t.
P t.
T h . B u t you m a y be a c t i n g w i t h m e as if I m a
h ig h p riest.
P t.
cold sw eat.
(la u g h in g ) Y o u r e t r y i n g to tell m e I m m i s b e
T h . (fir m ly ) N o w
h a v in g .
listen to m e.
Y o u a r e giv in g
y o u r s e l f a h a r d tim e . N o w w h y in t h e devil do
T h . T h i s is h o w y o u m u s t feel. I c e r t a i n l y d o n t
y o u h a v e t c w e a r a h a i r s h i r t all t h e tim e. O n e
believe y o u re m i s b e h a v in g . You h a v e a r ig h t
t o r t u r o u s id ea af te r a n o t h e r .
to y o u r o w n th o u g h t s . W h a t w e r e t r y i n g to do
h a d it. I re a l l y feel y o u ve a l w a y s h a d it. I
is t o find o u t h o w yo u can get a l o n g b e tte r
re a l l y feel y o u ve got a s t a k e in p u n i s h i n g
w i t h p e o p le . A n y m a y b e if yo u c a n w o r k o u t a
yourself. All t h e g u ilt feelings yo u h a v e a b o u t
Y o u ve a l w a y s
b e t t e r r e l a t i o n s h i p w i t h m e it will h e l p you get
y o u r p a r e n t s . Y o u m u s t feel t h a t y o u a r e a t e r
a l o n g b e t t e r w i t h o th e r s. T h a t d o e s n t m e a n
r ib le p e r s o n for fe eling t h e w a y y o u do.
I m a l w a y s r i g h t in w h a t I sa y. B u t I t h i n k I
P t.
c a n be m o r e objective a b o u t w h a t y o u d o t h a n
P t.
D o c t o r , I tell you, I get so u p s e t . I c a n t e a t o r

rest. I get u p in t h e m i d d l e of t h e n i g h t w i t h a
I c a n t get t h e t h o u g h t s o u t of m y m i n d a b o u t
w h a t w ill h a p p e n to m e w h e n th ey die.
you can. A n d if I p o i n t o u t t h i n g s t h a t se em
T h . L ik e w h a t ?
like critic is m , I m no t t r y i n g to be m e a n o r a r
P t.
(p a u se ) I d o n t k n o w . I m a f r a id I c a n t get
b i t r a r y . L e t s t a l k it ou t. I t s i m p o r t a n t for yo u
a l o n g w i t h o u t t h e m . A n d yet I h a v e th ese a w
to de cide if I m r i g h t or w r o n g .
ful t h o u g h t s t h a t s o m e t h i n g t e r r i b l e will h a p
D o c t o r , I h o p e y o u can be t o l e r a n t w i t h me. I
p e n to t h e m . [O b v io u s ly th e p a tie n t is c a u g h t
k n o w y o u a r e r i g h t in w h a t yo u a r e sa y ing . I ll
in
try.
p a r e n ts , fe e lin g tr a p p e d , re s e n tin g h is h e lp
T h . T h i s d o e s n t m e a n you h a v e to t a k e for g r a n t e d
everything
I sa y. A f te r all, I m no t a h ig h
p riest.
c o n flic t
o f d e p e n d e n tly
n e e d in g
h is
less d e p e n d e n c y , fe a r in g th a t h is a n g e r w ill
s o m e h o w b rin g a b o u t th e ir d e a th a n d tu r n in g
th is r e s e n tm e n t b a ck on h im s e lf. H is g u ilt fe e l
in g e n jo in s h im to p u n is h a n d to rtu r e h im se lf.
V a rio u s o th e r re s ista n c e s i n t e r f e r e w i t h
prog ress in th e r a p y . It m a y even be helpful to
an tic ip a te resistances if th e his torical d a t a an d
initial w o r k u p p o in t ou t a re a s of im p e n d in g
tr o ub le. E x a m p l e : An a c cid en t-p ro n e p a tie n t
w ith a n obsessive-compulsive p e rs o n ality seeks
th e r a p y for a n x ie ty a n d d epression. F r o m early
ch ildhood on h e has been fearful of h a r b o r in g
a d rea dful disease, the p re s e n t form of w h ic h is
cancer. At th e fifth session w h e n it becomes
a p p a r e n t th a t re a s s u ra n c e h as failed to allay
his fear of su cc u m b in g to a can cero u s process
of th e b ra in a k in to th a t of a colleague in his
T h is w ill p r o b a b ly p r e v e n t h im f r o m b e n e fittin g f r o m
th e r a p y .
T o tr y to ta k e a w a y h is
m a s o c h istic n e e d f o r s e lf- p u n is h m e n t w ith o u t

d e a lin g w ith th e basis f o r h is g u i l t w o u ld p r o v e
e ith e r f u t i l e o r w o u ld o n ly be te m p o r a r ily su c
cessfu l. ]
T h . N o w look. Y o u h a v e t h is n eed to p u n i s h y o u r
self a n d all t h e t o r t u r e y o u re p u t t i n g y o u r se lf
th ro u g h ,
and
all
your
sym ptom s
and
th e
m esses y o u get in to , a c c id e n ts a n d all, a r e , I

feel,
d irectly
related
to
t h is
n eed
for
self
p u n i s h m e n t . T h e r e a s o n I b r i n g this u p is t h a t
as l o n g as yo u h a v e t h i s n e e d , you w ill block
y o u r s e l f f r o m g e t t i n g well in o u r t r e a t m e n t .
145
W h a t w e a r e g o in g to d o is p l a n h o w y ou can
t h e r a p y a p p ro a c h e s . E x a m p l e : A p a ti e n t w h o
b r e a k this vicious cycle.
w a s m a k i n g p ro g r e ss u p to th e seventh session
b eg an to e x p erien c e a r e t u r n of sy m p to m s. H is
A tr e a tm e n t p la n th e n w a s evolved to help
d r e a m s revealed fears of a b a n d o n m e n t , feelings
h im b re a k his d e p en den cy ties by getting h im
of helplessness,
to ta k e v acations a w a y from h o m e a n d th e n to
th e r a p is t. A f r a n k discussion of h o w n a t u r a l it
find a n a p a r t m e n t for him self a w a y fro m his
w a s to e x p erien ce fear of b e in g u n a b le to fu nc
tion on his o w n as t h e r a p y t h r e a te n e d to end,
family. H a v in g been enjo in ed to vent his

an g er, the p a ti e n t b ecam e increasing ly a b le to
tolerate his hostility a n d to accept his p a r e n t s
for w h a t they w ere. W i t h s u p p o r t h e w a s able
and
r e s e n tm e n t t o w a r d
the
a n d h o w i m p o r t a n t in his g r o w th process it
w a s to tackle his fears a n d m a s te r th e m ,
b r o u g h t o u t e a rly a n x ieties a b o u t g oin g to
to resist th e ir in s in u a tio n s th a t he w a s a d is
school, leaving h o m e for college, a n d b re a k in g
loyal son for leaving th e m a n d for living his
u p w ith fo rm e r girlfriends. P u tt in g his presen t
o w n life. A d r a m a ti c ch a n g e occ urre d in his

sy m p to m s, an d a 2 -y e a r fo llow -up sh o w e d co n
tin u e d im p ro v e m e n t a n d m a t u r a t io n .
S eparation a n x iety will e m erg e as th e en d of
rea ctio n into th e perspective of a p a t t e r n th a t

w a s not so te r rib ly a b n o r m a l e n a b le d h i m to
te r m i n a te a t th e set d a te w ith feelings t h a t he
h a d th e stre n g th to c a rr y on by himself.
Special Applications of Technique

S h o rt-term
therapy
em braces
h etero
g eneo us g ro u p of in te rv en tio n s c ata ly zed by

th e th e r a p i s t s e n th u s ia s m , th e p a t i e n t s faith,
a n d sh ared hope. W h il e it is t r u e th a t te c h
Sokol (19 7 3), for e x a m p le , h a s devised a

s h o r t-t e rm m e th o d for h a n d li n g s i m p l e o r
e n d o g e n o u s de p res sio n s b ased on some p r i n
cies, th e choice of in terv e n tio n s a n d th e skill

w ith w h ich they a re im p le m e n te d a re crucial
ciples of p sy c h o a n a ly tic the o ry . T h e h y p o t h e t

ical a s s u m p ti o n s a r o u n d w h ic h th e t r e a tm e n t
process is o rie n te d co n te n d t h a t several factors
m u s t o p e r a t e to p r o d u c e a clinical d epressive
to success. It is to be expected th a t m od ifica

ti on s in tr a d itio n a l p s y c h o th e ra p e u tic te c h
reac tio n . F ir st, th e r e m u s t be a c u r r e n t loss of

som e k in d , such as th e d e a th o r rem oval of a
n iq u e s will be in tro d u ced by c e rta in th e r a p is ts
p erso n close to one. T h i s acts as a sp a r k , ig n it
n iq u e s serve to release i m p o r t a n t h e a lin g a g e n
w h o fashion th e ir th eo ries a r o u n d m e th o d s
t h a t seem to w o r k for th e m pe rs o n ally . T h i s is
ing th e explosive m i x tu r e of a n e a rlie r loss in
all to th e good, of course, except w h e r e the
th e c h i l d - p a r e n t r e la tio n sh ip . Second, a p r i m i
tive, p u n itiv e conscience (su perego ) m u s t exist
th e r a p ist a tt e m p t s to in c o r p o ra te all of p sy
th a t will no t p e r m it th e release of conflictual
ch o p ath o lo g y w ith in his cherished th e o ry a n d

to insist th a t on ly his m e th o d s a r e valuab le.
W e m a y forgive these narcissistic m a n e u v e rs
em otion s, p a r t ic u l a r ly hostility. Since hostility

c a n n o t be h a n d le d by th e sim p le m e c h a n is m of
re p ressio n , m o r e p rim itiv e ego m e c h a n is m s a re
utilized, such as de n ia l, introjection , a n d in c o r
p o ra tio n . U s u a ll y o th e r e m o tio n s c a n n o t also
shou ld the m eth o d s p re s e n te d have sufficient

value to ju stify e x p e rim e n tin g w ith th e m to see
if they fit in w ith o u r u n iq u e ideologies a nd
w o rk in g styles. A nd w e m a y be able to modify
an d s h ap e some of th e m to o u r p e rs o n a l a d v a n
ta g e . B u t, a c c e p t a n c e of t h e th e o r e t i c a l
prem ises for these inn ov ativ e p ro c e d u re s will
r e q u i re th o r o u g h e x p e ri m e n t a l validation.
be to lerate d , a n d b o th negative a n d positive

feelings a r e blotted out. T h i r d , this le ads to
f u r th e r s h a m e a n d guilt an d begins a regressive
s p i r a l . If w e concede th e validity of th is h y
p othesis in o r d e r to c u re a d e p re s sio n , hostility
t o w a r d th e lost object m u s t be recognized,
146
tolerated, an d released. Since the p a tie n t c a n
a n d a ssu m es th is is because h e lacks essential
not do this for him self, th e th e r a p is t m u s t do it
a tt r i b u te s to m e r it w o rth in e ss. H e a ss u m e s his

difficulties will c o n tin u e indefinitely in th e fu
for him . I r e a s o n e d , said Sokol, th a t, if the

a ttack cam e from me, th e p re s su re on th e p a
ti e n t s su perego w o u ld be d im in ish e d a n d the
tu r e , th a t failu re is his destiny. T h e s e c h a r a c
affectionate im p ulses could be expressed in d e

fending the lost perso n fro m this e x te r n a l a t
d ep ressio n. In tr e a tm e n t th e p a tie n t is en joined

to keep a reco rd of aspects of his negative
ta c k e r . U sin g this tactic b ro u g h t a b o u t a r e
t h i n k in g w h e n e v e r this occurs an d to connect

these episodes w ith a n y associated e n v ir o n
mission in th e cases described by Sokol.
teristics
c o n stitu te
th e
cognitive
triad
in
Lest one get too e n th u s ia stic a b o u t S o k o ls
m e n ta l events t h a t trig g e r th e m off. T h e sim p le
m eth o d, even th o u g h th e d y n a m ic s m a y so und
q u a n tify in g of a n y s y m p to m s in th is in stan ce
plau sib le, one m u s t re m e m b e r th a t only th ree

cases w ere cited in th is study. M o r e o v e r, in
negative t h i n k i n g tend s to red u ce th em . T h e

th e r a p is t, w h e n e v e r th e p a tie n t d u r in g a
e a c h case b o t h a n t i d e p r e s s a n t s a n d t r a n
q u ilize rs w ere co o rd in ately used. O t h e r in n o
session brin g s u p a negative th o u g h t, ask s th e
vations cla im in g good resu lts w ith d epression

exist an d e m p lo y different tec h n iq u e s orie n te d
t h e r a p y , to do th is by him self. T h r o u g h this

m e a n s th e p a ti e n t is help ed to see h o w he
m a k e s u njustified a s s u m p ti o n s ( a r b i t r a r y in
around
c o m p l e te l y
d i s s i m i l a r t h e o r i e s , for
p a ti e n t to re a lity test it an d th e n , a w a y from
instance, the cognitive th e r a p e u tic m e th o d s of

A. T . Beck (1971, 1976).
feren ces ), h o w h e m agn ifies th e significance
In cognitive th e r a p y an a tt e m p t is m a d e to
rectify c o nce ptu al d isto rtio ns in o rd e r to c o r
he uses insignificant s itu a tio n s to ju s tify his
rect the w ay s th a t reality is being experienced.
cognitive e r r o r s a r e identified, such as h ow

offensive details a r e used o u t of context w hile
In terv ie w in g tech n iq u es a n a ly z e defects in a

p a t i e n t s views of the w o rld (cognitive a s s u m p
tions o r s c h e m a ), his m e th o d s of stim uli
screening a n d d ifferen tiation , a n d th e e r r o
of selected events ( m a g n i fi c a ti o n , ) an d ho w
p o in t of view
( o v e r g e n e r a li z a tio n ). O t h e r
i g n o r i n g m o r e i m p o r t a n t c o n s t r u c t i v e facts
( selective a b s t r a c t io n ), h ow c irc u m stan ces
a n d t h o u g h t s t h a t do not fit in w ith negative
neous ideas th a t m e d iate destructive respo nse
s c h e m a s a r e b y p a s s e d ( m i n i m i z a t i o n );
p a tte rn s . H o m e w o r k a ss ig n m e n ts reinforce the
h o w u n re la te d events a re un ju stifiab ly a p p r o
p a t i e n t s ability to deal constructively an d c o n

fidently w ith ad a p tiv e tasks. T h e tr e a tm e n t is
p ri a te d to s u b s ta n ti a te his id eas ( p e r s o n a liz a

t i o n ). T h e p a ti e n t is en co u ra g e d to review his
sh ort term , consistin g of a p p r o x i m a t e ly 20

sessions on a tw ice-a-w eek basis. C o gn itiv e
th e r a p y for d ep ressio n is o r g a n iz e d a r o u n d a
n u m b e r of a s s u m p tio n s (R u s h & Beck, 1978;
R u s h et al, 1977). As a c o n sequ ence of early
events, the p a tie n t re ta in s a s c h e m a th a t
m ak es h im v u ln e r a b le to d epression . A m o n g
such events is the d e a th of a p a r e n t o r o th e r
record
im p o r t a n t perso n . W h a t results is a p redepressive cognitive o r g a n i z a t i o n . O p e ra tiv e

h e re is a global negative a ttitu d e on the p a r t of
th e p atie nt. T h u s he m isco nstrues situ atio n s to
a p o in t w h e re he has tailo red facts to fit
p r e c o n c e i v e d n e g a ti v e c o n c l u s i o n s ( R u s h ,
1978).
The
p a tie n t r e g a r d s him self as u n w o r th y
of th o u g h ts , to identify
th e m e s an d
as s u m p tio n s , a n d to identify p a st events th a t

s u p p o r t his fau lty schem as. P o in t by p o in t the
th e r a p is t offers a lte rn a tiv e in t e r p r e ta ti o n s of
these past events. By so d o in g he h op es th a t
sufficient d o u b t will develop in th e p a tie n t so
th a t he will e n g ag e in e x p e r i m e n t a l b ehav iors,
re co g n izin g the fallaciousness of his h y p o t h
eses, an d a rriv e at different, less destru ctive e x
p la n a t io n s for events. A m a r it a l p a r t n e r or
fam ily m a y also be involved in cognitive t h e r
ap y to reinforce co rrection of d isto rted negative
m e an ing s.
S tep by step th e p a tie n t is en co u ra g e d to u n
d e rta k e tasks th a t he h it h e r t o h a d considered
difficult ( g ra d e d task a s s ig n m e n t ) an d to
147

k e e p a r e c o r d of h is a c ti v it ie s ( a c ti v it y
sch e d u lin g ) a n d th e degree of satisfaction an d
necessary
to
com fort
th e
p a tie n t.
A pprox
im ately 15 sessions often lead, it is re p o r te d ,
sense of m a s te ry achieved ( re c o r d in g a mood
to a r e c o n s t r u i n g
g r a p h ). D i s c u s s i o n s
focu s o n
o thers, w h ich in t u r n facilitates th e a d o p tio n of
the p a t i e n t s reaction s to his task s a n d his
m o r e p ro d u c tiv e life r o l e s t o w a r d r a p i d p e r
in t h e r a p y
o f self a n d
s i g n if i c a n t
tendencies at m i n im iz a tio n of p le a s u re a n d
son ality a n d b e h a v io r ch an g e. T h e s im ilarity
success. H o m e w o r k ass ig n m e n ts a r e crucial.
of m a n y aspects of this E R T te c h n iq u e w ith
T h e s e r a n g e fro m b e h av io rally o rien ted tasks
F r e u d s
in severe dep ression to m o r e a b stra c t task s in
recognized.
less severe cases o rie n te d a r o u n d c orrec ting e x

isting schem as. S h o u ld negative tra n sfe re n c e
occur, it is h a n d le d in th e m a n n e r of a biased
early
cath a rtic
m ethod
w ill
be
A n o th e r e x a m p l e of th e use of a th eoretic al
p rin c ip le to fash ion a clinical a p p r o a c h is p r o
vided by Suess (1972). H e p o in ts o u t t h a t d y
cognition.
E m p lo y in g a cognitive model of p e rs o n ality ,
M o r r i s o n an d C o m e t a (1 97 7) h av e evolved
nam ic sh o rt-term
therapy
is o b s t r u c t e d in
w h a t th ey call e m o tiv e -reco n stru ctiv e s h o r t
te lle ctu aliz atio n , self-control, a n d a tt a c h m e n t
te r m th e r a p y ( E R T ) . T h e th e o ry b e h in d the
tec h n iq u e is t h a t u n f o r tu n a te e arly c h ild ho od
as
stress exp erien ces lead to a p e r s o n s i n a d e
p e rs o n a l re la tio n s h ip . A n i m p o r t a n t objective
the obsessive-com pulsive in d iv id u al by rigid

tendenc ies to avoid feelings of excessive inwell
as
by
g re a t
fears of s u r r e n d e r i n g
oneself to h u r t an d ex p lo ita tio n in a n y in t e r
q u a te c on struc tion of self a n d o t h e r s . T h i s
in in te rv ie w in g th ese p atie n ts , therefore, is to
p ro d u c e s a p lay in g of faulty roles a n d self-con
h elp th e m rec o g n ize th e ir feelings by w o r k in g

on th ose th a t a r e a ro u s e d in th e c u r r e n t i n t e r
c e p tu a liz a tio n s in later life. T h u s som e c h il

d re n , not being able to e n d u r e th e ir p a r e n t s as
no nloving, distort rea lity by c o n s tru in g th e m
view
situ atio n.
T hese,
m an ifested
in
v e r
b aliza tio n s, voice to ne, facial ex p res sio n , body
as loving an d them selves as bad. E ssen tially
movement
locked into th e role of bad child as a m e a n s of

re d u cin g the stress a n d confusion of p a r a
dealt w ith by such p h ra s e s as Y ou sound

a n g r y , Y ou look a n g r y , Y ou look dis
doxical
i n d i v id u a l s
g u s t e d , Y ou a p p e a r u n c o m f o rta b le in s id e .
s u b s e q u e n t life experiences a r e b u t r e p la y s of
early ro le s. W h a t m u s t o ccu r to overcom e this
referra l to p a s t histo ry a n d genetic origins.
d istortion th e n is a discovery of key conflicts

a n d a correction of th e ir in t e r p r e ta ti o n . Instead
theo retical, p h ilo so p h ical, o r intellectual dis
fam ily
c o m m u n ic a tio n s ,
of try in g to force this by in a p p r o p r i a t e search

strategies, as is the case in tr a d it io n a l p sy c h o
and
o th e r
n o n v e rb a l
c u e s ,
are
P re s e n t m e a n i n g s a r e m o r e i m p o r t a n t th a n
W h e n e v e r th e p a tie n t a tt e m p t s a diversion by
cussion, it is a rr e s te d an d th e focus red irected
at feelings, su ch as b eing a n g r y , guilty, affec-
th e r a p y , a te c h n iq u e of direct ex p e rie n c in g is
used by M o r r i s o n an d C o m e t a . P a tie n ts a re
tio nal, de pre sse d, an d so on. T h e defensive n a
asked to s h u t th e ir eyes an d to im m e rse

them selves in p a st events by focusing on the
c o nte xtual s u r ro u n d in g s (colors, odors, noises,
te x tu re ) of e arly e x p e rie n c e s d escribin g these
briefly. P eriodically, w h e n th e th e r a p is t w ishes
to aro u se the e x pression of a certain feeling,
th e p a tie n t is asked to h y p e rv e n tila te by
b r e a th in g d eeply a n d r a p i d ly for 30- to 60-
sh ou ld also be in te rp re te d , for e x a m p le , th e in
cessant a n d p a r a l y z in g need to m a i n ta i n co n
trol. Self-criticism p o w e re d by a n excessively
p u n itiv e su p e r e g o is te m p e re d by suggesting
second tim e p e r i o d s . G e s ta l t a n d ro le -p la y in g
t e c h n i q u e s m a y c o o r d i n a t e l y be e m p l o y e d .
sy m p to m s. In te lle c tu a liz a tio n s and d o u b ts

u tilized as a w a y of g u a r d i n g a g a in s t re c o g n i
tion of feelings in o n e s p re s e n t life m a y seduce
S u p p o rt is given a n d e m p a t h y sh o w n w h en
tu r e of silences on th e p a r t of the p a tie n t
the possibility of less critical attitud es. F o c u s

ing on th e e m o tio n s b e h in d v e rb a liz a tio n s
r a t h e r th a n the co n ten t is i m p o r t a n t, especially
when
th e
p a ti e n t
keeps
ta l k in g
about
his
148
th e th e r a p is t in to e n g a g in g in fruitless debates,
for e x a m p le , th e p a ti e n t m a y en g a g e in d a n
th u s falling into th e p a t i e n t s t r a p of a voiding
g ero u s overactivity, neglect of his diet, a n d
feelings. T h e p r o p e r resp o n se to th ese m a
fo rge tting to ta k e essential m edications. It is,
neuvers, claim s Suess, is to expose th e m as

resistances.
th erefo re, i m p o r t a n t to review w ith th e p a ti e n t
Som e in no vativ e a tt e m p t s at p r o p h y l a x is of
e m o tio n al illness have been m ad e. A m o n g
these is th e w o r k of Stein et al (1969) on brief
t h e r a p y w ith seriously phy sically ill patients.
his ideas o f his illness a n d his a ttitu d e s t o w a r d

it especially his hopelessness. By careful c larifi
catio n cou pled w ith re a s s u r a n c e w e m a y be
able to c orrect existing m iscon ception s an d
T h e d e velop m e nt of a n illness, p a r t ic u l a r ly of
cognitive d isto rtio n s. T h e r e l a ti o n s h ip w ith th e

th e r a p is t can g re a tly h e lp th e p a ti e n t to accept
a n in c u r a b le a n d d eb ilita tin g n a tu r e , im poses a
a factual a sse ssm en t of his situ atio n . T h e t h e r
severe stra in on a n y in d ivid ua l. W h e r e th e p a
a p is t h e re serves in a role sim ila r to the
tien t is u n a b le to accept th e im p osition of a
p ro tectin g p a re n t w ho m ak es p ain fu l and
t e m p o r a r y o r p e r m a n e n t h a n d ic a p , w h e r e his
self-im age
t h r e a te n i n g re a lity less in to le r a b le to th e child,

th u s e n a b lin g th e child to accept a n d face
d a m a g e d by the re a liz a tio n of his v uln erab ility ,
rea lity , w ith its h a z a r d s , r a t h e r th a n h a v in g to
path olo gical psychological reactio ns ( p a r t i c u
d en y a n d s h u t o u t (Stein et al., 1969).
security
is
th reaten ed
and
h is
larly anx iety, d ep re ssio n, tendenc ies to w a r d

den ial, a n g e r, a n d a v ariety of n e u ro tic a n d oc
M a n a g i n g a s h a t te r i n g of th e sense of m a s
casionally, in th ose w ith fragile ego stre n g th ,
tery is i m p o r t a n t , especially in th ose perso n s

w h o h a b it u a ll y m u s t m a i n ta i n control. T h e
psychotic m an ifesta tio n s) will im po se t h e m
fear th a t a n illness can strik e w ith o u t w a r n i n g
selves. B ecause th e p a ti e n t m a y as a con se

quence
becom e a p sy ch iatric c asu alty ,
a n d t h a t it m a y be a h a r b i n g e r of o th e r u n
p s y c h o th e ra p e u tic
as
d is asters destro ys th e in d i v id u a ls confidence in

his o w n body. R e a s s u r a n c e th a t a n tic ip a te d
in terv en tio n s in stitu ted
soon as possible a r e u rg ent.
known
and
perhaps
m ore
serious
physical
At th e C e n tr a l P sychiatric C linic in C i n c i n
c a ta s tr o p h e s a r e n ot inev itable an d th a t p r e
n a ti an early-access b rief t r e a tm e n t subdivision

(S te in et al. 1 9 6 9 ) a c c e p ts p a t i e n t s w h o
ventive m e a s u re s a r e a best m e a n s of h e lp in g
to avoid u n w e lc o m e tro u b le s m a y q u ie t th e p a
p referably have severe physical p ro b le m s of
t i e n t s fears. E n c o u r a g i n g th e p a ti e n t to v e n ti
late fantasies associated w ith the illness, th e
recent origin. U p to six sessions a r e given,

each lastin g from 15 to 50 m in u te s, spaced on
th e av erage of on e visit each w eek. In th e m a
jo r it y of th ese p a tie n ts sy m p to m a tic im p ro v e
m e n t an d re s to ra tio n of satisfactory fun ctio ning
h as followed th is b rief t r e a tm e n t (G o tts c h a lk et
al., 1967). T h e t r e a tm e n t process is best o r
ga n ize d by (1) h a n d li n g th e tendencies to
den ial, (2) m a n a g i n g a s h a tte rin g of th e sense
of m aste ry , a n d (3) d e a lin g w ith th e conviction
of im p a ir e d body integrity.
H a n d l i n g of the tendencies to den ial is c r u
cial. B la n k u nb elief often o p e ra te s as a p r i
m a r y defense to insu la te th e p a tie n t from the
im p lica tion s of his illness ( L in d e m a n n ,
S uch de n ia l, in terfe rin g w ith th e tr u e
m e n t of the reality situ a tio n , con stitutes
d a n g e r for th e ind ivid ual. In co ro n a r y
1944).
assess
a g reat
illness,
th e r a p is t is th e n in a b e tte r position to offer

advice c o n c e rn in g specific medical an d n e u
rological co n su lta tio n resources.
D e a lin g w ith th e conviction of im p a ir e d
body in teg rity involves r e s to rin g faith in o n e s
body. T h i s is especially necessary in tr a u m a t ic
in ju ries a n d surgical p ro c e d u re s. T o som e e x
te n t a re actio n of fatig ue an d a re a c tio n of
d ep re ssio n t e m p o r a r ily follow even relatively
m in o r accid en ts and o p e ra tio n s. B ut after
serious o p e ra tio n s , such as b re ast a n d lim b
a m p u t a t i o n s a n d effects of m u t il a ti n g acci
d en ts, a p ro lo n g e d p erio d of u p set c an be e x
pected. W it h the a d v en t of o p e n - h e a r t s u rg e ry
m a n y u n t o w a r d r e s i d u a l p s y c h o l o g ic a l s e
q u e la e h ave been re p o r te d . Severe a n x ie ty an d
psychotic reac tion s a r e especially th r e a te n e d in
149
pe rso n s w h ose a d a p tiv e b a la n c e is p re c a rio u s,
p a t i e n t s p h y sicia n , a n d th is m a y a lie n a te the
It does not r e q u i r e intensive p ro b in g to recognize ho w a n g ry a p a ti e n t is at w h a t h a s h a p -
p a ti e n t from essential sources of s u p p o r t a n d

com fort. O p e n i n g u p dis cussions a r o u n d this
pened to h im . Such a n g e r m a y be displaced o r
d y n a m ic can be most constructive,
projected onto fam ily m e m b e rs an d even o n the
Brief Group and Family Therapy

B rief g ro u p p s y c h o th e ra p y is a n econom ical
p ro x im a te ly tw o - t h ir d s of th e p a tie n ts have
w a y of h a n d lin g p a tie n ts w h o have th e m o t iv a

tion an d c apacity to in te rre la te in som e w a y in
been ra te d as im p ro v e d a t th e end of th e ir
tr e a tm e n t.
a g ro u p . As a d iagn ostic a n d in ta k e p ro c e d u r e
it h a s been em plo yed w ith success in c e rta in
A good deal o f lite r a tu r e h a s a c c u m u la te d on

th e subject of brief g r o u p th e r a p y , a n d a n u m
clinics (Peck, 1953; S to ne et al, 1954), p a r t i c u
b er of different m odels h av in g been described
larly w h e re th e r e a re w a iti n g lists a n d a n u n

de sira ble delay in ass ig n m e n t to a th e r a p is t.
H e r e the g ro u p serves as m o re t h a n a ho ld in g
o p e ra tio n , some p a tie n ts benefitting sufficiently
from th e g r o u p contact so th a t f u r th e r in
d iv i d u a l
treatm en t
is n o t
needed.
in th e first c h a p te r of this book. S o m e re p o r ts

on th e efficacy of s h o r t-t e rm g r o u p s a r e esp e
cially en th u siastic. T r a k a s an d L lo y d (1971)
w o r k in g w ith a n o p e n -e n d e d g r o u p of p a tie n ts
for no m o re t h a n six sessions re p o r te d tw ice as
A t th e
m u c h im p ro v e m e n t as w a s th e case in p a tie n ts
M e t r o p o li ta n H o s p ita l C e n te r in N e w Y ork,
receiving o th e r k in d s of h elp , in clu din g lo n g

te r m g ro u p t h e r a p y . W a x e r (1 97 7) in tro d u c ed
S adock a n d his colleagues (1968) h ave o p e r

ated a s h o r t-te rm g r o u p th e r a p y service for
m o tiv ated p a tie n ts from a g en e ra l h o sp ita l p sy
socially a n d econom ically deprived p a tie n ts as
c h ia tric w a r d into a g r o u p for no m o r e th a n
p a r t of a w a lk -in clinic. At the initial in terview
o ne m o n t h a n d w a s also very o p tim istic a b o u t

th e results. O n th e o th e r h a n d , M c G e e a n d
the 10 sessions limit is e x p la in e d by the social

w o r k e r w ith the a d d e n d u m t h a t sho uld th is be
M e y e r (1971) c o m p a r e d tw o g r o u p s of schizo
insufficient, lon ger th e r a p y m ig h t be a rr a n g e d .
p h re n ic s u tilizin g vario u s r a t in g m a t e ri a ls a n d
O n e - h o u r sessions a re held w eekly, conducted
fo un d th a t lo n g - te rm g ro u p s w e re m o r e effec
tive.
by a co th erap is t te a m of p sy ch iatrist an d social

w o rk e r. N o m o re t h a n eight p a tie n ts a re in a
g ro u p w ith new p a tie n ts ad d ed as vacancies oc
T h e kin d s of p a tie n ts , th e ir p r e p a r a t i o n for

t h e r a p y , a n d th e skill a n d p e rs o n a lity of th e
cur. T h e av erag e n u m b e r of sessions a tte n d e d
g r o u p th e r a p is t a r e obviously crucial elem ents
is five. T h e p a tie n t p o p u la t io n is h e te r o
g eneous edu catio n ally , racially, a n d diag n o stically. W h e r e necessary, c o m m u n ity agency
in d e t e r m i n i n g t h e r e s u l t s in s h o r t - t e r m
g ro up s. T h e t h e r a p i s t s a ttitu d e t o w a r d g ro u p
t h e r a p y a n d his interest in w o r k in g w ith a
g r o u p a re cru cial for success.
contact is m a d e for e n v ir o n m e n ta l alte ra tio n s.

T h e g ro u p discussions a r e po in te d to w a r d p r o
blem solving, each new m e m b e r , after being
in t r o d u c e d ,
b e in g
encouraged
to
give
b io g ra p h ical d a t a an d to rela te th e p ro b le m
t h a t b ro u g h t h im o r h e r to th e clinic. R eaction s
of o th er m e m b e rs to th e p a t i e n t s acco u n t an d
suggestions for coping w ith p ro b le m s a r e e n
c o u r a g e d , a n d g o a ls a r e f o r m u l a t e d . A p
A few p o in te rs m a y be helpful. O n e w a y of
a p p r o a c h i n g a p a tie n t to e n te r a g r o u p is su g
gested in th is excerpt:
T h . I believe t h a t y o u r t y p e of p r o b l e m will be
h e l p e d b est in a g r o u p se tting . W e will h ave
a b o u t six se ss ions .
P t.
W i l l t h a t be e n o u g h to c u r e t h is c o n d i t i o n ?
150
T h . Y o u s h o u l d get e n o u g h ou t of t h e r a p y to have
g o tte n s t a r t e d o n th e r o a d to g e t t i n g better.
W h e t h e r y o u will be all c u r e d is h a r d to say.
G e n e r a l l y , after so s h o r t a t i m e in t r e a t m e n t
y o u r s y m p t o m s s h o u ld be i m p r o v e d , a n d y ou
will h av e a n idea of h o w y ou c a n go a b o u t c o n
t i n u i n g to get w ell a n d s ta y well.
S ho uld the p a tie n t show resistance to e n t e r

ing a g ro u p , th is is h a n d le d as in lo n g -term
g r o u p th e r a p y (see W o lb e r g , 1977, p. 706).
A t the first g r o u p session m e m b e rs a r e i n
tro du ced by th e i r first n a m e s an d the confident
n a t u r e of the m eetings e m p h a s iz e d . T h e o bli
gatio n to come to all sessions is stressed, p a
tients a re told th a t th e n u m b e r of sessions is so
few th a t th e sooner th ey o p en u p a n d focus on
th e i r p ro b lem s, th e faster they will get better.
e ls ew h e re in d etail (W o lb e rg , 1977, pp . 7 0 8 719).

M o s t p a tie n ts w h e n th ey e n te r a g r o u p a re
hig h ly in t o le r a n t of criticism , w h ic h th e y a n
ticipate will h a p p e n shou ld th ey reveal t h e m
selves. In a w ell-co n du cted g ro u p th e p a ti e n t
becom es c a p a b le of d is tin g u ish in g b etw een
destructive,
hostile
a tta c k s
and
constructive
c r i ti c is m m o t i v a t e d by a d e s i r e to h e lp .
M o r e o v e r , h e begins to realiz e th a t some
critical c o m m e n ts a r e really no t p e rs o n a l but
a r e p ro jection s t h a t a r e b eing falsely directed
at him . S u ch ex p o su re s h e lp m a n y p a tie n ts b e
come less critical of them selves, less rigid a n d
defensive, an d m o r e accessible to re a s o n a b le
values. T h e s e le a r n in g s m a y g e n eralize ou tsid e
of th e tr e a tm e n t session an d in fluence r e l a t i o n
sh ips w ith oth ers. Less hostile to them selves,
T h . Yo u h a v e a n o p p o r t u n i t y to t a l k a b o u t th i n g s
h e r e t h a t y o u o r d i n a r i l y k e e p secret. J u s t o p e n
in g u p a n d p u t t i n g y o u r feelings into w o r d s
will help . W h a t y o u w a n t to do a b o u t u p s e t
ti n g m a t t e r s will be y o u r o w n de cision, b u t you
sh o u l d be a b l e to t h i n k m o r e cle a r ly a b o u t
w h a t to d o as a resu lt of y o u r g r o u p e x p e r i e n c e
pulses em erge.
A n u m b e r of stra ta g e m s m a y be em p lo y ed in
th e g ro u p to facilitate activity. O n e te c h n iq u e
is to ask each m e m b e r of th e g r o u p to talk
you get f ro m t h e discussions.
a b o u t an y fears h e o r she h a d as a n adolescent.

G r o u p m e m b e rs often a re ab le to ta lk m o re
W h e n you a r e r e a d y , you will w a n t to t a k e a c
easily a b o u t p a st fears a n d p ro b le m s, especially
tion a n d t h a t s h o u l d set you o n the r o a d to g e t
th ose they have overcom e, t h a n p re s e n t u n r e
and
the help
ti n g well.
P t.
they a r e m o r e lenient w ith p e rs o n s w ith w h o m

they a re relate d. C o o p e ra tiv e a n d te n d e r im
B u t w h a t sh o u l d I ta l k a b o u t ?
T h . T h e best w a y to s t a r t is to t a l k a b o u t w h a t
b r o u g h t yo u in to t h e r a p y , h o w it b e g a n a n d
w h a t h a s h a p p e n e d u p to t h e pr e se n t.
Sho uld the p a tie n t delve too m u c h into past

history, he sh ou ld be disco uraged, as should
an y too detailed th e o riz in g a b o u t his condition.
T h e focus should be on the p re se n t, an d it is
em p h a s iz e d th a t no m a t te r w h a t h as h a p p e n e d
to a p erso n in th e p ast, on e can c h a n g e if one
has the desire for change. As p a tie n ts begin to
talk , th e ir reac tion s to th e g ro u p an d to th e
th e r a p is t will become m anifest. Som e p a tie n ts
will try to convert th e g r o u p into a priv ate
session; th ey a r e then asked to ad d ress th e i r r e
m a r k s to the g r o u p r a t h e r t h a n the th e ra p ist.
T h e m a n a g e m e n t of th e g ro u p session as well
as special p ro b le m s th a t o ccur is described
solved ones o r a b o u t s itu a tio n s w ith a n i m

m ed ia te stress p o te n tial. P a tien ts can find
com fort in listen ing to h o w o th e r perso n s have
h a d to cope w ith difficulties sim ila r to th e ir
ow n. O n c e p ast fears a re a e ra te d , p re s e n t co n
cern s a r e ta k e n u p a b o u t som e c o m m o n p r o b
lem. S h o u ld p a tie n ts be on a ho sp ital w a r d ,
th ey m a y be q u e stio n e d as to ho w each feels
a b o u t a r o u tin e th a t som e h av e found d is ta ste
ful. O n c e th e ice is b ro k e n a n d c o m m u n ic a tio n
is flowing, m o re p e rs o n a l im m e d ia te p ro b le m s
m a y be a p p ro a c h e d .
A n in terestin g te c h n iq u e th a t m a y be used
w ith p a tie n ts w h o a re no t too sick, in a g r o u p
th a t is inactive a n d bogged d o w n , is ask in g for
a v o lu n teer to leave th e ro o m so th a t the rest of
the g r o u p can talk a b o u t h im , a ir in g th e i r i m
pression s of th e kind of a p e rs o n he is. A fter a
sh o rt perio d th e p a ti e n t is invited b ack into th e
151
room an d asked to relate h o w he felt w h e n he
la r socioeconomic b a c k g ro u n d s is d e sirab le to
w as o ut of the ro o m , w h a t th o u g h ts c a m e to
lend s u p p o r t to th e p a tie n t a n d to in te rp re t
w h a t is bein g felt.
him , and w h a t h e believes th e g ro u p felt an d

said a b o u t h im . T h e n a n o t h e r v o lun tee r p a
tient
leaves th e
ro om ,
an d
th e
process
B e c a u s e h o s p i t a l i z a t i o n is c o n s i d e r e d as
is
sp o n s o rin g regressive p a t t e r n s a n d destro y in g
rep eated. L a te r w h e n the g r o u p is m o r e in

tegrate d, the p a tie n ts m a y c o m p a r e h o w th ey
tern ativ es to p sy ch ia tric h o sp ita liz a tio n have
s e lf-c o n f id e n c e a n d social r e l a t i o n s h i p s , a l
origin ally felt a b o u t each o th e r w ith ch an g es in

th e ir p erceptions. T h i s te ch n iq u e c an stir u p a
suggested
g reat deal of feeling a n d an x ie ty an d sh o u ld be

restricted to p a tie n ts w ith good ego stru ctu res.
s p o n s o rin g an d m a i n ta i n in g p a th o lo g y in the
p re s e n tin g p a tie n t. At th e C o lo ra d o P sy ch o
In d ividua l sessions m ay co o rd in ately be held to

h a n d le anxieties.
R ole play in g an d p s y c h o d r a m a m a y also be
utilized in som e g ro u p s to help a p a ti e n t act
ou t w h a t he feels a b o u t different peo ple i m p o r
fam ily
group
approaches
on
the
basis th a t th e fam ily is actively involved in
p a th ic H o s p ita l a F a m ily T r e a t m e n t U n i t set

o ut to test the h y p oth esis th a t fam ily -o rien ted
crisis t h e r a p y h a s ad v a n ta g e s over o th e r m e t h
ods ( P i tt m a n et al, 1966). T h e u n it is m a n n e d
ta n t to h im as well as to re h e a r se n ew p a tt e r n s
by a te a m of p sy c h iatrist, p sy ch ia tric social

w o rk e r, a n d p sy ch iatric p u b lic h e a lth n u rs e
an d different w ay s of relating . V id e o ta p e r e
a n d o p e ra te s 24 h o u r s a day. All cases co n
cord in g an d feedback m a y also be e m p lo y ed as
sidered ca n d id a te s for im m e d ia te h o s p i ta l iz a
a w a y of giving th e p a tie n t insight into p a r a

doxical a n d a m b ig u o u s b eh av io r a n d c o m
m unications.
tion an d w h o live n o t too far from th e hospital

a re scru tin ize d for tr e a tm e n t by th e F a m ily
Since g ro u p s a re usu ally o p en -en d e d a n d
T r e a t m e n t U n it. U s u a lly th e crisis is b ro u g h t

on by a c h a n g e in role d e m a n d e d of o n e o r
p a tie n ts enter t h e r a p y at v ario u s levels of p sy

c h o lo g ic a l s o p h i s t i c a t i o n a n d r e a d i n e s s for
c h ang e, th e th e r a p is t will have to d is p la y a
m o re fam ily m e m b e rs p ro d u c e d by som e shift

in th e fam ily situ atio n .
con siderable deg ree of flexibility in th e m e t h
b rin g th e m e m b e rs to a re a liz a tio n th a t the
ods utilized at different times. P a rt ic u l a rly dif

ficult is w o rk w ith actively psychotic pa tien ts.
T h e conduct of such a g r o u p will call for m e t h
ods of a special k in d, such as those didactically
oriented to w a r d an e d u c a tio n a l goal (D ru c k ,
1978; K la p m a n , 1950, 1952; P resto n, 1954;
S ta n d ish & S e m r a d , 1963). H e r e topics are
A t th e u n it, w o r k is d o n e w ith th e fam ily to

desig nated p a ti e n t is no t the o nly cause of th e
crisis a n d th a t a solution will no t a p p e a r w ith
his rem ov al to a h ospital. R a th e r , th e en tire
fam ily is involved a n d , th erefore, respo nsib le
for b rin g in g a b o u t solutions. T h e b e h a v io r of
the d e sign ated p a tie n t is in te rp re te d as a n a t
t e m p t at c o m m u n ic a tio n . A n i n t e r p r e ta ti o n is
chosen th a t deal only tan g e n tia lly w ith the p a
also m a d e of th e fam ily role c h an g e s th a t led to
ti e n ts affects a n d conflicts. T h u s if p a tie n ts

w ish to discuss h a llu c in a tio n s an d d elusions, a
general discourse is given on h a llu c in a tio n s
th e crisis, w ith firm b u t e m p a t h ic c o n fr o n ta

tio n of all m e m b e rs of th e fam ily as to th eir
p a r t in th e p a t i e n t s upset. T h e i r respo nsib ility
is o u tlin ed, th e aro u n d -th e -c lo c k av ailab ility of
th e th e r a p is t e x p la in e d , a n d a h o m e visit
scheduled w ith i n 24 ho u rs. T a s k s a r e assigned
to each fam ily m e m b e r. T h e p a tie n t a n d fam ily
a n d delusions a n d not an y in d i v id u a ls d e lu
sions as a p e rs o n a l p rob lem .
In a brief g r o u p th e r a p y w ith th e socially
a n d econom ically deprived th e r e a re a d v a n
tages in h a v in g the g ro u p com p osed of p eers
w h o can identify w ith each o t h e r s e xperiences
a n d trib u latio n s. T h e th e r a p is t is often r e
g ard e d as a re p re se n ta tiv e of b u re a u c r a ti c a u
th ority , a n d th e presence of pe rso n s w ith sim i
a re in fo rm ed th a t a n y insistance on h o s p ita li
za tio n is a w a y of escap in g respo nsib ility an d
t h a t th e crisis will be resolved only if fam ily
roles an d ru les a r e altered. In this w a y each
fam ily m e m b e r is given s o m e th in g to do, such
152
as clean in g the kitchen, w rit in g a letter, ta k in g

m edications, a n d so on. T h i s is a w a y of tes t
to challenge. G r o w t h is not restricted to the

p a r t ic i p a n ts of th e g ro u p ; it also involves the
ing the fa m ily s coo peration . A m e m b e r of the
th e ra p ist.
te a m m ay actu a lly p a rt ic i p a te in h elp in g w ith
M u l t i p l e f a m il y t h e r a p y e s p e c i a ll y h a s
in creased in p o p u la r it y in recent y ears (L a -
one of th e tasks. T h e p a tie n ts an d occasionally

fam ily m e m b e rs m a y be given psych otrop ic
m edication s in a d e q u a t e dosage if necessary.
q u e u r , 1968; 1972), a n d a n excellent article on
T h e next step is th e h o m e visit to observe

th e fam ily in te ra c tio n s a n d if necessary to r e n e
g otiate role assig nm e nts. At first the fam ily as
n iq u e s h a s been w rit te n by L u b e r a n d W ells

( 1 9 7 7 ) . In m u l t i p l e f a m il y t h e r a p y th e
a u n it is seen d aily, at w h ich tim e th e beh av io r
m u t u a ll y s u p p o r tiv e of each o th e r in co n fr o n t
ing stressful a re a s ; intense fam ily feelings a re
of the m e m b e rs is m o n ito re d . T h e th e r a p is t
its lite r a tu re , ra tio n a le , an d som e of its te c h
f a m il ie s
and
th eir
m em bers
can
becom e
m a y a p p ly d irect or ind irect p re s su re to e n

co u rag e one o r a n o th e r pers o n (p a tie n t or
m o r e d ilu ted in th e g r o u p con tex t, a n d hence
fam ily m e m b e r living w ith i n or o u tsid e the
o b serv atio n
h om e) to change. T h e focus is on th e firm an d
fam ilies
u n c o m p r o m is in g need to accept responsibility.

T h e p a tie n t m a y be instructed to c o m m u n ic a te
families m a y be h e lp e d w ith a tim e -lim ited a p
m o re clearly an d not t h r o u g h his sy m p to m s.

T h i s o ften d r a m a t i c a l l y p r o d u c e s i m p r o v e
ment.
m o re a p p r o a c h a b l e , a n d fam ilies c an le a r n by
and
(L uber
id e n t i f i c a t i o n
&
W ells,
w ith
1 9 7 7 ).
oth er
M any
p ro a c h in this w a y , a n d for th ose w h o r e q u i r e

a lo n g er period of t r e a tm e n t th e k ind s of p r o b
lems n ee d in g f u r t h e r h elp will h av e been id e n
W ith this te c h n iq u e h o sp ita liz a tio n w as
tified.
D o n n e r an d G a m s o n (1968) h av e described
com pletely avoided in 42 of 50 cases, only an
th e ir e x p erien ce in d e alin g on a s h o r t-t e rm
av erag e of six h o m e o r office visits p e r family

b eing needed. T e n of th e 50 fam ilies called
basis (16 sessions) w ith g ro u p s of families e x

p erien cin g p ro b le m s w ith adolescents. T h e o b
over a m o n th follow ing d isc harge a b o u t a s u b
je ctives w ere (1) to pro vide a setting conducive
seq u e n t crisis, w h ich w a s u su ally h an d le d over

the telephone; several r e q u i r e d one o r tw o of
to e x p lo r a tio n of fam ily p ro b le m s th a t co n
fice visits.
S h o rt -te r m fam ily th e r a p y h a s h a d in c re a s
ing acceptance in clinics devoted to crisis in t e r
tr ib u te d to difficulties of th e adolescent m e m
bers, (2) to h elp families a c q u ir e n ew a n d b e t
ter so lution s to q u a n d a r i e s co n fro n tin g th e m ,
a n d (3) to em p lo y in sig hts g ain ed as a m e a n s
vention, th e theo retical base being th a t be
of re c o m m e n d in g f u r th e r t h e r a p y if needed.
h av io r d is tu rb a n c e is a p ro d u c t of a c o n tin u in g
fa m il y sy s te m d i s o r g a n i z a t i o n r a t h e r t h a n
rooted in individual patho log y. C o m b i n in g
p rin ciples from g r o u p th e r a p y a n d fam ily-
E v e n in g sessions of 1 Zi h o u r s once w eekly

w e re con du cted, u su a lly by a co th e r a p is t team .
O u t of th eir e x p e rie n ce a n u m b e r of tech n iq u e s
a r e re c o m m e n d e d . A t th e in itial session the
g r o u p is in stru c te d th a t a p ro b le m in one
fam ily m e m b e r involves no t only the m e m b e r
b u t the e n tire fam ily. O n e sh o u ld no t re g a r d
an y m e m b e r as th e b a d o n e o r sick o n e
centered e d u c atio n al a p p ro a c h e s , th e p r a c t i
tio n er functions as b o th th e r a p is t a n d e d u c a to r
(G u e rn s e y et al, 1971; W ells, 1974).
In fam ily t h e r a p y the th e r a p is t m u s t utilize
a m u ch m o re ch allen g in g a n d co n fro n tin g tech
n iq u e th a n in o r d i n a r y g r o u p th e r a p y since the
in terlock in g n e u ro tic fam ily m e c h a n ism s are
ex trem ely rigid a n d se lf-p erpetu atin g. Yet, the
degree of challen ge m u s t be titr a te d a g a in st the
q u a lity of the r e la tio n s h ip th a t exists betw een
the th e r a p is t a n d th e fam ily being treated. T h e
th e r a p is t m u s t also be read y to expose him self
because w h e n tr o u b le starts, th e r e is so m e th in g
go ing on in th e e n tire fam ily. A fa m ily e x
p lo r a tio n of th e p ro b le m en ab le s th e m to deal
w ith th e cause. All of us to g e th e r will tr y to
u n d e r s ta n d w h a t is goin g on in th e different
f a m il ie s t h a t c o n t r i b u t e t o w a r d t h e y o u n g
p e o p le s difficulties, a n d each can m a k e c on
tr ib u tio n s to th e o t h e r s . T h e g r o u p is told
153

th a t since fam ily m e m b e rs in o ne fam ily live so
process a re not to socialize o utside the g ro u p
closely, they m a y not be ab le to see th e p r o b
since th is will affect h o w they in te ra c t in the
lem as clearly as w h en th ey see th e sa m e p r o b

lem going on in a n o th e r family. By ob servin g
g ro u p .
As fam ily m e m b e rs a ir th e ir a n g e r, d e sp a ir,
ho w o th e r fam ilies solve th e ir p ro b le m s each
h u r t , an d in d ig n a tio n , n e w w ay s of d e a lin g
fam ily m ay o b ta in valu ab le insights. Feelings
w ith p ro b le m s g e n e ra lly em erg e. T h e families
should be v en tilated freely w ith no restrictio ns,

w h a t is said. O t h e r g r o u n d ru les a re th a t all
lose th e ir feeling of h a v in g s o m e th in g w ro n g
a b o u t th em , w h ic h isolates th e m from o t h e r s .
T h e ch an g es in one fam ily g r o u p reinforce
presen t
c h an g es in th e o th ers; th e fam ilies becom e ac
an d th e r e m u s t be no p u n is h m e n t at h o m e for
m e m b e rs
m u st
atte n d
each
session
(father, m o th e r, adolescent, a n d , if possible,
tive h e lp e rs of on e a n o th e r .
o th er siblings). F a m ilies d u r i n g th is t r e a tm e n t
Com m on Questions about Techniques

in Short-Term Therapy
T h e r e is a g r e a t d e a l o f c u r r e n t i n t e r e s t in
b io c h em ica l causes of e m o tio n a l p r o b
lem s, an d p a rtic u la rly ch e m ic al n e u r o t r a n s m i t t e r s , t h a t m a y b e i n f l u e n c e d by
p h a r m a c o th e r a p y . Do you believ e that
th is m i n i m i z e s t h e r o l e o f p s y c h o t h e r a p y ?
C e r t a i n l y it w o u l d b e q u i c k e r a n d
c h e a p e r to g iv e a p e r s o n a d r u g r a t h e r
t h a n to s p e n d s e ssio n a f t e r s e ssio n in i n
te r v i e w i n g .
W hat
you
are
ask in g
is w h e th e r
chic, in te rp e r s o n a l, social, a n d sp iritu a l factors

a r e all vital links in th e b e h a v io r a l c h a in , i n
fluencing each o th e r by feedback. N o o ne link
is most i m p o r t a n t. E v ery th o u g h t, idea, w ish ,
and
fan tasy
has
its b io chem ical
co rrelates.
C o n versely , b ioch em ical ch an g e s, in clu d in g the

in f lu e n c e s o f p s y c h o t r o p i c d r u g s , r e s o n a t e
th r o u g h o u t th e e n tire c h a in affecting o th er
links. B ut w h ile d ru g s m a y molify, it h a s been
d e m o n s tr a t e d t h a t they will n ot solve th e m a n i
d ru g s
fold social, in t e rp e r s o n a l, a n d o th e r dis to rtio n s
eventually will replace p sy c h o th e ra p y . A c u r
th a t a r e u b iq u ito u s . A ctu ally, m o r e p eo p le a re

b ein g fu nn eled back into h o sp itals in spite of
re n t article in a n a tio n a l m a g a z in e im plies th a t

we will in the n ot too d is ta n t fu tu re be ab le to
control all b eh av io r by injecting or e x tr a c tin g
chem icals into
and
from
th e
body.
In
my
o pin io n , this fr ig h te n in g possibility is q u it e r e

mote. In e x p lic atin g n e u ro t r a n s m it te r s , o r any
o th e r chemicals, as the u lt im a te in g red ien ts in
beh avior, bio chem ical e n th u s ia sts c o m m it the
sam e kind of e r r o r th a t th e classical F r e u d i a n s
m a d e in deifying the O e d ip u s com p lex as the
f o u n t a i n h e a d of all m o r t a l b li g h ts . B o th
n e u ro t ra n s m it te rs an d th e O e d ip u s c om p lex
m a y come into play, b u t th e y a r e m erely some
of th e agencies th a t a r e o p erativ e in th e c o m
p le x series of t r a n s a c t i o n s t h a t c o n s t i t u t e
h u m a n behavior. B iochem ical, n e u r o p h y s io
logical, d e v e lo p m en tal-co n d itio n in g , in t r a p s y
m e dic atio ns t h a n ever before. So let us give

b io ch em istry an d p h a r m a c o th e r a p y th e ir
p r o p e r d u e w ith o u t e n c o u ra g in g th e p u b lic to
seek cu res for sp iritu a l, social, in te rp e r so n a l
a n d e m o tio n a l ills in th e ir local d r u g stores. In
sh o rt, it is foolish to a n tic ip a te t h a t d ru g s will
ever re p lace good p sy c h o th e ra p y .
C a n y o u g iv e e x a m p l e s o f w h a t y o u m e a n
b y e c le c tic t h e r a p y ?
It is a r a r ity to d a y to find a th e r a p is t w ho
confines h im self to o ne specific te chn iq ue.
T h e r e a re several w ay s of a llev iatin g p sy ch o
logical distress. A m o n g th e m ost recent en tries
in to th e th e r a p e u ti c a r e n a a r e th e m o d e r n so
m a tic th e r a p ie s th a t a im at rectification of e x
154
isting neurop hy siolo gic al an d bio chem ical dis
I s n t t h e p r i n c i p l e o f e c l e c t i c i s m a n i n
tortions. A n effective th e r a p is t m ay , fro m tim e
v ita tio n
to time, have to p rescrib e o r refer his p a tie n t

for p re s c rip tio n of neu role ptic s for schizo
d e f e a t s it s p u r p o s e ?
If you a r e r e f e rrin g to eclecticism as a m i x
ing of v a rio u s th eo rie s into on e g r a n d s t e w ,
p h re n ic a n d o th e r psychotic reactions, a n tid e p re s sa n ts (T o fr a n il, E lavil, S in e q u a n , N a r
to
c o n fu sio n
th a t
u ltim a te ly
yes. It is foolish to a tt e m p t to a p p ly theo ries
dil, P a r n a t e , etc.) for deep dep ressio ns, a n ti-
related
m an ic
at
biochem ical lin k, to a n o th e r a r e a , for e x a m p le ,
tacks), m in o r tr a n q u il iz e r s (V aliu m , L ib r i u m ,
S erax , etc.) for severe a nx ieties, sedatives an d
the in tra p sy ch ic a n d in te rp e r s o n a l links or vice
m edicatio ns
( L it h iu m
for
m a n ic
to on e a re a of fu nction ing , say the
hy p n o tic s for th e te m p o r a r y relief of inso m n ia,
versa. All you will achieve is confusion. E ven if

o ne a tt e m p t s to m ix different th e o ries th a t
and
for suicidal
re late to a single link in th e b eh av io ra l chain ,
depressions. So d o in g will res u lt in correcting
th e resu lt c a n be a mess of s cram b le d ideas th a t

e x p l a i n n o t h i n g . O n th e o t h e r h a n d , if
electric convulsive t h e r a p y
r a p i d ly a host o f sy m p to m s th a t interfere w ith

p sy ch o th era p y .
A second m o de ava ilab le to th e th e r a p is t is
eclecticism refers to a te chnical b le n d in g of

m eth od s, each of w h ic h is suited for a different
d ive rtin g the p a tie n t a n d p r o d u c in g a c a lm in g
d im en sio n
effect th r o u g h biofeedback o r re la x in g e x
ercises, like m e d ita tio n , hyp n osis, a n d a u t o
such b le n d in g e n h a n c e th e efficiency of y o u r
genic tra in in g . A th i r d w a y is flooding the

m in d w ith p h ilo so p h ical, pe rsua siv e, o r su g
gestive fo rm u latio n s , as in cognitive th e r a p y . A
fo u rth g ro u p of te ch n iq u e s a tte m p ts to divert
th e p a tie n t th r o u g h e x te r n a liz a tio n of interests,
m usic th e r a p y , d an c e a n d m o v em en t t h e r a p y ,
of fu nc tion in g,
you can
th r o u g h
o p e ra tio n s. F o r e x a m p le , in a severe d e p r e s
sion you m a y w a n t to co rrect th e p ath o lo g y
in t h e b i o c h e m i c a l li n k by p r e s c r i b i n g
i m i p r a m i n e . Y o u m a y a ls o s i m u l t a n e o u s l y
decide to deal w ith th e in tra p sy c h ic p ro b le m
by u tilizin g p s y ch o an aly tic p sy c h o th e ra p y or
cognitive th e r a p y . M o r e o v e r, if a fam ily p r o b
po etry th e r a p y , social th e r a p y , a n d o c c u p a
lem exists, you will be wise to do som e fam ily
tional th e r a p y . A fifth m o d e is a lte ra tio n of the

e n v ir o n m e n t to red u ce stresses being im posed
therapy.
These
blended
te c h n iq u e s e n h a n c e
on th e p a tie n t a n d to s u r r o u n d h im w ith con
each oth e r. A fter all, if a su rg eo n h a d on ly one

te c h n iq u e at his disposal, like a p p e n d e c to m y , it
structive stim u li. A m o n g th e tactics em plo yed
w o u ld be silly to try to tr e a t every sto m a c h a c h e
h e re
o r bow el c r a m p by ta k in g o u t the a p p e n d ix .
a re
g uid anc e ,
m ilieu th e r a p y ,
m a r ita l
th e r a p y , fam ily th e r a p y , th e r a p e u tic co u n se l

ing an d casew ork , a n d s u p p o r tiv e g r o u p t h e r
apy . A sixth m od e aim s a t rectifying faulty
h a b its a n d develo pin g n ew a n d m o re p r o d u c
tive p a tt e r n s t h r o u g h b e h a v io r th e r a p y , role
play ing , a n d cognitive le a rn in g . A seventh
m o d e e x p l o r e s u n c o n s c i o u s c o n flic t a n d
releases laten t creative p o ten tials t h r o u g h d y
n a m ic p sy c h o th e ra p y , ex isten tial analysis,
tra n sa c tio n a l th e ra p y , e x p erien tial th e ra p y ,
h y p n o an aly s is, n a rco an aly sis, e x p lo r a to r y a rt
a n d p lay th e r a p y , visual im ag ery , an d an aly tic
g ro u p th e r a p y . As has been stressed, how ever,
tec h n iq u es in each of th e m odes do no t confine
th e ir influence to on e a rea. T h e y will influence
o th e r p a r a m e te r s in cognitive, em o tion al, and
be hav ioral areas.
If a p a t i e n t d o e s n o t r e s p o n d to th e t e c h
n iq u e s yo u a re usin g ev en th o u g h th e re
a p p e a r s to b e a g o o d t h e r a p e u t i c r e l a t i o n
sh ip , w h a t do y o u do?
T h e first t h i n g is to sea rc h for tra n sfe re n c e
t h a t m a y not be a p p a r e n t on th e surface. T h e
p a t i e n t s resistan ce to the th e r a p is t a n d to r e
lin q u is h in g his illness m a y be m ask ed by a
co m p la in t a n d seem ingly c oo perativ e a ttitu d e.
O fte n tr a n sferen ce becomes a p p a r e n t o n ly by
ob serv ing n o n v e rb a l b e h a v io r o r by se a rc h in g
for a c tin g -o u t ten den cies a w a y fro m th e r a p y . It
m a y be detected som etim es in th e p a t i e n t s
d re a m s. O n c e tran sferen ce is co nfirm ed , c o n
fr o n ta tio n , f r a n k discussion, a n d in te rp r e ta ti o n
155

a re in o rd er. A n o th e r re a s o n w h y th e p a tie n t
W h e n is c o u n t e r t r a n s f e r e n c e m o s t l i k e l y
m a y no t be re s p o n d in g well to tr e a tm e n t is
to a p p e a r ?
C o u n tertran sfere n ce
is lik e ly
to
appear
th a t the p r o p e r tech n iq u es a re not being e m

ployed th a t accord w ith the p a t i e n t s le a r n in g
a m o n g th e r a p is t s at a n y p h a se of tr e a tm e n t,
capacities. F o r e x am p le, som e p a tie n ts ca n n o t
selective c h a rac teristics in p a tie n ts s p o n s o rin g
seem to utilize the a b stra c t concepts of in t e r
a v e r s iv e r e a c t i o n s t h a t c a n
interfere
p retiv e tech niqu es. T h e y do b ette r w ith role
p ro gress.
im p a i r m e n t in
p la y in g o r assertive tr a in in g . O t h e r p a tie n ts
p a tie n ts is a n especially p r o m in e n t stim u lu s
resp o n d b etter to re la x a tio n m etho ds. O n e m ay
th a t sp a rk s off u n t o w a r d res p o n ses in m a n y
fruitlessly
his
professionals. T h i s w as b o rn e o u t in a stud y of
family, yet will find th a t he im p ro ves i m

m ediately w ith an in s p ira tio n a l su p p o rtiv e
th e reac tion s of n o n p s y c h ia tric p h y sician s to

medical p a tie n ts ( G o o d w in et al., 1979). T h e
g ro u p p a tt e rn e d after Alcoholics A n o n y m o u s.
T o do good s h o r t-t e rm th e r a p y , th e th e r a p is t
most disliked p a tie n ts w e re th ose w h o p o s

sessed stro n g p sy ch o p ath o lo g ic al c h a ra c t e r i s
w ork
w ith
an
alcoholic a n d
Se rio u s p sy ch iatric
w ith
m ust be flexible an d exploit a r a n g e of eclectic
tics. T h e a u t h o r of th e article concluded th a t
techn iq ues. If c e rta in te ch n iq u e s best suited for
th e e m o tio n of dislike in p h y sician s w a s a se n
a p a tie n t a re no t w ith in o n e s r a n g e of skills,
sitive clue to p sy c h iatric im p a i r m e n t in p a
one shou ld refer the p a ti e n t to a specialist.
tients. R e cog nition of th e in a p p r o p ria tiv e n e s s
W h eth e r
be t r a n s f e r r e d
of o n e s n eg ative feelings gives on e a n o p p o r t u
e n tirely o r seen jointly will d e p e n d on th e sp e
nity to e x a m i n e th ose feelings an d to control
cific p ro b le m a n d on h o w adv isable it is to

m a in ta in a th e r a p e u tic re la tio n s h ip w ith
th e m , th u s h e lp i n g to avoid adv erse effect on
th e
p atien t
is to
th e r a p y .
a n o th e r professional as a co th erap ist.

C a n c o u n t e r t r a n s f e r e n c e e v e r b e u s e d in
H ow
im p o rtan t
are
th e
t h e r a p i s t s a t
ti tu d e s in s h o r t - t e r m t h e r a p y ?
a th e ra p e u tic way?
Yes. T h e r a p i s t s reco g n izin g th a t th e ir ow n
A ttitud es a re im p o r t a n t, for instance, e n

th u s ia sm a n d conviction a b o u t w h a t one is d o
n e u ro tic feelings a r e bein g activated m a y look
ing. B egin n in g th e r a p ists, in th e ir ea g e rn ess to
n e u ro tic needs a n d drives in th eir p a tie n ts are
h e lp ,
that
activating th e ir p e rs o n a l reaction s. T h e y m ay
catalyzes th e r a p y . A p p a r e n tl y e x p e rie n c e for

som e reaso n d a m p e n s e n th u s ia s m , th e r a p is ts
th e n b ri n g u p th ese p ro v o c a tio n s as foci for e x

p lo ra tio n . T h e y m a y ask, is the p a ti e n t a w a r e
b ecom ing m o re scientific, cautio us, an d c o n

servative a b o u t th eir h e a lin g p o w e rs. S uch a t
of a b e r r a n t
titud es have a d a m p e n i n g influence. S o m e h o w
C o n f r o n t in g the p a tie n t w ith his b e h a v io r m a y

have a t h e r a p e u ti c im p a c t on him .
o ften
co m m u n icate
en th u sia sm
the th e r a p ist m ust get across to th e p a tie n t

conviction in th e validity of his a p p ro a c h . T h i s
en h an ces both th e placebo effect of th e r a p y and
consolidates the p a t i e n t s faith in the th e r a p is t,
th u s s tre n g th e n in g the th e r a p e u ti c alliance. A
show of confidence on the p a r t of the th e r a p is t
w ill h e lp c a r r y th e p a t i e n t t h r o u g h th e
resistance p h ases of tr e a tm e n t. W h e r e th e t h e r
ap ist a n ticip ate s a long perio d of tr e a tm e n t,
cues m ay be released th a t play into the p a
ti e n t s d ep en d ency a n d
th u s p ro lo n g in g th e r a p y .
fears of se p a r a tio n ,
no t only in to them selves, b u t also into w h a t
im p u lses
and
b e h a v io rs?
W hat
does th e p a tie n t w a n t to accom plish by t h e m ?
A re n e g a tiv e fe e lin g s in th e th e r a p is t a l
w ays ev id en c e of c o u n te rtra n sfe re n c e ?
O f course not. T h e p a ti e n t m a y be actin g in
an offensive a n d destru ctive w ay , legitim ately
stirr in g u p ir rita tio n a n d a n g e r in th e t h e r a
pist. T h e r e is no reaso n w h y , w h e n a w o rk in g
re la tio n s h ip exists, the th e r a p is t sho uld not
co nfron t th e p a ti e n t w ith his b e h a v io r in a
n o n c o n d e m n i n g b u t firm m a n n e r .
156
C a n y o u d e s c r i b e w h a t is m e a n t b y t h e
370), se a rc h in g for evidences of tran sfe re n c e
need
apy?
w ith resistances w h e n th ey arrive, c h a n g in g
f o r a c t i v i t y i n s h o r t - t e r m
th e r-
T h e need for activity on th e p a r t of the t h e r
a n d c o u n te r tr a n sfe re n c e , im m e d ia te ly dea lin g
apist is explicable on th e basis of the limited
from o n e te c h n iq u e to a n o th e r w h e n the fo r
m e r proves ineffective, a n d posing ch allen g in g
tim e availab le for tr e a tm e n t. Passive w a itin g
q u e stio n s a n d c o n fro n ta tio n s, a good d eg ree of
for the p a tie n t to w o rk t h r o u g h his p ro b le m
activity will co m e into play.
w ith i n a few sessions will b ri n g m e ag e r results.

It m a y be necessary to guide, su p p o r t, e x h o rt,
a n d con fron t th e p a tie n t as forcefully as is r e
q u ir e d at the m o m e n t, a lw a y s mindful of the
In fo cu sin g o n a lim ite d a re a , do w e n o t

sta n d th e d a n g e r o f n e g le c tin g im p o rta n t
need to p reserve a w a r m th e r a p e u tic climate.
p a r a m e t e r s o f a p e r s o n s li f e ?
In s h o r t- t e r m th e r a p y it is p ra g m a tic a lly
Activity in t h e r a p y m a y r e q u i r e an cilla ry serv
necessary to c irc u m sc rib e th e n u m b e r of v a r i a
ices of physicians,
bles w ith w h ic h one deals d u r i n g th e i n t e r

view. By c o n c e n tra tin g on a lim ited a r e a for
la w y ers,
social w o rk e rs,
te ac hers, a n d o th e r p rofessionals as well as

w h a te v e r c o m m u n it y reso urces a re needed at
th e m o m e n t. E specia lly in crisis in terven tio n,
focus a n d con fin in g o n e s w o rk to th a t a rea,

some th e r a p is ts feel they achieve th e g reatest
assistance w ith economic, ho usin g, a n d o th e r
im p act.
situ atio n al p ro b le m s m a y be necessary. By his
t h r o u g h m u ltip le chan nels: th e w a y he w alks,
activity the th e r a p is t c o m m u n ic a te s th e e xpec
th e w a y he sits, his bodily m o v em en ts in t a l k
tatio n s th a t an early res o lu tio n of the p r e s e n t

ing crisis is achievable. O ften it is e x a ctly th a t
expecta tion w hich serves as th e p r im a r y th era
ing, his facial expressio ns, rev ela tion s of his

p a s t life, h is c u r r e n t e n t a n g l e m e n t s , h is
p e u tic a g e n t ( A m a d a , 19 77 ) Activity will r e

q u ir e an a b a n d o n m e n t of a n o n y m i ty an d th e
rev ealing of oneself as a g e n u in e p erso n r a t h e r
th a n as a p rofessional a u to m a to n . T h i s does
not m e a n a r e lin q u is h in g of th e p ro p r ie tie s of
The
p atien t
reveals
h is
problem
d re a m s , th e m a n n e r of his r e la tio n s h ip to the

th e r a p is t, an d so on a n d so on. T h e th e r a p is t
m a y decide to w o r k w ith on e con stellation , let
us say th e in d i v id u a ls presen t re la tio n sh ip s ,
p e r h a p s focusing o n his im m e d ia te family. T h e
h op e is th a t by a lte rin g th e c h a ra c t e r of the
a n ethical t h e r a p i s t - p a t i e n t rela tio n sh ip , but

r a t h e r a loosening of th e s traig h tjack et of rigid
fam ily in te ra c tio n s a c h ain reaction will have

been started to in fluence o th e r r e la tio n sh ip s
fo rm ality a n d d e ta c h m e n t th a t a re so d e s t ru c
a n d u ltim a te ly th e deepest p a tt e r n s of o n e s
tive to good r a p p o r t. Activity m a y take the
t h i n k in g a n d feeling life. M e m o r ie s of p a st dif
form of p u tt in g into w o rd s the n e b u lo u s feel

ings of th e p a tie n t, an d it m a y even be
ficulties m a y so m etim es b r e a k th r o u g h w ith a

re a p p r a is a l of o n e s p a st existence. In deed , a
com plete rev olu tio n m a y ta k e p lace in th e p e r
e x p r e s s e d in d ir e c t a d v ic e g iv in g t h r o u g h
p re s e n tin g the p a tie n t w ith several o p tio n s an d
h elp in g him to m a k e th e p r o p e r choice.
H o w activ e s h o u ld th e th e r a p is t be? W h a t
i f b y n a t u r e t h e t h e r a p i s t is a p a s s i v e p e r
son?
Activity is th e k eynote of sh o r t-te rm t h e r
ap y. T h i s does not m e a n th e th e r a p is t shou ld
do all the talk in g . E ven a th e r a p is t w h o is
q u ite qu iet and reserved can a d o p t a style of
g r e a t e r a c ti v it y , a v o i d i n g s i tt in g back a n d
a llo w in g the p a tie n t to ra m b le on w ith verbal
inco nseq uen tialities. By u tilizing the p rincip le
of selective focusing (W o lb erg , 1977, pp. 3 6 6 -
son ality s tru c tu re . O r we m a y focus on a speci

fic s y m p to m e x p lo r in g its history, th e events
o r conflicts th a t in itiate it, th e c irc u m stan ces
th a t a m e lio r a te it a n d even s ta rt a re g im e n to
control it. W e m a y th e n find th a t w ith s y m p to
m atic im p ro v e m e n t o th e r d im e n sio n s of the
p e rs o n a lity a re positively influenced.
O n c e a f o c u s is c h o s e n , s h o u l d y o u i g n o r e
o r d ire c t th e p a tie n t a w a y fro m m a te ria l
b r o u g h t u p t h a t h a s n o t h i n g to d o w i t h
th e focus?
B ecause th e r e is so little tim e available, it is
u n p ro d u c tiv e to deal w ith all of the r a n d o m
157

events a n d ideas the p a tie n t b rin g s u p d u r i n g a
session. O ften these a re a dv anced in th e i n t e r
Is t e l e p h o n i n g t h e t h e r a p i s t p e r m i s s i b l e
in s h o r t- te r m th e ra p y ?
ests of resistance. Yet th e r e will occur incidents

of great concern to the p a ti e n t th a t on th e s u r
In s h o r t-t e rm th e r a p y , a n d especially in
crisis in terv en tio n , th e av ailab ility of th e t h e r a
face have little to do w ith th e a r e a of focus. T o
pist can be most re a s su rin g . W h il e th e t h e r a
ignore these will indicate to th e p a tie n t d is in
pist does not e n c o u ra g e th e p a tie n t to tele
terest an d lack of e m p a t h y , a p a r t fro m it being

b ad th e r a p y . F o r e x a m p le , if a core p ro b le m is
p h o n e as a ro u tin e , telling the p a ti e n t to call if
d e s t r u c t i v e c o m p e t i t i v e n e s s is s u in g o u t of
rivalry w ith a p a r e n t or sibling a n d th e p a tie n t
h as th a t m o r n in g found a lu m p on h e r breast,
it w o u ld be foolish to b yp ass th e p a t i e n t s
desire to talk a b o u t the incident. E ven lesser
a r e a s of t r o u b l e p r e o c c u p y i n g t h e p a t i e n t
should in c o m m a n d in g a tte n tio n c halleng e the
th e r a p ist to find a connection w ith a d eep er
an em erg en cy arises c an allay a n xiety and

p rese n t th e th e r a p is t as a c a rin g perso n, th u s
b olsterin g th e th e r a p e u ti c alliance.
W hat
is
th e
sessions th a t
co n v e n tio n a l
sh o u ld
num ber
b e s p e n t in
of
sh o rt
term th erap y ?
A good deal of v a ria tio n exists in th e times
focal pro b le m . T h i s can be do ne in most cases
alloted to s h o r t- t e r m th e r a p y . T h e s e r a n g e
from 1 session to 40, th e frequ en cies v ary in g
even th o u g h the ro u te chosen m a y be devious.

T h u s a p a t i e n t w i t h a c o re p r o b l e m of
from once to th r e e tim es w eekly, th e session

leng ths from 15 m in u te s to 2 ho u rs. O n the
passivity and lack of assertiveness, a p ro d u c t of

incom plete s e p a r a tio n -in d iv id u a tio n , is in ten t
av erag e, ho w e v e r, th e r e a r e a p p r o x i m a t e ly 6
on talk in g a b o u t an a r t ex h ib it he h ad a tte n d e d
vention, from 7 to 15 sessions over a 4 -m o n th
at a local m u s e u m . U n d e r n e a t h th e g re a t a d
span
m ira tio n for the a rtist is, it seems, a feeling of
t h e r a p y , an d as m a n y as 4 0 sessions in d y
envy an d d e s p a ir at o n e s o w n lack of p r o d u c
n a m ic s h o r t-t e rm p s y c h o th e ra p y . M o s t ses
sions a r e for a 4 5 - m in u t e h o u r . S om e t h e r a
tiveness. T h e p a tie n t m ay th e n be b ro u g h t
back to the core p ro b le m w ith th e s tate m e n t,
H o w w ou ld you c o m p a r e y o u r ow n ta len ts
w ith those of the a r t i s t ? If a th e r a p is t can n o t
sessions over a 6-w eek p erio d in crisis in t e r

in
su pp ortiv e-ed u catio n al
sh o rt-term
pists establish a set n u m b e r of sessions at the

first in terv iew a n d firmly a d h e r e to a t e r m i n a
find an y connections, a q u e stio n like W h a t
tion date. O t h e r th e r a p is ts a r e m o re flexible

a n d d e te r m in e th e len gth of tr e a tm e n t a c c o rd
does th a t have to do w ith y o u r o w n basic p r o b
ing to th e re s p o n se of th e p a ti e n t to t h e r a p y .
lem w e have been e x p lo r in g ? will u su a lly

help the p a tie n t re s u m e d e a lin g w ith m o r e sig
H o w e f f e c t i v e is t h e f i r m a d v a n c e d s e t t i n g
nificant m ateria l.
o f th e n u m b e r o f se s sio n s , a n d if e ffe c tiv e ,
H o w m u c h ad v ice g iv in g s h o u ld be u sed
in s h o r t- te r m th e r a p y ?
Advice giving in p s y c h o th e ra p y sh o u ld be
h a n d e d o u t s p a r i n g l y a n d s e le c ti v e ly a n d
only w h en p a tie n ts ca n n o t seem to m a k e an
s h o u l d n t t h i s b e a r o u t i n e w i t h a l l p a
tien ts?
T h e firm setting of lim its of tim e on t h e r
a p y , o rig ina lly described by R a n k (1947) an d
T a f t (1948), h a s been beneficially em p lo y e d by
m a n y t h e r a p i s t s ( H a s k e l l et a l, 1 9 6 9 ; S.
L ip k in , 1966; M e y e r et al, 1967; M u e n c h
im p o r t a n t decision by them selves o r if th eir

ju d g m e n ts a re so faulty th a t th ey will get into
difficulties should th ey p u r s u e th em . Even in
the latte r case it is best to p re s e n t a lte rn a tiv e s
to th e p a tie n ts for th e ir o w n choice a n d to c o n
tin u e q u e stio n in g th e m as to w h y th ey find it
difficult to p u r s u e a constructive course of ac
tion w ith o u t help.
1965; Shlien, 1964; Shlien et al, 1962). A n in

te re stin g fin d in g is th a t a te r m i n a ti o n d a te ac
cepted as an im m e d ia te rea lity will influence
the process of th e r a p y an d stim u la te g re a te r
p a ti e n t activity t h a n w h e re a n u n lim ited n u m
b er of sessions seduces the p a tie n t into c o m
pla ce n t to r p o r. T h e resea rch d on e tend s to
s u p p o r t th e a d v a n ta g e s of restrictin g sessions
158
in sh o r t-te rm th e r a p y to a d esignated figure.

A g ain, the th e r a p is t will have to exercise suffi
exact d a te of sessions o r th e d a te of te r m i n a ti o n
cient flexibility so as not to su bv ert his clinical

ju d g m e n t to a rigid rule. In certain cases he
p a tie n t h a s been f o r e w a rn e d at least tw o

sessions in ad v ance, except in th e in stan ce of
will w a n t to keep his o p tio n s o pen , m erely

n u m b e r of sessions a n d th a t he will decide on
p ro lo n g e d v acation s (a con ting ency th a t can

o ccur p a rt ic u l a rly in old er th e r a p is ts by v irtu e
of th e ir h av in g achie ved sufficient levels of age,
th e e x a c t n u m b e r
fatigue, o r econom ic security).
m e n tio n in g to the p a tie n t th a t he will lim it the

so o n a f t e r t h e r a p y
has
no difficulty sh ou ld be en c o u n te re d w h e r e the
started . T h e th e r a p is t m a y q u o te th e figure as
soon as he h a s a better idea of the exten t of the
p ro b le m a n d th e cap acity of the p a tie n t to
achieve projected goals.
How
fle x ib le
sh o u ld
one
be
about
a p p o in tm e n t tim e s , w h ic h u su a lly are

sp aced at w e e k ly in terv als.
A certain flexibility of a p p o in t m e n t tim es
W h a t d o y o u d o if a p a t i e n t k e e p s ta lk in g
a b o u t h o w h o p e le s s h e feels a b o u t g ettin g
w e ll a n d little else?
P a tie n ts often ex press h opelessness ab o u t
g ettin g well soon after th ey s ta rt th e r a p y . T o
such la m e n ta tio n s the th e r a p is t m a y reply,
T h e s e a r e resistances fighting back as soon as
you begin m a k i n g efforts to get well. T h e y will
will be re q u ire d , p a rtic u la rly in crisis in te rv e n
p ass if you d is re g a rd th e m a n d go a h e a d w ith
tion w h en d o u b le an d trip le sessions, several
th e p la n of actio n we d is cu ssed . N o m a t te r
h o w pessimistic th e p a tie n t m a y seem a b o u t
sessions on the sam e day, a n d th e spacing of

sessions a re d e te rm in e d by th e p a t i e n t s ra t h e r
him self, th e th e r a p is t sh o u ld re ta in a n o p ti
t h a n the th e r a p i s t s needs. Also d u r i n g th e first

w eek of t h e r a p y w ith p a tie n ts w h o a r e e x
m istic stance: N o m a t te r h o w ba d an d im p o s
sible th in g s seem , if you keep w o rk in g on y o ur
trem ely an x io u s th ree sessions will be needed

for a d e q u a t e su p p o r t, rea s su ra n c e , an d the
p ro b lem s, you can get b e t t e r . N a tu r a l ly , an

an aly sis of w h y th e p a tie n t feels hopeless w ith
consolidation of a re latio n sh ip . W e e k ly ses
p r o p e r in te r p r e ta ti o n of his m aso c h ism w o uld

be indicated. If the th e r a p is t k n o w s h o w to do
sions th e re a fte r u su ally suffice. T h e n th ere

m a y be a t a p e r in g off to on e session in 2 w eeks
cognitive th e r a p y , he m ig h t tr y to use this
an d the nex t in a m o n th , followed by t e r m i n a
next.
tion. S ho uld th e r e be no im p ro v e m e n t w ith

w eekly sessions, a n a d d itio n al w eekly session
depressed, an d p a r t ic u l a r ly w h e r e th ere is
early m o r n in g a w a k e n in g , loss of ap p e tite , or
in a g ro u p m ay be helpful, th e g r o u p th e r a p y
retard atio n ,
also being co nd ucted on a s h o r t-te rm basis.
p resc rib ed a lo n g w ith an y of th e o th e r

m e a s u re s re c o m m e n d e d above. S ho uld negative
d is c o u ra g in g th o u g h ts p ersist, th e p a tie n t m a y
be ta u g h t m eth o d s of b e h av io ra l aversive co n
trol (W o lb e rg , 1977, p p. 6 9 4 - 6 9 5 ) .
W h a t do y o u d o a b o u t tak in g a v a c a tio n
i n t h e m i d d l e o f a p a t i e n t s t h e r a p y ?
P r e p a r in g p a tie n ts for v acations o r o th e r
absences of the th e r a p is t is often overlooked.
Sufficient notice sh ou ld be given to allo w at
In
th e
event
an
the
p a tie n t
an tid ep re ssa n t
is severely
should
be
least tw o sessions before th e th e r a p is t d e p a rt s

in o r d e r to observe a n d m a n a g e the p a t i e n t s
H o w soon sh o u ld y o u d eal w ith an g ry ,

n e g a tiv e a ttitu d e s th a t a p a tie n t m an ifests
to w a rd y o u , e x p re s s e d by c ritic iz in g y o u r
reactions. N a t u r a l l y , if a verbal con tract w as

m a d e w ith the p a tie n t th a t included the tim e of
te r m in a tio n an d no notice h a d been given the
p a tie n t th a t th e re w o u ld be a n i n t e r r u p t io n of
tr e a tm e n t, s p r in g in g a vacation on th e p a tien t
can have a bad effect on the rela tio n sh ip . In
th e absence of a definite con tract involving the
c l o t h e s , y o u r o f f ic e f u r n i t u r e , e tc .
T h e m a i n te n a n c e of a positive w a r m w o r k
ing r e la tio n s h ip is, of course, th e best t h e r a
p e u t i c c li m a t e . W h e n e v e r n e g a t i v e fe e lin g s
th r e a te n , u n lik e lo n g -te rm t h e r a p y w h e r e th ey
m a y be a llo w ed to foster regression a n d th en
ana lyz ed , th ey m u st im m e d ia te ly be e xp lored
159
a n d d issipated as rap id ly as possible to resto re
a n d d i s t u r b i n g in flu ence at h o m e , t h a t h e r cru elty
the p a t i e n t s confidence. By th e sam e to k en , in

perso nal dress a n d g ro o m in g th e th e r a p is t
a n d constant agitation created the daily environm ent
should not a p p e a r so offbeat as to offend th e
d i r e effects u p o n m e a n d m y son. T h i s p ro v e d to be
sensibilities of his p a tie n t. O n som e level the

th erap ist becomes a model for the patient. T h e
t r u e b ecau s e ev ery s y m p t o m of a n x i e t y , fear, a n d
a rr a n g e m e n t a n d fu rn ish in g s of o n e s office
should also reflect o rderlin ess a n d good taste.
of ho stility a n d ch a o s a t h o m e a n d these h a d th eir
d e p r e s s i o n left m e w h e n M r s . G left last J u n e for

Florida.
S h e r e t u r n e d h o m e a few w e e k s a go a n d t h e t u r
m o il, cru elties, a n d h o stilities r e t u r n e d w i t h h er. I
h a d r e a c h e d a sta te of i n t e r n a l s ta b ility a n d e q u a
A re t h e r e a n y ris k s in s e e in g a n o t h e r
m e m b e r o f a p a t i e n t s f a m i ly , s u c h as a
h u s b a n d o r w ife?
t i r a d e s h a v e r e s u m e d , o p e n i n g u p ol d w o u n d s , a n d
Yes. A hostile m e m b e r m a y utilize th e in t e r
r e m a r k s I h a v e a l r e a d y s ta te d . I r e a l i z e she is d o in g
view as a w a y of a tta c k in g th e p a tie n t by m is

q u o ti n g for the p a t i e n t s discom fort so m e th in g
th is w i t h sa d istic i n t e n t , a n d a l t h o u g h I h av e every
the th e r a p ist h a s said th a t is d e tr im e n ta l to

the p atien t. A n e x a m p le is th e follow ing letter
f r o m you , I do feel d e e p ly h u r t a n d 1 d o no t w a n t to
received from a p a tie n t w h o did well in s h o r t

te r m th e r a p y . I h a d a n in terview w ith th e wife
n i m i t y w h i l e sh e w a s a w a y ,
but now
h e r daily
p a r t i c u l a r l y r e f e r r i n g to you as m a k i n g t h e specific
r e a s o n to d i s c o u n t a n d d isbelieve suc h s t a te m e n ts
go o n t h i n k i n g t h a t yo u m i g h t , for s o m e r e a s o n ,
h a v e g iven h e r th e s e te r r i b l e i m p r e s s io n s E x c e p t for
w h a t is u n d e r s t a n d a b l y a p e r s o n a l h u r t w i t h the
w e a p o n she is u s i n g a g a i n s t m e, 1 a m o t h e r w i s e
d u r i n g w h ich she vented h e r a n g e r at h e r h u s
fe eling fine. I felt I s h o u l d w r i t e y o u of t h is a n d give
b an d . She refused to co n sid er m a r it a l th e r a p y
y o u a n o p p o r t u n i t y to let m e k n o w t h e t r u t h of w h a t
o r individual tr e a tm e n t for h erself even th o u g h
y o u di d o r di d no t r e l a t e to M r s . G Y o u r r e p l y will
I felt I h a d m a d e some con tact w ith h e r w h e n I

saw her.
to seek t h e t r u t h .
r e m a i n strictly b e t w e e n us, b u t I d o o w e it to m y self

Cordially,
M r. G
D e a r D r. W olberg:
F o r som e tim e , I h a v e b een t a u n t e d b y M r s . G
w i t h d erisio n s based o n specific r e m a r k s sh e firm ly
C re d it in g c e rta in re m a r k s to th e th e r a p is t is
sta te s y o u m a d e to h e r c o n c e r n i n g me. T h e s e s t a t e
b o u n d to affect th e r e la tio n s h ip w ith th e p a
m e n t s a r e t h a t I a m " h o p e l e s s , t h a t 1 will n e v e r
tient. T h e best w a y to h a n d le the m i s u n d e r
get b e t t e r , t h a t I a m to o ol d to get h e l p , a n d
sta n d in g is to a r r a n g e a j o i n t session w ith the
w o r s e t h a n all, t h a t I h a v e n e i t h e r t h e d es ire n o r
p a ti e n t a n d o t h e r fam ily m e m b e r a v o idin g ac

c u satio ns a b o u t w h o said w h a t a b o u t w h o m .
t h e in c lin a tio n to get b e t t e r . T h e s e r e m a r k s h av e

b een r e p e a t e d l y hissed at m e, a n d a l t h o u g h I h av e
tr ie d to d i s c o u n t a n d e r a se t h e m as s t a te m e n ts fro m
yo u , th ey h av e been r e p e a t e d a n d I a m d e e p l y h u r t
T h e th e r a p is t m a y th e n in a n o n c o n d e m n a to ry
w a y h elp clarify w h a t h a s been h a p p e n in g .
e m o t i o n a l sta te p l e a d i n g for h elp . 1 h a d a severe
T h i s can be a sticky s itu atio n an d will call for

a g re a t deal of tact. T h a t incidents such as the
one cited in the letter above can occasionally
occur sho uld no t d isc ou rag e the th e r a p is t from
an x i e t y a n d d e p r e s s i o n a n d t h e d i s t r e s s i n g s y m p
seeking in tervie w s w ith o th e r fam ily m em b ers.
a n d h u m i l i a t e d t h a t th ey m a y p ossibly h a v e h a d you
as t h e i r source.
As you will re call, 1 c a m e to y o u in a d e s p e r a te
to m s of m u scle s p a sm .
I a t t r i b u t e d these to th e
conflict a t h o m e , p a r t i c u l a r l y t h e in t e r a c t i o n s b e
t w e e n m y son a n d his m o t h e r . H o w co uld I not
h av e th e d es ire n o r t h e i n c lin a tio n to get b e t t e r ? I
d ev elop ed a v er y effective r a p p o r t w i t h y o u a n d
a f t e r a few m o n t h s m y s y m p t o m s left m e. S o m e tw o
m o n t h s l ater, t h e si t u a t i o n a t h o m e s p o r a d i c a l l y
e r u p t e d , a n d it soon d ev elo p ed t h a t M r s . G w a s t h e
c o m m o n d e n o m i n a t o r (not m y son) as t h e p r o v o k i n g
C a n s u p p o rtiv e th e ra p y be a n y th in g m o re
t h a n p a l l i a t i v e , a n d i s n t d e p e n d e n c y e n
c o u r a g e d in t h is k i n d o f t r e a t m e n t ?
T h e s u p p o r tiv e process m a y become m ore
th a n palliative w h e re , as a result of th e re la
tio n sh ip w ith the h e lp in g agency, th e p erson
g ain s s tre n g th a n d freedom fro m ten sio n, and
160
substitu tes for m a l a d a p tiv e attitu de s an d p a t

tern s those th a t en ab le h im to deal p r o d u c
co ntrol, w h ile r a p i d ly p a llia tin g suffering a n d

p e r h a p s even r e i n s ta t in g th e p rev io u s p sy c h o
tively w ith e n v ir o n m e n ta l p re ssu re s an d in t e r
logical e q u il ib r iu m , o p e ra te like a tw o -ed g ed
nal conflicts. T h i s ch ang e, b ro u g h t a b o u t most
sw o rd. J u s tif ia b l e
effectively t h r o u g h the in s tru m e n ta l it y of a r e
seem, th ese skeptics insist th a t it fails to resolve
la tio n s h ip eith er w ith a tr a in e d professional in

in dividual th e r a p y o r w ith g r o u p m e m b e rs and
th e leader in g r o u p th e r a p y , m a y come a b o u t
as s y m p to m con trol
may
the u n d e rly in g p ro b le m s a n d difficulties th a t

n u r t u r e th e c u r r e n t crisis. Irre co ncilable u n
conscious needs a n d conflicts c o n tin u e to press
an y h elp in g situ a tio n . Som e d ep en d en cy is, of
for fulfillm ent, a n d , therefore, th ey insist, we

m a y a n tic ip a te a recrudescence o r s u b s titu tio n
course, inevitable in this k ind of a t h e r a p e u ti c

interac tion , the a d e q u a t e h a n d li n g of w h ich
of sy m p to m s. T h e s e a s s u m p ti o n s a re b ased on
an e rr o n e o u s clo sed -sy m p to m th e o r y of p e r
constitutes the difference b etw een the success
son ality dy nam ics.
o r failure of the th e r a p e u tic re la tio n s h ip in
m a y a c tu a lly resu lt in p rod uctive feedback th a t
also as a result of s p o n ta n e o u s r e l e a rn i n g in
scoring a t r u e p sy c h o th e ra p e u tic effect. D e
may
pendency
w ith in
of t h i s
k in d ,
how ever,
can
be
rem ov e
S y m p to m s once rem oved
b a r r ie r s
to
con structiv e
shifts
th e p e r s o n a l i t y s y s te m itself. E v e n
m an ag e d th e r a p e u tic a lly a n d c o n stitu tes a

p ro b le m only in p a tie n ts w h o feel w ith in
t h o u g h these facts h ave been k n o w n for years
them selves a p atho lo gic al sense of helplessness.
A vnet, 1962; M a r m o r , 1971; W o lb e r g , 1965)

M a r m o r , 1971) a n d have been c o rr o b o ra te d in
T h e sicker an d m o r e im m a t u r e th e p a tie n t, the

s tro n g e r his d ep en d e n cy is a p t to be. It is
essential th a t the h e lp in g agency be able to ac
cept th e p a t i e n t s d ep en d en cy w ith o u t re s e n t
m en t, g ra d in g th e d eg ree of s u p p o r t th a t is ex
(A le x a n d e r, 1944; A l e x a n d e r & F re n c h , 1946;
th e t h e r a p e u ti c resu lts b r o u g h t a b o u t by active

p sy c h o th e ra p e u tic m eth o d s, th e tim e -h o n o re d
credo b r a n d i n g s y m p to m rem o v a l as w o rth less
persists an d
feeds la c k of e n t h u s i a s m
tended a n d the responsibilities im posed on the

p a tie n t in acc ord ance w ith th e stre n g th of the
sy m p to m -o rie n te d
p a t i e n t s defenses. (See also th e second an d
follows.)
tech niqu es.
(See also
for
the
second q u e stio n above a n d th e q u e stio n th a t
th ird q u estion s th a t follow.)
W h e r e t h e a i m is t h e s i m p l e a l l e v i a t i o n o f
sym ptom s an d no p erso n ality alteratio n s
a r e d e e m e d n e c e s s a r y , w h a t ta ctic s h o u l d
be used?
T h e th e r a p e u tic tactics essential for th e
m odest a im of s y m p to m relief a re u n c o m p l i
cated, consisting essentially of develo ping a
w o rk in g rela tio n sh ip , e n c o u ra g in g e m o tio n al
ca tha rsis, giving p ro p e r s u p p o r t, g u id an ce , an d
suggestions, em p lo y in g tec h n iq u e s such as b e
hav io r th e ra p y and re lax atio n pro ced u res
w h e re these a re indicated, a n d , if necessary,
t e m p o ra r ily a d m in is te rin g p sy cho tro pic m e d i
cations.
I s n t s y m p t o m c o n t r o l a v e r y s u p e r f i c i a l
t h e r a p y , a n d d o e s n t it o f te n r e s u l t in a
r e tu rn of sym ptom s?
T h e r e a re still a s u b s ta n tia l n u m b e r of t h e r
apists w h o believe m eth o d s a im ed at sy m p to m
D oes th e ra p y focused o n h e lp in g o r re
m o v in g sy m p to m s p re v e n t a p erso n from
ach iev in g d e e p e r changes?
T h e evidence is o v e rw h e lm in g th a t s y m p
to m -o rie n te d th e r a p y does no t necessarily c ir
cu m sc rib e th e goal. T h e active th e r a p is t still
h a s a resp o n sib ility to w o r k t h r o u g h m u c h of
the p a t i e n t s re s id u al p e rs o n a lity difficulties as
is possible w ith i n the confines of th e av aila ble
tim e, th e e x isting m o tiv atio n s of th e p a tie n t,
a n d th e basic ego stre n g th s t h a t m a y be relied
on to su sta in n e w a n d b e tte r defenses. It is tr u e
t h a t m ost p a tie n ts w h o a p p ly for help only
w h e n a crisis cripp les th e i r a d a p ta tio n a re m o
tivated m erely to r e t u r n to th e d u b io u s ly
h a p p y day s of th e i r n e u ro tic ho m eostasis. M o
tiv atio n, ho w ev er, can be c h a n g e d if th e t h e r a
pist clearly d e m o n s tra te s to th e p a ti e n t w h a t
really w e n t on b e h in d the scenes of the crisis
th a t w e re respo nsib le for his up set. (See also

th e precedin g q u e stio n a n d th e th ird q u e stio n
above.)
W h a t d o y o u t h i n k o f G e s t a lt t h e r a p y ,
a n d is it u s e f u l in s h o r t - t e r m t h e r a p y ?
161
to
e n h a n c e social
a d ju s tm e n t.
W here
ru d i
m e n ts of a d a p ti v e skills a r e p re s e n t an d w h e re
a n x ie ty is no t to o p a ra l y z in g , th e in d iv id u a l in
a relatively b rief pe rio d w ith p r o p e r th e r a p y
a lo n g cognitive lines m a y be able to r e o r g a n iz e
G e s ta lt th e r a p y is one of th e m a n y m e th o d s
his t h i n k in g strateg ies a n d to find a lte rn a tiv e
t h a t if executed p ro p e r ly by a th e r a p is t w h o
solu tion s for p ro b le m s in living th a t a r e m u c h
h as faith in its efficacy can be e x trem ely useful.

S om e of th e te chn iq ues, like th e em p ty c h a ir
m o r e a tt u n e d to a con structiv e a d ju s tm e n t. I n
terv entio n p r o g r a m s a lo n g cognitive lines have
tec hn iqu e, a re especially v a lu a b le as a m e a n s

of stim u la tin g em o tio n a l cath a rsis, a rr iv in g at
of clinical a n d e d u c a tio n a l settings (Spivack et
been described th a t a re a p p lic a b le in a variety
an u n d e r s ta n d in g of su p p resse d a n d repressed
al., 1976). In m y o p in io n , th e tech n iq u e s r e
feelings, an d p ro v id in g a p la tfo rm for th e p r a c
lated to cognitive a p p r o a c h e s can be im p le
tice of b ehav iors th a t th e p a tie n t re g a r d s as
m e n te d w ith in a d y n a m ic fr a m e w o rk .
a w k w a r d o r forbidden. As w ith a n y o th e r te c h
n iq u e, resistances a r e a p t to e r u p t th a t will re
q u ir e careful an aly sis a n d resolution.
W h a t is e g o - o r i e n t e d p s y c h o t h e r a p y ?
Is c o g n i t i v e t h e r a p y o f a n y v a l u e as a
m e th o d in s h o r t- te r m th e ra p y ?
P r e l im in a r y
studies
a r e e n c o u ra g in g ,
but
Sarvis et al (1958) have w rit te n a b o u t th e ef
w h e t h e r it is s u p e r io r to o th e r m eth o d s in
fectiveness of tim e-lim ited eg o-orien ted p sy

c h o th e r a p y w ith o u t setting u p p re d e te rm in e d
j u d g e d by f u r t h e r rese arc h. T h e m a n y factors
c rite ria for m o tiv a tio n o r readin ess. N o a r b i
t h a t in fluence all p sy c h o th e ra p ie s for b e tte r or
tr a r y to pic is set, b u t focus is a p ro cess a ris in g
w o rse
out of th e in te rc h a n g e b etw een th e p a tie n t an d
t h e r a p y . It h a s p a r t ic u l a r ly been re c o m m e n d e d
t h e r a p i s t . T h e a u th o r s conceive of t h e r a p y as
b eing o p e n -en d ed , a p p lic a b le at an y p o in t in
in d e pre ssio n, b u t it is d o u b tfu l th a t it is a s u b
th e a d a p tiv e -m a la d a p tiv e in te g ra tio n s of e x

istence. T h e y re g a r d it as a li m i te d d y
n am ically directed form of p s y c h o th e ra p y th a t
especially in en d o g e n o u s dep res sio n . It m a y , as

a p s y c h o t h e r a p e u t i c a d j u n c t , f u n c t io n h e r e
is disting uished fro m p sy ch o a n a ly sis a n d psych oan alytically o rie n te d p sy c h o th e ra p y in both
C o gn itive t h e r a p y is most helpful in p a tie n ts

w ith biased a n d fau lty th i n k in g p ro b lem s,
process an d goals. A crucial focus is w h a t h as
obsessional
b r o u g h t th e p a ti e n t to t h e r a p y at th e tim e he
ap p lies for h e lp (w h y n o w ?). F r e q u e n c y of
positively to a w ell-co n d u cted a n d skillfully o p
sessions is flexible, d e p e n d in g on the needs of
cognitive t h e r a p y is d o n e a n d th e faith of the
th e p a tie n t; the total tim e devoted to t h e r a p y is

limited th o u g h no t p r e d e t e rm in e d in advance.
T h e th e r a p is t tries actively to e m p a t h iz e
w ith , co nceptualize, a n d in t e r p r e t th e p a t i e n t s
th e r a p is t in its efficacy. T o a th e r a p is t w ho
m a t e r i a l p a r t ic u l a r ly preco nscio us tre nd s, the

c u rr e n t th e r a p e u tic in te ra c tio n , an d th e evi
dence of tra nsferen ce, in te r m s of o n g o in g in
te g r a t i v e a d a p t a t i o n s r a t h e r t h a n t o w a r d
regressiveness.
c e rta in c o n ditio ns is difficult to say a n d will be
u n d o u b te d l y
a p p ly
also
to cognitive
s t i t u t e fo r a n t i d e p r e s s a n t p h a r m a c o t h e r a p y ,
as a p ro p h y la c tic r e t a r d i n g f u r th e r attacks.
and
p h o b ic
p a ti e n ts
re s p o n d in g
era te d p r o g r a m . A n i m p o r t a n t th in g is h o w
believes in its v alu e a n d w h o d edicates h im self

to th e a rd u o u s ta s k of a lt e r i n g established
cognitive fr a m e s of reference, it m a y be a
p referred a p p r o a c h . O t h e r t h e r a p is t s m a y be
m o r e dedica ted to a n d get b e tte r results w ith
te c h n iq u e s w ith w h ic h they h av e a special p e r
son al affinity.
W h at are the objectiv es o f co gnitive a p

p r o a c h e s to t h e r a p y ?
A r e t h e r e a n y d r a w b a c k s to u s i n g b e
h a v i o r t h e r a p y in d y n a m i c s h o r t - t e r m
th e ra p y ?
R e c e n t c o g n it iv e a p p r o a c h e s a t t e m p t to
im p ro v e p ro blem -so lv in g o p e ra tio n s as well as
N o t a t all. It can be q u it e useful. W h e r e the

th e r a p is t is o rie n te d to w a r d b e h a v io r th e r a p y ,
162
he will a p p r o a c h som e of the p a t i e n t s difficul
r e la tio n s h ip w ith th e th e r a p is t by m o b iliz in g
ties as m an ifestatio n s of fau lty le arn in g . H e
th e essential h o pe, faith, a n d tru st t h a t a re
will usu ally s ta rt th e r a p y w ith a b eh avioral
p arcels of every h elp in g process a n d by c u ttin g
analysis. T h e s y m p to m to be altered is a n a
t h r o u g h resistances th a t d elay th e essential es
lyzed to d e te r m in e w h a t benefits th e p a tie n t

derives from it. E x p lo ra tio n s will deal w ith
identification of factors th a t to u ch off an d r e i n
tab lis h in g of r a p p o r t. T h i s is especially im p o r

t a n t in detac h ed an d fearful in div idu als w h o
fo rcem ents th a t su sta in the m a la d a p tiv e be
a n d hence im p ed e the evolvem ent of a w o rk in g
h av io r a nd of elem e nts th a t reduce such be
rela tio n sh ip . S econd, h y pn osis, o w in g to its
hav ior. A ction r a t h e r th a n in sig h t is accented.
e n h a n c e m e n t of suggestibility,
A m etho d th a t h elps to e n c o u ra g e m otiv atio n is
th e
the k eeping of a daily d ia r y th a t scores the fre
p ro n o u n c e m e n ts , v erbal a n d n o n v e rb a l, th a t
m a y alleviate, at least te m p o ra r ily , sy m p to m s
qu encies of sy m p to m a tic occurrences. S im p le

score keep in g h a s been fo un d to red u c e the
n u m b e r of sy m p to m a tic upsets. T h e p a t i e n t s
positive efforts to control, alter, a n d reverse his
p u t u p defenses a g a in s t a n y kin d of closeness
ab so rption
by
th e
will p ro m o te
p a tie n t
o f p o s itiv e
t h a t i n t e r f e r e w i t h e x p l o r a t o r y te c h n i q u e s .
T h i r d , h y p n o s i s o fte n e x p e d i t e s e m o t i o n a l
m a la d a p tiv e b e h a v io r a r e re w a r d e d by a t t e n
cath a rsis by o p e n in g u p fo un ts of b o ttle d -u p

em o tio n, th e r e b y p ro m o ti n g t e m p o r a r y relief
tion, praise, a n d e n th u s ia sm . T h e p a t i e n t s
an d sig naling so m e sources of re s id u a l conflict.
reactio ns to th e tech n iq u e s sh o u ld be observed,
F o u r t h , im p e d im e n ts to v e rb a lizatio n a r e often
th e th e r a p ist being alerted to tra n sfe re n c e an d
rea d ily lifted by even light h ypnosis. Fifth,
resistance. T h e r e is no reaso n w h y d y n a m ic
princip les ca n n o t be ap p lied to w h a t is h a p
w h e re m o tiv a tio n is lackin g to w a r d in q u iry

into sources of p ro b le m s, h y p no sis, th r o u g h
p en in g d u r i n g beh av io r th e r a p y o r an y kind of
its te n s io n -a b a tin g a n d suggestive s y m p to m -
th e r a p y . (See also the follow ing questio n.)
relieving p ro p e r tie s, m a y h e lp convince th e p a
C a n b e h a v i o r t h e r a p y be u s e d f o r c o n d i
tio n s o t h e r t h a n p h o b i a s ?
tien t th a t he c an derive benefits fro m t r e a tm e n t

if he c o o p e r a t e s . S i x t h , by its effect on
resistances h y p n o sis m a y h e lp ex ped ite such
Yes, for v ario us cond itio ns like obsessions,

hy p o ch o n d rias, d epression , an d h a b it disorders
insight tech n iq u e s as im a g e ry , d r e a m recall,

a n d th e release of forgotten m em o ries. S eventh,
w h e re the sy m p to m s a re c irc um sc ribe d a n d th e
h y p n o sis m a y light u p transfe ren ce, r a p id ly
events th a t p ro d u c e th e sy m p to m s a re id e n ti
fiable. B ehav ior th e r a p is ts utilize beh av io ral
b rin g in g fu n d a m e n ta l p ro b le m s w ith a u th o r it y
t e c h n i q u e s a l o n g w i t h o t h e r m e t h o d s like
p h a r m a c o th e r a p y an d v ariou s k ind s of p sy c h o
th e r a p y . M o r e a n d m o re th e r a p is ts a re seeing
th e a d v a n ta g e of u tilizin g b eh av io r th e r a p y
w ith in a d y n a m ic fr a m e w o rk . In creasin g n u m
bers of analytically tra in e d th e r a p is ts a r e find
in g d e s e n s i t i z a t i o n , a s s e r t i v e t r a i n i n g , a n d
o th e r form s of beh av io r th e r a p y useful in th eir
w ork. (See also th e p re ced ing q ue stion .)
to th e surface. E ig h th , by d e a lin g directly w ith

d eterren ces to ch an g e h y p n o sis m a y ex p ed ite
th e w o rk in g - th r o u g h process, p a r t ic u l a r ly the
co nversion of insig ht in to actio n. T o w a r d this
end , te a c h in g th e p a ti e n t self-hypnosis m a y be
of value. F in a lly , hy p n o sis m a y som etim es be
helpful in th e t e r m i n a ti o n of t h e r a p y , e n a b lin g
the p a tie n t w h o h a s been ta u g h t self-rela xation
an d self-hypnosis to c a rr y o n th e t h e r a p e u ti c
process by himself.
W h a t is t h e v a l u e o f h y p n o s i s in s h o r t
te rm th erap y ?
Is h y p n o s i s e v e r u s e d w i t h a p s y c h o m i m e t i c d r u g to s p e e d u p t h e r a p y ?
H y p n o sis is chiefly e m plo y ed as a cataly st in

p sy ch o th erap y . It p o ten tially facilitates th e
th e r a p e u tic process in a n u m b e r of w ays. F irst,
hyp no sis m a y exert a positive influence on th e
th e r a p e u tic c h a n g es of a rec on struc tive n a t u r e

th r o u g h th e use of a c o m b in a tio n of h yp n o sis
a n d L S D a d m i n is tr a t io n in a te c h n iq u e they
L u d w i g a n d L ev ine (1 96 7) claim s u b s ta n tia l
163

te rm h y p no delic t h e r a p y . F ew o th e r t h e r a
p a r a m o u n t is no t yet too clear. H o w e v e r, p r a c
pists use this co m b in atio n .
tically s p ea k in g , a ssign ing to s y m p to m s some

rea s o n a b le etiology th a t th e p a tie n t can accept
W h at are th e p r in c ip le o bjectiv es of d y
n a m i c p s y c h o t h e r a p y , a n d h o w a r e th e s e
o b je c ti v e s r e a c h e d ?
th en be w illin g to e x p e r i m e n t w ith m o r e a d a p
In d y n a m ic a lly o rien ted th e r a p y th e objec
tive p a tte rn s . If no m o re t h a n a placebo, then ,
serves to e n h a n c e self-confidence a n d to lo w er
a n x ie ty an d ten sion levels. T h e p atie n t m ay
tive is to brin g the in d iv idu al to a n a w a re n e s s
insight can serve in the in te rests of e x ped itin g
of preva ilin g e m o tio n al conflicts, th e defenses

em ployed in avoiding such aw a re n e ss, the w ay
t h e r a p e u ti c goals.
O bv iou sly, th e m o re p erceptive a n d
such conflicts o rig in a lly h a d developed in the
tr a in e d the th e r a p is t, th e m o re likely will the
well
past, th e influence they h a v e ex erted o n d e
p a tie n t be h e lp e d to arr iv e at u n d e rl y in g etio
v elop m en t, the insidious w a y s they p ollu te

o n e s p resen t existence, a n d th e ir relevance in
logical factors. B ut, ho w ev er, a c c u ra te these

discoveries m a y be, a tr e m e n d o u s n u m b e r of
sp o n s o rin g ex istin g sy m p to m s a n d c o m p la in t
elem en ts
factors. Such clarification is in th e in terest of
t h e r a p e u ti c G e s ta lt. A g ain , this is not to d e
o th e r
th a n
insight
e n te r
into
the
h e lp in g to face an xieties a n d to develop n ew
preciate insight, b ut r a t h e r to assign to insight
w ay s of re la tin g to o neself a n d to people. I n
a significant but not exclusive im p o rtan c e.
te r p re ta tio n s , th e chief m eth o dolo gical tool, are

targ eted on defenses at th e sta rt, on a ny ex ist
ing anx iety, an d finally on th e drives an d im
pulses th a t a re being w a r d e d off. E ssen tial is
the m a i n te n a n c e of sufficient tension in th e in
terview to create an incentive for h a n d li n g a nd
w o rk in g th r o u g h of th e in itiatin g conflicts. A
most fertile a r e n a for e x p lo r a tio n is th e t r a n s
H o w i m p o r t a n t - i s d r e a m . a n a ly s i s as a n
a d j u n c t to w h a t e v e r t e c h n i q u e s a r e b e i n g
used?
D r e a m a n a ly s is con stitu tes a vital m e a n s of
h e lp in g p a tie n ts recognize som e of th e ir fu n
d a m e n t a l p ro b le m s an d th e ir o w n p a r t i c i p a
tion
in
fo sterin g
neu ro tic
m a lad ju stm en t.
ference, w hich p re s e n ts th e p a tie n t w ith a liv
W o r k i n g w ith college s tu d en ts, M e r r il l an d
ing e x a m p le of some of the core conflicts in ac

tion. M o s t vitally tra n sfere n c e in t e rp re ta ti o n
C a r y (1975) fo un d th a t focusing on d r e a m s
low ered resista nce to self-experience in s t u
enables the lin k in g of w h a t is going on in the
d en ts stru g g lin g w ith the in d ep e n d e n c e -d e p e n -
p resen t w ith
i m p o r t a n t d e te r m i n a n ts in the
dence conflict. It also red u ced a c tin g -o u t by
past. T ra n s f e r e n c e m ay not be display ed e x clu
e n c o u ra g in g the ac cep tan ce of d isow n ed feel
sively to w a rd th e th e ra p ist. It m ay be projected

to w a rd o th e rs outside of th e tr e a tm e n t s i t u a
ings. A d r e a m is best utilized in re la tio n to

c u r r e n t exp erienc e, th o u g h its ro ots in past
tion.
con d itio n in g s a r e not neglected especially w h en
In d y n a m i c t h e r a p y s h o u l d n t t h e c h i e f
a im b e t h e d e v e l o p i n g o f in s i g h t in th e
p a t i e n t s in c e w i t h o u t k n o w i n g t h e c a u s e s
a c u r e is im p o s s i b l e ?
M any
th e r a p ists still believe th a t
under
s ta n d in g the causes of a p ro b le m is ta n t a m o u n t
to a cure. T h e search for sources th e n goes on
relentlessly. S ho uld im p ro v e m e n t fail to occur,
the p a tie n t is enjoined to dig deeper. O b v i
ously, one task of t h e r a p y is to d e te r m in e u n
d erly in g causes; but we a re still at a stage
w h e re o u r k no w ledg e of which causes are
t r a n s f e r e n c e e l e m e n t s a r e o b v io u s in th e
d r e a m . ( C h a p t e r 12 deals extensively w ith the
use of d r e a m s in s h o r t-t e rm th e r a p y ).
A re p s y c h o a n a l y t i c t e c h n i q u e s , s u c h as
d r e a m a n a ly s i s , i m a g e r y e v o c a t i o n , i n t e r
p r e ta tio n of resistan ce a n d tra n sfe re n c e ,
a n d o th e r m o d e s of e x p lo rin g th e u n
co n scio u s a b s o lu te ly essen tial to w a rd
p r o m o t i n g d e p t h c h a n g e s in t h e p e r
s o n a l i t y ? It is s o m e t i m e s p o i n t e d o u t
that a n u m b e r o f p a tie n ts do achieve
co n sid erab le p erso n a lity g row th w hen
164
tre a te d by a th e ra p ist w h o u tilizes s u p

po rtiv e an d ed u catio n al m eth o d s ex c lu
s iv e ly , p u r p o s e l y a v o i d i n g p r o b i n g f o r
c o n f lic ts a n d d e a l i n g o n l y w i t h m a n i f e s t
sym p to m s a n d p ro b lem s.
T h e r e a re a few p a tie n ts w ho se rep ressio ns
F o r e x a m p le , in several cases referre d to m e

for h y p n o sis by e xp erie nce d h y p n o th e r a p is t s
w h o w ere u n a b le to induct a hy p n o tic state, I
was
ab le
easily
to
detect
th e
tran sferenc e
resistance th a t in terfered w ith h y p n o tic i n d u c

tion. W i t h o u t ex ceptio n, once th is im p e d im e n t
are n o t too severe, w h o se defenses a re no t too
w a s b ro u g h t to the surface a n d ex plo red w ith
rigid, a n d w h o possess a stro n g re adin ess for
th e p a tie n t, he w a s ab le easily to achieve a

satisfactory tran ce.
ch ang e. If the th e r a p is t is n o n ju d g m e n ta l and

em p a th ic , the th e r a p e u tic r e la tio n s h ip itself
can serve as a corrective em o tio n al experience.
T h e conception of p un itiv e a u th o r it y is altered ,
and
s o f te n in g
o f th e
superego
resu lts
in
s t re n g th e n in g of the self-image. T h i s , h o w
ever, is m o re likely in lo n g - te rm th a n in s h o r t
te r m th e r a p y . M o s t people do r e q u i r e som e
challenge in o r d e r to ch an g e , an d a certain
S o m e a u t h o r i t i e s in s is t t h a t t r a n s f e r e n c e
is n o t a p r o b l e m in s h o r t - t e r m t h e r a p y
s in c e t h e t i m e e l e m e n t is to o b r i e f f o r its
a p p e a ra n c e . O th e r a u th o ritie s base th e ir
e n tire strategy a r o u n d th e d etec tio n a n d
e x p l o r a t i o n o f t r a n s f e r e n c e . W h a t is t h e
d isc re p an c y ?
a m o u n t of a n x ie ty needs to be to lerated to give
In d y n a m ic s h o r t-t e rm t h e r a p y tr a n sferen ce
u p old h ab its an d p a tt e r n s e x c h a n g in g th e m
for u n fa m ilia r w ay s of behaving. W e see this
is a key d im e n sio n a n d sh o u ld alw a y s be

looked for. It is often p u rp o s e fu lly b ypassed o r
d u r i n g a n d after crises w h e n p eop le realize
overlooked w h e n th e th e r a p is t decides to act

like a giving, helpful, active, be nevolent a u
th a t th e ir u sual a d a p ta tio n s a r e ineffective and

can only get th e m into m o re trou ble. D u r i n g
th o rity , s y m p to m relief being e xp edited by this
s h o r t-te rm th e r a p y c o n fro n ta tio n s a n d in t e r
k ind of r e la tio n sh ip . In n o n d y n a m i c s h o r t-t e rm
p re ta tio n s im pose on th e individ ual challenges

w ith w hich he m ust come to grips. A p u r p o s e
t h e r a p y a benev ole nt ty p e of tra n sfe re n c e th u s

m a y be d e sira b le for results. W e a r e not so
ful focusing on unconscious m a te ria l can be

most helpful in p ro m o tin g self-u n d e rstan d in g ,
W e a r e m o r e vitally co ncern ed w ith a n o th e r
m u c h con cern ed w ith th is fo rm of transference.
w hich m a y th en act as a n incentive for change.
ty pe of tr a n sferen ce th a t acts as resistance to

tr e a tm e n t m a n ife stin g itself in d is tru s t, ho s
D o e s o n e h a v e to b e a p s y c h o a n a l y s t to
d e a l w i t h r e s is ta n c e ?
tility, excessive d e m a n d s for love an d a tte n tio n ,

sexu al im p ulse s, a n d so fo rth. Prog ress will be
O f course not. B ut th e th e r a p is t w h o h as no
u n d e r s ta n d in g of psyc h o an aly tic th e o ry an d
m e th o d is at a d is a d v a n ta g e in d e a lin g w ith
resistance. In m y su pe rv iso ry w o rk I have
in t e r r u p t e d unless this sho w of tra n sfe re n c e is

resolved. W h e t h e r it can be resolved d ep e n d s
on th e skill of th e th e r a p is t a n d th e p a t i e n t s
m o tiv atio n an d ability to w o r k it th r o u g h .
gotten the im p re ssio n th a t it is resistance th a t

p rin c ip a lly accounts for failu res in the active
a p p ro a c h e s like hypn osis a n d b eh avio r t h e r
apy . R eferrals to m e of a sizable n u m b e r of p a
tients w h o w ere u n a b le to achieve satisfactory
resu lts w ith n o n a n a ly tic th e ra p ie s , revealed in
Sicker p a tie n ts m a y r e q u i r e a n ex tend ed period

o f t r e a t m e n t to o v e r c o m e su c h d e s t r u c t i v e
practically every case th a t tra n sfe re n c e h a d in

terfered w ith positive responses to th e t h e r a
p is ts methods. Such reaction s occurred w ith
me also, but I w as soon able to detect th em
from the p a t i e n t s associations an d dream s.
T h e y th en co nstitu ted the focus in o u r th e r a p y .
transfe ren ce. W h e r e a th e r a p is t is tr a in e d to

detect tr a n sferen ce (e.g., by observin g n o n
verbal b eha vio r, slips of speech, a ctin g-o ut,
d re a m s , etc.) a n d deals w ith it by a p p r o p r i a t e
in t e r p r e ta ti o n , it m a y serve as a m ean s to w a r d
h e lp in g the p a ti e n t to u n d e r s ta n d som e of the
deepest conflicts. In s u m m a r y , w h ile th e t h e r a
pist m a y not w ish to in terfe re w ith a positive
tra nsferen ce, indeed he m a y e m p lo y it as a
p ro d to w a r d s y m p to m relief a n d positive c o r
165

rective b ehav io ral actio ns a negative t r a n s
o th e r w a y of in creasin g th e c o n c e n tra tio n of
ference will definitely r e q u i r e a tte n tio n a nd

resolution. In som e cases negative tran sferen ce
n e u r o t r a n s m i t t e r s in th e b r a i n a n d liftin g
d epression is by p re v e n tin g th e ir m e tab o lism
will a p p e a r
as
t h r o u g h in h ib itin g the e n zy m e m o n o a m in e o x i
te r m in a tio n poses a th r e a t. T h i s is especially

th e case w h e re se p a r a tio n -in d iv id u a tio n has
da se ( M A O ) . U s u a lly th e respo nse to th e

M A O in h ib ito rs (N a rd il, P a r n a t e ) is also d e
been im pa ire d.
layed.
to w a r d
the end
of t h e r a p y
W ould you u tilize o th e r te c h n iq u e s w h e n

t h e c h i e f m e t h o d e m p l o y e d is g r o u p t h e r
a p y o r f a m i ly t h e r a p y ?
G r o u p th e r a p y o r fam ily th e r a p y does not
restrict the use of an y o th e r te ch n iq u e s th a t
P sy c h o s tim u la n ts like d e x t r o a m p h e t a
m ines (D e x a m y l), for e x a m p le , a re som etim es

c a utio u sly used in mild depressio ns. W h e r e
d epression is s ec o n d ary to a n x iety , t r a n q u i
lizers ( L ib r iu m , V a liu m ) o ccasionally h elp , bu t
b ecause of the d a n g e r of h a b it u a ti o n , tricyclic
a n tid e p re s s a n ts o r low doses of n e u ro le p tics
m ig h t h elp an y of the m e m b e rs. T h e s e include
( M e lla r il) a r e p referred . In p r i m a r y depressio n
p h a r m a c o th e r a p y , in d ivid ua l th e r a p y , m ilieu
co m plicated by a n x ie ty tricyclics (E lavil, S in e
t h e r a p y , an d so on.
q u a n ) a re th e d ru g s of choice. A p a tie n t ta k in g
a n tid e p re s s a n ts sho uld be seen pe rio dica lly by
I s n t e l e c t r o c o n v u l s i v e t h e r a p y passe?
By no m ea n s. It still is a most, if no t the
most, effective tr e a tm e n t m e a s u re in d eep su i
cidal depressions. In excited m a n ic a n d sch izo
p h re n ic p a tie n ts it also is o ccasionally used
a ph y sician , p referab ly a p sy ch iatrist ac

q u a in t e d w ith d r u g th e r a p y , w h e r e th e t h e r a
pist is a n o n m e d ic a l perso n , since side effects
a re co m m o n .
w h en lith iu m a n d n eurole ptic s fail to q u ie t th e
Is l i t h i u m h e l p f u l in s c h i z o p h r e n i a ?
p a tie n t dow n.
N e u ro le p tic s a r e the p re fe rre d d ru g . A few

studies do reveal th a t in som e cases lith iu m
Is d r u g t h e r a p y still w a r r a n t e d in d e
p r e s s i o n , a n d if so, w h a t is its r a t i o n a l e ?
m a y be useful, bu t th e s u b g r o u p s th a t resp o n d
D efinitely it is w a r r a n t e d . T h e r e a r e differ
ent kin ds of d ep ression , of course, for e x a m p le ,
have n ot as yet been identified.
H ow do n e u ro le p tic s o p era te?
secondary to a n x ie ty o r hostility. T h e r e a re
N e u ro le p tic s block th e d o p a m i n e rece p to rs

in th e b ra i n in te rfe rin g w ith d o p a m i n e t r a n s
certainly biological correlate s in d epression.
mission.
The
p h r e n i a a r e believed to be th e p ro d u c t of d o p
depression
as
prim ary
con ditio n
latest h y po thesis is th a t
and
as
in d ep ressio n
S om e
of th e s y m p to m s
th ere is a deficiency of n e u ro t r a n s m it te r s , th a t
is, of cate ch olam in es at th e ad re n e rg ic re c e p to r
a m i n e excesses.
sites in the b ra in , p a r t ic u l a r ly a deficiency of

n o re p in e p h rin e , a n d also a deficiency of indo leam ines (serotonin). A n tid e p r e s s a n t d ru g s ,
n am ely th e tricyclic a n tid e p re s s a n ts (T o fra n il,
Elavil, S in e q u a n ) , increase th e c o n ce n tratio n
of n e u ro t r a n s m it te r s at th e re ce p to r site by
blocking th eir r e u p t a k e fro m the synapse.
W hich n e u ro le p tic s
sch izo p h ren ia?
W h e n tricyclic a n tid e p re s s a n ts a re used, th ey

m u st be given in a d e q u a t e d osag e (individually
are
of schizo
p referred
in
T h e r e a re several classes of n euroleptics:

first, th e p h e n o th i a z in e s ( T h o r a z i n e , M e l la ri l,
an d P ro lix in ); second, th e d ib e n z o x a z e p in e s
(L o x a p in e ); th ird , th e b u t y r o p h e n o n e s ( H a l
d o l) ; f o u r t h , t h e t h i o x a n t h e n e s ( N a v a n e ) ;
reg ulated ) an d th e effects m a y not be a p p a r e n t

for 3 to 4 weeks. After th e d epression lifts,
a n d fifth , t h e d i h y d r o i n d o l o n e s ( M o b a n ) .
O t h e r classes will p r o b a b ly be in tro d u ced as
well as a d d itio n s to each class. T h e r e is little
difference a m o n g th e v a rio u s d ru g s, but occa
the dosage is low ered to as sm all a m a i n t e

nan ce dose as sy m p to m control req uires. A n
sionally a p a ti e n t m a y develop an in to lera nce

to specific d ru g s a n d not to o thers. Som e p a
166
tients do well on d r u g th e r a p y ; som e do no t r e
d ru g s a r e n ot c o ntin ue d. R o u g h ly after th e first
sp o nd at all; a n d still others resp o n d so badly
atta c k th e p a ti e n t sho uld co n tin u e on m e d ic a
th a t th ey have to be ta k e n off m edications.
tion for 1 to I /2
S h o u l d n e u r o l e p t i c s b e u s e d w ith p s y c h o
t h e r a p y in s c h i z o p h r e n i a ?
It h as been sh o w n
in sch iz o p h re n ia th a t
a d e q u a t e dosages of n eu ro lep tics coupled w ith

fam ily th e r a p y a re followed by the sm allest
years. A fter a second a tta c k
th ey sho uld be prescribed for 2 to 5 years.

A fter a th ird atta c k they m a y have to be used
indefinitely w ith occasional d ru g-free holidays.
Su pervisio n is essential to see th a t the m e d ic a
tion s a re ta k e n a n d to adju st the d osag e to
lessen side effects an d sequelae.
n u m b e r of relapses. G r e a t flexibility is neces

sary on the p a r t of the th e r a p is t, e x p e r i m e n t
ing w ith o th e r m odalities also since special
techn iq ues will suit som e p a tie n ts a nd not
others. P e r h a p s th e most i m p o r t a n t th e r a p e u tic
agency is a good r e la tio n s h ip w ith the t h e r a
pist. P sy c h o th e ra p e u tic tech niq ue s a re v a lu e
less w ith o u t this.
W h e n w o u l d y o u p r e s c r i b e s l e e p i n g p ill s ,
an d w h ich w o u ld you reco m m e n d ?
W h il e b en z o d ia z e p in e s (V a liu m , D a lm a n e )
a re safer t h a n b a rb itu ra te s , they should very
ra re ly if ever be given to n e w p a tie n ts for in
so m n ia for m o re th a n 2 to 4 weeks. Beyond
th a t tim e co nsistent use causes th e m to lose
S h o u l d n e u r o l e p t i c s a l w a y s be e m p l o y e d
in s c h i z o p h r e n i a ?
th e ir effectiveness. O ccasio n al use of hy pn otics,
By no m eans. A ctually, th ey a re being

overem ployed a n d in som e cases used w ith o u t
rary
p ro p e r supervision a n d fo llow -up. Y o u n g p a
dosage is g e n era lly as effective as th e 30-m illi-
tients in th eir first atta ck , especially those

going th r o u g h a n identity crisis, often do well
g r a m d o s a g e , m a n y p e r s o n s a ls o f in d
m illig ra m s of V a l i u m (d ia z e p a m ) effective.
h ow ev er, can prov e helpful, as w h e n a te m p o

s tre s s s i t u a t i o n i n t e r f e r e s w i t h sleep.
D alm ane
( f lu ra z e p a m )
in
th e
1 5 -m illig ram
5
w ith o u t drugs. W h e r e sy m p to m s a re too dis

ru ptive, how ever, n eurole ptic s sho uld be used.
I f n e u r o l e p t i c s a r e u s e f u l in s c h i z o
p h r e n i a , w h y s h o u l d n t t h e y b e g i v e n i n
d e f in i te ly ?
T h e r e a re som e disag ree able side effects and
sequelae w ith neu roleptics, especially w h e n
given over a long perio d an d in larg e dosage.
T a r d iv e d yskinesia is a n eurological condition
th a t affects as m a n y as 40 p ercent of p a tie n ts
on p ro lo nged d r u g th erap y . O n ce ta rd iv e dys
kinesia h as become e n tre n c h e d , it m ay p lagu e
th e p atie n t p e rm a n e n tl y even after the d r u g is
w ith d r a w n . N e u ro le p tic s sh ou ld, th erefore, be
low ered in dosage after th e desired effect has
been achieved, an d p eriod ically th ey sho uld be
w i t h d r a w n (drug-free holidays) to see h o w the
pa tien t reacts.
A fte r a n a c u t e e p i s o d e o f s c h i z o p h r e n i a
a n d t h e p a t i e n t is r e l a t i v e l y s y m p t o m free, sho uld n e u ro le p tic s be co n tin u ed ?
Yes, for a w hile, if th e p a tie n t ha s been on
neuroleptics. T h e relap se ra te is g re a te r w h e re
In m a t c h i n g p a t i e n t a n d m e t h o d h o w
v a l u a b l e is a d e v e l o p m e n t a l d ia g n o s is ,
t h a t is, k n o w l e d g e o f w h e r e in t h e p a
t i e n t s d e v e l o p m e n t t h e p r i m a r y a r r e s t
occurred?
M a t c h i n g p a tie n ts an d m e th o d s is still an
unsolved p ro b le m . A n u m b e r of a tte m p ts have
been m a d e to establish c rite ria for a p a tie n tm eth o d a lig n m e n t, for e x a m p le , the s y m p to
m atic diag n osis (like b e h a v io r th e r a p y for
p h o b ia s , an in s p ira tio n a l g r o u p such as A A for
alcoholism , etc); th e ch ara cterolo gic diagn osis
(like the p e rs o n a lity typologies p ro p o s ed by
H o r o w i tz , see p. 217); resp on ses to h y p n o tic
in du ction (Spiegel & Spiegel, 1978); a n d the
d ev elo p m en tal diagnosis (B u rk e et al., 1979).
T h e la tte r a u th o r s believe th a t th e r a p e u tic
m e th o d s m a y be selected to resolve conflicts
w h ic h develop in different stages of d evelo p
m e n t (E rik so n , 1963). T h u s M a n n s tec h n iq u e
(1973) of focusing on s e p a r a tio n -in d iv id u a tio n ,
in an e m p a t h ic feelin g a tm o s p h e re , w ou ld
167

seem most useful w ith p ass iv e-d e p e n d en t p a
the
tients unsuccessful in resolving the a d o le s c e n ts
m eth od .
H o w e v e r, n o n e of th ese selection schem es,
conflict of identity vs. role co n fu s io n . H e r e

th e struggle over te r m in a tio n of th e r a p y b rin g s
th e early s e p a r a tio n -in d iv id u a tio n conflict to
th e fore a n d gives the p atie n t an o p p o r t u n it y to
resolve it in a favorable setting. T h e h y p oth esis
selection
of an
ap p ro p riate
th e r a p e u tic
involving s y m p to m m an ifestatio n s, c h a ra c te r
s tru c tu re , o r d e v e lo p m e n ta l conflicts, h a s been
p rov en e ntirely reliable. T h i s is because of the
in terference of n u m e r o u s m iscellan eou s p a
is th a t if p a tie n ts successfully m a s te r s e p a r a
tion from the th e r a p is t, th ey will move on to
tien t, th e r a p is t, e n v ir o n m e n ta l, tra n sfe re n tia l,
g re a te r in div idu atio n an d o vercom e th e i r d e
T h e very choice of a diag no sis an d th e identifi
p endency needs. P a tie n ts w h o in th eir d evelo p
cation of th e p re v a ilin g d e v e lo p m e n ta l conflict
m en t have moved beyond the crisis of identity
a r o u n d w hic h th e th e r a p e u tic p la n is o r
g a n iz e d is subject to th e t h e r a p i s t s bias as is
t o w a r d th e F i r s t A d u l t L ife S t r u c t u r e
(Levinson, 1977) a n d , in th eir efforts to es
tablish in tim ate rela tion s, h av e been blocked
by resurg ence of oedipal conflicts a re well
c o u n te r tr a n s fe re n tia l, an d resistance variables.
th e m eth o d to w h ich th e th e r a p is t is a ttu n e d .

T h i s bias will p re ju d ic e th e p a t i e n t s response.
A th e r a p is t w h o ap p lies h im se lf to a favorable
con
te c h n iq u e w ith e n th u s ia s m a n d conviction will
fro n tatio n style of Sifneos a n d M a l a n . P r o b

lems of the latency p erio d th a t em erg e d u r
ex pedite th e p a t i e n t s p ro gress, w h e r e a s the

s a m e t e c h n i q u e u se d c a s u a l l y a n d u n e n
suited to the in tellectual,
in terp re tiv e,
ing th e midlife tran sitio n b ro u g h t a b o u t by
thusia stically m a y h av e a m i n im a l effect on the
challenges of pro du ctivity , creativity, a n d the

m a t u ri ty to deal w ith n ew g e n e ra tio n s at h o m e
p a tie n t. T h e style of som e t h e r a p is t s an d th eir

inv estm ent in th e i r th eories will s u p p o r t or
an d at w o r k w ou ld be suited most for a c o r

rective ac tio n a p p r o a c h such as th a t of A lex
m ilitate ag ain st th e effective use of a n y of the
a n d e r and F re n c h , the m a x i m u m t h e r a p e u ti c
effect com ing from transfe ren ce m a n i p u l a
m e th o d s such as th ose p ro p o s e d by Sifneos,

M a la n , D avan lo o, A lex an d er and French,
L e w i n , Beck, a n d others. In s u m m a r y , at th e
tions a n d a m a n a g e ria l stance by th e t h e r a
p re s e n t stage of o u r k n o w le d g e we c a n n o t be
p is t. U n d e r th ese circum stances. B u rk e et al

(1979) contend, a careful d ev elo p m en tal d ia g
su re th a t a selected m eth o d exists for every p a
no sis w ill h e l p id e n tif y p a t i e n t s w h o can

benefit from p s y c h o th e ra p y ; it can also h e lp in
tien t we treat. O u r o p tio n s m u s t re m a in op en,

a n d we m u s t be w illin g to ch a n g e o u r m e th o d s
w h e n a selected te c h n iq u e p rov es to be sterile.
Conclusion
A w ide v ariety of tech niq u es is ava ilab le to a
th e ra p ist, th eir selection being d e te r m in e d by
the existing sy m p to m s a n d co m p la in ts of the
p a tie n t, th e fam iliarity of th e th e r a p is t w ith
ap plicab le m eth od s, an d the p a t i e n t s w illin g
ness an d ability to w o rk w ith th e chosen in t e r
ventions.
W h e t h e r we a tt e m p t to influence th e p a
ti e n ts b iochem istry th r o u g h p h a r m a c o th e r a p y ,
o r his n e urop hy siolo gy t h r o u g h o th er som atic
th erap ies o r rela x a tio n p ro ced u re s, or his h ab it
p a t t e r n s t h r o u g h b e h a v i o r t h e r a p y , o r his
in tra p sy ch ic s tr u c tu r e th r o u g h psy cho analysis,

o r his in te rp e r s o n a l reactio ns t h r o u g h g r o u p or
fam ily t h e r a p y , o r his social beh av io r th r o u g h
m ilieu th e r a p y , o r his ph ilo so p h ical outloo k
th r o u g h existe ntia l th e r a p y , the p a tie n t will
r e a c t g lo b a l ly to o u r m i n i s t r a t i o n s , ev ery
aspect of his being, from physiological m a k e u p
to h ig h e r psychic processes, being influenced
th r o u g h a feedback effect.
T h e p r o p e r use of te ch n iq u e s calls for a high
degree of ex pertise. R e q u ir e d a r e q u a litie s in
th e th e r a p is t th a t p e rm it e sta b lish in g r a p i d ly a
168
w o rk in g re la tio n sh ip w ith th e p a tie n t, a d e a l

ing w ith m o tiv atio n al deficiencies a n d o th e r
resistances as they develop, a n d a m a n a g i n g of
those p erso n al reactions th a t a re p rejud icial to
cou rag ed to p u t th e pieces to g eth e r for him self,

p a r t ic u l a r ly to figure o ut th e c ircu m sta n c es
th a t have im p a ir e d his a d ju s tm e n t p r i o r to
co m in g to tr e a tm e n t. T h e r e is an e x p lo r a tio n
m a i n ta i n in g an objective a n d e m p a t h ic t h e r a
as to w h y th e p a tie n t is n o w u n a b le to w o rk
peutic climate. T h e a tm o s p h e re for the most
o ut his prese n t difficulty by himself, com ing

hopefully to a re a liz a tio n of th e resistances th a t
effective o p e ra tio n
of tech n iq u es
may
p e ri
o d ic a l ly call fo r s u p p o r t a n d r e a s s u r a n c e
te m p e red by sufficient m a i n te n a n c e of tension
p re v e n t a res o lu tio n of prob lem s. T h e p a tie n t,
d u r i n g the in terv iew in g process to p ro m o te in
to relate s y m p to m s to p re c ip ita tin g h a p p e n in g s
centives for e x p lo r a tio n an d for e x p e r i m e n t a

tion w ith n ew p a tt e r n s of behavior. C o n f r o n t a
in th e p re s e n t e n v ir o n m e n t as well as to in n e r
conflicts w ith in himself. W h a t w e a r e tr y in g to
tion m a y p eriod ically be re q u ire d to b re a k
do is to m ob ilize som e insight in to th e u n d e r l y
th r o u g h resistances to chan ge, b ut c o n fr o n ta
ing difficulties. W e m u s t m odestly a d m i t th a t
tion if used m u s t be carefully titra te d ag a in st

th e p a t i e n t s toleran ce of an xiety . In te rp re tiv e
so m e of th e in sigh ts w e offer th e p a ti e n t a re
not alw a y s com p lete o r even correct. Even
activites on som e level a re re q u ire d , especially
th o u g h th ey a re p a rtia lly valid, how ever, they

often serve to alleviate ten sion s by p ro v id in g
w h en resistance to th e th e r a p is t, to th e t h e r a
p is ts tech niq ues, an d to ch a n g e p a ra ly z e s the
th e r a p e u tic effort. T h e m ost effective d e tec t
in g of a n d d e a l i n g w i t h su c h re s is t a n c e s
necessitates u n d e r s ta n d in g of h o w to im p le
m e n t d y n a m ic interv entio ns such as th e use of
d re a m s an d the analysis of transference.
S h o rt-te r m th e r a p y , even w h e re th e m eth o ds
a re su p p o rtiv e or reeducative, as h as before
e n co u rag ed in self-observation, is ta u g h t ho w
a n e x p la n a tio n th a t m a y help the process of

stab ilizatio n.
T h e nonspecific w ind falls of insight do not
in v alid ate th e specific pro fits th a t can derive
from a t r u e u n d e r s ta n d in g of the forces th a t
are u n d e r m in i n g security, vitiatin g self-esteem,
an d p ro v o k in g actions in im ical to th e in terests
of th e in div idu al. In o p e n in g u p a re a s for e x
been repe ated ly e m p h a s iz e d , is m u ch m o re ef
p lo r a tio n , th e s h o r t- t e r m th e r a p is t m u s t c o n
fective w h e re it is skillfully executed in a

p sy ch o d y n a m ic fr a m e w o rk . N o m o re th a n a
fine him self as closely as possible to ob servab le
m a y be needed to u n b a la n c e th e sh aky h o m e o
facts, avo iding spec ula tion s as to th eo ry so as

to redu ce th e suggestive c o m p o n e n t. T h e m o re
ex perienced th e th e r a p is t, the m o re c a p a b le he
stasis th a t h as ru led th e p a t i e n t s existence
w ill
an d to m a k e possible b e g in n in g constructive
changes in th e w a y th a t th e p a tie n t relates to
him self an d others. W h e r e the individ ual has
been b ro u g h t to som e recognition of th e in itia t
ing factors p recip ita tin g the difficulties for
w h ich he sou gh t help, w h e re he becomes cog
p e r t i n e n t d a t a f r o m t h e p a t i e n t s v e r b a l
c o n t e n t a n d a s s o c i a t i o n s , g e s t u r e s , facial
e x p r e s s i o n s , h e s i t a t i o n s , sile n c e s , e m o t i o n a l
o utb u rsts, dream s, and in terp erso n al reac
tio n s to w a r d a s s u m p tio n s th a t , in te rp re te d to
the p a tie n t, en a b le h im to reflect on , accept,
d eny , o r resist th e m . D e a lin g w ith the p a t i e n t s
few interview s conducted alon g d y n a m ic lines
n iz a n t th r o u g h inte rview in g of the p resence of

so m e p e r v a s iv e p e r s o n a l i t y p r o b l e m s t h a t
s a b o t a g e his h a p p i n e s s , w h e r e h e r e l a t e s
aspects of such p ro b le m s to his c u rr e n t illness,
an d w h e re he gain s a g lim m e r of a w a re n e s s
into early sources of difficulty in his re l a ti o n
sh ip w ith his p a re n t s an d o th e r significant p e r
sons, he will have the best o p p o r t u n it y to
proceed beyond th e profits of sy m p to m relief.
By pointed q u e stio n in g the p a tie n t is e n
be
of c o l l a t i n g
w ith
m in im al
d e la y
hesitancies to th e acceptance of in t e r p r e ta ti o n s
an d to th e u tiliz a tio n of his e x p a n d e d a w a r e
ness t o w a r d actions th a t m a y lead to ch ang e,
th e th e r a p is t c o n tin u e s to e x a m i n e his orig in a l
a s s u m p tio n s a n d to revise th e m in te r m s of an y
n ew d a ta th a t p re s e n t themselves.
Even th o u g h a th e r a p is t m a y u tilize a v a
riety of tech n iq u es, th e ir e m p l o y m e n t w ith in a
dynam ic fram ew ork
seem s to c a t a l y z e th e
169

t h e r a p e u t i c p ro c e s s. T h e p a t i e n t s u n i q u e
response to the m e th o d s em p lo y e d (in te rv ie w
ing , c o n f r o n t a t i o n , b e h a v i o r m o d i f i c a t i o n ,
if s u f fic ie n tly p e r c e p t i v e , w ill d e te c t so m e

tra n sfe r e n tia l b e h a v io r in the w a y the p a tie n t
h ypnosis, etc.) will alm o st inevitably expose
th e th e r a p is t is active a n d provocative. A n d yet
h a b itu a l
in a c o n sid era b le n u m b e r of cases th e p a tie n t
charac tero lo gic
styles a n d
perhaps
relates to th e t h e r a p e u ti c s itu a tio n , especially if
resistances th a t can become a n i m p o r t a n t focus
m a y control
d u rin g tr e a tm e n t. W h e r e the p a tie n t m anifests
sponses so th a t th ey a re not at all a p p a r e n t .
or mask
his tr a n s fe r e n tia l r e
a desire to e x a m in e his reaction s, th e results

m a y be p a rtic u la rly gratifying. A n d w h e r e a
transfe ren ce s itu atio n can be detected a n d e x
H e re , all is no t lost; since w ith th e o th e r d a ta

available, o n e m a y still be ab le to estab lish a
plored, an d its genetic ro ots u n d e rs to o d , a n e n
consociation b e tw e e n th e p a t i e n t s sy m p to m s
an d c o m p la in ts, c h a r a c t e r s t ru c tu r e a n d the
d u r i n g im p rin t m a y be etched. T h e th e r a p is t
should, th erefore, be alerted to an y b e h a v io r or
genetic ro ots of th e p re v a ilin g n e u ro tic needs

an d defenses. A hopeful p ro s p e c t is th a t t h e r a
a ttitu d es th a t in an y w a y reflect tr ansference.

O ften such beh av io r is not m an ifest a n d is d e
of th e s h o r t-t e rm con tact b u t will c o n tin u e the
tected only in d r e a m s an d actin g-out. Even
re m a in d e r of th e i n d i v id u a ls life.
th o u g h tim e in th e r a p y is sh o rt, the th e r a p ist,
pe u tic c h a n g e will not cease at the te r m in a tio n
CHAPTER 12
The Use of Dreams

T h e g ro w th of ego psychology a n d th e d e
v elo p m en t of n e w concepts r e g a r d in g energy
a n d identity hav e e n c o u rag ed m in im iz a tio n of
th e im p o rta n c e of d re a m s. M o r e o v e r, as we
h ave gain ed g re a t e r u n d e r s ta n d in g of ego d y
n am ism s, we have ten ded to veer a w a y from
th e tr a d itio n a l search for laten t d r e a m content.
T h i s d i v e r s io n
is u n f o r t u n a t e b e c a u s e th e
a v erag e d re a m em bo dies a m ass of in fo rm a tio n
W e have le a rn e d a g re at deal a b o u t d r e a m s
from c o n te m p o r a r y d r e a m resea rch . T h e R E M
p erio d s d u r i n g sleep th a t a re ac c o m p a n ie d by
d r e a m in g h ave been found to be associate d
w ith activity in th e limbic system , the p rim itiv e
p o rtio n of th e b ra in associate d w ith th e e m o
tion al life of th e ind iv idu al. T h i s lends e m
p h a sis
to
regressive
the
th e o ry
th a t
phenom enon.
the
dream
H ow ever,
is a
we are
th a t , sorted out a n d selected in relation to the
m erely talk in g h ere of the n e u ro ph ysio log ica l
p ro b lem s being dealt w ith at the tim e a n d the
activity th a t sp o n s o rs th e fo rm a tio n of d r e a m
p articu lar
im ages, not of th e i r specific c o n ten t or signifi

cance, w h ich m a y involve o th e r d im en sio n s
g o a ls
w ith
m ediately con cern ed,
w h ic h
can
we
are
im
be of inestim ab le
value in s h o r t-te rm th e r a p y .
P ro p e r ly utilized, d re a m s illu m in a te th e e x
isting d y n a m ic s of em o tio n a l illness. T h e y r e
veal conflicts, co pin g m ech a n ism s, defenses,
a n d c h a ra c te r traits. M o s t im p o rt a n tl y , they
th a n regressive e m o tio n al ones.

R e la x a tio n of ego controls lib erates needs
a n d im p u lse s th a t, lacking o p p o r t u n it ie s for
m o to r release, find access in senso ry discharge.
T h e co n te n t of th e d r e a m d r a w s fro m p a st i m
reflect w h a t is going on in an d th e p a t i e n t s
pulses, m em o ries, an d e xp erie nce s as far back
responses to the t h e r a p e u ti c process. T h u s ,
as
w h e re th e r a p y is not p roc eed ing well, d r e a m s
p u d ia t e d drives a n d d esires into d r e a m im ages
m a y reveal m o re th a n a n y o th e r form of c o m
m u n ic a tio n w h a t resistances a re o b stru c tin g
progress. E ven if the th e r a p is t does not la b o
riously w o rk o ut th e m e a n in g w ith the p a tie n t,
sets in to m otion o p p o sitio n a l defenses and p r o

h ib itio n s th a t m a y a p p e a r in th e d r e a m in a d i
as in s u p p o r t i v e a n d r e e d u c a t i v e t h e r a p y ,
d re a m s m a y still pro vid e guidelines for c ir c u m
ven ting ro adb lo cks to th e most effective use of
e arly
c hildh oo d.
The
conversion
of re
rect o r m ask ed w ay. Im m e d ia te ex pe rie nce s

a n d c u rr e n t conflicts p a rt ic i p a te in th e s t ru c
tu r e of the d r e a m . It is likely th a t a h a p p e n in g
in d aily life th a t the in div idu al in te rp re ts as
significant serves to stir up i m p o r t a n t needs,
techniques.
W h a t a re d re a m s ? W e m a y conceive of the m
fru stra tio n s , m em o rie s, and
as im ages o r fantasies th a t a re an intrinsic p a rt

of n o rm a l sleep. W e k n ow fro m h u m a n e x p e r i
c e r t a i n i m m e d i a t e e x p e r i e n c e s w i t h s p e c ia l
m e a n in g , a le r ti n g the ind iv id ual to signals th a t
in o th e r perso n s w ou ld go unn oticed.
Som e y ears ago, I in itia ted a g ro u p of e x
m ents th a t d r e a m d e p riv a tio n (inte rfe rin g w ith

d re a m in g by a w a k e n in g th e subject w h e n he
s h o w s p h y s i o lo g i c a l R E M S o r e l e c t r o e n c e p h a l o g r a p h i c e v id e n c e s of b e g i n n i n g to
d re a m ) can p ro d u c e pe rs o n ality a b e rr a tio n s .
170
drives from the
past. T h e la tte r, co n stan tly d o r m a n t, invest
p e r i m e n t s in t h e h y p n o t i c p r o d u c t i o n of
d re a m s . D r e a m s u n d e r hy p n o sis r a n g e from
fleeting fan tasy-like p ro d u c tio n s in light tr a n c e
THE USE OF DREAMS
171
states to, in d ee p e r stages of hyp n osis, hig hly

d i s t o r t e d s y m b o l i z a t i o n s a k i n to r e g u l a r
T h e d r e a m co n ten t is a d d itio n a lly subject to

c h a n g e s of a ttitu d e on the p a r t of th e d r e a m e r.
d re a m in g d u r i n g sleep. I fo un d th a t h y p n o tic
F o r e x a m p le , a p a tie n t on b e in g asked to b rin g
d re a m s could easily be trig gere d by im m e d ia te
in d r e a m s re s p o n d e d w ith the follow ing w r i t
stim uli an d th a t from the c o n ten t of th e d r e a m
ten c o m m e n ts to this suggestion:
one
could
not
alw a y s
identify
th e
specific
provocative stim u li th a t pro d u ced th e d re a m s.

T h u s b rin g in g a n o p en bottle of p e rfu m e u n d e r
T h e d o c t o r r e q u e s t s t h a t I d r e a m . H e is i n t e r
the nose of a pe rso n in a tra n c e , w ith no verbal

suggestions to influence associations, w o u ld in
es ted in h e l p i n g m e, so I b e t t e r d r e a m . In d r e a m i n g
som e ind ivid uals in sp ire a d r e a m th a t revived

m em o ries of p rev io u s e xperiences. At different
times the sam e stim u lu s acted to pro v o k e dif
ferent kinds of d r e a m conten t. F o r e x a m p le , in
one subject the p e rfu m e in itially to uch ed off a
d r e a m of b eing scolded by a m a te rn a l-lik e
I a m p l e a s i n g h is a u t h o r i t y , so w h y s h o u l d I d r e a m
j u s t b e c a u s e he as k s m e to. H e is t r y i n g to force m e
to do w h a t he w a n t s . B u t I w a n t t o do w h a t / w a n t
to do. I m a y n o t w a n t to d r e a m . B u t if I d o n t b r i n g
in a d r e a m , t h e d o c to r will be d i s p l e a s e d . S h o u l d I
def y h i m o r s h o u l d I p le a s e h i m ? W h a t will h a p p e n
if I d o n t d r e a m ? W h a t does h e w a n t m e to tell
h i m ? If I d r e a m a n d c o n f i rm w h a t he h a s said a b o u t
figure, the subject c ro u c h in g in guilt. N o o th e r
m e, h e w ill like me. If I d r e a m o p p o s i n g his ideas
d r e a m s o r fantasies w ere recalled. O n r e h y p
a b o u t m e, h e w ill n ot like m e o r he will p u n i s h me.
nosis th e subject w a s asked to r e d r e a m th e sam e

d r e a m an d to reveal it in th e tran ce. She
h is ideas, t h is will m a k e m e feel s t r o n g a n d s u p e
b ro u g h t u p a p le a s u ra b le sexu al d r e a m , w h ich
w a s followed by a second p u n itiv e d r e a m id e n
tical to the on e p reviously described d u r i n g th e
If I d o n t d r e a m o r I d r e a m s o m e t h i n g t h a t o p p o se s
r i o r . I do w a n t to find ou t a b o u t m y se lf so I can get
w ell, since m y t h e r a p i s t tells m e t h i s is h o w I can
h e l p h i m h e l p m e. T h i s is w h y I s h o u l d d r e a m . B ut
I a m g u i l t y a b o u t s o m e t h i n g s a n d a f r a id o f som e
w a k i n g s ta te . A p p a r e n t l y th e s u b j e c t h a d
repressed th e initial p a r t in the first tra nce ,
th i n g s , a n d I a m a f r a id of w h a t I w ill find o u t a b o u t
de n y in g the c o n ten t a n d reproce ssin g it by
M a y b e I ll find o u t s o m e t h i n g a b o u t m y self I d o n t
m yse lf if I d r e a m . So m a y b e I b e t t e r no t d r e a m .
e la b o r a tin g th e p u n is h m e n t scene. T h e p u n itiv e
like.
d r e a m m ig ht be considered e q u iv a le n t to the
m anifest co n ten t, th ose m a n ife sta tio n s a c c e p ta
n o r m a l . B u t if I d o d r e a m , I h a v e a b e t t e r c h a n c e of
getting
ble to th e p a tie n t. T h e repressed p o rtio n could
r e s p o n s i b i li t y o n m y s h o u l d e rs . I ll h a v e to be m o r e
be re g ard ed as th e la ten t co n te n t th a t th e p a
tient could not accept. O n a n o th e r occasion the
p e rf u m e s tim u lu s created a d r e a m of w a n d e r in g
th r o u g h a botan ical gard en .
T h e mood of a d r e a m also fashions the
d r e a m content. A n u pset p a ti e n t d u r i n g h y p
nosis utilized th e sou nd of a bell th a t I r a n g to
e la b o ra te a d r e a m of fire a n d fire e ngines w ith
reactions of anx iety. At a n o th e r session, d u r i n g
a quiescent p erio d of this p a t i e n t s th e r a p y , the
sam e so un d p ro d u ce d a d r e a m of w o rs h i p p in g
in a c hu rch. A d is tu rb e d fem ale p a tie n t a t the
b egin n in g of th e r a p y in te rp re te d m y to u ch in g
h e r h a n d d u r i n g hyp no sis adversely by d r e a m
ing of a m a n ch o k in g her. L a t e r in t h e r a p y th e
sam e stim u lu s p ro d u c ed a d r e a m in w h ic h h e r
fath er w as e m b r a c in g h e r tenderly.
It is n o r m a l
well,
but
to d r e a m , a n d
getting
well
will
I w a n t to be
th ro w
more
i n d e p e n d e n t , t a k e r e sp o n s ib ility . M a y b e I b e t t e r not
get well so fast. T h e r e f o r e , I s h o u l d n t d r e a m . O r
m a y b e if I do d r e a m , I c a n m e n t i o n o n ly those
th i n g s t h a t p l e a s e h i m a n d t h a t d o n t sc a re m e a n d
d o n t m a k e m e get well too fast.
N o t all p a tie n ts a re so obsessively s tim u la ted

by a casual suggestion. B u t in all p a tie n ts th e
act of d r e a m i n g does involve v a ry in g m o tiv a
tions th a t a r e in c o r p o ra te d in th e d r e a m w o rk
a n d fused into a com plex kin d of sy m bolism ,
dis to rtin g , re p re ssin g , d is p la c in g a n d o th erw ise
d i s g u i s i n g th e c o n t e n t . W h a t m a y c o m e
t h r o u g h is a c o m p r o m is e of p a r t fo rg etting an d
p a r t r e m e m b e r in g , of p r i m a r y a n d secon dary
process th in k in g , of p re s e n t an d p ast, of i m
p ulse an d defense.
172
The Structure of Dreams

T h e tr a d itio n a l co m p o n e n ts of a d r e a m a re
its (1) m anifest con tent, (2) la ten t co n ten t, a nd
(3) d r e a m w o rk . T h e m anifest con tent is o r
ego to m a k e un con sciou s a n d r e p u d i a te d ele

m en ts accep tab le to the d r e a m e r .
S y m b olism
is an
gan ize d
r e q u ire s tr a n s la t io n before its tr u e m e a n in g
w h e re b y on e object comes to re p r e s e n t a n o th e r
object th r o u g h som e q u a li ty o r aspect th a t the
c a n be c o m p r e h e n d e d . T h e
la te n t content
reflective of bo th
p ast
asso ciatio n
and sim ilarity
an d
tw o h ave in c o m m o n . In sy m b olism a b stra c t

a n d co m p lex ideas a r e ex p re s sed in sensorial
em b od ies conscious, preconscious, a n d u n c o n

scious elem ents
around
u n con scio us process o r
g an ize d in the fo rm of a cry ptic la n g u a g e th a t
p rese n t im pressions. T h e bricks a n d m o r t a r of
an d co ncrete term s. S o m etim es th e d re a m
the d r e a m a r e w h a t F re u d described as the
sym bols a r e recru ited from the c u ltu ra l a nd
d r e a m w o r k , w h ich defies th e law s of r a

tion ality an d logic. T h e chao tic u p su r g e o f ex
social w o rld th a t envelops th e d r e a m e r. At

o th e r tim es the k in d s of r e p r e s e n ta tio n s d r a w
c itatio n ch aracte ristic of regressive p r i m a r y

process m e n tal o p e ra tio n s m ak es for a t u m u l
from p rim itiv e la n g u a g e form s in w h ich o ral,
tu o u s an d b iz a r r e fusion of em o tion s, sym bolic
inen t.
form s, an d tim e sequences. O p e ra tiv e are
p o rtra y in co rp o ratio n , pow er, p u n ish m en t,
m ech a n ism s of co n d en satio n a n d d isp la cem en t.

In c o n d en satio n , c h aracteristics of m u l ti p le o b
a n d a n n ih i la t io n m e an in g s. A fear of sn akes or
d a g g e rs m a y accordin gly be a sym bol for a
jec ts are com b in ed into a co m p osite sym bolic

entity. A single im age m a y em b ra c e so m a n y
T e r r o r of bein g bitten by a n im a ls m a y disguise
excretory, an d p h allic c o m p o n e n ts a r e p r o m
These
sym bols,
ac tu a l
or
disguised,
w ish for a n in tact pen is o r p en al p e n e tr a tio n .
co m p le x fo r m u la tio n s th a t a good deal of

s ea rc h in g m a y be re q u ire d to reveal th e g reat
in in fan tile im p u ls e to d e v o u r th e m o t h e r or
v ariety of im b e d d ed m ea n in g s. In d is p la c e m e n t
e n erg y in h e r e n t in o ne idea is tr a n sfe r re d over
o b s e s s io n s , c o m p u l s i o n s , p h o b i a s , h y s t e r i c a l
her
breast.
D e lu sio n s,
h a llu c in a tio n s,
c o n v e r s io n s , m o r b i d a ffects, h y p o c h o n d r i a s ,
to a n o th e r . T h i s m a y ta k e th e form of p ro je c t
a n d p e rs o n a liz a tio n of o rg a n s or o r g a n systems
ing feelings an d actions from significant objects

o r a reas to seem ingly in n o c u o u s ones, an d
a r e often ex p licab le by c o n sid erin g th e ir sy m
from w ho le to p a r t ia l are as. W h a t results is

co nsid erab le dis to rtio n , w h ich is p a rtic u la rly
p ro m in e n t in th e p h e n o m e n o n of r e p r e s e n t a
tion by opposites w h e re in th e r e is a reversal of
the tr u e m e a n i n g of th e d re a m . T h u s action of
a kindly an d co ncern ed n a t u r e in a d r e a m m ay
conceal m u r d e r o u s in tent. T h e ind ivid ual often
e m p l o y s d i s g u is e d s y m b o ls of h i m s e l f in
d re a m s , clues to his id entity b ecom ing a p
p a r e n t only in his associations to th e d re a m s.
S ym bolism co n tr ib u te s to the rich an d often bi
z a r r e n a tu r e of d r e a m s tru c tu re . A n u n d e r
bolic co n n o ta tio n s . S im ila rly in d re a m s.

Because th e d r e a m is a co n d e n satio n of a
host of life ex periences, past an d p re s e n t, be
c a u s e it c o n t a i n s u n c o n s c i o u s c o m p o n e n t s ,
defenses, c h a r a c t e r drives in o p e ra tio n , a n d a p
p ro v in g an d c o n d e m n a to r y attitu d e s of a u t h o r
ity (su perego ), a selection of a re a s p e r t in e n t to
th e im m e d ia te goals of th e th e r a p is t w ou ld
seem to be in ord e r. T h i s does not m e a n th a t
w e a r e a lw a y s able to track d o w n th e essential
m e a n i n g of every d r e a m , for m a n y of th e m a re
so spo ttily re m e m b e r e d or so hig hly d istorted
tory for a tr a n s la t io n of the symbols. T h e use

of pictorial m e t a p h o r s an d th e e m p lo y m e n t of
th a t , w ith all of o u r a n a ly tic ex pe rtise , we m ay

be u n a b le to u n d e r s ta n d th em .
G e n e ra ll y , w e deal w ith th e m an ifest co n
te nt, w hich reflects the p ro b le m -s o lv in g ac
tivities of th e ego o r self system. A stu d y of th e
secon dary revision a r e m o des em p loy ed by the
m an ifest co n ten t will g e n e rally reveal a good
sta n d in g of the d r e a m e r , his p ro b lem s, a n d the

w a y th a t he con ceptua lizes is u su a lly m a n d a
THE USE OF DREAMS
173
deal a b o u t the defensive in te grity of th e ego,

an d specifically a b o u t th e co pin g m e c h a n ism s
tion o r ph ilo so p h ica l cam ouflage. T h e scotom a

t h a t cloud p erce p tio n of w h a t is go ing on in
the d r e a m e r h a b itu a lly em p lo y s o r late ntly
th e e n v ir o n m e n t
w ishes to em p lo y for p u rp o s e s of p ro b le m solv
d r e a m in g . T h i s a w a r e n e s s m ay, ho w ev er, be
ing in g en eral a n d specifically for the p ro b le m

prevalent at th e time. N o t only does th e d r e a m
m a sk ed by c o n v e rtin g social sym bols into p e r
give insights into th e defensive s t ru c tu r e an d

unconscious needs of th e d r e a m e r, it also
t h r o w s lig h t on th e c o n t e m p o r a r y so cial
r e a l it ie s t h a t p r e c i p i t a t e d t h e p r o b l e m for
m a y lift so m e w h a t d u r i n g
sonal sym bols. T h e late n t co n ten t of the d re a m

m a y in a d d itio n to unco nscio us conflicts refer
to social conflicts th a t th e in divid ual m a y have
been u n a b le to process a n d resolve read ily in
w hich help is being sought. T h e individual
his w a k in g life. P r o p e r in te r p r e ta ti o n can force

on th e indiv idu al c le a re r u n d e r s ta n d in g of the
may
social an d e n v ir o n m e n ta l realities w ith w h ich
have ratio n a liz e d
social d is to rtio n s by
subtle psychological m e c h a n ism s of self-decep
h e m u s t deal.
Techniques of Dream Interpretation

H o w d re a m s a re used in t h e r a p y will v ary
tim es a th e r a p is t will m erely listen to a d r e a m
a m o n g different th e ra p ists. It g en era lly suffices

to ask the p a tie n t to r e m e m b e r a n d b ri n g in
for his o w n in fo rm a tio n ; at o th e r tim es in t e r

p re ta tio n s a r e given th e p a tie n t. In ad v an ce of
an y d re a m s. W h e r e the p a tie n t forgets his

d re a m s , he m a y be enjoined to keep a p a d of
dream
p a p e r a n d a pencil n e a r th e h ead of th e bed
a b o u t it. M a n y p a tie n ts r a p i d ly becom e skilled
this th e p a tie n t is asked for associations to a

and
for
f o r m u la tio n
of im p ress io n s
a n d to record the d r e a m w h e n a w a k e n in g .
at u n d e r s ta n d in g th e m e a n i n g of th e i r d re a m s.
D r e a m s a re usu ally freshest in m in d before the
T o facilitate a ssociations, som e th e r a p is ts s u m
d a y s activities c row d o ut m em ories. If th e re

a re no d re a m s, resistance m a y be o p e r a t in g
m a r iz e th e d r e a m events a n d ask th e p a tie n t
since it is n o r m a l to d r e a m several tim es d u r

ing sleep. Some th e r a p is ts a tt e m p t to stim u la te
specific q u e stio n s in re latio n to peo ple a n d in

cidents in th e d r e a m . D r e a m i n g a b o u t different
pe ople is occasionally a w a y of r e p r e se n tin g
th eir dream less p a tie n ts th r o u g h hy p n o sis d u r

ing w hich it is suggested th a t the p a ti e n t be
different asp ects of oneself. T h e th e r a p is t , if

th e m e a n i n g of th e d r e a m is no t clear, m a y ask
able to recall i m p o r t a n t d re a m s. F a n ta s ie s an d
a b o u t th e setting of the d r e a m . D oes th e p a
d re a m s
the
tient recognize it? Is it in the p ast o r p res e n t?
tran ce state itself a n d discussed if desired d u r
D o es it have a n y significance for th e p a tie n t?

D o the c h a ra c te rs in th e d r e a m h ave any
m e a n i n g for o r re la tio n s h ip to the d r e a m e r ?
D o an y of th e c h a ra c te rs re p r e s e n t th e p a
m a y also be s tim u la ted
during
ing o r after the h yp n o tic session.

B ecause th e d r e a m em bo dies so m u c h m a
terial, th e r a p is ts g enerally select aspects for
discussion th a t accord w ith w h a t they a r e t r y
ing to e m p h a s iz e at a specific session: in cu lca
tion of insight, c o n firm a tio n of a h ypothesis,
p ro b in g of p a st t r a u m a t ic events a n d m e m
o rie s, d e fe n s iv e o p e r a t i o n s , t r a n s f e r e n c e
m a nifestations, resistances to the th e r a p is t and
to the tech niqu es, fears of u tilizing insig ht in
the direction of ch ang e, a n d so forth. S o m e
t i e n t s p a r e n t s , o r th e th e r a p is t, or oneself?
A re an y u n d e rl y in g w ishes o r needs a p p a r e n t ?
W h a t p e rs o n a lity tr a its a r e revealed in the
c h a ra c te rs ? W h a t m e c h a n ism s of defense a re
d is p la y e d flight, aggression, m as o c h ism , h y
p o c h o n d ria c a l p re o c c u p a tio n ? W h a t conflicts
a re a p p a r e n t ? W h a t is th e m o v em en t in a nd
th e o u tc o m e of th e d r e a m incidents?
174

in line w ith
one w a y of a v oidin g de alin g w ith reality p r o b
th eir theo retical p ersu asio n s, som e tr e a ti n g a
T herapists
in t e rp re t d r e a m s
d r e a m like a R o rsch ach , projectin g into it th e ir
lem s. T h e s e resistances sh o u ld be in te rp re te d .
O f vital im p o rt a n c e a r e th e revelatio ns in
o w n special fantasie s. W h ile this m a y be effec
d r e a m s of tr a n sferen ce in w h ich im pu lses, e x
tive for highly skilled, ex perienced , an d i n t u i
periences, a n d defenses in rela tio n sh ip to i m
tive professionals, it is b e tter for most t h e r a

pists to w o rk ou t the m e a n in g to g eth er w ith
the p atien t. It is a p o o r tactic to in te rp re t d o g
p o r t a n t p a st pe rs o n ag es a r e revived th r o u g h
th e agency of the th e r a p is t. A w e a lth of in
fo r m a tio n can be exposed in such d re a m s , an d
m a t i c a l l y th e l a t e n t c o n t e n t of t h e i n i ti a l
d re a m s revealed by a p a tie n t. F irst, th e t h e r
o p p o rtu n itie s a r e afforded th e p a tie n t an d t h e r
ap ist does not k n o w en o u g h a b o u t the p a
a n d p a tt e r n s d is tu r b th e p a t i e n t s presen t e x
apist for u n d e r s t a n d i n g of ho w e arly a ttitu d e s
tient a n d the op erativ e defenses. Second, to
is te n c e .
p e n e tr a te
t h r o u g h tran sfe re n ce distortion s. In th e process

of in t e r p r e tin g tran sferenc e, o n e m u s t alw a y s
into
the
u nconscious
p r e m a tu r e ly
will m erely p ro m o te g re a te r rep re ssio n of an d
T h is
p ro v i d e s
m eans
to
w ork
disto rtion in late r d re a m s as a w a y of avoiding

a n x ie t y . O n e m a y , h o w e v e r , p r o d u c t i v e l y
search for rea lity p ro v o ca tio n s th a t a re in iti
search for c u r r e n t rea lity reactions (for ex

a m p le , resistances to th e th e r a p is t or to the
tr a n sfe re n c e in d r e a m s is h an d le d will d ep en d
o n w h e n it a p p e a r s a n d its f u n c t i o n as
techn iq ues; fears, o r m i s i n te rp r e ta t io n s th e p a
resistance. A d e m a n d for infantile gratification
ated
by th e th e r a p is t p ers o n ally . T h e
w ay
tient m a y h a r b o r a b o u t t h e r a p y ) o r for b iz a r re
in te r m s of co m p lete givingness, lovingness,
hopes a n d e x p ectatio n s th a t could resu lt in a
a n d u n d e rs ta n d in g n e s s , a n e x p e c ta tio n of h u r t
a n d c o n d e m n a tio n for th e rev elation or e x
defeat of the t h e r a p e u ti c a tte m p t. O r c h a ra c te r

drives m ay a d v an ta g eo u sly be ex plo red as they
exh ibit them selves in the d re a m , pro vid ed th a t
pression of im p u lse s of w h ich the p a ti e n t is
th e p a tie n t is a lr e a d y a w a r e of these.
R esistance is a p t to occur as th e t r e a tm e n t
prog ress. Such d e m a n d s a n d exp ectation s will

r e q u i re careful in te rp re ta tio n . O n th e o th e r
process proceeds. It m ay a p p e a r in re la tio n to

the setting u p of th e w o r k in g r e la tio n s h ip at
h a n d , a delving into genetic foci, into i m p o r
the s tart of tr e a tm e n t, to the ex p lo r a tio n of the
a s h a m e d , can serve as blocks to th e r a p e u tic
ta n t e a rly fo rm ativ e ex periences, if em p loy ed

at all, m ay r e q u i r e tact a n d g re a t patience.
d y n a m ic s of th e in h e r e n t n e u ro tic process, to
P r e m a t u r e or too forceful in t e r p r e ta ti o n s m ay
the p u tt in g into action of insight, a n d , finally,
do m o re h a r m th a n good.
to the te r m i n a ti o n of th e r a p y . M a n ife s ta tio n s
O n e of th e w ay s th a t th e d r e a m can h e lp the
of resistance m ay first a p p e a r in d r e a m s tru c

tu re . T h e d r e a m pro vides a g reat o p p o r t u n it y
t h e r a p e u ti c process is by rev ealin g signals of

a n x ie ty before it becomes too in ten se an d in t e r
feres w ith t h e r a p y . W h e r e the d r e a m b rin g s
out a n x ie ty in re latio n to im p o r t a n t incidents,
to deal w ith it before it becomes an i r r e p a r a b l e

obstacle to tr e a tm e n t. O f co n fo u n d in g concern,
how ever, is the e m p lo y m e n t of d r e a m in g itself
as a form of resistance as the p a tie n t becomes
a w a r e of th e im p o rta n c e of d rea m s. H e m a y
th u s use d r e a m in g as a n outlet to f r u s tr a te or
im p ed e the th e r a p ist. T h e p a tie n t h e re m ay
d r e a m in cessantly an d try to flood th e t h e r a
p a st o r p re s e n t, it m a y be possible to h elp the

p a tie n t e n d u r e it en o u g h to avoid th e u p su r g e
of too g re a t resistance.
O fte n th e d r e a m will reveal th e nascent
drives th a t m a r s h a ll an xiety . T h e s e m a y be
im bed d ed in a p reg en ital fusion of sex uality
the d r e a m as a w a y to confuse th e th e r a p is t
an d to divert from central issues. S om e p a
a n d aggression. T h e i r em e rg en ce in sy m p to m s
a n d in a ctin g -o u t tendencies m ay be re s p o n si
ble for the p a t i e n t s c u r r e n t difficulties as well
as for a pervasive in h ib itio n of function a nd
tients b rin g in pages of w ritte n d re a m s, w hich

m a y o v erw h elm the th e r a p is t, a n d this m a y be
o th e r ego defenses. T h e stu died in te rp re ta tio n

of d r e a m e le m e n ts will do m u c h to w a r d d a r i -
peutic h o u r w ith a n a v a la n c h e of d re a m s , o r he
m a y unco nsciou sly e la b o r a te the sym bo lism of
175
THE USE OF DREAMS

fying th e p u n is h in g a n d m asochistic re p risa ls
of the superego. By fe rre tin g o u t projective,
denial, isolating, an d repressive defenses, as
masochistic m a n e u v e rs. O bv iou sly, th e in t e r

p re ta tio n s p re f e r r e d m u s t ta k e into a c c o u n t the
p a t i e n t s read in e ss for ch a n g e a n d th e in ten sity
th ey come ou t in the d r e a m w o rk , one m a y oc

casionally lib erate ea rly m em o rie s th a t concern
of an xie ty. A bove all, th e m a n n e r of in t e r
themselves w ith the fantasie s or actual e x p e r i

ences associated w ith the p a t i e n t s sadistic an d
ing o r r e t a r d i n g th e p a tie n t in accepting an d

in te g ra tin g the significance of th e d re a m s.
p re t a ti o n serves as an im p o r t a n t factor in h e lp
Case Illustrations
Case 1
S om etim es a p atie n t will presen t a long
com plex d r e a m th a t crystallizes an a w a re n e s s
tio n sh ip , b u t it w a s to lerab le a n d she d id not

believe she w a s too affected by it. It w a s better,
she said, t h a n h e r first m a r r ia g e to a n a u t h o r
itative m a n w h o kep t h e r d o w n a n d m in im iz e d
in symbolic te r m s of feelings th a t a re being

shielded from oneself. O ften , as is b r o u g h t o ut
h e r abilities, criticizin g h e r in cessantly. She
in th e session th a t follows, th e rep re ssin g agent
gentle, no n co m p etitiv e , an d easy to get alon g

w ith . B u t, for som e re aso n she w a s not h a p p y .
is guilt. B ecause th e feelings a re not being

acknow ledged, th ey m a y be converted into
chose h e r p re s e n t h u s b a n d
because he w as
H e r leg s y m p to m s sta rte d after the m a r ria g e ,
sy m p to m s physical sy m p to m s as in co nv er
sion reactions, self-castigation an d re m o rs e as
b u t th e p a tie n t could see no co nn ection be

tw een th e tw o . W i t h th e p a t i e n t s p e r m is
in reactive depression s, an d fears as in p ho bic

reactions. D u r i n g th e r a p y w ith e m p a th ic , e n
sion, I in te rview ed h e r h u s b a n d . H e gave me

so m e p r i m i t i v e , d i s o r g a n i z e d , c o n t a m i n a t e d
cou raging , n o n ju d g m e n ta l th e r a p ists, p a tie n ts

m a y come to g rip s w ith th e i r guilt a n d begin
resp on se s to the R o rs c h a c h cards. C lin ically, he
accepting th e ir rig h t to ex press feelings. Such
p ro b a b l y sch izo ph ren ic.

M y p a tie n t, a n e x tre m e ly ca p a b le a n d in
w as th e case in m y p a tie n t, a m a r r ie d w o m a n
im presse d me a s being at least b o rd e r lin e b ut
of 40, sent to m e by a gen eral p ra c titio n e r w h o

could find no org a n ic re aso n for the leg p ain s
telligent w o m a n , r a p id ly ca u g h t on to w h a t a
a n d difficulties in w a lk in g for w h ich th e p a
h ow ev er, no d re a m s , even t h o u g h I co n stan tly
tient h a d consulted him . A fter referrin g th e p a

tient to a neurolo gist a n d a n o rth o p e d ic s u r
re m in d e d h e r o f th e need to re p o r t d r e a m s to
d y n a m ic a p p r o a c h w a s all ab o u t. T h e r e w ere,
geon, w ho sim ilarly could find no o rg a n ic basis

for h e r com pla ints, the p r a c titio n e r advised the
p a tie n t to receive psychological help. She ac
cepted his advice read ily a n d d u r i n g the initial
in terview w e decided on a s h o r t-te rm p r o g r a m .
A w o rk in g alliance w as readily achie ved,
me. I kep t focusing on h e r re la tio n s h ip w ith

h e r h u s b a n d a n d en c o u ra g e d h e r to begin to
com e to g rip s w ith h e r d i s a p p o in t m e n t in him .
I insisted th a t she w o r k on h e r leg sym p to m s,
sayin g th a t th ey h a d so m e th in g to do w ith th e
w a y she felt. T w o sessions p r i o r to th e p re s e n t
one, she w a s finally able to a r tic u la te her
an d the p a tie n t spoke freely a b o u t h e r e a rly r e

lation ship difficulties, b ut she could seem to
find little w r o n g w ith h e r p re s e n t s itu atio n e x
cept for a feeling of d e ta c h m e n t from h e r h u s
b a n d , a m a n eight y ears y o u n g e r t h a n h erself
a b o u t w h o m she spoke little at first. She w as,
she ad m itted , not tru ly h a p p y w ith h e r r e l a
a n g e r at h e r h u s b a n d a n d even som e h a tr e d
t o w a r d him . S h e noticed th a t h e r a w a re n e s s of
h e r a n g e r te n d ed to relieve h e r leg sy m p to m .
T h e b r e a k t h r o u g h of th ese em otio ns, I felt,
insp ired d r e a m s th a t convinced h e r of the
d e p th s of h e r hostility t o w a r d h e r h u s b a n d , the
r e l a t i o n s h i p of t h i s h o s t i l i t y to h e r leg
176
sym p to m s, an d th e need to do so m e th in g ab o u t
h e r m a r ria g e . T h e session th a t follows is th e
seventh.
P t.
W e l l , t h e n I d o n t h av e t h e sy m p t o m s .
T h . A n d t h e n y o u d o n t t h i n k a b o u t t h e m .
P t.
T h a t s r i g h t , bu t n o t im m e d i a t e l y . I m m e
d ia te ly k n o w i n g d o es no t i m m e d i a t e l y reliev e
P t.
I ve decided t h a t I ve g otten m y self in a b ad
th e
s i t u a t i o n , (p a u se)
r e a c t i o n w h a t e v e r t h is t h i n g is, t h is guilt t h
T h . I t s a si t u a t i o n y o u ve b een in o r o ne y o u ve
P t.
getting
th e
b l a h , b l a h , b l a h , b u t l e t s call it g u i l t t h a t
W h a t r ve g o tten m yse lf into, a n d I try to act
will do.
nice, b u t so h e l p m e G o d I c a n n o t sa y: W e l l ,
s y m p t o m s fast, b u t i m m e d i a t e l y k n o w i n g w h y
I i m m e d i a t e l y get sy m p t o m s .
I get
look sw eetie [to A lfr e d h e r h u s b a n d ] I love
I m g e t t i n g t h e m is n o t i m m e d i a t e l y reliev ing.
you, a n d w e ll w o r k this t h i n g o u t . I c a n t do
T h e y d o n t cut off t h a t fast.
it. I m nice to h i m , bu t i t s a very i m p e r s o n a l
T h . Yes.
n i c e , a n d , o f co urse, I m t e r r i b l y a w a r e o f it.
P t.
W e l l , t h e y r e cu t off in a h u r r y in this w ay .
P robably to m o rro w m orn in g w hen I w ake up,
m a y p r o je c t a n d I m m o r e a w a r e t h a n h e is. I
I w o n t h a v e t h e m b ut t h a t w o u l d be a p eriod
t r y to do t h i n g s t h a t he w a n t s d o n e a n d so
of 24 h o u r s af te r I k n o w w h a t I m d oin g. But
fo rth , t h e best I c a n , b u t i t s hell. B r o t h e r , d o I
you see, t h is terrific t h i n g of h a t e th is w eek . I
g ive
ca n scarc ely be in t h e s a m e r o o m w i t h h im . I t s
m y se lf th e
business!
You
talk
about
sy m p t o m s , t h e n d o I get them !
colossal, a n d I h a d it y e s t e r d a y a n d i t s all I
m a k e the co n n e c tio n t h e n ? W h a t h a p p e n s to
ca n d o to be d ecent. It is a s u p e r h u m a n effort.
T h . H a v e y o u n o ticed t h a t t h e h a t e h a s b een pilin g
you?
u p o n t h e su r f a c e m o r e a n d m o r e ?
O h , t h e n t h a t s w h e n I feel g uilty . I feel so t e r
P t.
r ib ly gu ilty . I still d o to d a y , (p a u se)
T h . T h e r e w a s a t i m e w h e n you d i d n t h ave a n y
T h . Yo u
feel
evidence
of guilt
connected con
nected to w h a t ?
T h e w a y I r eact to A l f r e d s illness a n d p e r
T h . And
how
S u r e , sure.
h a t e for h i m a t all.
P t.
O h , b u t yo u k n o w t h a t , yes. Yo u see n o w , it
gets closer a n d closer to t h e su rface, a n d i t s
so nality .
just a l m o s t ph y sic ally i m p o ss ib le to co n tro l it.

does
the
g uilt
re fle c t
i t s e l f in
T h . W h a t do y o u feel like d o i n g w h e n yo u get th is
sym ptom s?
P t.
im m ediately
in g o r w h i c h is c o m b i n e d w i t h su p e r e g o a n d
T h . T h e n you get t h e m af ter t h a t . H o w d o you
P t.
bu t
g o tte n y o u r se lf into recen tly ?
I d o n t k n o w h o w w h e r e he is, a n d a g a i n I
P t.
sym ptom s,
t h i n g , th is feeling?
F eet a n d legs a lw a y s . W e l l , not a l w a y s , b u t
P t.
m o stly I get t h ere.
W e l l , i t s a p e c u l i a r t h i n g ,
I w o u l d like to
m a k e h i m i n a n i m a t e . I sa id t h e o t h e r d a y , to
T h . H o w do th ey se em n o w ? F eet a n d legs.
p u t h i m in his p lace, I w o u l d like to m a k e h i m
P t.
V e r y bad.
n o n f u n c t i o n a l so t h a t h e c o u l d n t b o t h e r m e at
T h . T h e y d o?
all. T h e o n l y r e a s o n I w o u l d n t w a n t to kill
P t.
T o d a y t h e y re bad.
T h . You
P t.
c o nn ect
it u p w i t h
h i m is b e c a u s e I k n o w t h a t t h a t w o u l d be on
y o u r g u ilt feelings
m y co nscience. B u t I d like to hit h i m p h y s i
t o w a r d A lfre d th en
c ally a t tim es.
W e l l , t h a t s w h a t I c on n ect u p w i t h , bu t I can
loathe him , oh,
be w r o n g a b o u t t h a t too, b e c a u s e in s i m i l a r
w e ll q u i t t h is a n d go on to s o m e t h i n g else.
c i r c u m s t a n c e s I u s u a l ly get th e s a m e t h in g . B ut
Sort of t h e s a m e su bject. I t s very i n t e r e stin g .
W ell, anyw ay,
L a s t n i g h t w h e n I w e n t to bed e a r l y a n d I c o n
d ep r e ss e d .
sciously t h o u g h t to myse lf, all r ig h t n o w , th is
I d o n t h av e the d e p r e ss io n t h a t
so m e ti m e s com es w i t h it.
t h a t h elp lift t h e s y m p t o m s to o ?
leg d e p a r t m e n t , b ecau s e th i s t h i n g k e p t m o u n t
in g y e s t e rd a y , yo u see.
T h . Yo u no ticed t h a t t h e s y m p t o m s b e g a n pilin g
N o t so far. At least not im m e d i a t e l y . I t h i n k it

does after a while.
T h . H o w long?
P t.
l o a t h e h im .
yet I k n o w w h a t I m d o in g , so I d o n t feel as
T h . T h e k n o w l e d g e of w h a t you a r e d o i n g does
P t.
I look a n d lie in bed a n d I
W e l l , m a y b e 24 h o urs.
T h . A n d after 2 4 h o u r s w h a t do y o u no tice?
up?
P t.
W o r s e r a n d w o r s e r , a n d I m g o in g to d r e a m
w h a t t h e hell is re a lly w r o n g w i t h m y legs.
U n c o n s c i o u s l y I m u s t k n o w w h a t t h e hell is
g o in g o n ; n o w I m g o i n g to d r e a m . M y d r e a m
THE USE OF DREAMS
177
t h e m o n k e y fa m i ly b e c a u s e o f its m o v e m e n ts .
is t h e m o st f a b u l o u s t h i n g y o u h e a r d in y o u r
life. W a i t u n til you h e a r . Y o u b e t t e r r e c o r d
A n d let m e see s o m e t h i n g c a m e in t h e r e b e
t h i s u h , I w r o t e it in t h e d a r k . I t h i n k I c a n
t w e e n o h , yes, so m e of t h e w o r d s I go t w e r e
recall it, a n d t h e n I ll go a n d c h eck it a n d see if
ter rific. So I t u r n e d to o n e of t h e w o m e n a n d
I m rig h t.
sa id, I w o n d e r w h a t t h is t h i n g is a n d s ittin g
T h . All rig ht.
u p t h e r e o n m y s h o u l d e r . I w a s n t f rig h te n e d
P t.
of it, b u t I d i d n t like it. I h a d no feeling of
I d r e a m e d t h a t I w a s in a b e d r o o m a n d t w o
p e t t i n g it.
w o m e n w e r e in t h e r o o m w i t h m e. N o w th ey
se em ed to be in so m e c a p a c it y like a m a i d a n d
T h . Yes.
a frien d, o r s o m e th i n g like t h a t r a t h e r i m p e r
P t.
Y o u k n o w m y u s u a l r e a c t i o n a b o u t all a n i
so na l c a p a c it y b u t t h e y w e r e t h ere. A n d it
m als. I m e a n if i t s a c a t, o r a d o g , o r a h orse,
w a s all very fri en d ly , a n d I forget w h a t w e
o r a w h i t e m o u se , o r a g u i n e a pig, o r a r a b
w e r e d o in g , w h e t h e r w e w e r e g e t t i n g clothes
b i t m a k e s n o diffe rence to m e I w o u l d p et
r e a d y to w e a r o r s o m e th i n g . B u t it w a s all a
it. B u t th is c r e a t u r e d i d n t p a r t i c u l a r l y f rig h te n
v er y p l e a s a n t a t m o s p h e r e . A n d all o f a su d d e n
m e. I d i d n t h a v e a feeling t h a t it w a s a sp i d e r
I s a w th is ver y s t r a n g e little c r e a t u r e a n i m a l s
in
a g a i n a b o u t this big (sp r e a d s fin g e r s a p a rt
in se cts, b u t I d i d n t w a n t to t o u c h it. It w a s
a b o u t 5 in c h e s), a n d it w a s a c r e a t u r e like I
the
se n se
T h . Uh-huh.
to get u p m y desk. T h e r e w a s a d esk o n the
P t.
o p p o s i t e w a l l a n d it w a s t r y i n g to get u p on
T h . An emu?
P t.
t h i n g w h a t is i t ? A n d o n e of t h e w o m e n
w hat
about
So t h is o n e w o m a n s a id , I w o n d e r w h a t it
m y desk. It co uld m ove s o m e w h a t like a s q u i r
I d o n t k n o w
feeling
i s . A n d sh e sa id, It lo oks like a n e m u .
rel o r like a m o n k e y , a n d I sa id , L o o k at t h a t
G olly,
h orrible
j u s t there.
h a d n e v e r seen before, a n d it w a s sort of t r y in g
said,
of m y
W h a t she t h o u g h t a n e m u is soft A m e r i c a n
g o at I t h i n k it is, I d i d n t lo ok t h is u p . I sa id ,
N o , i t s a n a n u s .
it i s .
W e l l , I sa id , t h a t s t h e s t r a n g e s t c r e a t u r e I
T h . I t s a n a n u s .
h a d ever s e e n . T h e o t h e r o n e sa id, It look s
P t.
A n d t h e n I said it w a s in t h e m o n k e y fam ily .
like a b a t , b u t it c a n t fly, it lo oks like a b a t .
S o t h e n it c a m e o v e r a n d it got o n m y r i g h t
A n d I sa id , I d o n t w a n t to see t h a t t h i n g , it
breast,
is so o d d . T h e n I so rt of lay over. I w a s sit
m onkeys j u m p u p a n d d o w n a n d chattered,
t i n g u p on to p o f t h e bed like I do so o f t e n
j u s t c h a t t e r e d . W e l l , t h e n t h e d r e a m faded.
a n d t h e n I so rt of lay o v e r t h e r e a n d I k n e w
A n d o n t h e fo llo w in g d a y I m o n t h e s a m e bed
t h e c r e a t u r e w a s c o m i n g a r o u n d . It c a m e over
a n d t a l k i n g o n t h e t e l e p h o n e to m y m o t h e r . I
th e bed t o w a r d m e a n d , O h G o d , it w a s so rt of
t old h e r a b o u t this s t r a n g e c r e a t u r e , a n d
a m a r k e d f ear a n d a c e r t a i n s h u d d e r . A n d o ne
t h o u g h t a b o u t it a n d w o n d e r e d w h a t h a p p e n e d
of t h e w o m e n sa id to m e, W e l l , yo u a l w a y s
to it. It w a s t h e r e , I w o n d e r w h a t h a p p e n e d .
and
it j u m p e d
up
and
down
like
said y ou w e r e n t a f ra id of r o d e n t s . O f c ou rse,
I ve got to find o u t w h a t h a p p e n e d . It m u s t be
I m n ot, for a lo ng t i m e I m n o t a f r a id of
h e r e in t h e h o u s e s o m e w h e r e . So t h e m a i d
r o d e n t s . A n d th is little c r e a t u r e c a m e ov er a n d
sa id, I t s b e h i n d t h e d o o r . So I go t u p a n d
got o n m e. It w a s o n ly a b o u t so b i g it h a d
w e n t over a n d b e h i n d t h e b e d r o o m d o o r th is
b r o w n a n d w h i t e sp o ts, no t p o l k a d o t s b ut
all h a p p e n e d in t h e b e d r o o m t h is all h a p
m o ttled .
p e n e d in t h e b e d r o o m b e h i n d t h e b e d r o o m
T h . Yes.
d o o r is th i s a n u s , I called it, folded u p like a
P t.
A n d it h a d a r m s a n d legs like a s p i d e r m o n k e y .
fro g m i g h t fold u p . O n l y t h e frog, I ve nev er
Yo u k n o w w h a t a sp i d e r m o n k e y is; its a r m s
seen o n e t h a t did, b u t th ey w o u l d be a b l e t o
a n d legs a r e to o lo ng for it a n d very ag ile, a n d
folded u p
its no se a n d its h e a d , well t h e y lo o ked like a
w all a n d n e x t to it is a little a n u s . D u r i n g the
like this. L e a n i n g u p a g a i n s t th e
frog. T h e r e w a s no d i f fe r e n t i a t i o n b e t w e e n t h e
night
head
t e l e p h o n e a n d to o k t h e t w o th ey h a d a w a k
and
the
body,
and
its
face
looked
it h a d
up
and
h a d a b ab y . So I got off the
s o m e w h a t froglike in t h a t its face w a s flat a n d
e ned
its sn o o t w a s s q u a r e . It d i d n t h av e t h e face of
m e d i a t e l y got o v e r on m y r i g h t b r e a s t a n d
u n f o ld e d .
The
big
anus
im
a m o n k e y a t all. bu t I d ecid ed it b elo n g e d to
started ju m p in g u p and chittering a n d c h a tte r
178
ing, a n d t h e little o n e exactly t h e s a m e w a s
w a s w h e n I first as k ed w h a t t h a t t h i n g w a s ,
o ver h e r e on th is s h o u l d e r j u m p i n g u p a n d
a n d t h is is g o in g w a y b ack, w a s t h a t o n e of th e
d o w n and chittering an d chattering. A nd I was
w o m e n sa id , I d o n t k n o w w h a t it is, b u t I a l
q u i t e i n t r i g u e d t h a t th is a n u s o ne d a y ol d could
w a y s s ta y a w a y f ro m t h i n g s t h a t I d o n t k n o w
c h itte r . It h a d le a r n e d so fast. A n d I t h o u g h t ,
w h a t t h e y a r e . T h e n t h e t w o a n u s e s (la u g h
m y G o d , these th i n g s m u s t r e p r o d u c e , b u t w i t h
in g ) k ep t j u m p i n g u p a n d d o w n a n d c h i t t e r in g
terrific r a p i d i ty .
a n d c h atterin g at me a n d chittering and c h a t
w hole
T h is
house w ould
w ould
be full.
be a w f u l ,
th e
t e r i n g a n d t h a t w a s t h e e n d of t h e d r e a m .
I ve go t to do
s o m e th i n g . A n d b e in g as I d o n t d islik e it a n d I
T h . A n d t h a t w a s t h e e n d of t h e d r e a m . Y o u w e r e
u p s e t w i t h b o th o f t h e m ?
h a t e k illin g c r e a t u r e s , w h a t a m I g o in g to do?
W h a t w a s I g o in g to d o ? A n d t h e n m y feelings,
Pt.
even in m y d r e a m ; I w a s rev o lted w i t h b o t h of
d r e a m , b e c a u s e u s u a l ly I d o n t r e a l i z e t h e m so
t h e m o r I w a s revo lted w i t h t h e idea of k illin g
m u c h , bu t
I did in th is. In lo o k in g for the
b o th b e c a u s e t h e r e w a s no w a y to d e t e r m i n e
a n u s , t h e c o m b i n a t i o n of n o t w a n t i n g to see it
w h e t h e r o r n ot t h e y cou ld conceive o r p r o d u c e
b u t w a n t i n g to k n o w w h e r e it w a s , a n d th en
maybe
m y terrific feeling a g a i n s t killing a n y c r e a
(p a u se )
tu re any
an im al or
d o in g
away
w ith
an
a n i m a l . A n d I got th is t h i n g , a n d , o f course,
th o u s a n d s of th ese little c r e a tu r e s .
T h . W e l l , t h a t s r a t h e r a n i n t e r e s t i n g d r e a m .
P t.
A n d t h e fact t h a t I let t h e m j u m p u p a n d d o w n
th e b a b y o f a n y a n i m a l is a l w a y s cute. I d o n t
o n m e, I let t h e m c h a t t e r a t m e. A n d it w a s i n
care w h a t it is, I got t h e t h i n g , a n d I t h o u g h t
t e r e s t i n g t h a t th ey w e r e very p e c u l i a r c r e a t u r e s
by go lly t h e o n ly t h i n g to do is I h av e to d is
t h a t h a v e n e v e r been seen t h e like of on th is
pose of o n e of t h e m . N o w I h av e to find ou t
e a r t h . B u t I d id no t w a n t to t o u c h t h e m o r pet
w h i c h o n e is the o n e t h a t b e a r s , w h i c h o n e is
t h e m o r fon dle t h e m , w h i c h I d o all c r e a t u r e s .
f em ale o r
So if t h a t i s n t so m e th i n g , so t h a t is t h e a n s w e r
w h e t h e r t h e y re bo th m ale. O f c o urse, t h a t got
to w h a t is w r o n g w i t h m y feet. N o w y o u ta k e
fem ale,
or
w hether
t h e y re
b o th
it f ro m t h e r e (la u g h in g ).
m ix e d u p t h e r e , b u t a n y w a y s o n e of t h e m m u s t
h av e given b ir th to the o t h e r one. M a y b e the
T h . Y o u ve t h r o w n it m y w ay .
big o ne w a s p r e g n a n t w h e n it c a m e into th e
P t.
r o o m y e s t e rd a y , w h i c h n o w s h o u l d be logical,
T h . (la u g h in g ) N o w w h e r e do t h e feet co m e into
b u t I k n o w t h a t all a n i m a l s d o no t m i n d incest.
t h e p i c t u r e ? W h a t do y o u m a k e o u t of th e
a son, t h e n a t a given l e n g th of tim e w h a t e v e r
(la u g h in g )
d re a m incidentally?
So, the r e fo r e , if th is little o n e t h a t s h e s h a d is

P t.
N o w , of co u r se , t h a t is A lfred. H o w in G o d s
t h e i r p e r i o d w o u l d be, w h y I d h av e a lot m o r e
w o r l d I c o u ld ever. . . . In m y c on s ciou s m i n d I
a n u s e s a r o u n d t h e hou se.
c o u ld n e v e r get t h e a t t r i b u t e s t o g e t h e r t h a t I
T h. The
so n
w ould
have
relations
w ith
re a l l y feel a b o u t h i m a n d p u t t h e m in w o r d s
the
n e v e r so p r a c t i c a l l y c o m p l e t e l y in t h e d r e a m .
m o t h e r ? [ W h a t th e p a tie n t is im p ly in g is th a t
h e r o w n r e la tio n s h ip w ith h e r h u s b a n d , s y m
P t.
I w a s r a t h e r u p se t, b u t I w o u l d n t face th is
m y e m o t i o n a l feelings w e r e t h e t h i n g in th is
T h . As yo u di d in r e p r e s e n t i n g h i m as a n a n u s . All
b o liz e d b y th e m o n k e y cre a tu re , is in cestu o u s.]
ri g h t , w h a t a r e y o u r as s o c i a t i o n s w i t h t h a t
T h e son w o u l d h a v e r e l a t i o n s w i t h t h e m o t h e r .
c r e a t u r e ? W h a t d o es t h a t c r e a t u r e h a v e t h a t
Alfred h a s ?
Is t h is a lily? (la u g h in g ) A n d so I t h o u g h t I ll
see if I m r i g h t n o w . So I s t a r t e d e x a m i n i n g
P t.
Long
arm s
and
legs m o n k e y l i k e
f ro m
the
t h e m , a n d th ey h a d n o s e x u a l o r g a n s at all.
m o n k e y fam ily . I ve a l w a y s t h o u g h t t h a t A l
T h e y w e r e j u s t in t h e ligh t as silver d o l l a r s
fred w a s a r a t h e r q u e e r - l o o k i n g p e r s o n . A n d
th ey w e r e t h e s a m e on b o th en d s ex cept o ne
I ve often t h o u g h t h e lo ok ed r a t h e r fro glik e b e
e nd o p e n e d , w h i c h
w a s o bv io usly a m o u th .
c a u s e o f th is g r e a t w i d e j a w a n d p o p eyes. So I
T h e y h a d n o tails. T h e y h a d these legs, so I
h a d th is s q u a r e n ose on th is c r e a t u r e . W h e n I
gave t h a t deal u p a n d t h o u g h t t h e g o d d a m n e d
first see h i m , I d o n t k n o w w h a t it is. H e s a
t h i n g s d o n t h av e a n y sex. W h a t a m I g o in g to
h y b r i d of so m e ty pe. T h e c r e a t u r e c a n t talk ,
d o n o w , b e c a u s e I d i d n t w a n t to kill b o t h of
c h a t t e r s all t h e t i m e a n d c a n t t a l k w h i c h is
t h e m . I h a d th is t h i n g , a n d I d i d n t k n o w w h a t
o n e of t h e t h i n g s t h a t a g g r a v a t e s m e a b o u t A l
to d o w i t h it. T h e n s o m e th i n g I m iss ed in t h e r e
fred.
179
THE USE OF DREAMS

T h . H e chatters?
fa n t a s t i c o n
P t.
H e c h a t t e r s all t h e tim e , b u t h e c a n t t a l k a n d
(la u g h in g ). I tie it in w i t h m y leg s y m p t o m s
this a n d
I w ish
y o u d tell m e
j u m p s u p a n d d o w n on me.
because they arrived im m ediately up o n m a r r y
T h . Is t h a t w h a t A lfred d o es ?
ing A lfre d. So it m a k e s so m e se n se w h e n I sa id
P t.
Yes, I t h i n k so; it is t h e w a y I feel a b o u t w h a t
to m y se lf very p o w e r f u l l y last n i g h t before I
h e d o es I m telling y ou a b o u t .
went
P t.
to s l e e p b e c a u s e it w a s e a r l y a n d
h a d n t h a d b u t a c o u p l e of d r i n k s d u r i n g th e
T h . Yo u also b r o u g h t u p f ro m t i m e to t i m e t h a t
h e s q u i t e h airy.
e v e n in g , o n e as a m a t t e r of f a c t b efo re I w e n t
H a i r y ? I cou ld just s i m p l y fix h i m u p for good.
to bed. I said I m g o in g to d r e a m a b o u t th is leg
T h . W h a t about?
t h i n g . W h a t does give m e t h e s e s y m p t o m s b e
P t.
c a u s e I n o ticed t h e w h o l e t h i n g m o u n t y e s te r
T h e n h e s co m p le te ly sexless.
T h . S ex les s?
d a y , p a r t i c u l a r l y w h e n I w a s k in d of d isg u s te d
P t.
H e w a s n t m a l e or fe m ale. I c o u l d n t find o u t
w i t h t h e w h o l e id ea t h a t he d i d n t g o to w o r k
w h a t h e w a s ; I lo ok ed h i m o v er a n d I c o u l d n t
o n T u e s d a y . W e l l , y e s t e rd a y m o r n i n g w h e n he
w a k e n e d u p a n d sa w t h a t I w a s m o r e d isg u s te d
find o u t w h a t h e was .
t h a n ever, I j u s t t h o u g h t I ll see if t h e old
T h . T h a t r e p r e s e n t s h o w you feel a b o u t A lfred?
u n c o n s c i o u s will u n b u t t o n by d r e a m i n g .
T h a t s a p r e t t y go od d e s c r i p t i o n of h o w you
P t.
feel a b o u t h i m ?
T h . A p p a r e n t l y it c a m e t h r o u g h .
Y e a h , I d o n t t h i n k t h e r e s a n y d o u b t of it.
P t.
It d id (la u g h in g ), a n d t h a t s h o w I co n n e c t th e
W h e n I w o k e u p I t h o u g h t , m y G o d , t h a t s a
leg s y m p t o m s w i t h A lfred b e c a u s e if I h a d h a d
p i c t u r e of Alfre d a n d
th e leg s y m p t o m s b efo re I m a r r i e d A lfred, I
I c o u l d n t believe it.
ever
w o u l d n t say t h a t . T h a t w o u l d n t m a k e to o
n oticed, p e o p l e h a v e co lo rs to me. N o w y o u re
go o d se n se, b u t I got t h e m i m m e d i a t e l y after
Brown
and
w hite
m o ttled .
If y o u ve
g r e y , a n d A lfred is b r o w n , w h i c h m i g h t also
m a r r y i n g h i m . W h e n I say i m m e d i a t e l y , I say
cover t h e a n u s d e p a r t m e n t , yo u see (la u g h in g ).
w i t h i n 4 w eeks , a n d I ne v e r h a d t r o u b l e w i t h
T h . Brown?
m y legs before. I d a n c e d , I w a l k e d , I d d o n e
P t.
ev e r y th in g . A n d I ve n e v e r b e e n w i t h o u t t r o u
H e s w h a t I call a b r o w n p e r s o n . Y o u r e a
g rey p e r s o n . S o m e p e o p l e a r e p i n k p e o p l e , a n d
ble since t h e m a r r i a g e .
so forth . T h a t m a y be a little farfetched, bu t
T h . It s o u n d s v er y su spicio u s.
I ve a l w a y s r e g a r d e d p e o p l e t h a t w ay .
P t.
T h . Also you feel as if y ou a r e s tu c k w i t h A lfre d,

t h e w a y you w e r e stuck w i t h t h e s e a n i m a l s .
P t.
It s o u n d s m o r e t h a n s u s p i c i o u s d o e s n t it? A n d
th is d r e a m w a s so vivid.
T h . It s o u n d s very, very s u s p ic io u s as if y o u ve
Y e a h , I c o u l d n t kill t h e m . I w a s a f r a id t h e r e
m i g h t get m o r e o f t h e m , w h i c h w o u l d be t e r r i
b een living w i t h it really.

P t.
T h i s is m y b e d r o o m , in b ack of th e d o o r , a n d I
ble. H e w a s d r a g g i n g d o w n o n m y b reasts ,
h a d t h e feelin g t h a t I m u s t k n o w w h e r e it is a
w h i c h w o u l d m e a n p u t m e in t h e m o t h e r role.
m e n a c e . It h a s a m e n a c i n g q u a l i t y , a n d yet I
In a w a y Alfred c h a t t e r s ex a c tly like m o n k ey s .
w a s n t a f r a id of it f ro m t h e s t a n d p o i n t of g e t
T h e m o n k e y s c h a t t e r a n d c l i m b o v er th i n g s
a n d j u m p u p a n d d o w n , a n d these c r e a t u r e s
tin g s t u n n e d .
T h . W h a t do y o u t h i n k h a s tied y o u d o w n to h im ,
h a d n o tails, (la u g h in g )
w h i l e r e a l l y fe eling th is w a y a b o u t h i m as y ou
T h . W e l l , n o w h o w c a n y ou u tilize th i s d r e a m c o n
o b v io u sly h a v e felt? W h a t h a s tied y o u d o w n
stru ctively for you rself? W h a t does this e x p l a i n
to h i m ? Y o u d o n t feel a n y d i f fe r e n tly t o w a r d
Pt.
to you t h a t you co uld use in a co n s tru c tiv e
h i m n o w t h a n y o u d id b efo re for a lo n g tim e,
way?
do
W e l l , it e x p l a i n e d th is m u c h to me: t h a t as
c e r t a i n feelings.
lo n g as I feel this w a y a b o u t A lfred , w h i c h is

th e
m ost
g raphic
thing
I v e
P t.
h a d w hich
to myself.
a b o u t it.
W ell,
the
I m m o r e c on s ciou s of t h e m , a n d I s u p p o s e I
T h . B u t h o w c o m e y o u a r e tied d o w n w i t h h i m for
so l o n g 3 y e a r s ? T h a t is a l o n g t i m e . . . to
T h . W e l l , h o w does t h a t tie in w i t h y o u r legs?

Pt.
A t least y o u re m o r e con scio us of
d o n t feel a n y d ifferen t, b u t I c o u l d n t a d m i t it
d o e s n t n eces sa rily sa y h e s like t h a t b u t I feel

th a t w a y a b o u t h i m I b e t t e r d o s o m e th i n g
you?
way
I find
it and
m aybe
live w i t h a m o n k e y n a m e d a n u s .
I m
P t.
I re a l l y t h i n k t h a t s a q u i t e b r i ll i a n t d r e a m
180
m y se lf (la u g h in g ). I h a d to l a u g h t h e m i n u t e I
fo u r, y ou co uld leave h i m , p e r i o d . A r e t h e r e
t e r r i b l y guilty .
a n y o t h e r p ossibilities yo u c a n t h i n k of?
T h . D id you?
P t.
j u s t i f y to y o u r se lf y o u r living w i t h h i m ; o r
re a liz e d w h a t I h a d d r e a m e d , a n d t h e n I felt
P t.
N o . W e l l , one, I m a y p r o j e c t so m e, I d o n t
Yes, of co u r se, t h e r e a s o n I ve lived w i t h h im
p r o je c t c o m p l e t e l y b e c a u s e w e k n o w t h a t he
all th ese y e a r s is j u s t t h a t g u i l t t h a t s th e
w a s a special k i n d o f c r e a t u r e . T w o , I m a r r i e d
w h o l e t h i n g . I felt t e r r i b l y g u ilty , a n d t h a t s
h i m o n a f lu k e in a n a t t e m p t to r u n a w a y fro m
m y o w n s u p e r e g o t h i n k i n g if I got a w a y fro m
w h y m y legs a r e bad.
T h . If y o u live w i t h a p e r s o n o n t h e basis o f gu ilt,
control or an y th in g rep re sen tin g a p a re n t, I
w h a t d o y o u feel a b o u t y o u r se lf for d o i n g a
w o u l d n t feel t h e w a y I did , a n d suffer t h e w a y

I did.
t h i n g like t h a t ?
P t.
W ell,
you
see,
that
T h . In
m y se lf yet.
So
I cho s e a
weak
man,
one w ho
w o u l d n t c o n t r o l me.
I h a v e n t d i s e n ta n g le d
other
words,
if y o u
d i d n t
m arry
your
T h . B u t if o n t h e b asis of gu ilt, y o u live w i t h s o m e
p a r e n t t h is tim e , like y o u d i d y o u r p r e v i o u s
b od y, w h a t d o you feel m i g h t h a p p e n in y o u r
h u s b a n d , y o u d be in c o n tr o l of t h e sit u a t i o n .
self e v a l u a t i o n , in y o u r a t t i t u d e s t o w a r d y o u r
Y o u d be a b l e to m a n i p u l a t e a n d h a n d l e th e
self? [ / f e e l I can u se c o n fr o n ta tio n to c h a lle n g e
situation.
h e r d efe n se s sin c e sh e a p p e a r s to h a v e fa i r l y
P t.
I w a s n o r m a l e n o u g h a p p a r e n t l y to
m a k e so m e a t t e m p t a t a d j u s t i n g A lfred to som e
h a ve
se nse of n o r m a l i t y o t h e r w i s e I w o u l d n t h av e
a good
w o r k in g
r e la tio n s h ip
a n d sh e
w o u l d n t f e e l 1 w a s p u t t i n g h e r d o w n .]
P t.
T hree,
g o o d in s ig h t in to w h a t is h a p p e n in g . A lso w e
w o r k e d so h a r d o n h i m . I d i d n t k n o w t h a t at
t h e tim e , b u t I m u s t h a v e h a d a very s t r o n g
D epreciation.
T h . S elf-d e p r e c ia tio n . H o w can yo u resp ec t y o u r
d r iv e , o r, believe m e, I w o u l d n t h a v e p u t in
self u n d e r th o s e c ir c u m s t a n c e s ? W o u l d n t it be
t h e effort a n d t i m e t h a t I di d in t r y i n g to m a k e
e x p e c t i n g t h e i m p o ss ib le of y o u rself? A n d th en
w h a t w o u l d y ou d o if you d i d n t r esp ect y o u r
s o m e so rt o f a m a n o u t of him .
T h . W e l l , w h a t so rt of a jo b h a v e you d o n e w i t h
self? T h e r e w o u l d be w a y s of co v er in g y ou rself
u n d e r t h e c i r c u m s t a n c e s w o u l d n t t h e r e ?
P t.
that?
P t.
in t r y i n g to a d j u s t a h o m o s e x u a l to n o r m a l it y .
T h . N o t b e in g a b l e to e x p r e s s h o stility, w h a t h av e
I d o no t t h i n k it is possible.
y o u been d o i n g w i t h it?
P t.
K n o c k i n g t h e hell o u t of m y se lf (la u g h in g ).
T h . Y o u t h i n k all the effort y o u h a v e m a d e t o w a r d
[H e r la u g h te r is a c tu a lly a se lf-c o n sc io u s d e
a d j u s t i n g h i m to a h e t e r o s e x u a l life h a s g o n e to
w aste?
fe n s iv e m a n e u v e r. I t conceals a g r e a t d e a l o f
m is e r y a n d se lf-co n cern .]
P t.
I t h i n k I p r o b a b l y feel m o r e s t r o n g l y t h a n th a t
in t h e case of A lfred, b e c a u s e he w a s a b l e to
T h . Yo u m e a n y o u re a n e x p e r t o n p u n i s h i n g y o u r
P t.
I h a v e c o m e to t h e c o n c lu s io n t h a t a n y b o d y , i n
c l u d i n g y o u , cou ld c o m p le te ly w a s t e y o u r t im e
Y eah .
self, a r e n t y o u ?
m a k e a better ad ju s tm en t p ro b ab ly th an 9 out
I m a n e x p e r t on ho stility a n d w h a t to do w ith
of 10, a n d it leaves h i m b e i n g n o t h i n g . G o d ,
it. W e l l , t h a t s t h e sto ry as p l a i n as t h e n ose on
the h om osexuals th a t
y o u r face, a n d I can see it. I m still r e a c t i n g to
p l e n t y of t h e m , th ey a r e h o m o s e x u a l s a n d they
I know , and
I know
love t h e fact t h a t I m a g irl, a n d I love it. A n d
it, b u t I c a n still see it.

T h . All r i g h t, t h e p o t e n t i a l i t i e s for d o i n g s o m e th i n g
th ey a r e b e t t e r a d ju s te d p e o p l e t h a n A lfred or
a b o u t it po sitively a r e lim ite d to a n u m b e r of
t h e o t h e r b oys t h a t I h a v e seen a n d h a v e g otten
th in g s. O n e , e i t h e r y o u re p r o j e c t i n g into h im
m a r r i e d . S o m e of t h e m h a d o n e c hild. J e s u s ,
a t t i t u d e s a n d feelings t h a t yo u h av e t o w a r d
th ey get th e m se lv e s in to a t h i n g w h e r e they
n e v e r get th e m se lv e s o u t of it.
m e n in g e n e r a l , o r t o w a r d c e r t a i n m e n ; o r,
t w o , h e s a special k i n d o f p e r s o n w h o m you
T h . In w h a t w a y ?
m a r r i e d o n a flu ke a n d th e r e f o r e y o u re r e
P t.
s p o n d i n g to h i m as a special kind o f p e r so n .
T h e y are nothing. T h e y never become h etero

s e x u a l t h e y d o n t. A n d if t h e y do , t h e y m u st
T h r e e , t h e r e s a possib ility yo u m a y feel t h a t
be h a n g i n g in t h e H a l l of F a m e , b e c a u s e t h e r e
he m a y d ev elo p, he m a y c h a n g e , a n d this m a y
a r e n t m a n y of t h e m . A lfred is n o t h e t e r o s e x
THE USE OF DREAMS
181
u al, bu t n e i t h e r a r e t h e h o m o s e x u a l s , a n d m y
a n d t h e r o v i n g eye is r e a lly so m e th i n g . T h e y
g u y c a n t a c c o m m o d a t e h i m s e l f to a n y t h i n g .
c a n t h e l p it; i t s p a r t o f t h e m a n y m o r e t h a n
W e never h av e sex.
I c a n p u t T i g e r , m y m a l e d o g , w i t h a little fe
T h . H e s n e u t e r ?
Pt.
m a l e d o g a n d ex p e c t h i m to sit a n d look a t h er.
H e b ecom es n e u te r .
I m s ittin g a n d t e llin g y ou a b o u t p s y c h i a t ry . I
T h . J u s t like t h a t m o n k e y .
Pt.
love this. A n y w a y , i t s m y o b s e r v a t i o n see,
Y e a h , h o n e s tly , t h a t ' s w h a t I t h i n k to d a y . Ask

me an o th e r day, and
y ou ask ed m e w h a t I ve d o n e to A lfre d. See,
I m ight have a n o th er
t h a t s w h a t I t h i n k I ve d o n e , a n d t h a t s w h y I
idea. I d o n t t h i n k so I ve w a t c h e d , so I g u ess
feel so g o d d a m n e d g u i l t y a b o u t leav in g h im .
t h a t s on e p lace m y g u ilt feeling arriv es .
Y o u w a n t e d to k n o w w h y I d i d n t leave h i m
T h . T h a t y o u ve t a k e n h i m a w a y f r o m h o m o s e x u a l
T h . I t s q u i t e p o ss ib le t h a t y o u r g u i l t h a s b een su ch
life?
Pt.
e a r lie r.
I ve t a k e n h im a w a y f ro m s o m e t h i n g t h a t he
t h a t y o u felt it w o u l d p r a c t i c a l l y kill h i m to
ob v io u sly enjo yed. A n d t h e w a y he e a r n s his
leave h i m , a n d you k n o w t h a t h e is a r a t h e r
living, it i s n t lo ok ed d o w n o n to o m u c h . [A l
u nstable person
fr e d
t e llin g w h a t m a y h a p p e n in h i m w h e t h e r you
is a
w in d o w d esig n er. \ M o s t of th e m
a r e th ey h a v e a terrific tim e . T h e y h a v e a
lo usy ol d a g e t h a t s tr u e . W h e n th ey get to be
live w i t h h i m o r not.
P t.
old, th ey h av e t h e s e w h y i t's p r e t t y b a d , bu t
b u t I d i d n t r e a l i z e t h a t before.
T h . In o t h e r w o r d s , y o u re j u s t n o t g o i n g to save
in o n e a r e a , so th ey d o n t g r o w u p in it. O r
h im . If t h e p ro cess w i t h i n h i m is a d es tru ctiv e
t h e y re a r t i s t s or sin g e rs , o r t h e y a c c o m m o d a t e
o ne, it m a y defy a n y b o d y s a b i l i t y to h e l p h im .
th em se lv e s to t h e f e m i n in e p a r t of t h e i r n a t u r e .
O n t h e o t h e r h a n d , you m a y w a n t to h a n d l e
W h y , th ey have a p r e t t y good life. O n l y w h e n
w h a t e v e r you decid e to d o in a carefu l w a y
t h ey get so t h a t they r e a l i z e t h a t t h e y a r e n t
living a full life t h a t t h e y suffer so d a m n e d
m uch, and
w i t h him .
P t.
I t h i n k t h a t s w h e r e I feel g u ilty
T h a t s w h a t w ill h av e to be b e c a u s e I d o n t
t h i n k I k n o w th is, b u t it is s o m e t h i n g I feel i n
a b o u t A lfred , I re a lly do.
t u itiv e a b o u t , if you believe in i n t u i t io n . T h e r e
T h . Y o u kind of feel t h a t y o u w e a n e d h i m a w a y
P t.
M y livi ng w i t h h i m , I ve c o m e to r e a l i z e t h a t
n o w , m y living w i t h h i m w ill n o t p r e v e n t it,
even t h a t t h e y a d j u s t to. A b u n c h o f t h e m get

old t o g e t h e r . So w h a t , t h e y just d o n t g r o w u p
H e s u n s t a b l e , a n d t h e r e is no
h a v e been a few ti m e s in m y life w i t h Alfre d
f ro m t h a t g r o u p a n d t h a t he c a n t go b ack to it.
w h e n I h a v e seen h i m w a l k a w a y f ro m him self.
H e ll go b ack , bu t t h a t will be as m u c h a n a d
T h a t is t h e o n ly w a y I c a n p u t it. N o w he w a s
j u s t m e n t as it w a s to a d j u s t to a h e t e r o s e x u a l
s t a r t i n g to w a l k a w a y f ro m h i m s e l f be fore he
sit u a t i o n . A n d w i t h it h e will h a v e hellish guilt
c a m e u p to see y o u y e s t e r d a y as if h e w a s n t
b ecau s e he will k n o w t h e r e s s o m e t h i n g b etter,

b ecau s e he will h av e g l i m p s e d it. I t h i n k h o
h ere.
T h . T h a t s sort of a p sy c h o tic -lik e r e t r e a t .
m o s e x u a l s th e i r m o t h e r s sh o u l d be s t r a n g l e d
P t.
p o i n t n u m b e r o n e th ey sh o u l d be let a l o n e
T h . O v e r the border?
I m s p e a k i n g n o w n o t of k ids in t h e i r y o u n g
P t.
t een s, b u t I m t a l k i n g a b o u t g u y s w h o get to be
H e gets w h a t I call o v er t h e b o r d e r . ( p a u s e )
S o m e d a m n e d t h i n g t h a t h e will w a l k a w a y
f ro m h i m s e l f is t h e o n ly w a y I c a n p u t it. H e s
25 a n d 28 a n d t h e i r p a t t e r n is p r e t t y well set.
no t t h e r e a n d t h a t sc are s t h e hell o u t of me.
It's a p e c u l i a r t h in g . I h a v e t h e m a r o u n d the
O f co u r se,
h o u s e all t h e t i m e a n d I m fairly o b s e r v a n t ; I
d o n e to h i m . N o w , t h a t m a y be very n e u r o tic ,
c a n ' t h e l p b ut be I t s a p e c u l i a r t h i n g . I t s t r u e
but
even w i t h Alfred, a n d I k n o w a n o t h e r o n e w h o
d on e.
h a d a s i m i l a r e x p e r i e n c e t h a t s G e o r g e w h o
I c o n nect it w i t h s o m e t h i n g I ve
I a p p a r e n t l y c o n n e c t it w i t h
what
I ve
T h . W e l l , you h a p p e n to be th e p e r s o n h e s living
is m a r r i e d a n d h a s a child. H e w e n t b ack to
w ith
h o m o s e x u a l it y . G e o r g e called m e t h is m o r n i n g ,
w i t h y o u c a n act as a t r ig g e r. B u t if it w e r e n t
a n d I h a d a lo ng talk w i t h h im . N ice guy,

m a l a d j u s t e d as hell to ev ery p a r t of life. You
get th e m in a ro o m w i t h o t h e r h o m o s e x u a l s ,
n o w , a n d c o n s e q u e n t l y his ex p e r i e n c e s
y ou, it m i g h t be s o m e t h i n g else.
P t.
I r e a l i z e t h a t n o w , bu t I still b l a m e m yself on
t h a t score.
182
T h . W e l l , d o y ou b l a m e y o u rself so m u c h t h a t i t s
h a s t o w a r d y ou is as if y o u a re his m o t h e r . D o
g o in g to p a r a l y z e y o u rself f ro m d o i n g w h a t
you t h i n k is t h e best for y o u ?
P t.
Pt.
N o , no, i t s not g o in g to sto p me.
T h . W h a t w o u l d be t h e best t h i n g to d o ?
P t.
y ou believe t h a t ?
th is terrific love to j u s t l o a t h i n g me.
T h . A n d y o u r e k in d of fed u p w i t h t h a t d e a l you
T h e best t h i n g for m e to d o is to leave h im .

I m s u r e of t h a t. I d o n t k n o w h o w t h e hell I m
d o n t w a n t to be his m o t h e r .
P t.
I t s n o d ecen t r e l a t i o n s h i p if I m g o in g to be
g o in g to d o it r ig h t th is m i n u t e . As you k n o w
h is m o t h e r I m i g h t as w ell re a l l y act like his
w h a t kin d of sp ot I ve g o t t e n m y self into fi
m o t h e r (la u g h in g ). R i g h t ? I t s j u s t n o good. So
n an cially .
I c a n see t h e p a t t e r n cut o u t for w h a t I h a v e to
T h . F i n a n c i a l c i r c u m s t a n c e s a r e c e r t a i n l y su ch th a t
d o, a n d I d r a t h e r sto p b e a t i n g m y se lf o n th e
you w o u l d n t w a n t to do a n y t h i n g u n til you

P t.
T h a t s w h y he v acillates so terrifically f ro m
h ead .
w e r e m o r e self-sufficient a n d s e cu re ?
T h . B e a t in g y o u r se lf on t h e feet.
T h a t s r i g h t. W e l l , I c a n t, I d o n t k n o w h o w
P t.
to d o it. So I ve go t m yself in t h a t k in d of spot,
D uring
the tim e
period
th at
I h a v e to go
t h r o u g h to do it, t h a t is s o m e t h i n g w e can
w o r k o ut a little bit.
a n d I t h i n k I feel g u ilty a b o u t t h a t g ettin g

m y se lf in t h a t k in d of spot. B u t af te r m a r r y i n g
T h . A n d y o u r o w n feelings a b o u t l eav ing h i m too.
h i m I w a n t e d to go d o w n t h e r o a d to d e s t r u c
P t.
T h a t s b e a t i n g m yself on t h e feet, t h e g uilt

t h i n g . A n d I d o n t q u i t e k n o w h o w to act w i t h
tion , a n d I p la y e d ev ery c ard in su ch a m a n n e r

t h a t I did. N o w , I d o n t feel t h a t w a y a b o u t it
A lfred in t h a t if I let m y a g g r ess iv e feelings
a n y m o r e , a n d I can see w h a t I ve been d o i n g to
c o m e o u t , it w o u l d p r o b a b l y co m e o u t w a y
myself. B u t it laste d sufficien tly u n t i l I w a s in
o v e r b o a r d a n y w a y . I ve held t h e m in a long
p h y sic al p a i n . H o w I feel g u ilty t h a t Alfred
tim e . I m a f r a id I m ig h t do s o m e t h i n g a w f u l to
h a s to sp e n d ev ery ce nt he m a k e s on m e, w h ic h
h i m so I k eep sort o f p r e t e n d i n g a r o u n d th e
I know
h o u s e a b o u t th is a n d t h a t , a n d h e ll sa y, O h ,
rationally
I s h o u l d n t b ecau s e G o d
k n o w s h e h a d t h e a d v a n t a g e o f all t h e m o n e y I
I love y ou so m u c h . A n d I d o n t k n o w w h a t
h a d for m a n y y e a r s before o u r m a r r i a g e . So h e
t h e hell to sa y to t h a t I m e a n I d o n t k n o w
p u t s in a few m o n t h s of f o rk i n g u p t h e d o u g h
b e c a u s e w h a t I say d o e s n t h a v e a n y r i n g of
a n d I d o n t see w h y I s h o u l d feel to o b a d ly
t r u t h , a n d t h a t itself k eep s m e in a n u p r o a r . I
a b o u t it. B u t b e in g th e k in d of c r e a t u r e I a m , I
get v a r i o u s r e a c t i o n s f ro m it S o m e t i m e s I sh u t
act t h a t w a y . I d o n t see a n y t h i n g to d o except
u p f ro m a n x i e t y . I feel v er y s o r r y , a n d t h e n I
to w a i t u n t i l I c a n feel no t even su re, b u t j u s t
look
even p a r t l y s u r e t h a t w h a t
c o u l d n t see it bef ore . N o w I see, I m e a n really
I m w o r k i n g on
at
him
and
th in k
how
in t h e he ll
n o w will h a v e so m e m erit.
see. N o w little t h i n g s like t h i s a r e rid ic u lo u s ,
T h . In t e r m s o f finances you m e a n ?
b u t th ey s h o w h o w h a r d I r eact. W e h a v e th is
P t.
T h a t s r i g h t, I m e a n f in an ces. If I find t h a t it
bed w h i c h is fixed just like y o u r c o u c h it s
h a s even s o m e m e r i t a l i m ite d m e r i t living
got
alo n e , I c a n live on very little w h y I w o u ld
b e d r o o m is no t fixed u p like a b e d r o o m ; i t s
t a k e t h e p l u n g e th en .
fixed u p as a n o t h e r r o o m . W e sleep t h e r e a n d
like
this.
I t s
l o un ge.
The
I re a lly w o u l d b ecau s e I
a g a i n s t t h i s t h i n g on m y side, a n d h e h a s his
d o n t t h i n k , I d o n t feel t h e r e is a n y f o u n d a t i o n
side. A lfred will n e v e r sit u p s t r a i g h t in this
to b u ild o n for t h e t w o of us at all. I t h i n k it
t h i n g ; he will a l w a y s lean o v er as close to m e
w o u l d be a c r u t c h d e p a r t m e n t f ro m h e r e on
as he can get. M y r e a c t i o n is to t a k e h i m a n d
o ut for b o th of us. A n d if h e s ever g o in g to
sh o v e h i m
m a k e a n y t h i n g of his life o n e w a y o r t h e
n e v e r lies s t r a i g h t h e c u rv es t o w a r d m e a n d it
Oh
yes,
I w ould.
o t h e r w h i c h e v e r w a y he decid es to go i t s
h ig h g o d d a m n t i m e h e starts.
T h . V i r t u a l l y , you k n o w t h e c h a r a c t e r of h is r e l a
t i o n s h i p w i t h you.
P t.
back
w a t c h T V o r r e a d w i t h o u r feet o u t s t r e t c h e d
T h . Y ou w o u l d ?
P t.
h e gets in bed, he
j u s t a g g r a v a t e s me.
T h . It d oes ?
P t.
S u r e , it a g g r a v a t e s t h e hell ou t o f me.
T h . You d o n t w a n t a n y m o n k e y s j u m p i n g u p a n d
T h e son a n d I 'm t h e m o t h e r .
T h . H e s t h e son , a n d the a t t i t u d e a n d feeling he
away. W hen
d o w n o n you.
P t.
(la u g h in g ) I d o n t w a n t a n y s p i d e r m o n k e y s
183
THE USE OF DREAMS

j u m p i n g u p a n d d o w n on m e, a n u s e s (la u g h
been o p p r e s s i n g
in g ) in o t h e r w o r d s.
s t r a n g e r . A fter a few m i n u t e s of this, I got a
m e even t h o u g h
he w as a
s u d d e n n e w idea l a r g e l y b e c a u s e t h is m a n r e
s p o n d e d s y m p a th e ti c a l ly . I felt I w a s n t really
Case 2
d e a d , b u t su ffere d a m n e s i a . I w a s e x t r e m e l y
h a p p y . I r e a l i z e d m y d i s a p p e a r a n c e for 2 to 3
m o n t h s w a s t h a t I w a s in a m n e s i a , no t d ead . I
O n e of the most difficult p a tie n ts I have ever
s t a r t e d to tell p e o p l e I h a d a w e i r d e x p e r i e n c e
treate d w a s a y o u n g college stu d en t w h o w en t
in w h i c h I t h o u g h t I w a s d e a d . 1 t h o u g h t it
into a negative tran sferen ce even before she
w a s a n a m a z i n g t h i n g b i z a r r e a n d w e ir d . I
saw m e at the first visit. A severe p h o b ic re a c
felt I w a s a n e x p e r t on c o n f o rm i t y , b u t I h a d
tion motivated h e r to seek help , b ut u p o n m a k

ing the a p p o in t m e n t she b eg an to fa n tasy m y
j u s t acted as a co n f o rm i s t in a n u n u s u a l w ay . I
forcing h e r to p e rf o rm a g a in s t h e r will. S e n s
ing h e r resistance d u r i n g th e first session, I
h a d b een sub m is siv e even t h o u g h I k n e w all

a b o u t w h a t m a d e for c o n f o rm i t y . B u t I w a s
h a p p y a b o u t t h is, to r e a l i z e t h a t I felt d is
c o u r a g e d b e c a u s e I felt n o b o d y c a r e d a b o u t me.
said, I get the im p ression you find it h a r d to

talk because you a re afraid of m y re a c t io n s .
T o this r e m a r k she exp lod ed, I feel people
have no respect for me, if I show w e a k n e ss
In h e r associations she said th a t b eing a w a y

w a s like n o b o d y cared for h er. As a child she
especially. I m getting a n g ry at you. I th i n k

you get some satisfaction a b o u t h u m i li a ti n g
felt this, a n d she w a s s u r p ris e d w h e n she h ad

been a w a y for 2 o r 3 h o u r s to discover th a t h e r
me. L ik e m y p a re n ts , m y fa th e r especially. H e
gets som e kind of thrill ou t of criticizing me. I
m o t h e r a n d fa th e r h a d been w o rried . All of h er
th i n k th ey say, Y ou a re shy, w eak. Y ou are
son, an d this w a s like b e in g dead. T h e tall
e m b a rra ss e d . G e t u p th ere an d p e rfo rm a n d
m a n w ith th e m o u s ta c h e w a s like h e r fath er
w e ll w a t c h ! B ut I feel so h u m iliated . M y
w h e n she w a s 6 or 7. I r e m e m b e r accusing
m y fa th e r of indifference o r dislike, of w a n tin g
w h ole life is sp en t saving face. I never let th e m

know . T h e y a lw a y s try to sh a m e m e . M y
reply w as to the effect th a t she did n ot t h i n k I
could accept h e r as she w a s w ith all h e r faults
life she h a d felt like a s tra n g e a b n o r m a l p e r
to h u r t me. H e g ra d u a l ly convinced me I w as
w ro n g . I got a su d d e n feeling you a r e like m y
fath er.
a n d prob lem s. H o w could y o u , she retorted .

T h e p ro b le m really w as, I co u n tered , t h a t she
could not accept herself an d th erefore projected
this feeling o n to me. W it h this the p a tie n t
sto rm ed o ut of th e ro om . S he re t u r n e d , n e v e r
theless, for h e r nex t session, an d she c o n tin u e d
to u p b r a i d a n d a ttack me. At the tw elfth
session she p re s en ted this d r e a m w h ich in d i
cated th e b eg in n in g of re s o lu tio n of h e r n e g a
tive tr ansference.
P t.
I w a s c o m i n g b a c k f ro m a l o n g t r i p d u r i n g th e
s u m m e r . 1 h a d b een h it c h h i k i n g . 1 t a l k e d to
p e o p le a n d felt d i s c o u ra g e d . I n s t e a d of e n g a g
in g in n o r m a l activities, I w i t h d r e w a n d said I
w a s dead , c o n t r a r y to a p p e a r a n c e s . H o w e v e r , I
sa w a tall m a n w i t h a m o u s t a c h e , a n d I b e g a n
to a s s a u l t h i m v erb ally . I sa id h e w a s d i c t a
t o r ia l like a N a z i in d e a l i n g w i t h m e. H e h a d
Case 3
F re q u e n t ly th e tr a n sferen ce e lem en ts a r e not
as clearly o bvious as they w e re in th e foregoing
d r e a m , th e id entification of th e th e r a is t being
m o r e hig h ly sym bolized. T h e th e r a p is t w h o is
on th e w a tch for tra n sfe re n c e resistan ce will be
a l e r t e d to t r a n s l a t e d r e a m s y m b o ls t h a t
forecast sto rm y w e a th e r a h e a d . P a tie n ts w h o
h ave some psychological k n ow led ge, or w h o
h ave re a d psychological books, o r w h o have
h a d som e t h e r a p y a re often ab le to decode the
dis guised sym bo ls them selves, o p e r a t in g as a
c o th e ra p is t. T h i s is illu s trated by a p a tie n t
w ith a p ro b le m of d e p e n d e n c y w h o d r e a m t in
o ra l te r m s a n d w h o w ro te o u t th e following:
184
W e d n e sd a y n ig h t
I a m in a b a k e r y w i t h a n u n u s u a l l y lu sc io us-lo o king a r r a y of b a k e d goods. I se em to r e m e m b e r t h a t

s o m e t h i n g I b o u g h t lo oked so go od t h a t I a te a piece
w h i l e I w a s in t h e sh o p . Also , I v a g u e ly r e m e m b e r
sitive b a ro m e te r th a t ind icates th e o n c o m in g of

a n em o tio n a l sto rm . A p a ti e n t in th e m idd le
stages of t h e r a p y b egan co m in g late for a p
p o in tm e n ts. O n ly u p o n u r g i n g did she re p o r t
th e follow ing d r e a m :
a r r a n g i n g w i t h t h e w o m a n b e h i n d t h e c o u n t e r to d e
liver so m e b a k e d g o od s to m y h o m e l a t e r o n . I r e
m e m b e r giv in g h e r q u i t e explicit d i r e c t i o n s a b o u t
g e ttin g to m y p lace. ( M y as so ciatio n s w h e n I a w o k e
went
s o m e th i n g
like
th is,
I was
The
woman
se ek in g
f ro m
was
her
m other
s u b s titu te .
the
co m fo rt
I n e v e r got f ro m m y o w n m o t h e r . . . .
P t.
I w a s a s le e p on a d esk o r t a b l e in y o u r office. I
w a y lyin g o n m y side w i t h m y kn ees b e n t . You
w a l k e d o v er to m e. Yo u w e r e a s h a d o w y f ig u re
t h a t I c o u l d b a r e l y see t h r o u g h closed lids. I
k n e w I s h o u l d w a k e u p , b u t I w a s c u r i o u s to
T h e n , D r . W o l b e r g is a m o t h e r s u b s t i t u t e too. H i s
see w h a t y o u w o u l d d o a n d I lacked t h e w ill to
voice w a s c o m f o rtin g , s y m p a th e ti c ; h e w a s giv ing
a w a k e n . Y o u t o u c h e d m e. I h a d b een co ver ed ,
m e s o m e th i n g I d w a n t e d f ro m m y m o t h e r )
b u t y ou r e m o v e d t h e cov er a n d I r e m e m b e r
T h u r s d a y o r F r id a y n ig h t
t h i n k i n g I h o p e I h a v e a p r e t t y slip o n . At
I a m in a cafeteria. A p p a r e n t l y I a m e a r l y , for I
first y o u r t o u c h w a s p l e a s a n t , s e x u al-lik e, a n d
a m t h e o n ly c u s t o m e r t h ere. I w a l k d o w n t h e lo n g
I felt r a t h e r g u i l t y for n o t le t t i n g you k n o w I
food tab le, bu t I c a n t se em to r e m e m b e r a n y t h i n g
w a s re a lly a w a k e . G r a d u a l l y y o u b e g a n to t u r n
on it excep t a l a r g e r o a s t t u r k e y , w h i c h w a s a lm o st
in to a s i n i s t e r figure . Y o u l o ok ed in to m y eyes
a t t h e v ery e n d of t h e table. W h e n I co m e to th e
w i t h a l ig h t a n d sa id, T h a t s a lovely b lu e
t u r k e y , I decid e t h a t this is w h a t I d like, b u t I
e y e . I b a r e l y m u m b l e d , I t s g r e e n , feeling
w o n d e r if t h e ca f e te r ia p e o p le will w a n t to spo il its
t h a t if y o u d i d n t k n o w t h e c o lo r of m y eyes it
a p p e a r a n c e by c a r v i n g so m e off for m e be fore t h e
m e a n t you d i d n t k n o w m e. I r e a l i z e d w i t h a
o t h e r c u s t o m e r s get t h e r e . S o m e o n e a n d a g a i n I
sh o c k I d i d n t k n o w t h e c o lo r o f y o u r eyes,
h a v e a va g u e feeling t h a t it w a s a w o m a n w o r k e r
e i t h e r . B r o w n , I t h o u g h t , b u t I w a s n t sure.
a s s u r e s m e t h a t it will be q u i t e all r i g h t. (I d o n t r e
T h e n you said to m e, W h a t a r e t h e th i n g s
m e m b e r a n y a s so ciatio n s to th is d r e a m . As I t y p e it
I ve told y o u ? I s t a r t e d to m u m b l e , M a n y
n o w , it occu rs to m e t h a t I w a n t to be f irs t w ith
t h i n g s . Y o u sa id , N o , I h a v e told y o u n o t h
my m o th er? p e r h a p s w ith D r. W o lb e r g ? but am
in g .
a f ra id t h a t i t s n o t r i g h t t h a t I s h o u l d be.)
a b s o l u te ly n o t r e s p o n s i b l e for a n y t h i n g I m ig h t
I took
this
to
m ean
that
you
are
d o. T h e s e t h i n g s m a d e you s e e m sin is ter to me.

Y o u s lo w ly b e g a n to c h a n g e in t o a n o t h e r m a n
Case 4
P e r h a p s the most im p o r t a n t use of d re a m s
in sh o r t-te rm t h e r a p y is, as h as been indicated,
th e signals th a t they em it p o in tin g to th e b e
g in n in g d ev elo pm en t of a negative transfe ren ce
reaction th a t, if u n h eed ed , m a y e x p a n d to
block o r d estroy pro g ress in th e r a p y . W h e r e a
th e r a p is t does no t e n co u rag e th e p a tie n t to r e
p o rt all d re a m s , th e p a tie n t m a y forget or
rep ress th em , a n d the only sign the th e r a p ist
m a y notice t h a t th in g s a re no t going well is
th a t th e p a t i e n t s sy m p to m s r e t u r n or get
w orse, th a t d is tu rb i n g a c ting -o ut beh av io r a p
p ears , or, w o rse, th a t th e p a tie n t sim p ly d ro p s
out of th e r a p y . W h e r e d re a m s a re re g u la rly r e
po rted , the th e r a p is t will have a vailab le a se n
w h o s e e m e d to be a d erelict, a n d I k n e w I m u s t
get u p . I s t r u g g l e d to a w a k e n myself, a n d I fi
n a l l y succeeded. I r a n to t h e d o o r a n d r a n ou t
o f t h e r o o m , b u t t h e r e w e r e a lot of pe o p le . In
a m i r r o r t h e r e I s a w a n u t t e r r u i n I lo oked
8 0 y e a r s old a n d t e r r i b l y u g l y a n d I believe
sc a r r e d . All t h e p e o p l e w e r e ol d a n d ug ly. It
w a s a village o f d is c a r d e d useless, a n d helpless
p e o p l e . A feeling of h o r r o r o v e r c a m e m e, a n d ,
as I s t a r e d a t t h a t face, I tr ie d to co m fo rt
m y se lf t h a t it w a s o n l y a n i g h t m a r e a n d I
w o u l d soon w a k e u p , a n d I fo u n d it very dif
ficult u n t i l I w a s n t s u r e a n y m o r e if it w a s a
n i g h t m a r e o r real.
I
fin ally
woke
up
from
the
dream
so
f rig h t e n e d t h a t I w a n t e d to w a k e m y h u s b a n d ,
b u t I d ecided to t r y to c a l m d o w n . I fell asleep
a g a i n a n d h a d a seco nd d r e a m . I d r e a m e d I
h a d sta y ed u p all n i g h t w r i t i n g a p a p e r y ou
THE USE OF DREAMS
185
a s k e d m e to do. I s t a r t e d to b r i n g it in to th e
(2) T h e se co nd d r e a m w a s t h a t a m a t h p r o
r o o m you told m e to. It w a s locked . I d ecid ed to
fessor w a s t r y i n g to s t a r t m y g i r l s c a r a n d he
h a v e so m e coffee a n d c o m e b ack . I did. T h i s
c o u l d n t s t a r t it, b u t I could. [I h a d a fe e lin g
t i m e y o u r wife w a s in t h e r o o m . S h e told m e
h ere th a t h e w a s b e in g c o m p e titiv e w ith m e
w h o she w a s . I sa id I k n e w . T h e n sh e told m e
a n d w a s p u t t i n g m e d o w n f o r n o t m a k in g h im
she w a s y o u r d a u g h t e r s m o t h e r as t h o u g h this
w e ll fa s te r . ]
m a d e h e r a f ig u re of g r e a t i m p o r t a n c e a n d
(3) T h e n
I was
lo o k in g
for
sh oes
in
d ig n ity . T h i s m a d e m e feel g u i l t y a n d gave m e
w i n d o w . I s a w s o m e t h i n g I liked. I w e n t in,
th e feeling t h a t I co uld n o t see you a n y m o r e .
a n d h e d i d n t h a v e m y size. T h e sh oe s w e r e
S h e d i d n t w a n t m e to a n d in resp ec t to h e r
nice m a s c u l in e - l o o k i n g ones.
sa c re d n e s s as a m o t h e r I c o u l d n t.
sa y in g h e r e th a t h e c o u l d n t f i t in to a m a n s
[ W a s h e re a lly
sh o e s o r th a t th e s to r e k e e p e r w h o m ig h t be m e
H a d I not becom e alerted to th e b eg in n in g

t r a n s f e r e n c e , w h ic h c e r t a i n l y r e f le c t e d a n
o edipal p ro b le m , I a m convinced th a t m y
sinister
q u a litie s
w o u ld
have
becom e
so
o v e rw h e lm in g in h e r unco nscio us m in d th a t
she w ould have d iscon tin ued th e r a p y . As m a t
ters stood, w e w ere able to en g a g e in fruitful
discussions follow ing m y in te r p r e ta ti o n of h e r
d rea m .
c o u l d n t h e lp h im ? P r o b a b ly b o th .]
(4) I w a s w i t h a b a r b e r a n d he p u n c h e d a
h ole in m y h e a d a n d h e w a n t e d to co ver it w i t h
a t o u p e . I believe I sa id , N o t h i n g d o i n g . I
w a s a n g r y a t h i m . [A p p a r e n tly a n o th e r re fe r
ence to m y in e ffe c tu a lity a n d to h is b u ild in g
r e s e n tm e n t to w a r d m e.]
(5) T h e n I w a s w i t h o n e o f t h e kid s I gr e w
u p w i t h . T h e r e w a s a to ilet in t h e r o o m . I w a s
w a i t i n g for a n o p p o r t u n i t y to go. I d ecid ed to
sit d o w n it w o u l d n t m a k e m e so self-con
scious s t a n d i n g t h e r e a n d u r i n a t i n g o n ly a few
d r o p s . B u t h e got u p a n d w a l k e d out.
Case 5
(6) T h e n yo u w e r e a t d i n n e r at m y house .
Y o u h a d to go to t h e b a t h r o o m . Y o u o p e n e d u p
T h e follow ing d r e a m illu strates the e ru p tio n

of negative tr a n sferen ce in a y o u n g m a n w ith a
p ro b le m of u r i n a r y frequ ency . T h i s o ccu rred at
the te n th session a n d w a s re la te d to his h a v in g
met a y ou ng lady w ith w h o m h e m a d e a date.
H e had a p e n c h a n t for m eetin g c o n tro llin g
the
w rong
b athroom
door.
and
Then
were
you
away
went
a
long
in to
the
tim e .
w o n d e r e d if y ou h a d t h e s a m e p r o b l e m I h a d .
In discussing his d r e a m he stated th a t sitting

d o w n on a to ilet w a s a n esca pe from his e m
w o m e n w h o d o m in a te d h im an d w h o finally
frigh tened h im off. T h e u r i n a r y s y m p to m w a s
associated in his m in d w ith lack of m asculinity .
b a rr a s s m e n t. D id it m e a n , I ask ed, also t h a t it

w a s a fem in in e g estu re a n d a w a y of say ing
O u r re la tio n sh ip h ad been going alo n g well
believe th a t I could n o t h e lp h im achieve his

goals? T h e d r e a m , I insisted, p o in te d o u t his
an d the p atie n t h a d been im p ro v in g , b u t at the

last session he spoke of th e slowness o f his
pro gress. T h e d r e a m th a t h e rela ted to m e in
th e te n th session w a s in six p arts:
Pt.
(1) I m et a f rien d in a l a u n d r a m a t . I told h im

I w a s e n g a g e d a n d he w a n t e d to see p i c t u r e s of
m y girl.
I kept thu m b in g thro u g h
a lot of
b oyish p i c t u r e s a n d t h e last o n e w a s a go od
one, m o r e fem in ine . M y as s o c i a t i o n s to this is
t h a t t h e n e w girl is a ph ysic al ed t e a c h e r a n d I
w o n d e r e d h o w f e m i n in e sh e is. I d o m e e t di f
fere n t p e o p l e in t h e l a u n d r a m a t I use.
th a t h e w a s not q u it e a m a n ? A n d did he
feelings th a t I w a s ineffective. At th is j u n c t u r e
I p ra ise d h im for his ab ility to criticize me,
a n d I asked h im to associate to his feelings
a b o u t me. T h i s op en e d the d o o r to his critical
a tt it u d e to w a r d his passive fa th e r for n ot do ing
m o r e for him . F o r th e n ext tw o sessions we
w o rk e d on his negative tran sferen ce ; in t e re s t
in g ly , h is u r i n a r y s y m p t o m i m p r o v e d rem a rk e d ly . H e w a s delig hted also th a t he could
act m o re a ggressive to w a r d his new g irlfriend
t h a n h e h a d t o w a r d a n y o th e r w o m a n in the
p ast.
186
Case 6
k nife a n d kill h er. I said i n ste a d , Y o u r e a lly

h a t e y o u r s e l f a n d w a n t to kill y o u r s e l f . S h e
Illu strativ e of the use of d re a m s to select a
t r ie d to kill h e r s e l f by t h r o w i n g h e r se lf u n d e r a
th e r a p e u tic focus as well as a m e a s u r e of

p rog ress is th e case of a y o u n g single w o m a n of
car. I g r a b b e d h e r a n d sa id, P le a s e let m e

h e l p y o u . S h e cried a n d cried a n d said she
d i d n t w a n t to live. S h e said sh e felt g u ilty for
30 w h o h ad been a d m itted to a m en ta l in s titu
[ T h e th o u g h t I h a d
t r y i n g to t a k e m y life.
tion after she h a d tried to c o m m it suicide. At
a b o u t th is d re a m w a s th a t sh e f e l t th a t g r o w in g
the end of 18 m o n th s of h o sp ita liz a tio n she

w as tak en ou t by h e r p a re n ts , a n d I w as asked
u p a n d a s s u m in g a h e te r o s e x u a l ro le w a s f o r
to see h e r in c o n su ltatio n w ith th e object of
m o th e r w ith in herself. C o u ld h e r su ic id a l a t
deciding w h o th e best th e r a p is t for h e r m igh t

be. A p a r t from a slight e m o tio n al d u lling , I
te m p t be a d esire to k ill th is in tro ject? ]
could find no active evidence of s c h izo p h ren ia,
bicycle
w h ic h w a s th e diag no sis given h e r at the h o s

pital. T h e d r e a m she revealed at the initial in
stopped
b id d e n b y h e r m o th e r , o r r a th e r th e in tro je c te d
T h e seco nd d r e a m w a s I w a s r i d i n g o n a
stand.
w ith
at
my
m other
a house
M other
w ith
sta yed
and
brother.
people
there
w ith
We
I c o u l d n t
a
co usin
J a n e t . M y m o t h e r a n d m y b r o t h e r got o n o n e
terview w as the following:
bicycle. I w a s o n a n o t h e r bicycle. T h e y kep t

g iv in g m e d ir ectio n s, a n d I re s e n t e d t h a t . T h e n
P t.
I w a s on a d a t e w i t h a m a n a n d he p r o p o s e d to
I w a s r i d i n g a l o n e in the c o u n t r y a n d w e n t
m e. I w a s f ri g h t e n e d a b o u t g o i n g to bed w ith
o v er a cliff a n d d ied.
t h is m a n . T h e n I s a w m yself s u c k lin g at m y
[ T h e p a tie n t a d d e d j I
se em to be in t e r r o r of m y n e w i n d e p e n d e n c e .
m o t h e r s b r east. I felt n a u s e a t e d a n d r a n a w a y .
I t s like in t h e d r e a m . Yet I feel a feeling of
I felt e m p t y a n d helpless. T h e n I sa w s o m e
li b e r a t io n .
b od y h o l d i n g u p t w o f in g e rs o n e r e p r e s e n t e d
I k n o w m y r e l a t i o n s w i t h p eo p le
sin ce w e b e g a n to t a l k a b o u t d e p e n d e n c e a r e
m a l e a n d t h e o t h e r f em ale. S o m e b o d y c a m e
m u c h b e t t e r . I c a n get a n g r y at m y f a t h e r a n d
a l o n g a n d to ok t h e m a l e f in g er, a n d I w a s left
b r o t h e r a n d a t m y se lf for b u i l d i n g t h e m u p as
w i t h th e fem ale finger. I w a s u p s e t a t bein g
t h o s e w h o c a n t a k e c a r e of me.
forced to give u p b ein g a boy. I h a d to be a

gi rl. T h i s m a d e m e an x i o u s .
T h e d re a m , w h ic h I reco rd ed bu t did not in

te r p re t, gave me a clue as to h e r s e p a r a tio n -in d iv id u atio n , d e p e n d e n c y -in d e p e n d e n c y p ro b
lem, an d I decided th a t this w o u ld be th e d y
n a m ic focus in o u r t h e r a p y after w e h ad
w o rk ed ou t the tim e in m y schedule. I saw h e r
once w eekly a n d I focused, w h en ev er p r o p i
tious, on h e r need for a m o t h e r figure, h e r fear
of fun ction in g like a w o m a n , a n d h e r p ro b le m
of identity. A fter 6 m o n th s of t h e r a p y at th e
tw e n ty -fo u rth session she b ro u g h t in th e fol
low in g tw o d re a m s:
F o r th e n ext 10 sessions w e w o rk e d on h er
gu ilt feelings a n d killing fantasies in re la tio n to
h e r e m e r g in g ind epe nd e n ce. In th e co urse of
th is the fo llow ing d r e a m occu rred :
P t.
I a m a l o n e in a c a r , d r i v in g all alo n e . I a m
e n j o y i n g it. I k n e w w h e r e to go. M y m o t h e r
sm iles at m e a n d I a m h a p p y .
[H e r a ssoci
a tio n s f o l l o w ] S ince c o m i n g to see y o u I feel

m y activ ity is r elease d . L a s t w e e k I h a d a d a t e
and
I e n jo y e d myself.
I k n o w yo u feel I m
k e e p i n g m y se lf in a b o x b e c a u s e of g u ilt a n d I
k n o w y o u a r e r ig h t. As yo u say, i t s b e t t e r for
m e to m a k e m is t a k e s a n d w a l k by m y se lf t h a n
to h a v e s o m e o n e c a r r y me.
P t.
T h e first d r e a m w a s t h a t I w a s h a v i n g a n af
f a ir w i t h a t e a c h e r I h a d in h i g h school. (I h a d
a c r u s h o n th is t e a c h e r w h e n I w a s in school.)
M y m o t h e r fo u n d o u t a n d w a s fu rio u s . S h e
w a n t e d to kill me. S h e said I d r u i n m y life.
S h e p u lle d o ut a knife, a n d sh e told m y b r o t h e r
a n d f rie n d s to get knives. I w a s g o i n g to get a
T h e p a tie n t h erse lf s p o n ta n e o u sly t e r m i

n a te d t h e r a p y a fte r th e forty-first session. She
sent m e a n a n n o u n c e m e n t of h e r m a r r i a g e 11
m o n th s after this. I te le p h o n e d h e r to com e to
m y office for a fo llo w -up session. T h e ch an g e
in th e p a tie n t w a s s trik in g h e r p o stu re , h er
THE USE OF DREAMS
187
poise, the confident m a n n e r in h e r sp eak ing .
She re p o r te d t h a t she felt te r rib le after this
A p a rt from a few m i n o r rifts w ith h e r p a re n ts ,
dream
th ere w ere no u p se ttin g episodes to s p e a k of.
ca m e up . H e r associations w e re to th e effect
She avow ed b eing h a p p y a n d a d ju s te d to m a r
th a t h e r se x u al re latio n s w ith h e r h u s b a n d
( t o w a r d w h o m sh e b o r e a g r e a t d e a l of
riage, w hich she described as a g iv e-an d -tak e

p ro p o s iti o n . A te lep h o n e fo llo w -u p 5 years
and
th a t old fears of h o m o s e x u a lity
hostility) h a d ceased. W h e n he is u n h a p p y
after h er te r m i n a ti o n revealed th a t she h ad

given b irth to a child an d h a d m a d e a n e x
w h ic h is most o f th e tim e I h av e to m a k e the
cellent a d ju s tm e n t.
feel like it. I m no t in te re s te d .

M y i n t e r p r e ta ti o n of the d r e a m w a s to th e
first advances. B ut I refuse to because I d o n t
effect th a t she w a s strivin g to achieve s tre n g th

an d
Case 7
in d e p e n d e n c e
through
m a s c u li n it y th e
sym bol of s tre n g th in o u r c u ltu re . W e d is

cussed he r a n g e r at d iscovering as a child the
T h e w o rk in g - th r o u g h of a p ro b le m in id e n
tity t h r o u g h
tra n sfe re n c e
may
be se e n
in
a n o th e r case of a 32 -y e ar-o ld m a r r ie d w o m a n
w ith a n obsessive p e rs o n a lity s t ru c tu r e w h o
p erio d ically
w o u ld
g et
strong
attack s
of
depression an d an x iety . D u r i n g these episodes

she becam e rid d led w ith g re a t d o u b ts a b o u t
m i n o r choices a n d w o uld b a d g e r h e r h u s b a n d ,
J o h n , an d h e r friends to m a k e decisions for
h er, w h ich she th e n w ou ld reject. A n attractiv e
f e m in in e -a p p e a rin g w o m a n , she e x p ressed at
th e initial interv iew con cern a b o u t w h o she
w a s an d w h e re she w as h ead ed . D u r i n g th e in
terview I asked h e r to tell m e a b o u t a n y past
d re a m s , an d she stated she could not r e m e m b e r
h e r d re am s. At th e th i r d session she b ro u g h t in
th e follow ing d r e a m w hich she h a d w ritte n
dow n:
We
m ales for th e ir sense of freed o m a n d in d e

pendence. A lth o u g h she fan tasied fu n ctio n in g
like a m ale, she stated th a t th e r e w e re no e p i
sodes of h o m o s e x u a lity . S h e fell in love w ith a
y o u n g m a n w h o m she m a r r ie d a n d b o re a
child w h o m she che rishe d, b u t she c o n tin u e d to
be dissatisfied w ith herself as a w o m a n , believ
in g th a t so m e h o w she w a s d a m a g e d a n d infe
rior.
S h e d eveloped a good r e l a ti o n s h ip w ith me,
a n d we c o n tin u e d to discuss h e r u n h a p p y
m a r it a l u n io n an d h e r conflict in re latio n
to t h e d e p e n d e n c y - i n d e p e n d e n c y im b a l a n c e .
E vidence of tra n sfe re n c e followed the first h y p
notic session, w h ich
w a s in tro d u ce d
at the
sixth visit. T h e follow ing d r e a m is an e x a m p le

of ho w a res p o n se to a t h e r a p e u ti c tec h n iq u e
( h yp no sis here) m a y reveal a p a t i e n t s stru gg le
w e r e at a r e s o r t J o h n
co up le.
fact th a t she lacked a pen is a n d h e r envy of
was
attracted
to
and
I and
som eone
another
there
who
se em ed to c h a n g e f ro m a m a n to a w o m a n , to a girl
w ith resistan ce an d h o w it h elps th e th e r a p is t

to o rg a n iz e strateg ies to deal w ith em e r g in g
resistance.
in h e r 20s. T h e r e w e r e en dles s d e ta ils a b o u t a c a r

nival n i g h t w i t h a n i m a l s a n d all s o r ts of g a m e s . T h e
n i g h t before w e w e r e leav in g , this girl a n d I w e r e
g o in g d o w n
S h e stoo pe d
like a sc hool b u i l d i n g . I w a s in m y old p ub lic

sc hool. I w a s h e s i t a t i n g a b o u t g o i n g b ack to
kissed h e r
tripped.
I w a s in D r _________ s office | h e r g e n e r a l p r a c
titio n e r] t h e n s o m e h o w I left a n d it w a s m o r e
d o w n to h e l p me. I g r a b b e d h er, p u l l e d h e r d o w n ,
and
t h e s t a ir s a n d
P t.
(I w a s d efinite ly a m a l e a t th is
sc hool [C o u ld sh e be id e n tify in g m e w ith h e r
p o in t). I p u t m y t o n g u e in h e r m o u t h . I w a s still on
g e n e r a l p r a c titio n e r a n d g o in g b a ck to sch o o l
th e b o t t o m a n d she w a s l e a n i n g o v er m e, b u t I w a s
th e tr e a tm e n t w ith m e?] T h e n t h e d o c t o r saw
a m a n . S h e a s k e d m e w h y I h a d n t let on so o n e r
m e on th e l a n d i n g a n d told m e to c o m e in.
t h a t I c ared for her. I told h e r it w o u l d n t w o r k ou t
T h i s s o m e h o w solved t h e p r o b l e m as it m a d e
b ecau s e of J o h n a n d it w a s ju st as well. I go t u p to
m e feel w a n t e d a n d di d n o t give m e t h e feeling
leave. I r a n d o w n t h e s t a ir s a n d said g o o d b y e .
I h a v e w h e n I h a v e to m a k e t h e o v e r t u re s . H e
T h e n I c h a n g e d it to a u r e v o i r .
tr ie d to h y p n o t i z e me. [ T h is e sta b lis h e s m e as
188

th e d o c to r in th e d re a m .] I s t a r t e d to go u n d e r
b oo k. I t h o u g h t it w o u l d be so p l e a s a n t to h av e
d e e p ly , b u t I su d d e n l y c a u g h t myself. H e trie d
a c u p of coffee w i t h you, a n d I t h o u g h t , a l
a g a i n . H e t o u c h e d m y b r e a sts . W h e n I p u lle d
t h o u g h I s u p r e s s e d t h is t h o u g h t , 1 w a n t e d y ou
b ack , h e g o t a n g r y . I h a d t h e distinct feeling in
to m a k e love to m e. B u t it w a s a q u i e t feeling
t h e d r e a m t h a t h e t o u c h e d m e not o u t of a n y
w i t h a feeling of so ftnes s, flir t a t i o u s n e s s , a n d
desire, bu t o n ly to m a k e m e r e a l i z e t h a t I h a d
even
b r e a s t s ju st like a n y o t h e r w o m a n a n d t h a t I
s o m e ti m e s h a v e of m y m a k i n g love to you b e
was
a little sa d n ess .
N o t like t h e i m a g e
no
c a u s e I w a n t to see you a r o u s e d ; I w a n t to feel
w o r se . T h i s a t t i t u d e of c o m p l e t e lack of p u t
s o m e f o rm of p a s sio n fro m you j u s t because
ti n g m e o n a p ed es tal gave m e all a t o nce a
y o u r c o n s t a n t c a l m n e s s se em s a k i n d of rejec
feeling of f re e d o m a n d a feeling of in te n s e s o r
tion . T h i s feeling h a s a g r e a t d eal of h o stility
like
any
other
w o m a n no
be tte r ,
ro w . It w a s as t h o u g h I w a s s t r u g g l i n g for m y
in it, bu t t h e feeling I h a d a t h o m e w a s d iffer
ri g h t to be d ifferent, b u t at t h e s a m e t i m e I
en t.
re a l i z e d t h a t m y s t r u g g l e w a s in a w r o n g d i r e c
W h y do I feel t h e s e x u a l i m p u l s e w h e n I a m
tion. H e tr ie d to h y p n o t i z e m e a g a i n . T h i s
a l o n e o r w h e n I feel m y r e l a t e d n e s s to t h e total
tim e t h e r e w e r e tr ic k s involved, m a k i n g m e see
w o r l d as w h e n 1 lo ok ed in B r e n t a n o s w i n d o w
co lored b alls c o m i n g o u t o f a b a g a n d so fo rth.
a n d s a w r e p r o d u c t i o n s of s o m e of t h e a r t o b
M y r a t i o n a l m i n d kep t s t r u g g l i n g a g a i n s t su ch
jects
a p ossibility , a n d even t h o u g h I s a w t h e m , I
f r i g h t e n s m e. If I h a d been w i t h a m a n in m y
I love? T h e
strength
of t h e se x u a l i ty
felt th ey re a lly w e r e n t t h e r e . A g a i n , I h a d th is
a p a r t m e n t , I do n o t t h i n k I c o u ld h a v e resisted
feeling of o u r wills b e in g p itte d a g a i n s t each
g o i n g to bed w i t h h i m . In fact, t h e u r g e to
o t h e r . I w a n t e d so m u c h to love, bu t I c o u l d n t
a d u l t e r y is very s t r o n g . I se em to w a n t m y se x
u al p a r t n e r to aid m e in k e e p i n g t h is r e l a t e d
se em to give u p t h e strug gle.
ness to t h e w o r l d (to life, e t e r n i t y , etc.). I k n o w
M y in t e r p r e ta ti o n s dealt w ith h e r resistance
t h a t I c a n t n o w h a v e a c o m p l e t e a n d sa tis fyin g
to giving u p the kin d of id en tity th a t m a d e h e r

feel safe, w h ich she, of course, could do if th is is
o r g a s m a n y o t h e r w a y . J o h n s c o m p l e t e p r e o c
w h a t she w a n te d . I w o u ld like to h elp h e r, b ut
love m a k i n g beco m es a n er o tic ep is o d e on ly.
c u p a t i o n w i t h h i m s e l f s t a n d s in m y w a y so t h a t
M y soul is no t r elease d o r n o u r i s h e d .
she h a d a rig h t no t to ch an g e if she so w ished .

At this p o in t th e p a tie n t sta rte d crying, a n d she
In o u r dis cussion we talk ed a b o u t h e r u p
confessed being u n h a p p y w ith the w a y she w as,

b ut she w a s afraid to c hang e. At the n in th
b rin g in g , h e r intensely close re la tio n s h ip w ith
session she sp ok e of a d r e a m th a t she h a d th a t

a p p e a r e d to in dicate th a t she tru ste d me m o re
w h o w a s a s o m e w h a t sh a d o w y figure in her
a n d w as u tiliz ing h e r re la tio n s h ip w ith m e as a

g r o w th vehicle:
Pt.
h e r m o th e r, a n d the d e ta c h m e n t of h e r fath e r,
life.
S e v e ra l
s e s s io n s
later
sh e
revealed
th is
d re a m :
I h a d a d r e a m of s o m e o n e r u n n i n g af ter m e
a n d m a k i n g love to m e in t h e su n l i g h t . | H e r
P t.
I c a m e to y o u r office w h i c h w a s s o m e h o w d if
a sso cia tio n s w e re to th e effect th a t la te r th e
fere n t. It h a d a b e d r o o m . W e w a l k e d in to th e
n e x t m o r n in g sh e w a s re a d in g J u n g 's T h e U n
b e d r o o m . S o m e h o w w e w e r e on t h e bed a n d
discovere d Self. | T h i s g ave m e a w o n d e r fu l
w e w e r e kissing. You w e r e o n t o p of m e, a n d I
feeling of c o m p le te n e s s a n d a sense of s t i m u l a
w a s h a p p y to be in t h a t p o sitio n . I felt y o u r
tion a n d p e a c e a t t h e sa m e tim e . A feeling of
t o n g u e in m y m o u t h , a n d
w e ll- b e in g so s t r o n g t h a t I really did no t feel

t h a t a n g r y feeling I u s u a l ly h av e w h e n J o h n
goes o u t. I re a lly did no t m iss h im ; even m y
fear of b e i n g a l o n e w a s s o m e w h a t stilled, no t
c o m p le te ly , bu t a g r e a t deal. I felt a w a v e of
s t r o n g se x u a l d es ire a n d w ish e d you w e r e t h e r e
w i t h me. I w a n t e d to talk to you a b o u t the
1 put my hands
u n d e r y o u r s h i r t a n d felt y o u r back. F o r a split

se co nd , I h a d t h e fear t h a t I w o u l d n o t find
y o u r b ack m a s c u l in e feeling like, hu t it w as.
Yo u r efu s ed to go a n y f u r t h e r , e x p l a i n i n g t h a t
if w e did, you w o u l d no t be a b l e to h elp me.
Y o u s e em ed s o r r y t h a t it h a d g o n e t h a t far,
a n d I b e g a n to be f rig h t e n e d t h a t it m i g h t i n
THE USE OF DREAMS
189
fluence o u r r e l a t i o n s h i p . H o w e v e r , I also felt
h e r to c o n tin u e w o r k in g at h e r p ro b le m by
q u i t e h a p p y , a n d t h e n you c a m e in I s a w t h a t
herself. T h e p a ti e n t accepted this. D u r i n g th e

nex t few y ears she cam e in tw o tim e s because
of a brief o bsessional episode w h e n she could
it re a lly w o u l d he all r i g h t. T h e r e w a s no re al
c h a n g e in th e r e l a t i o n s h i p e x c e p t t h a t I felt
m o r e f e m i n in e a n d p e r h a p s a little g u ilty as
t h o u g h I h a d seduced you. B ut I w a s really
q u i t e pleased.
not m a k e u p h e r m in d in re la tio n to h e r c o n
ti n u in g c a re e r as a book ed ito r a n d the school
ing of h e r child. N o m o re t h a n several sessions
A m o n g h e r a ssociations w a s h e r sta te m e n t,
w e re needed o n each occasion to get h e r to
M y r e la tio n s h ip w ith J o h n th a t d a y w a s
easier, an d I felt as th o u g h I w a n te d h i m . She
d e p e n d e n t a g a in on a n a u th o r it y figure w h o
avow ed the need for a stro n g m ale figu re in
recognize th a t she w a s tr y in g to m a k e herself
h er life to h e lp m a k e h er feel fem inine.
w o u ld tre at h e r like a child. H e r m a r it a l an d

sexu al a d ju s tm e n t im p ro v e d co n stan tly , an d
T h e r a p y w a s te r m i n a te d ag ain st h e r w ishes
but at m y insistence th a t it w a s necessary for
th e im ag e of herself as
increasing ly c onsolidated.
fem ale
b e cam e
Conclusion
D re a m s , like conscious th in k in g , a re d y
na m ic ally m otiv ated by u rg e n t conscious an d
m e n ta l events a r e so significant as to p ro m o te a
d r e a m a n d w h a t m e a n in g these events h a v e for
u n c o n s c i o u s n e e d s . B e c a u s e r e a l i t y t e s ti n g ,
logic, an d correct con ceptio n s of tim e an d
th e p a tie n t, (3) u n d e r s ta n d in g w h a t is goin g on

fro m th e p a t i e n t s s ta n d p o in t in th e re l a ti o n
space a re m o re or less su s p en d e d in sleep an d
s h ip b etw een th e th e r a p is t a n d th e p a tie n t, (4)
because re p ressio n
is lo w ered, th e d r e a m e r
detec tin g e a rly resistan ces a n d tra n sfe re n c e dis
m a y exp ress basic w ishes, conflicts, a n d fears

th a t one w ou ld not o rd i n a ril y p e rm it oneself to
to rtio n s th a t p o te n tia lly can block p ro g re ss in
ex perien ce in w a k in g life.
D r e a m s m a y th u s serve n ot only as a re v e la
p a ti e n t is m a k i n g in t h e r a p y , a n d (6) p ro vidin g
tory screen for un co nscio u s w ishes an d past

m em o ries, b ut also p e r h a p s m o re im p o r t a n tl y
p ro b le m s a n d e x istin g an d laten t capacities for

a d a p ta tio n .
as a w a y of reflecting p re s e n t a d a p tiv e an d
pro blem -so lvin g activities, h a b it u a l c h a ra c t e r
In w o r k in g w ith d re a m s th e th e r a p is t h a s a
tool a p p lic a b le in all form s of s h o r t-t e rm t h e r
p a tte rn s , an d th e special w a y s a n ind ivid ual is

in te rp re tin g a n d co pin g w ith c u r r e n t situ atio n s
a p y th a t can lead to a b ette r u n d e r s ta n d in g of

a p a t i e n t s p ro b le m s, to re co gn itio n of the
in the p resen t. D u r i n g th e r a p y d r e a m s a re
p a rtic u la rly im p o r t a n t in ( l ) identifying c o n
flicts an d defenses to w a rd p ro v id in g a d y n a m ic
focus, (2) reco gn izin g w h a t im m e d ia te e n v ir o n
q u a li ty of the w o rk in g r e la tio n sh ip , a n d to
an o v ercom ing of d e v elop in g obstacles th a t
t h r e a te n th e effectiveness of th e th e r a p e u tic
process.
tr e a tm e n t, (5) d e te r m i n in g w h a t p ro g re ss th e
a w in d o w into th e p a t i e n t s views of fu tu re
CHAPTER 13
Catalyzing the Therapeutic Process

The Use of Hypnosis
In th e r a p y m u c h tim e is co n su m e d in cop ing
be of special m erit. Such v a u n te d catalysts a re
w ith resistances to th e yielding of ego-syntonic
subject, h ow ev er, to va ria bles of th e r a p is t p e r
p a tte rn s. It is tr a d itio n a lly a ssu m ed th a t this
son ality an d p a ti e n t resp on se th a t can n eg ate
ex tend ed perio d is in evitable as p a r t of th e

process of w o r k i n g - t h r o u g h . T h e r e is, h o w
m ost co m m o n ly em p loy ed te c h n iq u e s utilized
ever, some evidence th a t c ertain expediences
to accelerate tr e a t m e n t a re h ypnosis, n a r c o
m a y be em p lo yed to ca ta ly ze pro gress. O n e
a n a l y s i s , e m o t i v e r e l e a s e s t r a t e g i e s , g u id e d
im a g e ry , b e h a v io r t h e r a p y , G e s ta lt th e r a p y ,
an d even reverse th e i r influence. A m o n g th e
m ode h as a p a r a d i g m in crisis situ atio ns d u r

ing w hich
m o tiva tion
h as
been created
for
ch an g e th a t o th e rw ise w o u ld not have d e

veloped. U sin g this idea, som e th e r a p is ts a t
te m p t d u r i n g th e r a p y to create m in o r crisis
situ atio n s for the p a tie n t by tactics such as a g
ex p e rie n tia l t h e r a p y , d r e a m an alysis, fam ily

th e r a p y , a n d in tro d u c tio n of th e p a tie n t into
an active g ro u p .*
C e r ta i n w a y s of e x p e d itin g insig ht have also
been helpful, for e x a m p le , citing specific e p i
gressive c o n fro n tatio n a n d o th e r w ays of s t ir
sodes fro m th e tr e a tm e n t of o th e r p a tie n ts (of
rin g u p anx iety . T h e object is to convince the
course, a n o n y m i ty is m a i n ta i n e d ) th a t in som e
p a tie n t th a t p u r s u it of o n e s u su a l m od e of b e
h av in g is offensive to o th ers a n d u n p le a s a n t for
respects re late to th e p a t i e n t s p ro b le m . T h i s
oneself. In this w a y the th e r a p ists try to b re ak

th r o u g h resistances to p ro d u ctiv e change.
th e
In p a tie n ts w h o a re ca p a b le of c o u n te n a n c
ing challenge a n d c o n fro n tatio n such m eth o d s
m a y prove successful. U n fo rt u n a te l y , w h e re a
w eak ego s tr u c tu r e exists, w h e re th e p a ti e n t is
hostile to o r excessively defensive w ith a u t h o r
ity, o r w h e re negative transfe ren ce precip itate s
too readily, the rela tio n sh ip will not sustain
the p a tie n t d u r i n g the tu m u lt u o u s r e a d j u s t
m e nt period. T h e p atie n t will eith e r leave
th e r a p y or show no resp o nse to the p ro ced u res
being used. W i t h such p a tie n ts it is b etter to
em p lo y a n a p p r o a c h orien ted a r o u n d a d e
libe rate m a in te n a n c e of a positive relatio nsh ip.
A search for o th e r strateg e m s th a t can
h asten the t h e r a p e u ti c process has yielded a
n u m b e r of in terv e n tio n s th a t have, in the
o p in io n of those skilled in th e ir use, p ro ven to
m a y serve as a projective te c h n iq u e to cu shio n

p a t i e n t s
a n x iety
and
help
m ain tain
defenses th a t m ig h t o th e r w is e be sh a tte re d by
direct in t e r p r e ta ti o n s of th e p a t i e n t s p e rs o n a l
re action s (A. W o lb e r g ,
1973, pp. 1 8 5 -2 3 4 ) .
A n o t h e r m e t h o d is th e u se o f m e t a p h o r s
th r o u g h re la tin g stories o r anecd otes th a t illu s
tr a te p o in ts th e th e r a p is t w a n t s to get across to
th e p a tie n t (D e L a T o r r e , 1972).
T h e r a p i s t s develop p e rs o n a l preferences in
the choice of c a ta ly zin g techniqu es. T h e s e
g e n e rally relate to th e ir successes w ith th e m a
jo r i t y of p a tie n ts . In m y o w n e x p e rie n c e I have
found hy p n o sis of g re at v alue, a n d I r e c o m
m end it w ith no illusion th a t it can be helpful
to all th e ra p ists. It sho uld be e x p e rim e n te d
w ith to see if it blends w ith o n e s style of w o r k
ing th era p e u tic a lly .
* S ee W o lb e r g 1 9 7 7 , p p . 2 4 5 - 2 5 0 , 6 8 5 - 7 4 0 , a n d 7 6 1 8 2 3 fo r a fu ll d e s c r ip tio n o f th e s e m e th o d s .
190
CATALYZING THE THERAPEUTIC PROCESS: HYPNOSIS
191
When to Use Hypnosis

H y p n o sis is p a rtic u la rly suited for th e p a
w a s no t fully convinced th a t h e needed it. I ac
tient w h o is p a ra ly z e d by resistance. R esis
cepte d th e p a t i e n t s n egative feelings, b ut I

specu lated th a t his tension m ig h t be r e s p o n
tance is em bo died in overt o r covert b e h a v io r

p a ttern s. U su a lly , the p a tie n t is u n a w a r e of
such m a n e u v e r s .
R e s is ta n c e is p a r t i c u l a r l y
obstructive w h e n it blocks the special te c h

n iq u es th a t a re em p lo yed in p sy ch o th erap y .
sible for at least some of his sy m p tom s. I offerred to sho w h im h o w to r e la x so th a t he

m ig h t derive so m e th in g beneficial o ut o f the
p re s e n t session. H e ag reed, a n d I th e n induced
enab le th e p erso n to re s p o n d b e tter to t r e a t
a light tran ce , in th e co urse of w h ich I suggested

a g en eral state of re la x a tio n . A fter th e tr a n c e
ment.
w a s te r m in a te d , th e p a tie n t s p o n ta n e o u s ly a n
H y p n o sis m a y be a d v a n ta g e o u sly em plo yed

in the course of p s y c h o th e ra p y u n d e r th e fol
no u n ced th a t he h a d never felt m o re re lax ed in
low ing conditions:
sessions of hypn osis. In the course of h y p n o re -
H y p n o sis m ay h e lp resolve such resistance an d
his life an d asked if he could hav e several m o re

la x a tio n I ca su ally suggested to h im th a t th e re
m ig h t be em o tio n a l reaso ns w h y his b la d d e r
When the Patient Lacks

Motivation for Treatment
h a d become tense a n d u p set, a n d I in q u ire d

w h e th e r he w o u ld be intere sted in find ing out
H y p n o tic tech n iq u e s m a y be helpful in co n

vincing an u n m o tiv a te d p a ti e n t th a t he can
w h e th e r this w a s so. W h e n he ag reed, I gave

h im a p o sth y p n o tic su ggestion to r e m e m b e r
an y d r e a m s h e m ig h t have w ith in th e nex t few
derive so m e th in g m ean in g fu l from tr e a tm e n t.
days.
A p a tie n t m a y feel res e n tm e n t t o w a r d th ose

w h o insist th a t he get psychological h elp ; he
m a y be afraid of rev ealing secret o r d isg ustin g
H e res p o n d ed w ith a series of d r e a m s in

w h ich he saw him self as a frigh ten ed perso n
aspects of his life; he m a y feel d is tru s t for th e
escap in g from situ atio n s of d a n g e r a n d being

blocked in his efforts to achieve freedom . H is
th e r a p ist o r refuse to recognize a n em o tio n a l
associations w e re a b o u t th e d e m o c ra tic rig h ts
basis
o bstruction s th a t c o n trib u te to the lack of in
of op p ressed p eop le th r o u g h o u t th e w o rld and

the futility of ex p re s sin g th ese rig h ts in th e face
centive for th e r a p y can u su a lly be h an d le d by a
of cruel a n d u n c o m p r o m i s in g d icta to rsh ip s th a t
skilled th e r a p ist in the initial in terv iew s w i t h
seem ed to be th e o rd e r of th e day. W h e n asked

h o w th is affected h im p ers o n ally , living as he
for his
co m pla ints.
These
an d
o th e r
out recourse to hypnosis. O cca sio na lly, th o u g h ,

even skillful a p p ro a c h e s do not resolve th e p a
ti e n ts resistance to accep ting help. At this
point, if the p a tie n t p e rm its ind uctio n, h y p
nosis m ay p rov id e a positive exp erien ce th a t
significantly a lte rs re c a lc itra n t attitu des.
F o r e x am p le, a p a tie n t w h o h a d great
did in a d e m o c ra tic regim e, h e sarcastically r e

plied th a t o ne could be a p ris o n e r even in a
d em o cracy . Since his fa th e r h a d died, he h a d
been obliged to ta k e over th e resp o n sib ility of
looking after his m o th e r. N o t only did she
resistance to p sy c h o th e ra p y w a s referred to me
by an in ternist. H e suffered from u r i n a r y fre
quency, w hich h a d defied all medical in te rv e n
m a n d e d an ac co u n t of all of his m ovem ents.

H e realized th a t she w a s a sick, frightene d
w o m a n a n d t h a t c o n seq u en tly it w as his d u ty
to devote him self to h e r com fort for h e r few r e
tio n a n d h a d b e c o m e so s e r io u s t h a t it
th re a te n e d his livelihood. H e resen ted being
sent to a psych iatrist a n d a n n o u n c e d to m e th a t
there w as no sense in s ta rtin g w h a t m ight
prove to be a lo ng an d costly process w h e n he
insist th a t he stay in h e r h o m e, but she also d e
m a i n in g years. T h e s e revelation s
t u r n i n g p o in t at w h ic h w e w e re able
o u r sessions in to e x p lo r a tio n s of his
c o n flicts. A s h e r e c o g n i z e d h is
w ere the
to convert
needs an d
rep ressed
192
hostility an d his tre m e n d o u s need for p e rs o n a l

f r e e d o m , he r e a l i z e d t h a t h e h i m s e l f w a s
tr e a tm e n ts ,
largely respo nsible for th e co ndition th a t w as

v irtua lly enslav in g him . It w a s then possible
for h im to h e lp his m o th e r find n ew friends
W h a t she w a n te d , she insisted, w as sufficient

relief from physical distress to en able h e r to
function at w o r k an d in h e r re la tio n s h ip w ith
an d to move into a re t ir e m e n t village. W h e n
h e r family. In light of h e r d i s a p p o in t m e n t w ith
u n s u c c e s s fu l
p a r t ic u l a r ly
in
view
p sych o th erap eu tic
of a
p ast
experience.
he resolved som e sources of his deep re s e n t
interview p sy c h o th e ra p y , I suggested hy p n o sis
m ents, his b la d d e r sy m p to m s d is a p p e a re d c o m
pletely. M o r e significant w a s a g r o w t h in
as a possible w a y of h e lp in g h e r to achieve
assertiveness a n d self-esteem th a t im p ro v e d th e
q u a lity of his social relatio n sh ip s.
When the Patient Refuses to

Begin Therapy Unless Assured of
Immediate Relief of Symptoms
som e lessening of h e r tr o u b le . She ag ree d to

give it a trial. T h e n ext five sessions w ere
sp en t in te a c h in g h e r h o w to re la x a n d h o w to
co ntrol h e r sy m p to m s. H e r resp on se w a s d r a
m atic, a n d h e r a ttitu d e t o w a r d m e c h a n g e d
from suspicion an d hostility to friendly c o o p e r
ativeness. S h e rea d ily e n te r e d into a t h e r a
p eu tic r e la tio n sh ip , a n d once t h e r a p y h ad
s ta rte d , th e r e w a s no need for f u r th e r h y p
S y m p to m s m a y be so u p se ttin g to th e p a
tien t th a t th e r a p y will be refused unless th e re
nosis.
is first a re d u ctio n o r rem o val of sym p to m s.
When the Patient has Such Deep

Problems in Relationships with
People that Therapy Cannot Get
Started
W h e n sy m p to m s a r e so severe th a t th ey create
physical em ergencies, as in cases of persisten t
vomiting, hiccup ing , o r p araly sis, th e th e r a p ist
m a y be able to resto re function th r o u g h s u g
gestions in hypnosis. After this the th e r a p ist
m a y p ro c e e d w i t h o t h e r p s y c h o t h e r a p e u t i c
te chn iqu es. In less severe cases, insistence on
sy m p to m a tic relief m a y be a tactic for d e m o n
stra tin g the th e r a p is t as a sy m p a th e tic p erson
A good w o r k in g re la tio n s h ip b etw een p a

tient an d th e r a p is t is m a n d a t o r y for an y kind
of p sy c h o th e ra p y . T h i s is p a r t ic u l a r ly essential
in th e r a p y th a t tries to b ri n g a b o u t m od ifica
concerned w ith the suffering of th e p a tie n t.
tion of a p e rs o n a lity th a t is p ro n e to anxiety.
H y p n o sis w ith suggestions a im e d at r e l a x a
T h i s typ e of p e rs o n a lity often feels g re a t stress
tion, tension co ntrol, an d s y m p to m re d u ctio n

can create an a tm o s p h e r e conducive to a t h e r a
peutic w o rk in g re latio n sh ip . H y p n o s is c an also
ex ped ite th e le a r n in g of n ew h a b it p a tt e r n s
th r o u g h dese nsitiz atio n an d re c o n d itio n in g (be
h av io r th erap y ).
A p a tie n t w h o cam e to m e w ith an o bses
sional neurosis co m p la in e d of belching a n d hic
w h e n th e th e r a p is t p ro b es for conflicts a n d
challeng es h a b it u a l defenses. W i t h som e sick
p a tie n ts th e p r o p e r w o rk in g r e l a ti o n s h ip m a y
n ever develop o r m a y ta k e m a n y m o n th s to a p
p e a r because of such factors as fear of closeness
or in ten se hostility to w a r d a u th o r ity . R e l a x a
tion d u r i n g h y p n o sis m a y resolve fears, re d u ce
hostility, a n d cu t d o w n th e tim e p e rio d r e
cu p in g after m eals. T h i s caused h e r g re at e m

b a rr a s s m e n t a n d fre q u en tly forced h e r to skip
q u ir e d for th e d e v e lo p m e n t of r a p p o r t. T h e p a
tient often feels a n e x tr a o r d i n a r y w a r m t h an d
meals. She w a s so p reoccu pied w ith w h e th e r

o r not h e r s y m p to m s w o u ld o v erw h elm h e r
th a t she could scarcely enjoy food w h e n invited
ou t to dine. H e r sy m p to m s forced h e r to seek
medical help, in the course of w h ich she w a s
referred to me. At th e initial in terview she
closeness to w a r d th e th e r a p is t even after only

on e or tw o h y p n o tic sessions. A th e r a p e u ti c r e
la tio n s h ip m a y crystallize u n d e r these c i r c u m
stances, a n d it will th e n be possible to proceed
te s ti ly p r o t e s t e d b e in g se n t for p s y c h i a t r i c
w ith p sy c h o th e ra p y w ith o u t hypnosis.

O n e of th e m ost severely d is tu rb e d p a tie n ts I
ever treated w as a p a ra n o id a l m an w ho
193
u p b ra id e d me d u r i n g o u r first session for m y
h a d a d r e a m a b o u t th e m ost w o n d erfu l th in g
delay in a r r a n g i n g a co n su ltatio n w ith him .
th a t could h a p p e n to a p e rs o n , he w ould
p ro b a b l y feel free from ten sio n as well as ex
H e w a s upset, h e said, because he w a s in

volved in litigious pro ceeding s a g a in s t his b u si
ness p a rt n e rs , w h o h a d p re s u m a b ly deceived
h im a b o u t th e ir business p ro spe cts w h e n they
first induced h im to bu y a sh a r e of th e c o m
p an y . A n o th e r legal case w a s p e n d in g a g a in s t
a n e ig h b o r w h o had in a lot a d jo in in g his
p erie n c e a g en e ra l state of p le a s u re th a t w ou ld
m a k e h im h a p p i e r t h a n he h a d ever been in his
life. A fter an in terval of 10 m in u te s he w as
b r o u g h t o u t of th e tran ce. U p o n o p e n in g his
eyes, h e revealed, w ith h u m o r , h a v in g had a
house built a g a ra g e th a t the p a tie n t co n
d r e a m of lying on a h a m m o c k w h ile lovely

slave girls circled a r o u n d h im w ith baskets of
sidered an eyesore. B ut w h a t he most desired
fruit. I suggested th a t he r e t u r n in 2 d a y s an d
from the co n su ltatio n w ith m e w a s to d e

te r m in e the feasibility of h y p n o tiz in g his wife
b ri n g his wife if she w ished to ac c o m p a n y him .
in o rd e r to o b ta in from h e r th e t r u th of h e r e x
act w h e re a b o u ts d u r i n g an ev enin g w h e n he
D u r i n g th e second session, w h ic h w a s held

j o i n t l y w ith his wife, his wife tea rfu lly p r o
claim ed h e r innocence, w h e r e u p o n the p atie n t
w a s o ut of to w n on business. H e h a d carefully
p e tu l a n tl y asked h e r to leave m y office if she
e x a m in e d h e r tu b e of con tra ceptive jelly before

his d e p a r t u r e a n d a g ain u p o n his r e t u r n . At
w a s going to act like a b a b y . W h e n she

p ro m ise d to con trol herself, he re q u es ted th a t
first he could see n o difference, bu t h e c o m p u l
she w a it for h im in th e recep tio n ro o m . H e
sively re tu rn e d to it, r u m i n a t i n g a b o u t w h e th e r
th e n told m e h e h a d felt so well since his first
he h a d not m a d e a m istake in his o rig in al co n

clusion a b o u t his w ifes innocence. F o r w eeks
he h a d been subjecting h e r to c ro s s -e x a m in a
visit th a t he h a d decided th a t several m o re
tions, carefully ta b u l a ti n g co n tra d ic to ry r e

m a r k s until he h a d convinced h im self th a t she
claim ed , un til he h a d healed his o w n n e rv e s .

A fter this in itia tio n into th e r a p y , he u n d e r w e n t
w as concealing th e t r u th a b o u t a ren d ezv o u s

w ith h e r lover. T h e p o o r w o m a n , p ro te s tin g
a n u m b e r of sessions of p s y c h o th e ra p y w ith
a n d w i t h o u t h y p n o s i s , d u r i n g w h ic h w e
sessions of h y p n o sis w o u ld be v a lu a b le for his

in s o m n ia . H is w ife s p ro b le m could w a it, he
h e r innocence fro m the start, h a d becom e so
w o rk e d on several p ro b le m s th a t concerned
confused by his c o n fro n tatio n th a t she des

pe ra te ly tried to m a k e u p stories to cover tiny
h im . H e e n d ed th e r a p y w h e n h e h a d achieved
discrepancies in h e r m in u te - b y - m i n u te a ccou nt
of his ten sio ns w ith his p a r t n e r s , a n d th e re e s

ta b lis h m e n t of a satisfactory r e la tio n s h ip w ith
his wife.
of activities on th e fatal evening. W i t h a s h a r p

eye for h e r inconsistencies, th e p a tie n t h a d
seized on h e r flou nd erin gs to t r a p h e r in to an
adm ission of lying, w h ich th e n convinced h im
all th e m o re of h e r infidelity. A firm believer in
the p o w ers of hyp no sis, he challenged h e r to
su b m it to a h y p n o tic reliving of th e even ing in
q uestio n in his presence.
U p o n finishing this accou nt, the p a ti e n t in
q u ire d a b o u t m y m eth o d s of tr a n c e ind uctio n
since he h a d been r e a d in g a b o u t the subject. I
vo lun teered to d e m o n s tra te th e h a n d -le v ita tio n
te ch n iq u e to h im , a n d he c autio usly ag re ed to
be a subject. Before too lo ng he en te re d in to a
tra n c e, d u r i n g w h ich I suggested th a t h e w o u ld
soon begin to feel m o r e relax ed , secure, an d
self-confident. If he vis ualized a h a p p y scene o r
a m a r k e d re d u c tio n of his sy m p to m s, a n easing
A n o th e r p a ti e n t s p en t th e first 3 m o n t h s of
t r e a tm e n t w ith m e in fruitless asso ciatio nal ex
plo ratio n s. H e p rote ste d th a t n o th i n g w as
h a p p e n i n g in re g a r d to his s y m p to m s or
a n y th i n g else. H e did no t h av e eith e r a
w a r m o r h ostile a tt it u d e t o w a r d p sy c h o th e r
a p y . H e a p p e a r e d to resent a n y c o n tin ued
q u e s tio n in g c o n c e rn in g his feelings a b o u t me.
T h e r e w a s a con sistent d e n ia l re actio n to my
in te rp re ta tio n s . A fter I in du ced h im to try h y p
nosis, he w a s a b le to achieve a m e d i u m trance.
F r o m th e very first h y p n o tic session his e n
th u s ia s m a n d e n e rg y in creased. H is activity
a n d p ro d u c tiv ity also im p ro v ed r e m a rk a b l y ,
a n d w e w e re a b le to achieve a good th e r a p e u tic
194
result. W it h o u t hypnosis, I a m convinced th a t

his d e ta c h m e n t could not have been p e n e
trated .
a n x ie ty but, n evertheless, agreed to try. D u r

ing th e process of d e ep e n in g th e tr a n c e she
su d d e n ly b ro k e d o w n a n d cried fitfully. E n
c o u ra g e d to discuss w h a t she felt, she clenched
When the Patient is Unable to

Verbalize Freely
h e r fists a n d shriek ed , N o , n o ! A fter e x p lo d

ing into a c o u g h in g spell, d u r i n g w h ic h she
could h a rd ly catch h e r b re a t h , she gasped over
an d over th a t sh e w a s c hoking. At m y sugges
W h e n c o m m u n ic a tio n is blocked, th e r e can

be no th e r a p y . S o m etim es th e u su al u n b loc kin g
tion th a t she b rin g it u p , she b ro k e into a
techn iq ue s m a y fail to re sto re verbal c o m m u n i

cation. In such an event hy p n o sis can often be
s h i t rep e a te d ly a n d s p ittin g w ith a n g ry e x

citem en t. A few m in u te s of this frenzied be
effective, a lth o u g h the w a y in w hich it is used
h a v io r w ere followed by c o m p la in ts of e x h a u s
will d ep en d on the causes of the difficulty. T h e
ti o n .
m ere induction of a tran ce m ay un co rk e x p lo

sive em o tion s ag ain st w h ich the p a tie n t h ad
speech, w h ich co n tin u e d for the r e m a in d e r of
defended by refusing to talk in th e w a k in g
T h i s p e rf o rm a n c e w a s re p e a te d in s u b s e q u e n t
to r re n t of foul lan g u a g e , p ro n o u n c i n g th e w o rd
T hereupon
sh e
reso rted
to
norm al
the session, even after she h a d been aro u sed .
state. C a t h a r t i c release in th e tr a n c e m a y re
sessions, a lt h o u g h th e p a tie n t re s p o n d ed w ith
store n o rm a l v erbal expression. If th e p a t i e n t s

silence is du e to some resistance, it m ay be p o s
d i m i n i s h e d f u r y . T h e t h e r a p e u t i c p ro c e s s
gained g re a t m o m e n tu m , an d th e young
sible to exp lo re an d resolve it by e n c o u ra g in g

the p a tie n t to talk d u r i n g hypnosis. In speech
p a ra ly sis ( a p h o n ia ) re s u ltin g from hy steria
w o m a n w a s ab le to c u rb h e r s t a m m e r . T h e e x
perien ce o p en ed th e d o o r to a discussion of her
g re a t concern over bow el activities. T h i s w a s
these tec h n iq u es m ay not suffice, a n d direct
related to ex tre m e ly rigid toilet tr a in i n g as a
suggestion m ay be needed to lessen o r e lim i
child by an obsessive, o v erd iscip lin ary m o th e r
n a te the sy m p to m . Speech d iso rd ers m a y be

trea ted an d so m etim es helped by lessening t e n
w h o m a d e h e r feel gu ilty a n d frigh tene d ab o u t

toilet activities. Feces, fro m e arly c h ild ho od on,
sion d u r i n g the tran ce, an d th ere m a y th e n be

a carry o v er into th e w a k in g state. W h e n the
w ere e q u a te d w ith poison an d destru ctio n . O u r

th e r a p e u ti c sessions w ere largely concerned
speech difficulty is caused by needs th a t forbid

th e e xpression of painful sou nd s o r ideas, an
w ith clarifying h e r m isconceptions. As she d e

veloped a m o r e w h o leso m e a ttitu d e t o w a r d h er
bow el fu nctio ns, h e r g en era l feelings a b o u t
explosive o u tb u r s t d u r i n g hypn osis m a y not

only release the capacity to talk freely, bu t will
also open u p a re a s of conflict th a t can be b en e
ficially explored.
A y ou ng w o m a n , a severe sta m m e re r, cam e
for th e r a p y because of in c a p a c ita tin g p hob ias.
O n c e she h a d established r a p p o r t w ith m e, she
e x p r e s s e d h e r s e l f s a t is f a c to r ily , b u t a s w e
began to e x a m in e h e r fantasies and d re a m s ,
she experienced so p ro n o u n c e d a relap se in h er
sp e e c h d i s t u r b a n c e t h a t sh e w a s a lm o s t
in articu late. She c o m p lain ed th a t w h ile she
could talk better t h a n ever before w ith h er
friends, she could scarcely co m m u n ic a te w ith
me. Since p ro g re ss h a d come to a halt, I su g
gested hyp no sis as a w a y of h e lp in g h e r to
relax. She reacted to this suggestion w ith
herself im p ro v ed ,
and
her
speech difficulty
pra ctica lly d is a p p e a re d .
When During Therapy the Patient

is Unable to Engage in
Unrestricted Exploration
A p a ti e n t m a y m a i n ta i n rigid con trol w h e n
he d re a d s psychological a re a s of conflict th a t
m a y be e xposed. H e th u s c a n n o t p e r m it his
ideas to e m e rg e freely an d u n re s tr a i n e d ly in
the process of e x p lo r in g u n g u a r d e d aspects of
his psyche. W h e n the p a ti e n t is blocked be
cause of resistance, hy p n o sis m a y be a possible
solution. N o t on ly m a y it b rin g the p a ti e n t into

contact w ith repressed e m o tio n s an d th o u g h ts,
but it also m ay h e lp h im to a n a ly z e his blocks.
195
T h e im p ro v e m e n t sh o w n by one of m y p a
tients illu strates h ow v a lu a b le h y p n o tic d re a m
T h i s w as tr u e of a p a tie n t w h o h a d re tre a te d
in du ctio n can be. T h e p a tie n t ca m e to me for
to a highly stru c tu re d a n d rigidly directed form
p sy c h o th e ra p y w h e n he could find no relief for
of verbal e xpression. A tte m p ts to a n a ly z e his

loss of sp o n ta n e ity p ro d u ced little response.
After flo und ering , w ith no im p ro v e m e n t and
severe rectal itching. H e h a d tried every kind

of m ed icinal o ral and injection tr e a tm e n t. A l
th o u g h we soon established a good w o rk in g re
m ere repetitio n of insignificant items, I in
la tio n s h ip , he w a s u n a b le to r e m e m b e r his
duced hypnosis a n d en co u ra g e d the p a ti e n t to

talk a b o u t w h a t really w a s b o th e r in g h im . H e
d re a m s. In th e tr a n c e I suggested th a t he
w o u ld have a d r e a m th a t w o u ld e x p la in his
rectal itching. H e res p o n d e d w ith an an x iety
revealed th a t he h a d felt g uilty in th e p a st few

weeks for h av in g m a s tu r b a t e d in m y office
d r e a m of a m a n w ith a h u g e pen is a p p r o a c h i n g
b a th r o o m after one of o u r sessions. H e h a d not
h im from th e re a r . H e w a s told to forget the
w a n te d to tell m e a b o u t this incident because
d r e a m o r recall a n y p a r t of it th a t he w ish ed to
he k new it w a s n ot an a d u lt act. H e th e n asso

ciated this action w ith h av in g been c a u g h t as a
re m e m b e r after he h a d a w a k e n e d . U p o n o p e n
child m a s tu r b a t in g in his a u n t s b a th r o o m .
N o t o n ly h a d he b e e n r e p r i m a n d e d a n d
w a rn e d by his a u n t, bu t also his p a r e n t s h a d
p ro m p tl y been told, T h e p h y sic ian w h o r e
ing his eyes, he co m p la in e d -of tension, b ut he

did not r e m e m b e r his d re a m . H e a d m itted
so m e relief in his rectal itching. T h a t sam e
nig ht he h a d a d r e a m of rid in g a ro ller coaster
w ith a m a le friend. H is d r e a m suggested c o n
ferred th e p a tie n t to m e also frow ned on his
cerns ab o u t h o m o s e x u a lity . In la ter d r e a m s he
m a s tu r b a t o r y practices, classifying m a s t u r b a
tion as id io ts delight, w hich is n ever in
w a s able to c o u n te n a n c e h o m o s e x u a l im pu lses
dulged in by a m a t u r e p e r s o n . R e assu re d by
n o sis w a s r e s p o n s i b l e for o p e n i n g u p a
re pressed a n d r e p u d i a te d a r e a of guilt a n d co n
my h a n d lin g of these revelations, th e p a tie n t

w as able to c o n tin u e w ith his associations in
a n d to discuss th e m d u r i n g th e session. H y p
flict.
the w a k in g state.
In in stances w h e re th e r e is a d e a r t h of
d r e a m m a te ria l the p a tie n t m a y be tr a in e d to
d re a m in the tra n c e o r t h r o u g h p o sth y p n o tic
su g g e s tio n s d u r i n g n o r m a l slee p . G e n e r a l
topics of specific topics m a y be suggested as th e
d re a m content. O n c e this process is s ta rte d , it
m a y be possible for th e p a tie n t to c o n tin u e
When the Patient Seems Blocked

in Transferring to the Therapist
Distorted Attitudes toward
Parental and Other Early Figures of
Authority
d re a m in g w ith o u t hy pnosis. H y p n o s is can also

be u sed to r e s t o r e f o r g o t t e n e l e m e n t s of
d re a m s, to clarify d istortion s e la b o r a te d to d is
guise th eir m e a n in g (secondary elab o ra tio n s),
an d to help the p a tie n t exp lo re by m e a n s of
d re a m s attitu d e s to w a r d p eop le an d d is tu rb in g
elem ents in ev ery day life. D u r i n g hy p n o sis
s p o n t a n e o u s d r e a m s m a y o c c u r r e f le c t in g
unconscious a ttitu d e s, m em o ries, em o tio n s,
an d conflicts. S o m etim es th ey reveal to th e p a
tient the m e a n in g of th e im m e d ia te hy p n o tic
experience as well as dis to rtio n s in r e la tio n s h ip
w ith the th e r a p ist, caused by co nfusing the
th e r a p ist w ith early a u th o r it y figures.
C h ild h o o d experiences, p a rtic u la rly re la

tio n sh ip s w ith p a re n t s a n d siblings, by th eir
fo rm ative in fluence on attitu d e s, values, feel
ings, an d b e h a v io r leave an indelible im p rin t
a n d affect the w a y th e a d u lt res p o n d s not only
to o th e r peo ple b u t also to oneself. B ecause
som e of th e most i m p o r t a n t fo rm ative e x p e r i
ences a r e fo rg otten, o r r e m a in h azy , o r a re
dissociated fro m th e fears a n d an xieties w ith
w h ich th ey w e r e o rig in a lly link ed, they subversively in fluence fau lty w ays of th in k in g a n d a c t
ing. Som e of th e tra n sfe re n c e d is to rtio n s m a y be
uncovered by h y p n o sis, a n d th e i r in t e rp re ta ti o n
196
m a y b rin g the p a tie n t to a re a liz a tio n th a t he
tigh tly did she squ eeze h e r th ig h s to g e th e r th a t
also res p o n d s in destructive a n d u n n e c e ss a ry
they ached w h e n she em erg ed fro m th e tran ce.
w a y s in m a n y o th e r situation s. T h e lesson
learn ed can serve as the basis of new , m o re
w h ole so m e a ttitu d e s to p re s e n t-d a y a u th o r ity ,
a ttitu d e s th a t fo r tu n a te ly will in all likelihood
m a k e life m o r e c om fo rta b le a n d productive.
A p atie n t w h o ca m e for t h e r a p y en tered
easily into the h yp n o tic state bu t becam e m o re
an d m o re re c a lc itra n t to suggestions. H e h a d
Before th e next in d u c tio n I in s tru cted h e r to

keep h e r legs s e p a r a te d . As I p roceeded w ith
suggestions, she b ecam e flushed, o p en ed h e r
eyes, a n d ex claim ed th a t she k n ew w h a t w a s
u p se ttin g h er. I re m in d e d h e r of h e r g r a n d
fath er, she said, w h o , w h e n she w a s a sm all
child, h a d tossed h e r into bed a n d held he r
close to his body on several occasions. She h ad
alw a y s been subm issive to his fath e r (and later
felt his erect p en is a g a in s t h e r body, a n d this
to o th e r m a le au th o ritie s). A lo ng w ith th is he

felt g reat in n e r rag e, tu r m o il, a n d d epression ,
alth o u g h he w a s o u tw a r d l y calm . It seem ed to
h a d bo th excited a n d frig htene d her. It becam e

a p p a r e n t th a t th e h y p n o tic e x p erien ce r e p r e
m e th a t his e n te r in g h yp n o sis w a s a m e a n s of
pleasin g me. T h i s w a s th e c u s to m a ry role
h o p e d for a n d feared sexual seduction. H e r leg
w ith m ale a u th o r it y , p a tt e r n e d after the w ay
C o n ti n u e d tr a n c e in d u ctio n s w ith th e p a tie n t

d im in ish e d h e r fears, a n d she th e n rev ealed be
he reacted to his father. F o r years, I h ated
sented for h e r a n episode d u r i n g w h ic h she

crossing w a s a defense a g a in s t these fantasies.
m y f a t h e r , he said. H e c o u ld n t stan d being
ing ab le to h av e b e tter sexual re la tio n s w ith
contradicted. I re m e m b e r n eed in g to lose at
her husband.
A n o th e r p a ti e n t, w h o suffered from period ic
card s delib erately so th a t fa th e r w o u ld n ot get

upset over m y w in n in g . I a m never ab le to be
atta c k s of n a u s e a , vom iting , a n d g a s t ro in t e s t i
successful: it m ak es m e too a n x i o u s . W h e n I
nal crises, w a s referred for hy p n o sis after tw o
in te rp re te d to h im th e w a y th a t he w a s r e a c t
ing to me, he at first denied it. B ut th e n he a p
y ears of tr a d it io n a l p sy ch o an aly sis h a d failed

to relieve h e r sy m p to m s. B ecause she ten d ed to
shield h erself fro m a w a r e n e s s of he r p ro b le m s
p eared to see th e light, w ith th e resu lt th a t he

challenged m e first by resisting hy p n o sis a n d
finally by m an ifesting a total inab ility to e n te r
the h y p no tic state, I accepted his refusal to
com ply, even en c o u ra g e d it. At this p h a s e the
p a tie n t ex perienced d r e a m s of tr iu m p h . I t s
h e a lth ie r to d r e a m of feeling love r a t h e r th a n
h ate. F o r th e first tim e, I realize I loved m y
fath er. I cried in m y sleep. I felt m y fath er
really loved me, b ut we h ad this wall betw een
us. I aw o k e feeling I really loved h i m . T h i s
ch an g e in feeling w as a c c o m p a n ie d by an
a b a te m e n t of sy m p to m s an d a cap acity to
relate m ore cooperatively. Soon th e p a tie n t
w a s ab le to e n te r hypn osis easily an d w ith o u t
re s e n tm e n t, as a m e a n s of p leasin g him self
not me.
A n o th e r p a tie n t, e x p e rie n c in g frigidity, w as
referred to m e by h e r p sy ch o a n a ly st for some
hy p n o tic w o rk . After the th ird in du ctio n she
told m e th a t she felt th e need to keep h e r legs
crossed d u r i n g the en tire tra n c e state. So
w ith
stro n g
rep ressio n s,
I felt
th a t
tran s
ference, w h ich h a d n ot developed significantly

d u r i n g h e r p re vio us t h e r a p y , m ig h t be i m p o r
ta n t in h e lp in g h e r to g ain insig ht into h e r
p ro b lem s. A fter she h a d been tr a in e d to e n te r a
m e d i u m tra n c e , I suggested th a t she w ou ld
d r e a m of h e r feelings a b o u t m e. She failed to
d r e a m ; in stead she h a d a h a llu c in a tio n consist
ing of a p e c u lia r taste in h e r m o u t h , w h ic h she
described as b it te r s w e e t. T h i s tas te persisted
for several h o u r s after h e r session. T h a t e v e n
ing she h a d a n i g h t m a r is h d r e a m in w h ic h a
w o m a n , w h o se h a n d b a g bo re th e in itials B.S.,
took a sm all boy into the b a t h r o o m to h e lp h im
to u r i n a te a n d w a s h up. S h e w a s u n a b le to in
te r p re t th e d r e a m . A tr a n c e
w h ich she recalled fo rg otten
d r e a m , n a m e ly th a t th e sexes
tic ip a n ts h a d c h a n g e d as they
b a th r o o m ; th e a d u lt h a d been
a girl. T h e n ex t few sessions
w a s in d u c ed in
elem ents o f the
of th e tw o p a r
h a d e n te re d the
a m a n , th e child
w ere s p en t d is

cussing a r e a c t io n to m e th a t the p a ti e n t h ad
197
th a t m a d e h e r w a n t to stop
h a v io r adversely. T h e tr a n c e can be i n s t r u m e n
tal in recalling the repressed ex perience, an d
tr e a tm e n t. She w a s positive th a t I resented her,

an d she reco un ted several m in o r incidents in d i
th e e x a m i n a ti o n of the associate d em o tio n s

h elps to e lim in a te d eb ilita tin g sy m p to m s.
developed an d
catin g to h e r th a t I did not have h e r best i n t e r

ests at he art. S h e w as positive th a t I p re fe rred
a y o u n g m a n w h o se sessions preceded h e rs be
O n e p a tie n t suffered from p erio dic atta c k s of

sh o rtn ess of b re a t h , a n affliction th a t r e s e m
bled a s th m a . H e w a s given a su ggestion in
cause I once h a d kept h im late, th u s o v e r l a p
h y p n o sis th a t he w o u ld r e t u r n (regress) to his
p in g h er time.
first attack. In a scene in w h ic h he saw him self

as a child of 3 sta n d in g in a sno w drift on a
In the tr a n c e th a t followed, she b ro k e into

hysterical crying, identifying me as h e r father,
back po rch , he described h ow he slip ped an d
w h ose n ic k n a m e w as Bing. ( T h e in itials B.S.
fell into a h ig h sn ow drift, g a s p in g for b re a th as
in th e d re a m stood for Bing. H is last n a m e
th e
began w ith an S. B.S. a p p a r e n t l y w a s linked
p a n ic , ch o k in g as he talked , he told of being

rescued by his m o t h e r an d fath er. T h i s story
to the b it te r s w e e t taste she h a d in h e r

h allu c in a tio n .) H e h ad been both fa th e r an d
m o th e r to h e r (c han ged from m a le to fem ale in
sn ow
filled his nose a n d
th r o a t.
W it h
w a s verified by his p a r e n t s as a tr u e e x p e r i
ence. T h e y w e re a m a z e d th a t th e p a tie n t re
the d re a m ), h a d p re fe rred h e r b r o t h e r to her
m e m b e re d th e exact details o f th e accident, and
(h er reaction to th e m a le p a tie n t w ho se h o u r
th e y confirm ed th a t a s t h m a t i c attack s h ad
preceded hers), a n d had a lw a y s re m in d e d h er

th a t he re grette d th a t she h a d not been b o rn a
b eg u n soon a fter this in cident. It w a s th e n es

ta b lis h e d in t h e r a p y th a t in te rp e r s o n a l s i tu a
boy (her being b r o u g h t into th e b a th r o o m as a
ti on s in w h ic h th e p a tie n t felt t r a p p e d caused
boy in th e d r e a m possibly indicated th a t she

h a d finally succeeded in a chieving a m a s c u lin e
h im to resp o n d w ith th e s y m p to m of cho kin g

for b re a th . T h i s p a tt e r n h a d o rig in a lly been es
tablishe d w h e n h e a c tu a lly h a d been physically
statu s). T h e r e a f t e r , she e xp erie nce d stro n g sex

ual feelings to w a r d m e a n d s h a m e fu lly ask ed if
I did not h ave a preference for h e r a m o n g all
t r a p p e d . W i t h this re cog nition , th e s y m p to m

w a s m a r k e d ly alleviated.
m y o th e r patien ts. F r o m th e n on it w a s possi

ble to a n a ly z e th e origin s of th ese feelings in
h e r relatio ns w ith h e r fath e r an d to see th a t
som e of h e r s y m p to m s w ere associate d w ith
fantasies of w a n tin g to be a boy th r o u g h a c
q u ir in g a penis. H y p n o s is succeeded r a p i d ly in
a llo w in g us to u n d e r s ta n d w h a t w as b eh in d
When the Patient Seems to "D ry

U p" in Conversations, Being
Unable to Produce Any More
Significant Material
h e r difficulty.
P erio d s of resistan ce m a y develop d u r i n g the
When the Patient has Forgotten

Certain Traumatic Memories
Whose Recall May Help the
Therapeutic Process
In some
sub m erged .
to come to
sy m p to m s,
em o tio n al states m em o ries m a y be

B ecause th ey co n stan tly th r e a te n
the surface, a n x ie ty an d defensive
w h ich bolster rep ressio n , affect b e
co urse of t h e r a p y c h a ra c te riz e d by an alm o st

co m p le te cessation of activity. T h e p a tie n t will
spen d m a n y sessions in fruitless a tt e m p t s at
co n v ersatio n ; he seem s to be u p a g a in s t a b a r
r ie r th a t he c a n n o t b re a k t h r o u g h . A ttitu d e s of
d i s a p p o in t m e n t an d hopelessness c o n tr ib u te to
his in e rtia un til he resigns him self to m a k in g
no f u r th e r efforts. H e m a y even decide to
a b a n d o n th e r a p y . W h e n such circu m stan c es
th r e a te n , h y p n o sis m a y be tried to m obilize
pro du ctivity . A variety of te c h n iq u e s m ay be
198
used, in clu d in g v e rb alizin g o n e 's th o u g h ts

w ith o u t
restrain t
(free a s s o c i a t i o n )
in th e
tran ce, d re a m a n d fantasy stim u la tio n , m i r r o r
herself w as ab le to in te rp re t th e tran sferen ce to

m e of h e r feelings for h e r father. F r o m th e n on
she prog ressed satisfactorily in tr e a tm e n t.
ga zin g , a u to m a tic w ritin g , play th e r a p y , d r a

m atic acting, regression and reliving (revivifi
cation ), an d the p ro d u ctio n of e x p e rim e n ta l
conflicts (W o lb erg , 1964). T h e specific m etho d
em ployed is u su ally d e te r m in e d by th e t h e r a
p is ts ex pe rie nce an d p reference as well as by
th e p a t i e n t s a p titu d e s in w o rk in g w ith o ne or
a n o th e r techn iq ue.
A p atien t w h o had been w o rk in g satisfac
When the Patient is Unable to

Deal with Forces that Block the
Transformation of Insight into
Action
The
m e re d e v e lo p m e n t of in sigh t
is not
to rily w ith m e began to develop silences th a t

greatly puzzled h e r since she had u p to this
e n o u g h to in s u re th e correction of n e u ro tic a t
tim e been q u ite g a rr u lo u s in h e r ram b lin g s.

W h e n I try to th in k , my m ind goes b l a n k ,
t o w a r d c o n s t r u c t i v e a c ti o n . U n f o r t u n a t e l y ,
th e r e a re often a nx ieties an d resistances th a t
she said. N o th in g comes to m e . A fter several
o b stru c t this process an d b rin g th e r a p y to an
f r u s tr a tin g sessions, h ypnosis w a s induced, a nd
in com plete end. H y p n o s is is som etim es useful
titu d es
an d
p a tt e rn s ;
it m u s t
be em ployed
she w a s enco u rag ed to talk a b o u t h e r m ental
in c o nv erting insightful p erc ep tio n into action,
m ea n d e rin g s . S h e began to m o a n an d cry.

G rief, grief. I t s all d e a t h as if its all over.
an d it can achieve this goal in a n u m b e r of

w ays. F irst, o ne m a y a tt e m p t by vario u s te c h
n iq u e s to e x p lo r e resistance to ch a n g e, the p a
I t s m y father; he died of cancer, a n d I took

care of him . H e keeps co m in g back. It chokes
tien t asso ciatin g to fantasies o r the d r a m a ti c
me up. I t s as if its all h a p p e n in g a g a i n . T h e
a c tin g -o u t of ce rta in h e a lth y courses of action.
pa tien t th en revealed, ex p re s sin g g reat feelings
Second, p o sth y p n o tic su ggestions can be m a d e
of guilt, th a t w hile she had nu rse d h e r father
to the effect th a t the p a tie n t will w a n t m ore
d u r i n g his illness, she h ad exp erien ced ten d er
an d m o re to e ng age in actions th a t a re neces
a n d th en v o lu p tu o u s feelings for him . D u r i n g
sary an d th a t a re being resisted. T h i r d , role

p la y in g can be used, th e p a tie n t d r a m a ti z in g
his illness she w as able to have h im all to

too w illing to let h er ta k e c a re of him . Sexual
v ario u s situ a tio n s in the p re s e n t o r fu tu re and

v e rb a liz in g insights or fears to the th e ra p ist.
excitem ent w as stro n g d u r i n g this perio d, a nd

she h a rb o r e d guilt feelings d u r i n g a n d after her
f a t h e r s d ea th , scarcely d a r i n g to th i n k a b o u t
it. I'm frightened. I k no w I felt guilty about
tal conflicts m a y be set u p to test the p a t i e n t s

r ea d in e ss to ex ecute necessary an d desirab le
acts a n d to investigate re a ctio n s to th e ir c o m
my desire to be close to m y father. After he

died, I felt cold an d d etach ed. M a y b e th a t is
w h y I c a n 't feel a n y th i n g for men now . I
pletion.
O n e of m y p a tie n ts , a m a n w ith a passive
p e rs o n a lity , h a d g ain ed in sig ht into som e of
realize I do this w ith all m en, th a t is, I w a n t to

baby them , take care of them . I h a d been t a k
ing care of one m a n I kn ow w h o got sick w ith
the ro ots of his p ro b le m d u r i n g t h e r a p y ; he

also realized th e destructive c on se qu enc es of
his failu re to be self-assertive. H e w a n te d to
ch a n g e but w a s p a ra ly z e d at k n o w in g h ow to
begin. T h e best he could do w as to fa ntasiz e
h erself for the first time. H e r m o th e r w a s only
the flu. I s p o n g e-b ath ed h im an d got so sex

ually excited I could h a rd ly stan d it. T h e
th o u g h t occurs to me th a t I w o uld like to take
F o u r t h , in s o m n a m b u lis tic subjects e x p e r i m e n
care of you too. I'm so a s h a m e d to talk ab ou t

t h i s . F ro m this the patien t stated she u n d e r
w a lk in g into his e m p l o y e r s office a n d boldly

ask in g for a p r o m o tio n . In his fan tasy he w as
re w a rd e d w ith a h ig h e r position a n d a h a n d
stood the reason for her guilt feelings an d w hy

they w ere cau sin g resistance to th e r a p y . She
so m e raise in salary . But. he could not m u s te r

the co u ra g e to face his e m p lo y e r in real life.

an d he expressed fears of bein g tu r n e d do w n .
199
In h y pn otic role p la y in g he took the p a r t both
n a tio n . In terv als b etw een visits w ith the t h e r a

pist a re g ra d u a l ly p rolon ged . In the b eg in n in g
of h im self a n d his e m p lo y e r a n d v e h em e n tly
th e p a tie n t m a y reso rt to d a ily sessions of self
discussed th e p ro s an d cons of his position.
hy p n o sis b ecause of anx iety . B u t as m o re con

fidence is developed in th e ability to survive
H o w ev er, he still could not get him self to act.

Since he w as ab le to develop p o sth y p n o tic a m
nesia, I decided to try to set u p an e x p e r i m e n
tal conflict. I suggested th a t he im ag in e h im self
askin g for a p ro m o tio n . T h e n I told h im to
forget th e suggestion b ut, u p o n e m e rg in g from
the tran ce, to feel as if he h a d actua lly m a d e
the requ est. T h e first tw o a tt e m p t s w e re fol
lowed by tension, h ead a ch es, an d d is c o u ra g e
alone, self-hypnosis exercises become ir re g u la r,

an d finally th ey a re reso rted to on ly w h e n t e n
sions cry for relief. In m a n y p a tie n ts , how ever,
r e g u l a r re la x a tio n exercises a re a n i m p o r t a n t
p a r t of a d ju s tm e n t a n d m a y be p ro lo n g e d in
definitely w ith beneficial effect. In this respect
a re la x in g a n d e go -bu ild ing cassette ta p e m ay
be of help.
ment. T h i s indicated th a t th e p a ti e n t w as not

yet p re p a r e d to take the necessary step for
T h e situ a tio n s just described a re no m ore
w a rd . W e , no netheless, c o ntinu ed discussion
t h a n b rief o u tlin es of h ow h yp n o sis m a y be ef
an d role p laying , a n d a th i r d e x p e rim e n ta l
fective in p s y c h o t h e ra p y a n d only suggest the
situ ation resulted in a feeling of elation a n d a c
v a rio u s w ay s in w h ich th e tr a n c e can be used as
co m p lish m e n t. T h e next d ay th e p a tie n t s p o n
a n a d jun ctive c a ta ly z in g p ro c e d u r e . Since all
taneo usly a p p ro a c h e d his em p lo y e r a n d w a s

re w a rd e d w ith success. T h e r e a f t e r the p a tie n t
p sy c h o th e ra p y is a blend of th e t h e r a p i s t s in d i
began to act w ith m o re a ss u ra n c e , a n d his

pro gress in th e r a p y helped h im to become
ap is ts will o p e r a t e identically. E a c h th e r a p is t
m o re positive in his g eneral behavior.
becom e n e u ro tic a lly ill a n d h o w they get well

ag ain . If a th e r a p is t believes th a t unco nscio us
When the Patient has Problems in

Terminating Therapy
ro tic ailm e nts, digg ing will be in du lg ed to u n

cover the em o tio n a l conflictual poiso n t h a t has
vidual p e rs o n a lity a n d te c h n iq u e s, no tw o t h e r
h a s a p a r t ic u l a r p h ilo so p h y a b o u t ho w peo ple
m em o ries an d conflicts a r e th e basis for all n e u
Difficulties in en d in g t h e r a p y a re som etim es

e xperienced by p a tie n ts w ho , h a v in g been freed
of n eu ro tic sym p to m s, a re afra id of losing w h a t
they
have
gain ed
an d
suffering
acc u m u la te d . O n c e it is released, the psyche

will p re s u m a b ly heal. F r e u d a n d B re u e r o rig i
n ally used h y p n o sis in th is w a y a n d scored
occasional success w ith som e p atie n ts . T h e y
recorded
th eir
findings
in
S tu d ie n
uber
relapse.
H y s te n e , th e re v o lu tio n a ry book th a t w as a
P a tie n ts w ith d e p e n d e n t p e rs o n a litie s m ay

resist en d in g tr e a tm e n t w ith a sto u n d in g s t u b
p r e c u r s o r of p s y ch o an aly tic th eories a n d m e t h
bornness. C o n t r a r y to w h a t m igh t be expected,

the ad ro it a p p lic a tio n of h yp n o sis can help
some of these p a tie n ts t o w a r d self-reliance by
relieving th e ir tension at p o in ts w h e re th ey try
to act ind ep en d e n tly . T h e p a tie n t m a y also be
ta u g h t self-hypnosis for p u rp o s e s of re la x a tio n
an d sho w n how to in vestigate s p o n t a n e o u s ly
th r o u g h d re a m s , fantasie s, a n d asso ciatio ns
the pro b lem s th a t arise daily from d e m a n d s to
a d ju s t to sp ecific s i t u a t i o n s . In th i s w a y
r e s p o n s i b i l i t y is t r a n s f e r r e d to th e p a t i e n t
to w a rd becom ing m o re ca p a b le of self-d eterm i
ods. A lth o u g h h y p n o sis used in th is w a y m a y be

in s tr u m e n ta l in re leasin g repressed m em o ries,
w e n o w k n o w t h a t the m a jo rity of p a tie n ts are
not helped by th is process alone. In te re stin g
a n d d r a m a ti c as a r e the results, ad d itio n a l tech
n iq u e s a r e n ecessary if w e a r e to achieve lasting
benefit.
T h e r e a re o t h e r th e r a p is ts w h ose theories
a b o u t how p eo ple becom e e m o tio n a lly ill in
volve th e concepts of faulty le a r n in g an d c o n d i
tion in g. T h e y use hy p n o sis to reinforce th eir
stra te g e m s of teac h in g th e ir p a tie n ts new p a t
te r n s of h a b it fo rm a tio n , th in k in g , a n d action.
200
A lthough
these b e h a v io r a l m eth o d s are
to a m a l g a m a t e h yp n o sis w ith o n e s p e rs o n a lity
respo nsib le for co nsid erable pro g ress in the
an d technical tra in in g .
tr e a tm e n t of som e ailm en ts, th ey a r e not suc

B ut
It sho uld be stressed a g a in th a t h y p n o sis a n d

an y o th e r ca ta ly z in g te c h n iq u e m u st be used
O n e of the most i m p o r t a n t po in ts to be
intelligently w ith in the co ntex t of a c o m p r e

hensive t r e a tm e n t p la n an d w ith d ue re g a r d for
cessful in d ealin g w ith all problem s.

n eith e r is an y o t h e r tech n iqu e.
m a d e abo ut h yp n o sis is th a t it can be helpful

as a catalyst irrespective of th e m e th o d of psy
li m i t a t i o n s .
c h o th e ra p y . S o m e th e r a p is ts a r e not able to use
p u rp o s e , bu t th e i r ineffectiveness tend s to dis

credit th e m as w o r th w h il e p ro c e d u re s a n d to
hyp no sis w ith a n y m e a s u re of success, eith er

for pe rs o n ality reason s o r because of u n -
A p p lied
in d iscrim in ately
su c h
tech n iq u e s not o nly fail to serve a th e r a p e u tic
im p e d e
th eir
acceptance.
U sed
at
strategic
resolvable prejudices. T h i s does not in valid ate
p o in ts in p s y c h o th e ra p y , c ata ly z in g m eth o d s
h yp n o sis as a proce dure. H y p n o sis , like a n y
m a y facilitate progress. In this w ay th ey can
o th e r a re a of sp ecializatio n, re q u ire s p a r t ic u l a r
abilities a n d skills. N o t every th e r a p ist is able
add an im p o r t a n t d im en sio n to th e technical

skills of the psy ch o th era p ist.
Case Illustration
T h e f o l lo w in g is th e f o u r t h t h e r a p e u t i c
ev ery se nse of t h e w o r d , w h o re a lly b e h a v e d as
session w ith a m ale p a tie n t w h o ca m e to t r e a t
o n e, t h a t m a n y of h e r difficu lties a n d h ostilities
m e n t because of w o rk p ro b le m s an d terrify in g
n i g h t m a r e s of w h ic h th e p a t i e n t h a d no
T h . If sh e m a r r i e d a m a n ? [O b v io u sly th e p a tie n t
m em o ry . T h e s e con ditio ns h a d existed for

several years, a n d after a period of p s y c h o t h e r
P t.
w o u l d be erase d .
h a s d o u b ts a b o u t h is m a s c u lin ity .]
a p y w ith a p sy ch o an aly st in th e M i d w e s t, he
h a d derived som e benefit from th e sessions.
H o w ev er, he w a s u n a b le to r e m e m b e r any
If sh e h a d m a r r i e d a m a n y o u k n o w w h a t I
m e a n a forceful g u y w h o re a l l y r a n t h e roost
a n d h e r , w h o , well {pause).
T h . Yo u m e a n , sh e w o u l d t h e n s t r a i g h t e n o u t ?
P t.
Yes
d r e a m s or to associate freely. T h e session th a t

follows is the first one d u r i n g w h ich hypn osis
T h . So t h a t t h e e m p h a s i s w o u l d be on w h e t h e r you
w a s em ployed. It illu strates th e use of variou s

tec h n iq u es in h y p n o a n a ly s is for the p u rp o s e of
exp osin g a d y n a m ic focus.
P t.
w o u l d like to be t h is k i n d of gu y . W o u l d y o u ?
guy?
P t.
P t.
I a m in g o od s h a p e to d a y , really, for no p a r t i c
C e r t a i n l y . W e l l , I d o n t sa y t h a t a m a n h a s to
b e I d o n t m e a n he h a s to be b r u t i s h o r s t u b
u l a r r e a s o n t h a t I can t h i n k of, a n d y e s t e rd a y I
b o r n o r in se n sitive o r u n i n t e l l i g e n t o r d ull. I
d i d n t feel so good. I h a d a fight w i t h m y wife
d o n t t h i n k a n y of th o se t h i n g s a r e n eces sa ry
w h e r e I c a m e off ver y b adly.
just
T h . S hall w e g o into t h a t 3
Pt.
Yes. Yes. Yes.
T h . D o you t h i n k you w o u l d like to be a forceful
I w as thinking
t h e last t i m e t h a t
to be a w e l l - a d j u s t e d
man.
D o n t you
agree?
this h a s
T h . M m . All r i g h t, if you sense t h a t t h e r e is a
d e g e n e r a t e d in to o ne session af te r a n o t h e r , my
c e r t a i n lack in y ou, t h a t s h o u l d be w h e r e w e
c o m p l a i n i n g a b o u t m y wife. Y o u k n o w , I m e a n
t h e m a t e r i a l is all t h e sa m e. W h e n
1 think
a b o u t it, 1 a m really c on vin ced th e t r o u b le is
d irect o u r t h e r a p e u t i c effort.
P t.
R i g h t , I s h o u l d sa y so; I a g r e e a h u n d r e d p e r
cent. T h a t is ex actly m y p o i n t , t h a t , y ou k n o w ,
w i t h me, not w i t h h er. N o t t h a t sh e d o e s n t
I felt n o t m u c h w a s a c c o m p l i s h e d last tim e,
h av e h e r t r o u b le s , d o n 't m i s t a k e m e; b u t I a m
t h a t I h a d sp e n t all this t i m e t a l k i n g a b o u t m y
r e a lly co nv inced if she h a d m a r r i e d a m a n , in
wife, w h a t I said a n d w h a t sh e sa id. W h a t she

said is n o t as i m p o r t a n t as w h a t I d i d a b o u t it,
T h . W h a t e v e n ts h a p p e n e d o n t h e d a y p r e c e d i n g
o r w h y t h e s i t u a t i o n ever got to t h e p o i n t
your nightm are?
w h e r e she w o u l d say s u c h a t h i n g . S h e is no t
P t.
th e p a t i e n t , {pause)
T h . Y ou w ere here?
T h . All r i g h t , t h e n w h a t w o u l d y o u like to ta l k
P t.
201
Pt.
W e l l , I c a m e h ere.
Yes
about?
T h . A n y t h i n g else?
W ell, I h ad a n ig h tm a re T u e s d a y night, that
P t.
N o . I h a v e n t even d o n e m u c h w o r k . I t r ie d it.
w a s t h e n i g h t . I h a d n o m e m o r y of it, e x cep t
I h a v e a v er y difficult t i m e w o r k i n g . I tr ie d
w h e n I w o k e u p I t h o u g h t I w a s c h o k i n g ; no t
r e a d i n g , a r o m a n t i c sto r y , a c t u a l l y in r o m a n t i c
ex a c tly c h o k i n g , b u t m y t h r o a t w a s full of
t e r m s . It is a b o u t a w o m a n w h o n e v e r t h o u g h t
p h l e g m , o r so m e th i n g . I h a d n e v e r h a d t h a t
sh e h a d a n y c h a r m b u t p l e n t y o f c h a r a c t e r , a n d
o n e before , a l t h o u g h , as y o u k n o w , I h av e
a g u y w i t h t r e m e n d o u s c h a r m w h o t h o u g h t he
n e v e r b een a b l e to r e m e m b e r a n i g h t m a r e . [It
h a d n o c h a r a c t e r . T h i s , as I say , in fictiona l,
is quite possible, I feel at this point, that the

nightmare contains a core problem that he is
repressing. ]
d r a m a t i c , r o m a n t i c t e r m s a r e m y w ife a n d I.
T h . It m a y be p ossib le to c a t c h it, to h a v e it r e p e a t
a p y , a n d I a c t u a l l y h a v e d o n e a lot for h e r . S h e
P t.
N o w , m y wife, sh e h a d d o n e a t r e m e n d o u s lot
f or m e, in m a n y , m a n y w a y s , t r e m e n d o u s t h e r
itself a n d r e m e m b e r it in h y p n o s is .
loo k s d ifferen t. S h e w a l k s i n t o a r o o m differ
T h a t w o u l d be f ascin atin g .
e n tly . S h e is a n a s s u r e d , a t t r a c t i v e , c h a r m i n g
T h . W e m i g h t be a b l e to revive it so t h a t y o u will
w o m a n . S h e is v ery w ell lik ed a n d a d m i r e d ,
b e a b l e to see t h e k in d o f n i g h t m a r e t h a t you
r e p re s s , a n d m a y b e get so m e clues as to w h a t
a n d she w a s n t th i s w h e n I m e t her.
T h . Y o u h a v e re a l l y h e l p e d h e r a g r e a t deal in th is
th e s e n i g h t m a r e s a r e all a b o u t . N o w w h a t w a s
P t.
area.
t h is fight all a b o u t ? J u s t tell m e very r a p i d l y .
P t.
V e r y r a p i d l y , last n i g h t , as y o u k n o w , o u r
T h . D o e s sh e r e a l i z e h o w m u c h y o u h a v e h e lp e d
Yes, a n d sh e h e l p e d m e t r e m e n d o u s l y .
her?
h o u s e is in a big t u r m o i l , w i t h o u t a k itchen
r e a lly ; w e h av e a t e m p o r a r y k i t c h e n , a n d so
P t.
Yes, s u r e sh e does.
fo rth . I t o o k a n a p b efo re d i n n e r , before w e
T h . S h e r e a l i z e s t h e n t h is m a r r i a g e h a s to g o o n ?
w e n t o u t to d i n n e r last n i g h t . W e go o u t to
P t.
O h , yes; o h , yes. A c t u a l l y t h i s m a r r i a g e will
d i n n e r a l m o s t ev ery n i g h t b e c a u s e w e h a v e n o
go o n , n o m a t t e r w h a t I say . T h i s m a r r i a g e
k itc h e n . I sa id, I a c t u a l l y a m a f r a id t h a t I a m
b asically ,
g e t t i n g a n e m i c a g a i n , b e c a u s e I w a s , a n d she
n eed
sa id, A r e yo u t a k i n g y o u r m e d i c i n e ? t h is is
m u c h . W e give a lot to e a c h o t h e r . It h a s been
pills a n d stuff a n d I said to h e r , N o , I a m
g o i n g to p ieces a lot lately, b u t basically t h e
n ot, b e c a u s e I d o n t h a v e e n o u g h for l u n c h .
f o u n d a t i o n is g o o d , I t h i n k ;
T h e p o i n t o f it is, w h e n I t a k e t h is m ed icin e,
(laughs) I t h i n k I a m s u r e , (pause)
each
basically is a g o o d m a r r i a g e . W e
other;
we
n eed
each
other
very
I a m n o t sure.
th e s e pills, I h a v e a r a v e n o u s a p p e t i t e ; I h av e
T h . All r i g h t. D o yo u w a n t to r e l a x n o w ?
to h a v e for l u n c h a c o m p l e t e m eal w i t h p o
P t.
Yes. D o y o u m i n d if I t a k e m y co at off? I t s
t a to e s a n d vegetables, t h e w h o l e d a m n e d thin g .
h ot; i t s t i g h t ; a n d I t h i n k I ll d o b e t t e r w i t h it
T h i s w a s a c ritic is m of h e r a n d sh e b lew sky-
off. (takes off coat.)
h i g h , a n d I felt lo usy a n y w a y , a n d I did no t

co m e u p to s c ra t c h a t all. T h a t is w h a t it w a s
all a b o u t . W e w e n t to d i n n e r . W e l l , n o, w e
h a d a fight a h a l f h o u r l ater. W e c a m e h o m e .
S h e w a n t e d to m a k e love. I felt so lo usy , I w a s
re a lly so tire d , sick, tire d .
T h . W h a t d a y w a s t h is?
P t.
O h , t h a t w a s y es terd ay .
T h . T h a t w a s y e s t e rd a y ?
Pt.
a n y of these, u su a lly p erfectin g o ne tec h n iq u e.

T h e r e l a x a t i o n m e t h o d d e s c r ib e d in th e
c h a p te r d e a lin g w ith th e m a k i n g of a re la x in g
a n d e g o -b u ild in g cassette ta p e I find is the
m o st s u ita b le te c h n iq u e for m ost patie nts.
T h a t w a s y e s te rd a y , t h a t w a s last n ig h t.
T h . T hursday?
P t.
T h e h y p n o tic in d u c tio n process I will use is

h a n d levitation. T h e r e a r e m a n y m e th o d s of
tr a n c e in d u c tio n an d a th e r a p is t m a y e m p lo y
Yes.
T h . S u p p o s i n g you j u s t lean b ack ; st r e t c h y o u rself

o u t, a n d , for a m o m e n t , close y o u r eyes a n d
202
b eg in r e l a x i n g . R e l a x y o u r f o re h e a d ; p u r p o s e l y
as it to u c h e s y o u r face, y o u will be as leep,
c o n c e n t r a t e o n y o u r f o re h e a d , a n d y o u r eyes,
d e e p l y as leep. Y o u w ill be very, v ery tire d.
and
your
your
E v e r y t h i n g is fl o a t in g off in t h e d istan c e. Y o u
sh o u l d e rs . L et y o u r a r m s r e l a x . R e la x y o u r
a r e g e t t i n g v ery d r o w s y , v er y d r o w s y , d r o w s i e r ,
body. T h e n b r i n g y o u r h a n d s , th e p a l m s of
d r o w s i e r , d r o w s i e r . Y o u r h a n d is m o v i n g u p ,
y o u r h a n d s , d o w n o n y o u r th ig h s. O p e n y o u r
u p , u p , u p , t o w a r d y o u r face; it a p p r o a c h e s
eyes;
face,
w atch
and
your
your
neck,
hands. J u s t
and
o b se rve y o u r
y o u r face. Y o u r eyes will s o on close, a n d you
h ands. C o n c en trate on everything your hands
w ill go d e e p l y to sleep; b u t d o n o t fall asleep
do ; so rt o f focus all y o u r a t t e n t i o n o n y o u r
u n t i l y o u r h a n d to u c h e s y o u r face. Y o u r b r e a t h
h a n d s a n d k eep all o t h e r s e n s a t i o n s in t h e p e
in g is g e t t i n g d e e p ; y ou a r e g e t t i n g v er y tire d ;
r i p h e r y . Y o u m a y n otice t h a t y o u r h a n d s feel
e v e r y t h i n g is s l i p p i n g a w a y i n t o t h e distan c e.
he a v y as
y o u r thig hs.
Y o u r ey es a r e s h u t t i n g . Y o u a r e g o i n g in to a
P e r h a p s yo u notice t h e r o u g h n e s s of t h e t e x
th ey p r e ss d o w n
on
d e e p , d e e p , d e e p sleep; yo u a r e v er y d r o w s y
t u r e o f y o u r t r o u s e r s o n y o u r f in g e rtip s a n d
n o w . You a r e v er y tire d , very sleepy . Y o u r h a n d
p a l m s . Y o u m a y n otice t h e w a r m t h of y o u r
is c o m i n g t o w a r d y o u r face; n o w it t o u c h e s y o u r
h a n d s , o r a little t i n g l i n g in y o u r h a n d s . N o tic e
face. N o w y o u a r e g o i n g to sle ep , a n d y o u a r e
w h a t e v e r se n s a t i o n s t h e r e m a y be. C o n c e n t r a t e
g o i n g to s t a y a s le e p u n t i l I give t h e c o m m a n d to
your
attention
on
your
hands;
w atch
your
h a n d s . T h e n ex t t h i n g y ou will no tice as you

o bse rv e t h is o v er h ere, t h is r i g h t h a n d , is t h a t
very slo w ly y o u r fin g ers will b eg in to s p r e a d ,
th e sp aces b e t w e e n t h e fin g ers will be w i d e r
a n d w id e r .
w a k e u p . Y o u r sleep is g e t t i n g d e e p e r , a n d
a n d d e e p e r . [The p a tie n ts hand
touches his face; his eyes close; and he is breath
ing deeply and regularly. ]
deeper,
1 a m g o i n g to t a k e y o u r h a n d o v er h e r e a n d
b r i n g it d o w n to y o u r t h i g h , j u st like this. You
T h e sp a ces b e t w e e n fin g ers g r o w w i d e r , a n d
keep
g etting
dro w sier,
and
drow sier,
and
w i d e r , a n d w i d e r , j u s t like t h a t . A n d t h e n you
d r o w s i e r . L is t e n car e f u lly to m e. I a m g o i n g to
b eg in to n otice t h a t t h e r e will be a lifting of the
s t r o k e y o u r left a r m , a n d y o u r f o r e a r m a n d
fin gers, slo wly. O n e of t h e fin g ers will st a rt
y o u r h a n d , a n d as I s t r o k e t h e m , I a m g o i n g to
lifting f ro m y o u r t h i g h , a n d t h e n t h e rest of th e
c o u n t fro m o n e to five. Y o u will no tice t h a t as
fin gers w ill follow, a n d t h e n t h e h a n d s will
I c o u n t , y o u get t h e feeling as if y o u r a r m h a s
slow ly begin to lift a n d m o ve s t r a i g h t u p in the
b e c o m e j u s t as stiff a n d h e a v y as a b o a r d . A s I
air, m o v ing , m o v in g , a n d as th ey m ove, you
s t r o k e it, t h e a r m gets h e a v i e r , a n d h eav ier,
will
as t h e y m ove,
a n d h e a v i e r . Y o u r a r m is g e t t i n g he a v y a n d
slow ly , a u t o m a t i c a l l y , w i t h o u t a n y effort on
stiff, h e a v y a n d stiff, h e a v y a n d stiff, j u s t like a
w atch
t h e m , fascin ated,
y o u r p a r t . T h e n y o u r h a n d m oves u p , u p . It
board. T h e arm
m oves
stiff, stiff, stiff, stiff. O n e , it g ets stiff a n d heavy
to w ard
your
face;
eventually
it will
is g e t t i n g h e a v i e r , h eav ier,
to u c h y o u r face, bu t o n ly w h e n it to u c h e s y o u r
like a b o a r d . T w o , j u s t as stiff as a b o a r d .
face will yo u be asleep . [77i<? w ord sleep is
T h r e e , stiffer a n d stiffer; t h e a r m
used only because it signifies the deepest kind

of relaxation. Obviously the patient will not be
asleep] . Y o u will get d r o w s i e r a n d d r o w s i e r ,
stiff. F o u r , stiff a n d h eavy . F ive, stiff, h eavy ;
b ut y ou will n o t fall as leep , a n d y ou m u s t not
fer it becom es. It will be im p o s s i b l e to r a ise it
is g e t t i n g
w h e n I try to b e n d it, it w ill resist m o t i o n . T h e

h a r d e r y ou try to m o v e it, t h e h e a v i e r a n d stif
fall asleep u n til y o u r h a n d to u c h e s y o u r face.
no m a t t e r h o w h a r d yo u try. H o w e v e r , w h e n I
A n d as y o u r h a n d m o ves t o w a r d y o u r face, you
s n a p m y fing ers, w h e n I s n a p m y fin g ers, y o u r
get d r o w s i e r , a n d d r o w s i e r , a n d d r o w s i e r , a n d
a r m will re la x , (pause, then sound of fingers

snapping) N o w y o u can r a ise y o u r a r m , if y ou
w i s h . (The patient lifts his arm slightly.)
j u s t as soon as y o u r h a n d to u c h e s y o u r face,
you will feel y o u r se lf d o z i n g off a n d g o i n g to
sle ep, d e e p l y asleep . Y o u a r e g e ttin g very tired
N o w , r e l a x y o u r se lf all o v er a n d fall asleep ,
n o w , ve ry, ver y d r o w s y ; y o u r eyes a r e g e ttin g
even
h e a v i e r a n d h e a v ie r ; y o u r b r e a t h i n g is g e ttin g
ve r y , v ery , v ery tig h tly g l u e d t o g e t h e r , as if
deeper.
Y o u r ey es a r e g lu e d t o g e t h e r ,
d e e p e r a n d a u t o m a t i c ; you feel y o u r se lf g e ttin g
little steel b a n d s b in d t h e m to g e t h e r . T h e y a r e
very, ver y tire d , v ery d r o w s y ; y o u r h a n d is
very t i g h t l y b o u n d t o g e t h e r . T h e h a r d e r y ou try
m o v i n g u p , u p , u p t o w a r d y o u r face. As soon
to o p e n y o u r eyes, t h e h e a v i e r y o u r lids are. F i
203
n a l l y t o g e t h e r , a n d you feel y o u r s e l f d o z i n g off,
th e h a n d d o e s n o t w ith d r a w .) N o w y o u r h a n d
g o i n g into a n even d e e p e r sleep. Y o u a r e g e t t i n g
r e t u r n s to n o r m a l s e n sa tio n . N o w t h e left h a n d
drow sier,
is g o i n g to s t a r t g e t t i n g n u m b . It is g o in g to
drow sier,
very tire d , very, very
sleepy, (lo n g p a u s e )
h a v e a feeling, a p e c u l i a r feeling, a l m o s t as if I
L is te n car e f u lly to m e. I a m g o in g to str o k e
h a d in jected n o v o cain all th e w a y a r o u n d th e
your h and, and your forearm , an d your arm ,
w r i s t . T h i s gives yo u a s e n s a t i o n of n u m b n e s s
a n d as I d o t h a t , it will b e c o m e ju st as light as
t h a t in c r e a se s to a p o i n t w h e r e y o u get t h e feel
a f e a th e r . As a m a t t e r of fact, it m a y st a rt
in g yo u a r e w e a r i n g a stiff, he a v y , l e a t h e r
s w in g i n g u p in t h e a i r s p o n t a n e o u s l y ; it will b e
glove. T h e r e is a sense o f fe eling, b u t n o re al
co m e so lig ht t h a t it will a l m o s t a u t o m a t i c a l l y
se nse o f p a i n ,
sw in g s t r a i g h t u p in t h e a i r , j u s t as lig ht a s a
se nse o f p a i n ,
a se n se of fe eling, b u t n o real
f e a t h e r , s t r a i g h t u p . It floats a r o u n d in t h e a i r
se nse of p a i n .
As soon as y o u feel y o u r h a n d
a se n se of fe eling, b u t no real
n o w , floats a r o u n d in t h e a i r , j u s t as lig h t as a
g r o w i n g n u m b a n d y ou h a v e a s e n s a t i o n as if
f e a th e r . It floats a r o u n d in t h e a i r , j u s t as lig ht
y o u a r e w e a r i n g a stiff, h e a v y , l e a t h e r glove,
as a fe a th e r , u n t i l I s n a p m y fing ers . ( T h e p a
i n d i c a t e it to m e by r a i s i n g y o u r h a n d a b o u t 6
tie n t e a s ily lifts h is a rm a n d w a v e s it.) T h e n it
in ches.
will slow ly co m e d o w n , s lo w ly d o w n . N o w it
down.
(H a n d
rises.)
Good.
Now
bring
it
slo w ly c o m es d o w n , r i g h t d o w n to y o u r t h i g h ,
I a m g o i n g to p o k e t h is h a n d w i t h a p in ,
a n d you slip off in to a d e e p e r sleep, a d e e p e r
a n d you will n otice, in c o n t r a s t to y o u r r ig h t
sleep. ( T h e a rm co m e s d o w n .) W h e n I t a l k to
h an d , w hich
y o u n ex t, you will b e still m o r e d e e p l y asleep.
h a n d will b e n u m b ; t h e r e will be n o r e a l p a i n .
(lo n g p a u s e )
Y o u w ill h a v e a se n s a t i o n of feeling, b u t no
N o w , I w a n t you to i m a g i n e y o u r se lf w a l k
is r a t h e r t e n d e r , t h a t t h is left
real p a i n . I will s h o w yo u, no p a i n even w h e n
ing o u td o o r s. As soon as y ou see y o u r s e l f w a l k
I p o k e it very d e e p ly , n o p a i n . Yo u n o tice the
ing o u t d o o r s ,
d iffe rence w h e n
inches.
raise y o u r left h a n d
(H a n d
rises.)
Now
bring
about
it d o w n .
I t o u c h t h is h a n d o v er h e r e
a n d t h e h a n d h e r e . Y o u notice t h a t , d o n t yo u?
A g a in v isu a lize y o u rse lf w a lk in g o u td o o rs,
P t.
r a i s e y o u r left h a n d a b o u t 6 in ches. (H a n d
T h . All r i g h t , n o w go to sleep, m o r e d e e p l y alseep.
rises.) N o w
b r i n g it d o w n .
A g a i n v isua lize
Yes.
W h e n I t a l k to y o u a g a i n , y o u w ill be even
y o u rself w a l k i n g o u t d o o r s on t h e street, a n d
m o r e d e e p l y as le e p , m o r e d e e p l y as leep, (lo n g
see y o u r se lf e n t e r i n g
pau se)
an
alley b e t w e e n t w o
b u ild in g s. Y o u t u r n in to t h e a l l e y w a y a n d you
N o w listen car e f u lly to me. E v e n t h o u g h you
w a l k slo w ly , a n d , as yo u do, o n t h e r i g h t - h a n d
a r e as leep, it will be p o ss ib le for y ou to ta l k to
side of t h e a l l e y w a y y o u n o tice a p a i l of w a t e r ,
m e j u s t like a p e r s o n t a lk s in his sleep. Y ou
s t e a m in g h o t w a t e r . As soon as y o u see t h a t ,
w ill be a b l e to t a l k l o u d ly a n d distinctly, bu t
r a i s e y o u r h a n d a b o u t 6 inches. ( H a n d rises.)
y o u will n ot w a k e u p . I w a n t y o u to i m a g i n e
G o o d . N o w b r i n g it d o w n . L is t e n car e f u lly to
y o u r s e l f w a l k i n g o u t d o o r s a g a i n , b u t this tim e
m e. T r y n o w to test h o w h o t t h a t w a t e r is. See
y o u w a l k o u t in to a c o u r t y a r d a n d y o u see a
y o u r se lf w a l k i n g over to t h e p a i l of w a t e r . Yo u
c h u r c h , a b e a u tif u l c h u r c h , steep le, s p i r e , a n d
t a k e y o u r r i g h t h a n d a n d p l u n g e it in to th e
a bell. As soon as y o u see t h e c h u r c h , ind icate
w a t e r , a n d as y o u do, y o u get a se n s a t i o n of
it by y o u r h a n d r isin g . ( H a n d rises.) G o o d .
sc ald ing , of heat. A s soon as y o u feel t h a t , i n d i
N o w b r i n g it d o w n . N e x t you see t h e bell; t h e
cate it to m e by y o u r h a n d r i s i n g a b o u t 6
bell b eg in s to move; t h e bell m oves, a n d it
in ches. ( H a n d rises.) T h e h a n d feels t in g ly a n d
s t a r t s c l a n g i n g . Y o u h e a r t h e c l a n g clearly. As
se nsitive a n d t e n d e r . I a m g o i n g to s h o w you
soon as y o u h e a r t h e bell c l a n g i n g , i n d i c a t e it
how
to m e by y o u r h a n d r i s i n g a b o u t 6 inches.
tender.
I a m g o i n g to s h o w y ou h o w
t e n d e r it is by p o k i n g it w i t h a pin.
( H a n d rise s.) N o w b r i n g y o u r h a n d d o w n .
As soon as I p o k e y o u r h a n d w i t h a p i n , it
Y o u t u r n a r o u n d f ro m t h e c o u r t y a r d , a n d
m a y feel v ery , very p a i n f u l a n d t e n d e r . I will
you go b a c k to y o u r h o m e . Y o u w a l k into the
sh o w you. V e r y , ver y p a i n f u l , j u s t like t h a t .
living r o o m . Y o u go o v er to t h e r a d i o . Y o u
(P a tie n t w ith d r a w s h a n d .)
t u r n y o u r r a d i o o n , a n d yo u h e a r a s y m p h o n y
In
c o n t r a s t , th is
o t h e r h a n d is n o r m a l . ( T o u c h e d w ith a p i n ,
orchestra
B e a u tif u l
m u sic
c o m es
fro m
the
204
P t.
Th.
P t.
Th.
P t.
Th.
P t.
Th.
P t.

radio. As soon as you hear it, indicate this to
me by your hand rising about 6 inches. (Hand
rises.) Good. Now bring it down. Can you
recognize the music?
Uh-huh.
W hat was the music?
It is something by Bach.
Good. Next, you decide to go to the theater.
You walk along the street. T hen you notice a
theater; you have a hunch that you want to see
something in this particular theater, but you
dont know exactly what it is you want to see.
You dont even look at the billboard to see
what may be playing. You walk right into the
theater, down to the fourth row orchestra and
sit down. You look up and notice that the cur
tain is down. There are very few people in the
theater. You are rather curious as to what is
behind that curtain.
Uh-huh.
As soon as you observe yourself sitting in the
theater, indicate it to me by your hand rising
about 6 inches. (Hand rises.) Good. Now bring
it down.
In your curiosity you notice that there is a
man with a gray suit, a tall young man, up
there on the platform. [To enhance identifica
tion, this person is of the same sex and attire
as the patient.] He seems to be peering behind
the curtain as if his patience has almost come
to an end and he would like to see what is go
ing on backstage. But as he turns around, you
notice that he has a horrified expression on his
face as if he has seen something horrible, about
the most horrible thing that could happen to a
person. As you observe that, you begin to
absorb some of that feeling. [This is a tech
nique of imagery evocation often useful in
many ways.) And you wonder what is behind
that scene. I am going to count from one to
five, and then snap my fingers. At the count of
five, as I snap my fingers, the curtain will sud
denly rise and you will see a scene that is what
this man saw, the most horrible thing that can
happen to a person, (counting to five, then
sound of fingers snapping) Tell me about it as
soon as you see it.
No, no (crying)-, no, no, no (crying)-, no, no,
no, no, no; I dont know; I dont know
(screams with anguish).
Tell me.
I dont know; I dont know.
T h . W hat has frightened you?
P t.
Oh (crying), oh, no, no, no.
T h . T h e curtain is down.
P t.
Yes.
T h . Something frightened you.
P t.
Yes. (crying)
T h . T h e curtain goes down.
P t.
(crying) Oh, oh, oh.
T h . You saw something that frightened you.
P t.
I dont know; I dont know what I saw.
T h . All right, now listen carefully to me. I am go
P t.
Th.
P t.
Th.
P t.
Th.
P t.
Th.
P t.
Th.
P t.
Th.
ing to help you. Something frightened you;

something continues to frighten you all the
time, and we have got to liberate you from
that. You want to be liberated from that fright,
dont you?
Yes, yes, yes.
You would like to get over that fright. T hat
fright makes you insecure. T h a t fright may
hold the key to your trouble.
Yes, yes, yes, yes, to the nightmare.
And when we uncover that fright and see what
it is and get it out of your system, get rid of it,
well solve your nightmares.
Yes, that will be good.
Now listen carefully to me. You dont know
when this is going to happen. I am going to
help you. You want to be helped?
Yes, yes.
All right, now listen to me. As you sit there,
the scene is going to change completely.
Instead of being a horrible scene, it will change
to a happy scene. You are going to notice the
same man peering behind the curtain again,
but this time when he turns around, he has a
happy expression on his face. T h e whole at
mosphere has changed. He feels very happy,
very contented. As you see this wonderful ex
pression on his face, you too feel a part of it.
You realize he has seen the most wonderful
thing that can happen to a person. You feel as if
it is about to happen to you. You watch that
curtain very closely. At the count of five, I will
snap my fingers and you will see the most won
derful thing that can happen to a person.
(counting to five, then sound of fingers snap
ping) As soon as you do, I want you to tell me
about it without waking up.
It is a play. No, no. (crying)
It is a play?
No. It is a play (crying in an agitated way).
It is a play?

Pt.
Th.
Pt.
Th.
Pt.
Th.
Pt.
Th.
Pt.
Th.
Th.
Pt.
Th.
Pt.
Th.
Pt.
Th.
Pt.
Th.
Pt.
Th.
Pt.
Th.
I am not happyoh, oh. [Apparently the

nightmarish image is still with the patient,
neutralizing the happy scene.]
You are not happy. T h e other thing bothers
you, doesnt it?
I dont know what is behind that curtain. I
dont know. I dont want to know. (crying in
anguish)
You dont know?
No
Listen carefully to me. You dont know what is
behind it, but you would like to know and get
rid of it?
Yes.
I am going to try to help you now so you will
get rid of it once and for all. (Patient continues
crying.) Listen.
Yes, yes.
I am going to count from one to five. At the
count of five, suddenly a number is going to
flash into your mind.
T h e number will be the number of letters in
the word that holds the clue to what is behind
the curtain that frightens you. It may hold the
clue to what is behind the nightmare that
frightens you. As I count from one to five, a
number will suddenly flash into your mind as
if it has been etched out. T h a t number will be
the number of letters in the word, the key
word, which contains a clue to this whole
thing.
Uh-huh.
And the letters all taken together, unscram
bled, will give us the clue to the word that is so
significant, that has within it the core of your
problem. Do you understand me?
Yes, yes.
Give me the first number that flashes in your
mind when I count to five. One, two, three,
four, five.
Eleven.
Eleven. All right, now rapidly from one to five,
when I reach the count of five, a letter will
flash into your mind. Give me the letters,
regardless of the order. One, two, three, four,
five.
Pt.
Th.
Pt.
Th.
Pt.
Th.
Pt.
Th.
Pt.
Th.
Pt.
Th.
Pt.
Th.
Pt.
Th.
Pt.
Th.
Pt.
Th.
Th.
Pt.
Th.
H.
One, two, three, four, five.
P.
R.
Pt.
Th.
205
M
I.
L.
E.
H
O.
A, m, n I dont know.
I will do it again. One, two, three, four, five.
A. O.
All right, now listen carefully to me. I am go
ing to count from one to five, and this time
when I reach the count of five, all these letters
will just scramble together and make a word
that will give you a clue. You understand me?
Yes.
Oh, oh, homophrile, homophrile.
Homophrile? [77iir word, it was determined
later, w as frie n d and lover o f men, a
designation of homosexual. The p a tie n ts
concern of his wife not being married to a man
is somehow related to the fear that he is a ho
mosexual. ]
Now, you have a clue. You are going to have a
dream. T h e dream will not be too scary a
dream, but it will be a first step in coming to
an understanding of what this fear is. Do you
understand me? T h e dream will be the first
step.
Yes.
It will have within it the essence of the word
that you just spelled out for me. As soon as you
have this dream, which may or may not be like
the nightmares you have, you will open your
eyes and wake up. As soon as you awaken,
everything will be blotted out of your mind. It
will be as if you are waking from a sound
sleep. T hen what I will do is tap three times
on the side of the desk, like this. (three taps)
With the third tap you will suddenly re
member the dream that caused you to wake
up. Do you understand me?
Yes.
You will have a dream. T h e dream will con
tain a clue, and then, as soon as you have had
the dream, you will wake up. But you will blot
206

th e d r e a m f ro m you m i n d , o r it will b e very
b r e a k i n g d o w n of y o u r r e p r e s s i o n . A s w e keep
v a g u e in y o u r m i n d . Y o u w o n t r e m e m b e r , b u t
a t t h is, y o u s h o u l d g r a d u a l l y be a b l e to lift
o n t h e t h i r d t a p t h e w h o l e t h i n g w ill p o p into
y o u r r e p r e s s i o n s a n d b e c o m e l i b e r a t e d f ro m
th is m o n s t e r t h a t h a s y o u by t h e t h r o a t .
y o u r m in d . D o y o u u n d e r s t a n d m e?
P t.
Yes.
P t.
T h . G o to sleep a n d h a v e a d r e a m , a n d t h e n w a k e
m a d e m e cry b e c a u s e I d i d n t see a n y t h i n g . I
u p . [ T h e o b ject in h a v in g th e p a tie n t rep ress
k n o w y o u said it w a s p l e a s a n t as I a p p r o a c h e d
th e d r e a m s is to p r o te c t h im fr o m a n y associ
t h a t c u r t a i n a g a i n . W h a t m a d e m e cry, I h av e
a te d a n x ie ty . T h e ta p p in g s ig n a l m a y release
th e d re a m i f th e a n x ie ty is n o t too g re a t.]
n o idea.
T h . M m , hmm.
T h . ( A fte r se v e ra l m in u te s th e p a tie n t a w a k e n s .)
P t.
I c a n t e x p l a i n it to you . I d o n t k n o w w h a t
P t.
I c e r t a i n l y h a d a s t r a n g e e x p e r ie n c e .
H o w do yo u feel?
T h . D o y o u feel y o u w e r e in a t r a n c e ?
A little tire d.
P t.
I m u s t h a v e b een . It is a f u n n y t h i n g , I could
T h . A little tire d . W h a t a r e you t h i n k i n g a b o u t ?
h e a r y ou, I k n e w w h a t w a s h a p p e n i n g . I can
P t.
r e m e m b e r . I a m s u r e I recall t h e t h i n g , a n d yet
W e l l , well, I k n o w I cr ied. B u t . . .
T h . A n y t h i n g else? (p a u se a n d th re e ta p s)
P t.
t h e r e is n o q u e s t i o n t h a t I w a s h a r d l y myself,
like in t h e cr ying.
O h , yes, I w a s o n t h a t stage.
T h . I a m s o r r y t h a t it h a d to be as p a i n f u l as it
T h . Yes.
P t.
w as.
A n d on ly I c a m e i n t o it w a s t h e r e w a s a
w o m a n se ated a t a desk a n d she h a d h e r h a i r
P t.
w a s so r ed , d a m a s k , a r e d h o u s e o n t h e stage, a
T h . Yes.
so rt o f a w h o r e h o u s e . T h i s w o m a n I g u ess w a s
P t.
so rt o f a m a d a m e ; a n d t h e r e is a p a i n t i n g by
T h . U h-huh.
P t.
S h e h a d a very s h a r p nose. M a y b e it w a s o n e
T h . It s h o u l d m a k e y o u feel b e t t e r , a n d it s h o u ld
of t h e e n t e r t a i n e r s . A n y w a y , sh e w a s se a te d at
p o ss ib ly e n a b l e y o u to r e m e m b e r y o u r d r e a m s
h e r desk, a n d this is o n t h e stage, r e d lights,
o r n i g h t m a r e s . H o w d o you t h i n k y o u w o u l d
a n d I w a l k e d in a n d she gets u p a n d g reets me;
feel if a t h i n g like y o u r d r e a m h a p p e n e d in
a n d she is a n o l d e r w o m a n , so rt of, a n d she
r e a l i t y ? S u p p o s i n g yo u w e r e to w a l k in to a
b eg in s to caress m e. O n l y it gets to o m u c h ,
house
c l u t c h i n g a t m y clothes . A n d t h e n a b o u t five
h a r p i e s w h o c a m e a t yo u a n d s t a r t e d t e a r i n g at
g irls co m e o u t, a n d th ey b e g in c a r e s s i n g m e,
y o u r sk in ? H o w do y o u t h i n k y o u w o u l d feel
to bite m e, to a t t a c k m e, to t e a r off m y clothes.

in to h a r p i e s a c t u a l l y , in t h e clas sical se nse of
T h e c r y i n g , a n d it w a s n t p a u s e ) .
and
w ere
g r e e te d
by
th e s e
claw ing
in a s i t u a t i o n like t h a t ?
P t.
I w a s f r i g h t e n e d , f rig h t e n e d ; I w a n t e d to get
o u t of th e w h o r e h o u s e .
I a m s u r p r i s e d , a little f ri g h t e n e d , t u r n al m o s t
T h . T h e r e is a s e x u a l tin g e to t h is?
t h e w o r d . I b ack a w a y f ro m t h e m a n d b ack
P t.
a w a y f ro m t h e m , a n d I fall o v er t h e footlights
T h . D o y o u r e m e m b e r a n y t h i n g a b o u t letters?
in to t h e o r c h e s t r a pit. T h a t w a s t h e d r e a m I
P t.
ju st had.
O h , yes, v e r y defin ite ly ; yes, v er y definite ly.

I r e m e m b e r all t h e letters, b u t it d i d n t com e
o u t w i t h a n y t h i n g , d id it?
T h . I see.
T h . Y o u c a m e o u t w i t h a g r o u p of l etters t h a t st a rt
T h e w h o l e t h i n g is red. O h , boy , w h a t di d I go
th ro u g h today?
I r e m e m b e r cry in g ,
w i t h h - o -m - o .
P t.
T h . Y o u s e em ed to go t h r o u g h p le n ty .
P t.
A n d t h a t is tru e.
T o u l o u s e - L a u t r e c , t h a t is w h o h e r face w as.
b u t t h e n a f t e r t h e i r cares ses st a r t e d , t h e y s t a r t
P t.
S t r a n g e l y e n o u g h , I c a n t e x p l a i n it to you . I
c a n t r e m e m b e r . It w a s al m o s t a re lease .
tied on to p o f h e r h e a d , a n d t h e w h o l e t h i n g
and
I c o u l d n t stop.
I d i d n t u se all t h e letters, d id I?
T h . N o t all.
I
rem e m b e r w h a t I w ent th ro u g h , actually. I re
P t.
I a m n o t v e r y go od at a n a g r a m s , b u t I will try
to f i g u re o u t w h a t t h is m e a n s .
m e m b e r y o u told m e to look b e h i n d t h a t c u r
t a i n , a n d , y o u k n o w , I c o u l d n t see b e h i n d it. I
d o n t k n o w w h y I cr ied t h o u g h . I w a s sc are d.
T h . S o m e t h i n g sc are d you. Y o u h a v e g o t t e n a clue
as t o w h a t t h e essence of y o u r n i g h t m a r e s
m i g h t be.
It is j u s t t h e firs t clue, t h e first
A t th e n ext session
a n o t h e r d r e a m th a t he
th e h y p n o tic e x p erien ce
solved th e resista nce to
th e p a ti e n t re p o r te d
a c tu a lly re m e m b e r e d ,
a p p a r e n t l y h a v in g r e
d r e a m in g . A w o m a n
207
d re a m s. A fter a q u a r r e l he w o u ld a lm o st a l
w e a rin g a red g o w n d escend ed a flight of

stairs. H e noticed w ith te r r o r h e r exposed
w ays
pu bic a rea, w h ich consisted of a n open g a p in g
a r o u n d th e fifteenth session h e sta rte d c o m
have
a n ig h tm are
th at
e v e n in g .
At
m o u th . As h e w a tc h e d , th e w o m a n c h a n g e d
p la i n in g th a t his s y m p to m s w e re n o t being
in to a t h r e a te n i n g tig er w ith a fierce o pen

m o u th . At this p o in t the p a ti e n t b eg an to d is
relieved as ra p i d ly as he w ish ed , an d he associ

a te d th is w ith th e fact th a t his fa th e r did not
cuss his feelings a b o u t his m o th e r, w h o m he

re m e m b e r e d as w e a r in g a red g o w n . H e w a s
h e lp h im m u c h . T h e tr a n s fe r e n c e elem en ts
w ere exposed in his d r e a m i n g a b o u t m e as b e
overprotected by his m o th e r, his fa th e r h a v in g

been an e x trem ely passive p erso n w h o died
ing ineffectual like his fa th er. I in te rp re te d his

tra n sfe re n c e feelings, a n d th e in t e r p r e ta ti o n s
w h e n the p a tie n t w a s you ng . H e re m e m b e r e d
h a d a d r a m a ti c effect on h im , e n a b li n g h im to
w ith guilt h a v in g some v agu e sexual feelings
see h o w he w a s t r a n s la t in g w h a t h a d h a p p e n e d
to w a r d
her.
W hen
h e m a r r ie d , th e r e w e re
before in th e h e re a n d n ow . F r o m th is p o in t on
some p ro b le m s w ith im p o ten ce a n d sexual

indifference, bu t his wife w ooed h im o u t of his
w e w e re ab le to establish excellent r a p p o r t . H e
w a s able to r e la te sp end id ly to his wife a n d his
a p a th y . B ut th is seduction a p p a r e n t l y o pen ed
u p a pocket of o edip al anxieties. O ccasio n al
c h ild ren , his w o r k block d is a p p e a r e d , a n d his

n i g h t m a r e s van ished .
h o m o s e x u al fantasies w e re n ot acted out. It is

interestin g th a t he b egan to r e m e m b e r his
n ig h t m a r e s w h ich w ere p a tt e r n e d after the
tr a te d in C h a p t e r 15, w h ic h d eals w ith the

m a k i n g of a cassette tap e, as well as in th e case
h y p n o tic d r e a m a n d d e a lt w ith his fears of
illu s tra tio n in th is c h a p te r. O t h e r tech n iq u es
women.
m a y be fou nd e ls ew h ere (W o lb e rg , 1948).
Soon he identified
his wife in his
H y p n o tic
in d u c tio n
te c h n iq u e s
are
illu s
Conclusion
In m ost cases interview p s y c h o th e ra p y will
proceed satisfactorily w ith o u t n eed in g to resort
nosis as a n ac c e le ra tin g te c h n iq u e w h e r e (1)

incentives for in tervie w t h e r a p y a r e lacking,
to
(2) sy m p to m relief is a n exclusive m o tiva tion ,

(3) r a p p o r t is delayed in develo ping , (4) v e r
cata ly zin g
tech n iq u es.
H ow ever,
w hen
ce rta in blocks to tr e a tm e n t develop o r w h e n it

is difficult to define a d y n a m ic focus, m e a s u re s
b a liz a tio n
to resolve resistance or to accelerate p ro g ress
d r e a m s a n d fan tasie s a re fo rg otte n, (6) t r a n s
is b lo c k e d o r i m p o v e r i s h e d , (5)
m a y be of value. H e r e a w ide r a n g e of m eth o d s
ference a r o u s a l
is available, in clu d in g co n fro n tatio n s, h y p

nosis, narc o a n a ly sis, beh av io r t h e r a p y , G e s ta lt
p ressed m e m o rie s re q u i r e recall, (7) g re a te r
th e r a p y , guided im ag ery , em otive release s t r a t

egies, e x p e rie n tia l th e r a p y , d r e a m a naly sis,
fam ily th e r a p y , an d a n a ly tic g r o u p th e r a p y .
P r e f e r e n c e fo r t e c h n i q u e s is g e n e r a l l y d e
term in ed by the t h e r a p i s t s t r a in i n g a n d e x
perience w ith certain m odalities. R esistance, of
m a te ria l is fo rth co m in g , (9) insigh t is not being

converted in to actio n , a n d (10) w h e n th e r e a re
p r o b l e m s in t e r m i n a t i o n . H y p n o s i s a ls o
e n h a n c e s t h e p l a c e b o effect in t h e r a p y ,
intensifies th e force of suggestion, a n d o pen s
th e floodgates of e m o tio n a l ca th a rsis. Som e
th e r a p is ts m a y n o t be a b le to u tilize hyp no sis
as a n a d ju n c t in t h e r a p y because th ey fear its
effects o r a r e skeptical of its value. In such
course, can also develop w ith these cata ly z in g

in terv ention s, a n d th e m a n ife sta tio n s of r e
sistance m a y serve as a d y n a m ic focus, th e
u n d e rs ta n d in g a n d w o rk in g th r o u g h of w h ich
m a y be of co n seq uen ce for both s y m p to m relief
a n d person ality change.
C e r ta i n ad v a n ta g e s ac crue to th e use of h y p
is d eem ed essential,
(6) r e
activity is essential in th e in te rv iew , (8) little
cases they m a y be m o r e a m e n a b le to o th e r a c
c e le ratin g te c h n iq u e s (W o lb erg , 1977, pp.
761-833).
CHAPTER 14
Crisis Intervention
In recen t years a g re a t deal of p l a n n i n g h a s
ib ility o f o n e s defenses, t h a t is, th e p re v a ilin g
been conducted in th e U n ite d States in a n a t
ego s tren g th .
te m p t to low er th e r a t e of ad m issio n s to m e n ta l
T h e im m e d ia te res p o n se to a situ a tio n th a t
in stitu tions, d im in ish th e incidence of suicides,

q u ie t th e o u tb r e a k of violence in th e streets,
is in t e rp re te d as cataclysm ic, such as th e su d

d e n d e a th of a loved one, a violent accident, o r
a n irre trie v a b le s h a t te ri n g of security, is a
a n d in g en eral red uce p sych iatric m o rb id ity .

O n e of the m a i n d ev elo p m en ts t o w a r d these
goals h a s been th e evolvem ent of m eth odologies
d a z e d s h o c k r e a c t i o n . A s if to s a f e g u a r d
oneself, a p e c u lia r d en ial m e c h a n is m in t e r
in th e a re a of crisis in terv en tion . T h e re c o g n i
venes ac c o m p a n ie d by n u m b n e s s a n d d e ta c h
tion th a t crises a r e so co m m o n in th e lives of
m e n t. T h i s defensive m a n e u v e r , h ow e v e r, does
all people h a s e n c o u ra g e d th e g r o w th of w alk -
no t p re v e n t th e in tru s io n of u p s e ttin g fan tasie s
in c lin ics , p s y c h i a t r i c e m e r g e n c y u n i t s in
g en era l h o sp itals, suicide p re v e n tio n ho t-line
or
frig htening
n ightm ares
from
b reaking
of o th e r
th r o u g h p e rio d ically . W h e n th is h a p p e n s ,
d e n ia l a n d d e ta c h m e n t m a y a g a in in terv en e to
facilities w h o se a im is re s to rin g , in as few

sessions as possible, the psychological bala n c e
ree s tab lish a te n u o u s e q u il ib r iu m , on ly to be

followed by a re p e titio n of fearsom e r u m i n a
of person s in states of e m o tio n a l e x citem en t or
tions. It is as if th e in d iv id u al is b o th d en y in g
a n d th e n tr y in g so m e h o w to a c q u ir e u n d e r
te lep h o n e
services,
and
variety
collapse.
W h a t h a s becom e p ain fu lly a p p a r e n t is th a t
sta n d in g
practically every ind iv id u al alive is a p o te n tial
and
to
resolve a n x ie ty a n d
guilt.
V a r i o u s r e a c t i o n s to a n d d e fe n s e s a g a i n s t
c a n d id a te for a b re a k d o w n in th e ad a p tiv e
a n x ie ty m a y p re c ip ita te self-accusations, a g
e q u il ib r iu m if th e stressful p res su res a r e suffi
g ression, p h o b ia s , an d excessive ind ulg ence in
ciently severe. A crisis m a y p re c ip ita te a r o u n d

an y incident th a t o v e rw h e lm s o n e s co p in g ca
pacities. T h e crisis s tim u lu s itself b e ars little
r e la tio n s h ip to th e in tensity of th e v ic tim s
reaction. S om e p erso n s can to le ra te w ith e q u a
n im ity tr e m e n d o u s h a rd s h ip s an d adversity.
O t h e r s will sho w a c a ta s tr o p h ic res p o n se to
w h a t seems like a m in o r m is h a p . A specifically
alcohol or tr a n q u il iz e rs . M o r e o v e r , d o r m a n t
p a st conflicts m a y be a ro u s e d , m a r s h a ll in g
n e u ro tic sy m p to m a tic a n d d isto rted c h a rac terologic d isplay s. At th e core of this c o n fo u n d
ing cycle of d e n ia l a n d tw isted rep etitiv e r e
i m p o r t a n t event, like a b a n d o n m e n t by a love

object, can to u ch off an explosive reac tio n in
m em bering
is, first, th e
m i n d s a tt e m p t to
p ro tec t itself by re p re ssin g w h a t h a d h a p p e n e d

a n d , second, to heal itself by re p ro cessin g a n d
w o r k in g t h r o u g h th e t r a u m a t i c e x p e rie n c e in
o r d e r to reconcile it w ith th e p re s e n t reality
one w h o w o u ld resp o n d m u c h less dra stica lly

to b om b in g s, h u rr ic a n e s , cataclysm ic floods,
s h i p w r e c k , d i s a s t r o u s re v e r s e s o f e c o n o m i c
fo rtu n e , an d m a j o r accidents. T h e tw o i m p o r
ta n t variab les a re, first, th e m ean in g to th e in
situa tio n. In a n individual w ith good ego

stre n g th this stru g g le u su a lly te r m i n a te s in a
successful res o lu tio n of th e crisis event. T h u s ,
follow ing a crisis situ a tio n , m ost p e o p le a r e c a
div idu al of th e c a la m ity a n d , second, th e f le x
u p th e pieces, p u tt in g th em selv es to g e th e r, a n d
p ab le after a p erio d of 4 to 6 w eeks of p ick in g
208
CRISIS INTERVENTION
209
lines s i m i la r to
tim e to p ro v id e for re s o lu tio n of in n e r conflicts
before. P eo ple w h o com e to a clinic o r to a
a n d th e re shu fflin g of th e in tra p s y c h ic s tru c
p riv a te p ra c titio n e r a re th ose w h o h ave failed
tu r e , th e m o st w e can h o p e for is to b r i n g the
to achieve re s o lu tio n of stressful life events.
p a ti e n t to so m e a w a re n e ss of h o w u n d e rl y in g
In som e of th ese less fo r tu n a te in d iv id u als

th e ou tcom e is d u b io u s , e v e n tu a tin g in p r o
p ro b l e m s a r e re la te d to th e i m m e d i a te crisis. It
longed an d even p e r m a n e n t c rip p lin g of fu n c
significance o f th is associatio n a n d in th e p o s t
tion in g. T o s h o r te n th e s tru g g le a n d to bolster
t h e r a p y p e rio d w o r k t o w a r d a b e tt e r m e n t of
success
fu n d a m e n ta l c h a ra ctero lo g ic disto rtio ns. O b

viously, w h e r e m o r e t h a n th e u s u a l six-session
re s u m in g
th e ir
in
lives a lo n g
tho se
who
o th e r w is e
w o u ld
be
destined to a failing a d a p ta tio n , p s y c h o th e ra p y
is g ratify in g h o w som e p a ti e n ts will g r a s p the
offers the in divid ual a n excellent o p p o r t u n it y
lim it o f crisis-o rien ted t h e r a p y c an b e offered,
to deal con structively w ith th e crisis.
th e g re a t e r w ill be th e p ossibility of d e m o n
In th e p sy c h o th e ra p e u tic tr e a t m e n t of crisis
situ atio n s (crisis t h e r a p y ) th e goal is r a p i d
s t r a ti n g th e o p e ra tiv e d y n am ic s. Y et w h e r e th e
e m o tio n al relief a n d no t basic p e rs o n a lity

m odification. T h i s does n ot m e a n t h a t w e
th e e x isting crisis often s tim u la te s such a m o ti
neglect o p p o r t u n it ie s to effectuate p e rs o n a lity
nifica nt
q uo .
change.
Since
such a lt e ra t io n s
w ill
re q u i r e
p a ti e n t possesses a m o tiv a tio n for c h a n g e a n d

v a ti o n even six sessions m a y re g iste r a sig
im p a c t
on
th e p sy chological
statu s
Variables Determining the M ode of

Crisis Therapy
Catastrophic Symptoms Requiring
Immediate Attention
Selection of te c h n iq u e s in crisis t h e r a p y a re
g eared to fo u r v a riab les (W o lb e rg , 1972). T h e
first
v a ria b le
we
must
con sider
re la te s
to
ta t io n s w ith a p sy c h ia trist skilled in th e a d m i n

is tra tio n of so m a tic t r e a tm e n ts w ill, of course,
be in ord er. E le ctro co nv ulsiv e t h e r a p y m a y be
necessary to i n t e r r u p t suicidal d ep re s sio n o r e x
citem en t. A cu te psychotic a tt a c k s u s u a lly yield
to a re g im e n of th e n e u ro le p tic s in th e m e d i u m
cata str o p h ic s y m p to m s th a t re q u i r e im m e d ia te
h a n d lin g . T h e m ost co m m o n e m e rg en cie s a re
severe d e p ression s w ith stro n g suicidal t e n
of a su p p o r tiv e a n d sy m p a th e tic re la tio n s h ip . It
dencies, a cu te psychotic u p sets w ith aggressive

o r b iz a r re b eha vio r, in ten se a n x ie ty a n d p a n ic
states, excited hysterical re actio n s, a n d d r u g
w ith m i n im a l ex p res sio n s of c e n s u r e o r in

c re d u lity for d elu s io n al o r h a ll u c in a t o r y c on
tent. P a n ic re a c tio n s in th e p a ti e n t r e q u i r e not
o n ly fo rtitu d e o n th e p a r t of th e th e r a p is t , b ut
a n d a lc o h o l ic i n t o x i c a t i o n s . O c c a s i o n a l l y ,
sy m p to m s a r e sufficiently severe to c o n stitu te a
p o rte n to u s th r e a t to th e in d iv id u al o r o thers,
u n d e r w h ich circu m sta n c es it is essential to
consider im m ed iate h o sp ita liz a tio n . C o n
ferences w ith re spo nsible relatives o r friends
will th e n be essential in o r d e r to m a k e provision
for th e most a d e q u a t e resou rce. F o r t u n a te l y ,
t h i s c o n t i n g e n c y is r a r e b e c a u s e of th e
availability of m o d e r n so m a tic t h e r a p y . C o n s u l
m a y r e q u i r e a lm o s t s u p e r h u m a n f o r e b e a ra n c e
to listen a tte n tiv e ly to th e p a t i e n t s co ncerns,
also th e ab ility to c o m m u n ic a t e c o m p a s sio n

b len d e d w ith h o p e. In a n em e rg e n c y r o o m in a
h o sp ita l it m a y be difficult to p ro v id e th e q u ie t
objective a t m o s p h e r e t h a t is needed, b u t a n a t
tentiv e s y m p a th e tic d o cto r o r n u rs e c a n do
m u c h to r e a s s u r e th e p a tie n t. L a te r , fr e q u e n t
v is its , e ven d a i l y , d o m u c h to r e a s s u r e a
f r ig h te n e d p a ti e n t w h o feels h im se lf o r h erself to
be o u t of co n trol.
210
L ess c a ta s tr o p h ic sy m p to m s a r e h a n d le d in
acc orda nce w ith th e p re v a ilin g em o tio n a l state.
T h u s d u r i n g th e first stages of d enial a n d
d e ta c h m e n t, tech n iq u e s of co n fro n ta tio n an d
active in te r p r e ta ti o n of resistances m a y h elp to
get th e p a tie n t talk ing . W h e r e th e r e is e x tre m e
respectful li sten in g a n d q u e s tio n in g will give

th e
th e r a p is t
d a ta
r e g a r d in g
th e
character
s tr u c tu r e of th e p a tie n t, th e need for u p s e ttin g

involvem ents, projective tendenc ies, a n d th e le
g itim a te h a r d s h i p s to w h ic h th e p a ti e n t is
in e s ca p a b ly exposed. A n a ss ay of th e e x istin g
rep re ssio n , h y p n o tic p ro b i n g a n d n a rc o a n a ly sis

m a y be useful. O n the o th e r h a n d , w h e r e the
a n d p o te n tia l in n e r stre n g th s in re la tio n to th e
p a ti e n t is flooded by a n x ie ty , ten sio n, guilt,

s t re s s fu l
id entification of re m e d ia b le p ro b le m a re a s will
en a b le th e t h e r a p is t b e tte r to focus th e t h e r a
events, a tt e m p t s a r e m a d e to reesta blish c o n

trols th r o u g h r e l a x a ti o n m e th o d s (like m e d i ta
p eu tic efforts. C ru c ia l is so m e kin d of cognitive

re p ro cessin g t h a t is m ost effectively a c c o m
tion , au to gen ic tr a in i n g , re la x in g h y p n o t h e r
a p y , a n d bio feedback), or by p h a rm a c o lo g ic a l
plished by in t e r p r e ta ti o n . T h e object is to h e lp
th e p a ti e n t find a different m e a n i n g for the
tr a n q u il iz a t io n (V a liu m , L ib r i u m ) , o r by rest,
u p s e ttin g events a n d to evolve m o r e a d e q u a t e
diversions (like social activities, hobbies, an d
w a y s of coping.
and
ru m in atio n s
concerning
th e
o ccu p atio n al th e r a p y ), o r by b e h a v io ral d e se n

sitization a n d rea s su ra n c e .
The Nature of the Precipitating

Agency
u n a v o id a b le stresses th a t m u s t be e n d u r e d a n d
The Impact of the Family on the

Patient
T h e th i r d v a ria b le , th e im p a c t on th e p a
tient of th e fam ily system, is especially i m p o r
u n d e r re a s o n a b le r e s tra in t, a tte n tio n can be
t a n t in c h ild re n a n d ad olescen ts as well as in

th ose living in a closely k n it fam ily system .
focused on th e second im p o r t a n t v a ria b le in the
T h e im p a c t of th e fam ily m a y n ot be i m
crisis reaction , th e n a t u r e of the p re c ip ita tin g

agency. T h i s is u su a lly in th e form of som e e n
m e diately a p p a r e n t , b u t a crisis fre q u e n tly in

dicates a co lla p sin g fam ily system , th e en d
v ir o n m e n ta l episod e t h a t th r e a te n s th e in d i
v id u a ls security o r d a m a g e s th e self-esteem. A
re su lt of w h ic h is a b r e a k d o w n in th e identified
p a t i e n t s c a p a c i t i e s fo r a d a p t a t i o n . C r i s i s
d ev elo p m en tal crisis, b ro k e n love affair, rejec

tion by or d e a th of a love object, violent
th e o r y a ss u m e s th a t th e fam ily is th e basic u n it

a n d th a t a n e m o tio n a l illness in a n y fam ily
m e m b e r c o n n o te s a d is r u p ti o n in th e fam ily
ho m eostasis. S uch a d is r u p ti o n is n ot a lto
g e th e r b a d b ecau se t h r o u g h it o p p o r t u n it ie s
a r e o p e n e d u p fo r c h a n g e w i t h p o t e n t i a l
O n c e tr o u b le s o m e s y m p to m s
a re b ro u g h t
m a r it a l discord, p ers istin g d e lin q u e n t b e h a v io r

a n d d r u g c o n s u m p tio n by im p o r t a n t fam ily
m em bers, tra n sp o rta tio n or in d u strial and
o th e r accidents, d ev elo p m en t of an in c a p a c ita t
ing o r life -th re a te n in g illness, c a la m ito u s fi
n a n c ia l reverses, a n d m a n y o th e r p rovocative
events m a y be th e trig g ers t h a t set off a crisis.
It is r a r e th a t th e e x te r n a l p re c ip ita n ts th a t the
p a ti e n t holds re spo nsible for th e p re s e n t t r o u
bles a r e entirely o r even m ost i m p o r t a n tl y the
cause.
Ind eed, th e th e r a p is t will u su a lly find th a t
th e p a tie n t p a rtic ip a te s actively in in itiatin g
a n d su s ta in in g m a n y of th e e n v ir o n m e n ta l m is
benefit to each m e m b e r. T r a d i t i o n a l p sy c h o
t h e r a p y a tt e m p t s to tr e a t th e ind ivid ua l p a ti e n t
a n d often relieves th e fam ily of res p o n sib ility
for w h a t is g o in g on w ith th e p a tie n t. C risis
th e o ry , on th e o th e r h a n d , insists t h a t ch a n g e
m u s t involve m o r e t h a n th e p a tie n t. T h e most
f r e q u e n t l y u s e d m o d a l i t y , c o n s e q u e n t l y , is
fam ily t h e r a p y , th e object of w h ic h is th e
h a rn e s s in g a n d e x p a n s io n of th e con structiv e
elem en ts in th e fam ily s itu a tio n . T h e th e r a p is t
fo rtu n es th a t p re s u m a b ly a r e to b lam e. Yet
does
not
attem p t
to
h alt
th e
c r i s is
by
CRISIS INTERVENTION
211
re a s su ra n c e b ut r a t h e r to utilize th e crisis as
te rv e n tio n is a s h o r t- t e r m process, it sh o u ld be
an in s tr u m e n t of change. D u r i n g a crisis a
m a d e clear t h a t visits a r e lim ited. T h i s is to
fam ily in distress m a y be w illin g to let a t h e r a
a v o id d e p e n d e n c i e s a n d r e s e n t m e n t s a b o u t
t e r m i n a ti o n .
pist e n te r into th e p ictu re, re c o g n iz in g th a t it

c a n n o t by it s e l f c o p e w i t h t h e e x i s t i n g
em ergency. T h e b o u n d a rie s a r e at th e s tart
fluid en o u g h so th a t n ew con solid atio ns be
come possible. T h e fam ily system p r i o r to the
crisis a n d after th e crisis u su a lly seals off all
p o in ts of en try . D u r i n g th e crisis, before n ew
a n d p e r h a p s even m o re d estru ctiv e decisions
have been m a d e , a p o in t is re ach ed w h e r e we
The Patient's Behavior and Its

Roots
T h e fo u r th v a ria b le is often the c rucial fac
to r in in tia tin g th e crisis situ atio n . U n reso lv ed
m a y in tro d u ce som e n ew perspectives. T h i s
a n d d e m a n d i n g c h ildh oo d needs, defenses an d

conflicts th a t o b tr u d e them selves on a d u lt a d
p o in t m a y exist for on ly a sh o rt p erio d of tim e;
j u s t m e n t , a n d co m pulsively d ra g o o n th e p a
th erefo re it is vital th a t th e r e be no delay in
tie n t in to activities th a t a re b o u n d to en d in
r e n d e r in g service.
T h u s a crisis will p e rm it in te rv e n tio n th a t
disa ste r, w o u ld seem to invite e x p lo r a ti o n s th a t

a th e r a p is t , tr a in e d in d y n a m ic p s y c h o t h e r a
w o uld not be acc eptable before n o r s u b s e q u e n t
p eu tic m e th o d o lo g y , m a y w ith som e p ro b in g
to th e crisis explosion. O n e d e te r e n t fr e q u e n tly

is the fa m ily s insistentence o n h o sp ita liz a tio n ,
be able to identify. T h e ab ility to relate th e p a
no lon ger being able to cope w ith th e identified

p a t i e n t s u p s e ttin g beh avior. A ltern ativ es to
ing, a n d th e circ u m sta n c e s of th e ir d ev elo p
h o sp ita liz a tio n will p re s e n t them selves to an
recog nition of h o w p e rs o n a lity difficulties have
astu te th e r a p ist w h o estab lish es contact w ith

the family. Som e of the o p era tiv e d y n a m ic s
b r o u g h t a b o u t th e crisis, w o u ld be h ig h ly d e
sirable, p r o b a b l y c o n stitu tin g th e difference b e
m a y become s ta rtin g ly a p p a r e n t by listen ing to
tw een m erely p a llia tin g th e p re s e n t p ro b le m
th e in te rc h a n g e s of the p a tie n t an d th e family.
a n d p r o v id in g so m e p e r m a n e n t so lutio n for it.
The
m ost im p o r t a n t resp o n sib ility of the
t i e n t s o u tm o d e d a n d n e u ro tic m odes of b e h a v
m e n t in e a rly co nd itio n in g s, as well as th e
th e r a p is t is to get the fam ily to u n d e r s ta n d

whac is going on w ith th e p a ti e n t in th e ex is t
S in c e t h e g o a l s of c risis i n t e r v e n t i o n a r e
lim ited , h ow ev er, to re e s ta b lish in g th e precrisis
e q u il ib r iu m , a n d th e tim e allo tted to t h e r a p y is
ing setting an d to d e te rm in e w h y th e crisis h as
circu m sc rib ed to th e m e re a c h ie v em en t of this
occu rred no w . U n d e r s t a n d a b l y th ere is a h is
goal, w e m a y no t be a b le to do m u c h m o re
tory to the crisis a n d a v ariety of so lu tion s have
t h a n to m erely p o in t o ut th e a re a s for f u r th e r
been tried. T h e th e r a p is t m a y ask h im self w h y
w o r k a n d e x p lo r a tio n . B ecause crisis th e r a p y
th ese m e a s u re s w e re a tte m p te d a n d w h y th ey
is goal limited, th e r e is a te n d en c y to veer
failed, o r at least w h y th ey have no t succeeded

sufficiently. T h e fam ily sho uld be involved in
solutions to be utilized a n d sho uld h ave an
idea as to the reaso n s for this. A ssig n m e n t of
tasks for each m e m b e r is an excellent m eth o d
of getting peo ple to w o rk to g e th e r a n d such
a ssig nm en ts m a y be q u it e a r b i t r a r y ones. T h e
a w a y fro m in sig h t th e r a p ie s o rg a n iz e d a r o u n d
p sy c h o d y n a m ic m od els t o w a r d m o re active beh a v io r a l- le a r n i n g te c h n iq u e s, w h ich a r e d i
re c t e d at r e i n f o r c i n g a p p r o p r i a t e a n d d i s
c o u ra g in g m a l a d a p ti v e beh av ior. T h e effort
h a s been d irec ted t o w a r d th e tr e a t m e n t of co u
im p o r t a n t th i n g is to get every m e m b e r in
volved in some w ay . T h i s will b rin g out
certain resistances w h ich m a y have to be n e
gotiated. T r a d e s m a y be m a d e w ith th e object
of securing b etter co o p era tio n . Since crisis in
ples, of en tire fam ilies, a n d o f g r o u p s of n o n r e

lated peo p le as p r i m a r y th e r a p e u ti c i n s t r u
m en ts. T h e basic th e r a p e u ti c th r u s t is, as has
been m en tio n e d , o n such p ra ctica l a re a s as th e
im m e d ia te d is tu r b i n g e n v ir o n m e n t a l situ a tio n
and
th e p a t i e n t s d is ru p tiv e sy m p to m s, e m
212
plo ying a co m b in a tio n of active p ro c e d u r e s like
crisis t h e r a p y
d r u g t h e r a p y a n d m ilieu t h e r a p y . T h e few
th e r a p e u ti c p r o g r a m .
sessions devoted to t r e a tm e n t in crisis in te rv e n
In
p lanning
o rg a n i z in g
o r in a c o n ti n u in g
a c o n ti n u in g
program
we
tion certainly p rev en t a n y extensive concern
m u s t recognize, w ith o u t m i n im iz i n g th e v alue
w ith th e o p e ra tio n s of un con sciou s conflict. Yet

a g re a t deal of d a t a m a y be o b ta in e d by ta lk in g
of d e p th a p p r o a c h e s , t h a t n o t all perso n s,
a s s u m in g th a t th e y can afford lo n g - te rm t h e r
to th e p a ti e n t a n d by stu d y in g th e in te ra c tio n s
a p y , a re sufficiently well m o tiv ate d , in tro sp e c
of th e fam ily,
in fam ily th e r a p y a n d
tive, a n d possessed of q u a litie s of sufficient ego
t h r o u g h th e o b s e r v a t i o n s o f a p s y c h i a t r i c
n u rs e , c a se w o rk e r, o r p sy ch iatric te a m w h o
s tre n g th to p e r m it th e use of o th e r t h a n e x
visit th e hom e. Such d a ta will be helpful in
aim e d at crisis res o lu tio n an d s y m p to m relief.
b o th
p e d ie n t, w o rk a b le , a n d g o a l-lim ite d m eth o d s
Technical Suggestions
The
average
p atien t
app ly in g
fo r h e l p
g enerally c o m p la in s a b o u t a d is tu rb i n g s y m p
to m such as ten sio n, a n x ie ty , d epressio n , i n
so m n ia , p a n ic k y feelings, physical p ro b le m s,
a n d so on. A ssociated life events a r e con sidered
seco nd ary c ircu m stan ces even t h o u g h it m a y
becom e obvious th a t th ey a re th e p r i m a r y e tio
logical p re c ip ita tin g agencies. S o m etim e s the
p a tie n t recognizes th e im p o rta n c e of a t r a u
m atic situ atio n , such as s e p a r a tio n , divorce,
d e a th of a fam ily m e m b e r, a n accident, o r fi
na n cia l
d isa ster,
and
will focus dis cussions
a r o u n d pain fu l associations to these. In a p

p ro a c h in g such a p a tie n t, e m p a th ic listen ing is
th e keynote. T h e most th a t can be d on e d u r i n g
th e first tw o sessions is to identify th e key t r o u
ble are as, a n d p e r h a p s re a s s u re th e p a tie n t
th a t th e r e are w ay s of co pin g w ith th e diffi
culty since o th e rs h ave also gone t h r o u g h sim i
la r u p s e ttin g events a n d w ith p r o p e r t h e r a p y
hav e o vercom e th e m a n d even h ave gotten
s tro n g e r in th e process. T h e follow ing is a n e x
cerp t from a n early interv iew w ith a w o m a n
suffering fro m a reactive de pression.
Pt.
It all se em s hop eless.
I j u s t c a n t se em to p ull
m y se lf t o g e t h e r af ter J a c k left m e. I k eep fall

in g a p a r t a n d c a n t in te r e st m y se lf in a n y t h i n g .
T h . Y o u r r e a c t i o n is c e r t a i n l y u n d e r s t a n d a b l e .
W h y s h o u l d n t y o u feel i n d i g n a n t , h u r t a n d
a n g r y , a n d d e p r e ss e d . B u t y o u w o u l d like to
get o v e r J a c k , w o u l d n t y ou, a n d g o o n to be
h ap p y again?
Pt. (p a u se ) D o y o u t h i n k t h a t s p o ss ib le?
T h . If I d i d n t, I w o u l d n t be s i t t i n g h e r e w i t h you.
O th e r w o m en have gone th ro u g h sim ilar deser
t i o n s a n d h a v e c o m e o u t on t o p . A n d y o u can
too.
Pt. I d like to st a rt .
T h . W e h a v e s t a rt e d .
In allo w in g a p a ti e n t to focus o n his p r e s e n t
in g p r o b l e m the th e r a p is t m u s t alw a y s a tt e m p t
to a n s w e r th e q u e stio n s W h y n o w ? W h y did
the difficulty b r e a k o u t at th is tim e ? D id the
p a ti e n t in an y w a y p a rtic i p a te in b rin g in g
a b o u t th e crisis? T h o u g h th e la t te r m a y seem
obvious, th e p a ti e n t m a y n ot see this clearly,
bu t t h r o u g h in te rv ie w in g a n d clarification he
m a y be h e lp ed to identify th e sources of th e
crisis a n d o n e s p e rs o n a l p a r t ic i p a ti o n in it.
It is i m p o r t a n t to be a lert to h o w th e crisis
c a n be c o n v e r t e d i n t o a n o p p o r t u n i t y fo r
ch an g e. A p p r a is a l of th e p a t i e n t s ego stre n g th ,
flexibility, a n d m o tiv a tio n a r e h elpful, t h o u g h
th is assay at first m a y n ot be e ntirely accu rate.
T h e p a ti e n t w h e n first a p p ly i n g for h e lp is at
low ebb a n d m a y n ot p re s e n t a n o p tim istic p ic
tu r e of la te n t p o tentialities. T h e s e m a y filter
t h r o u g h l a t e r o n as h o p e p e n e t r a t e s th e
d epressive fog in w h ic h th e p a ti e n t is e n
veloped.
A s p ro b le m s becom e clarified a n d identified
CRISIS INTERVENTION
213
th r o u g h in terv iew in g , th e p a tie n t a n d th e
v ery actively to stress a n d suffer a g oo d deal.
fam ily in fam ily th e r a p y will b e tte r be a b le to
Y o u c a n d o s o m e t h i n g a b o u t t h i s to r e d u c e
deal w ith such p ro b le m s constructively. T h e

th e r a p is t m a y som etim es do n o th in g m o r e th a n
y o u r o v e r r e a c t i o n to stress.
facilitate ven tilatio n of th o u g h t s a n d feelings

a m o n g th e fam ily m em b e rs. V e rb a li z a ti o n a n d
co m m u n ic a tio n h av e g re a t p o w e rs of h ealing .
T h e th e r a p is t need not sit in j u d g m e n t over
w h a t is being said n o r a lw a y s offer golden
w o rd s of advice. By k ee p in g c o m m u n ic a tio n
T h e fo llow ing is a s u m m a t io n of p rac tical

p o in ts to p u r s u e in th e p ractic e of crisis i n t e r
vention.
1. See the p a tie n t within 24 hours o f the

calling fo r help even if it m e a n s cancelin g an
a p p o in t m e n t . A crisis in th e life o f a n in d i
o p en , by ask in g the rig h t q u e stio n s, o ne m a y
v id u al is a p t to m o tiv a te o n e to seek h e lp from
h elp the fam ily to p rod uctiv e decisions th a t

will lead to p ro b le m solving a n d re solu tion . It
som e o utside agen cy t h a t o th e r w is e w o u ld be

a v o id e d . S h o u l d s u c h a id be i m m e d i a t e l y
m a y be difficult at th e s tart to get th e fam ily

m e m b e rs to o p e n u p after y ears of w i t h d r a w a l
a n d secret m a n ip u la tio n s . A sim p le inv itatio n
like I believe yo u will all feel b e tte r if you
each tell m e w h a t is on y o u r m i n d m a y get
th e c o n v e r s a t i o n a l
p ro c e s s
g o in g .
If n o n e
starts, th e th e r a p is t m a y ask a p e r t in e n t q u e s
tion as a n o p e n e r o r m a k e a sim p le s t a te m e n t
such as I ll bet each of you feels w o rrie d
a b o u t w h a t h a s h a p p e n e d . W h y d o n t yo u each
talk a b o u t th i s .
Som e p a tie n ts a re ex tre m e ly concerned w ith
th e ir physical sy m p to m s th a t a cc o m p a n y o r a re
m a n ifesta tio n s of a nx iety , a n d th e y m a y be
convinced, in spite of n egativ e physical fin d
ings, th a t th ey h ave a t e r m i n a l disease. W h e r e
th e r e is a p re o c c u p a tio n w ith th ese sy m p to m s,
a n e x p la n a tio n such as the follow ing m a y help:
u n a v a ila b le , o n e m a y in d e s p e r a tio n exp loit

sp u r io u s m e a s u re s a n d defenses t h a t a b a te th e
crisis b u t c o m p r o m is e a n o p ti m a l a d ju s tm e n t.
M o r e insidiously, th e in centive for t h e r a p y will
v an is h w ith re s o lu tio n of th e em e rg en cy. T h e
th e r a p is t s h o u ld , th erefo re, m a k e every effort
to see a p e rs o n in crisis p re f e ra b ly o n th e very
d a y th a t h e lp is req u es ted .
2. A t th e in itial interv iew alert you rself to
patien ts a t high risk fo r suicide. T h e s e a r e (a)
p e rs o n s w h o h a v e a p rev io u s h is to ry o f a t
te m p ti n g suicide, (b) e n d o g e n o u s d e pression
( h i s t o r y o f c yclic a t t a c k s , e a r l y m o r n i n g
a w a k e n in g , loss o f ap p e tite , r e t a r d a t i o n , loss of
en erg y o r sex drive), (c) y o u n g d r u g a b u sers,
(d) alcoholic fem ale p a tie n ts , (e) m id dle-ag ed
m e n recently w id o w e d , div orced, o r se p a r a te d ,
(f) elderly isolated persons.
3. H andle im m ediately any depression in
T h . W h e n a p e r s o n is u p se t e m o t i o n a l l y ev ery p a r t
the above patients. Avoid h o s p ita liz a tio n if
of t h e b o d y is affected. T h e h e a r t goes faster;
possible excep t in d eep d ep re s sio n s w h e r e a t

te m p ts a t suicide h av e been m a d e rece n tly o r
t h e m usc le s get t e n s e r; h e a d a c h e s m a y o ccur;

o r t h e st o m a c h m a y g et u pse t. P r a c t i c a l l y ev ery
organ
in t h e b o d y m a y be affected.
F o rtu
n a t e l y , w h e n t h e e m o t i o n a l u p s e t p asses, t h e
o r g a n s w ill t e n d to recover.
S ho uld the p a ti e n t w o n d e r w h y o th e r p eo p le
react less intensely to tr o u b le s t h a n h e does
a n d b lam e h im self for failing, he m a y be told
th a t he can do so m e th in g a b o u t it:
th e p a s t o r a r e seriously t h r e a te n e d n o w . Electroconvulsive t h e r a p y is best for d a n g e r o u s

d epressions. In s titu te a n ti d e p r e s s a n t m e d ic a
tio n s (T o fr a n il, E lav il, S in e q u a n ) in a d e q u a t e
dosage w h e r e th e r e is n o im m e d ia te risk.
4. Evaluate the stress situation. D o e s it
a res p o n s i v e p e r s o n to even
seem sufficiently a d e q u a t e to acc o u n t for th e

p re s e n t crisis? W h a t is th e fam ily situ atio n ,
a n d h o w is it re la te d to th e p a t i e n t s u p se t?
W h a t w e re p a s t m o des of d e a lin g w ith crises,
a n d h o w successful w e re th e y ?
5. E valuate the existing su pport system s
n u a n c e s , b u t also b a d for y o u since y o u r eact
available to the p a tien t th a t y ou c a n u tilize in
T h . C h i l d r e n a r e b o r n d i f fe r e n t s o m e a r e active,
so m e less active. Y o u h a v e a sensitive n e r v o u s
system , w h i c h is b o t h go o d a n d b a d ; g oo d b e
ca u s e y o u a r e
214
th e th e r a p e u tic p la n . H o w solid a n d reliab le

a r e certa in m e m b e rs of th e fam ily ? W h a t c o m
m u n i ty resources a re av ailab le? W h a t a re the
11. A v o id e x p lo rin g f o r d y n a m ic fa cto rs.

T i m e in t h e r a p y is too sh o rt for this. T h e r a p y
m u s t be rea lity o rien ted , g e a re d t o w a r d p r o b
s tren g th s of th e fam ily w ith w h o m th e p a tie n t
lem solving. T h e goal is re s to ra tio n of th e
w ill live?
6. E s tim a te th e p a t i e n t s ego reso u rc e s.
precrisis stability. B u t if d y n a m ic factors like

tra n sfe re n c e p ro d u c e resistan ce to t h e r a p y o r
W h a t ego resou rces does th e p a ti e n t h av e to
to th e th e r a p is t , deal r a p i d ly w ith th e r e
d ep e n d on, estim a ted by successes a n d achiev e

m en ts in th e p a s t ? Positive cop ing capacities
sistances in o r d e r to dissipa te th e m . W h e r e d y
n a m ic m a t e r i a l is t h r o w n at th e th e r a p is t,
a re of g re a te r im p o rta n c e t h a n the p rev ailin g
u tilize it in tr e a t m e n t p la n n i n g .
12. A im f o r in c r e a sin g se lf-r e lia n c e a n d
path ology.
7. H elp the p a tie n t to an a w a ren ess o f the
fin d in g a lte rn a tiv e co n stru ctive so lu tio n s fo r
fa cto rs in volved in th e reaction to th e crisis.
p ro b le m s. It is essential th a t th e p a tie n t a n t i
T h e p a t i e n t s in te rp e r s o n a l re latio ns sh o u ld be
cip ate fu tu re sources o f stress, l e a r n in g h o w to
review ed in th e h o p e of u n d e r s ta n d in g an d
cope
re e v alu atin g attitu d e s a n d p a tt e r n s th a t get the
skills a n d e lim in a tin g h a b its a n d p a t t e r n s th a t
p a ti e n t into difficulty.
8. P rovide though tfu l,
ca n lead to tro u b le .
13. A lw a y s in vo lve th e fa m ily or sign ifican t
e m p a th ic
listen in g
w ith
th ese
by
s t re n g th e n i n g
a d a p tiv e
are
oth ers in th e trea tm e n t p la n . A crisis r e p r e
essential to e n h a n c e th e w o rk in g r e la tio n s h ip
a n d to resto re h op e. T h e th e r a p is t m u s t com
sents b o th a n in d iv id u al a n d a fam ily system

collapse, a n d fam ily t h e r a p y is helpful to a lte r
m u n ic a te a w a re n e s s of th e p a t i e n t s difficulties.
T h e p a ti e n t sh ou ld be h elp ed to re alize w h a t
th e fam ily system. A fam ily m e m b e r o r signifi

c a n t frien d sh o u ld be assig ned to supervise
p ro b le m s a re stress re la te d a n d th a t w ith
g u id a n c e o ne c a n le arn to cope w ith o r rem ov e
d r u g in ta k e w h e r e p res c rib ed a n d to s h a r e
and
s u p p o r tiv e
re a ssu ra n c e .
T hese
th e stress.
9. U tilize tra n q u ilizers o n ly w h ere a n x ie ty
is so g re a t th a t the p a tie n t can n ot m a k e deci
sions. W h e n th e p a ti e n t is so concerned w ith
fig htin g off a n x ie ty th a t th e r e is n o c o o p era tio n
w ith th e tr e a tm e n t p la n , p rescrib e an
anxiolytic (V a liu m , L ib riu m ) . T h i s is a te m p o
r a r y e xp ed ie n t only. In th e event a schizo
p h re n i c p a tie n t m u s t c o n tin u e to live w ith
hostile o r d is tu rb e d p a r e n t s w h o fail to r e
spo nd to or refuse ex p o su r e to fam ily th e r a p y ,
p rescrib e a n e u ro le p tic a n d establish a w a y to
see th a t m edicatio ns a re ta k e n re g u la rly .
10. D e a l w ith the im m ed ia te p r e s e n t a n d
a v o id p ro b in g o f the p a st. O u r chief co ncern is
th e h e re a n d no w . W h a t is th e p a t i e n t s
p re s e n t life s itu a tio n ? Is tr o u b le im p e n d in g ?
T h e focus is on a n y im m e d ia te d is ru p tiv e
s itu a tio n respo nsible for th e crisis as w ell as on
th e corrective m e a s u re s to be exploited. H i s
torical m a te ria l is con sidered only if it is d i
rectly linked to th e c u rr e n t p ro b lem .
resp o n sib ility in d epressed p atie n ts .

14. G ro u p th e ra p y can also be h elp fu l b o th
as a t h e r a p y in itself a n d as a n a d ju n c t to in d i
v id u a l sessions. C o n ta c t w ith p eers w h o a re
w o r k in g t h r o u g h th e i r difficulties is r e a s s u ri n g
and ed u catio n al. Som e th e ra p is ts consider
sh o r t- t e r m g r o u p t h e r a p y s u p e r io r to in d i
v id u a l t h e r a p y for crises.
15. T e rm in a te th e ra p y w ith in six session s if
p o ssib le a n d in ex tre m e circu m stan ces no la ter
than 3 m o n th s a fter tre a tm e n t has s ta rte d to
avoid d ep en den cy . T h e p a ti e n t is a s s u re d of
f u r th e r h elp in th e fu tu re if re q u ire d .
16. W h ere th e p a tie n t n eeds a n d is m o ti
v a te d f o r fu r th e r h elp f o r p u rp o s e s o f g re a te r
p e r s o n a lity d e v e lo p m e n t a fte r th e p r e c r is is
eq u ilib riu m h as been resto red , in stitu te o r
refer f o r d y n a m ic a lly o rie n te d sh o rt-te rm th er
a p y . In m ost cases, ho w ev er, f u r th e r t h e r a p y is
n ot so u g h t a n d m a y n ot be needed. M a s t e r y of
a stressful life exp erien ce t h r o u g h crisis i n t e r
ven tio n itself m a y be followed by n e w l e a r n
ings a n d a t least som e p e rs o n a lity g ro w th .
CRISIS INTERVENTION
215
Com m on Questions About Crisis Intervention

W h a t w o u l d y o u c o n s i d e r a c ris is b y d e f i
n ition ?
W h a t co n stitu te s a crisis v a rie s in d e fin itio n .
S om e re stric t th e d efin itio n to o n ly v io len t
em ergencies. O th e rs re g a rd a c risis as re a c tio n s
to an y s itu a tio n th a t u p se ts th e a d a p tiv e b a l
A re c o m m u n ity m e n ta l h e a lth concep ts of

a n y u s e i n c r is i s i n t e r v e n t i o n ?
D ra w in g on c o m m u n ity m e n ta l h e a lth c o n
c ep ts is c o n sid ered by som e to be of in e stim a b le
h e lp in crisis in te rv e n tio n (S ilv e rm a n , 19 7 7 ),
ance. M a n y co n sid er th a t a n y in d iv id u a l a p
p ly in g for h e lp is a c tu a lly in som e sta te of
p a rtic u la rly w h e n th e goal is a serv ic in g of

s iz a b le p o p u la tio n s . H e r e a p u b lic h e a lth
o rie n ta tio n e m p lo y in g system s th e o ry a n d an
crisis.
ecological p o in t o f view m a y re d u c e th e in c i
H o w f a r b a c k w a s c ris is i n t e r v e n t i o n o r
g a n i z e d as a s t r u c t u r e d t e c h n i q u e ? A r e
th e re u seful read in gs?
E ric L in d e m a n n (1944) w a s a m o n g th e first
to recognize th e valu e of c risis in te rv e n tio n in
his w o rk w ith
th e victim s o f th e C o co n u t
G ro v e (B oston) fire d isa ste r. T h e o rg a n iz a tio n

o f em ergency services in h o sp ita ls a n d c o m m u
n ity m en tal h e a lth cen te rs to h e lp p e rso n s u n
d en ce of fu tu re crisis a m o n g ta rg e t p o p u la
tio n s. Id e n tific a tio n o f p o te n tia l u se rs of m e n
ta l h e a lth services, e x p lo ra tio n o f th e k in d s of
p ro b le m s th a t ex ist, a n d a n assa y of a v ailab le
s u p p o rt sy stem s a n d service p ro v id e rs a re im
p o rta n t in p la n n in g e d u c a tio n a l p ro g ra m s as
w ell a s in fo sterin g p o litic a l a ctiv ity to m eet
e x istin g needs.
be m in ed v a lu a b le ideas a b o u t sh o rt-te rm in
Is t h e r e a n y w a y o f s o l v i n g t h e w a i t i n g lis t p r o b l e m , w h i c h i n m a n y c lin ic s p r e
v e n t s s e e i n g c r is is p a t i e n t s i m m e d i a t e l y ?
te rv en tio n (B u tc h e r & M a u d a l, 1976; C a p la n ,

1 9 6 1 , 1 9 6 4 ; C o le m a n & Z w e r lin g , 1 9 5 9 ;
m o st clinics. C o n v e rtin g lo n g -te rm th e ra p e u tic
d e rg o in g critical a d a p tiv e b re a k d o w n s h a s c o n
trib u te d a body of lite r a tu re o u t of w h ic h m ay
D a rb o n n e & A llen , 1967; H a r r is et al, 1963;

Ja c o b s o n , 1965; Ja c o b s o n et a l, 1965; K a lis et
a l, 1 9 6 1 ; M o r le y ,
S w a rtz , 1971).
1965;
R usk,
1971; J .
C a n o n e a p p l y t h e p r i n c i p l e s o f c r is i s i n
t e r v e n t i o n to c o n d i t i o n s o t h e r t h a n e m e r
ge n c ie s?
E m erg en cies c o n stitu te o n ly a sm all p r o p o r
tio n of th e co n d itio n s for w h ic h p e o p le seek
h elp . C rise s for th e m ost p a r t a re of a lesser
in ten sity , b u t, n o n eth eless, a re in need of im
m ed iate services to in su re th e h ig h e st d e g re e of
th e ra p e u tic effectiveness.
H o w to re d u ce w a itin g lists is a p ro b le m in
services to s h o rt-te rm services a n d th e use of
g ro u p th e ra p y a re often h e lp fu l. S om e in n o v a
tiv e p ro g ra m s h av e been devised to d eal w ith
th is situ a tio n , for e x a m p le , th e sc re e n in g e v a l
u a tio n
te c h n iq u e
d escrib ed
by C o rn e y
and
G re y (1 9 7 0 ) th a t a llo w s in all cases an im

m e d ia te access to p ro fe ssio n a l h e lp , e lim in a tin g
th e w a itin g list a n d serv in g as th e first ste p in
a c risis-o rie n te d p ro g ra m .
W h a t has th e e x p e rie n c e b e e n w ith w alk i n c lin ic s as to t h e k i n d s o f p a t i e n t s w h o

s e e k crisis i n t e r v e n t i o n ?
V ery m u ch so, b u t m ost p a tie n ts w ill r e

q u ire m o re sessions for a n a d e q u a te w o rk -u p ,
in s titu tio n of tr e a tm e n t, a n d fo llo w -u p . T h e
T h e r e is g e n e ra l a g re e m e n t on th e need for
a flex ible p o licy of a d m ittin g p a tie n ts for crisis
th e ra p y w ith o u t ex clu sio n irre sp e c tiv e o f d ia g
n o sis, age, a n d socioeconom ic s ta tu s. C itin g
th e ir e x p e rie n c e in o p e ra tin g th e B en ja m in
R u sh C e n te r, J a c o b s o n et a l (1 9 6 5 ) list som e
av erag e n u m b e r of sessions is six; so m e tim e s a

few m o re sessions a re given.
in te re stin g sta tistic s. A b o u t o n e -th ird of th e

p a tie n ts w e re d iag n o se d p sy c h o n e u ro tic , one-
A r e o n e - s e s s i o n c o n t a c ts f o r c ris is i n t e r
v en tio n of any v alue?
216
th ird p e rs o n a lity d iso rd e rs, o n e-fifth psy ch o tic,
su ch a s re h a b ilita tio n w o rk e rs, p ro v id e d th e y
an d so m ew h at less tr a n s ie n t situ a tio n a l d is

o rd ers. A p p ro x im a te ly 15 p e rc e n t h a d m ain ly
a re tra in e d to w o rk w ith p e o p le in crises.
acu te p ro b lem s, a n d 63 p e rc e n t h a d ch ro n ic
p ro b le m s w ith a c u te difficu lties su p e rim p o se d .
H a s a n y t h i n g b e e n d o n e w i t h c ris is i n t e r
v e n t i o n g r o u p s , a n d a r e t h e r e a n y l e a d s as
to t e c h n i q u e ?
In th e first y e a r a n d o n e -h a lf o f o p e ra tio n ,
5 6 .6 p e rc e n t of p a tie n ts saw th e ir th e r a p is t for
less th a n fo u r sessions, a lm o st o n e -h a lf h a v in g
S om e w o rk h a s been d o n e w ith crisis in te r
o n e session. O n ly 1.8 p e rc e n t h a d m o re th a n
v en tio n in a g ro u p se ttin g (B e rlin , 1970;

C r a r y , 1 9 6 8 ; S tr ic k le r & A llg e y e r, 1 9 6 7 ;
six visits. T h e im p ro v e m e n t ra te w as e stim a te d
T ra k a s
a t tw o -th ird s of th o se tre a te d . M o re d a ta on

th is q u e stio n m ay be fo u n d in C h a p te r 1,
L o s A n g eles P sy c h ia tric Service) crisis g ro u p
D o n t so c ial c a s e w o r k e r s d o a g o o d d e a l
o f crisis i n t e r v e n t i o n in s o c ia l a g e n c i e s ?
C risis th e r a p y is often a p p ro p r ia te ly m a n
a g e d by tr a in e d so c ia l w o r k e r s , a n d
th e o r e tic a l c o n c e p ts a s c o n c e p tu a liz e d
its
by
L lo y d ,
19 7 1 ).
A t th e
B e n ja m in
R u sh C e n te r-V e n ic e B ra n c h (a d iv isio n o f th e
th e r a p y
M o d e ls of S h o rt-te rm T h e r a p y .
&
is in s titu te d
w ith w a lk -in
p a tie n ts .
T h e g ro u p s a re o p e n -e n d e d a n d h e te ro g e n e o u s
(M o rle y & B ro w n , 19 6 9 ). T h e fo rm a t a llo w s
o n e in d iv id u a l p re g ro u p in te rv ie w fo llo w ed by
five g ro u p sessions. E x c lu d ed fro m g ro u p th e r
a p y a re se rio u s
su icid al o r h o m o c id a l risk s
a n d o v e rt psychoses. A t th e first g ro u p session
L in d e m a n n (1 9 4 4 ) C a p la n (1 9 6 1 ), a n d o th e rs
th e p a tie n t is a sk ed to tell th e g ro u p w h a t
a re c o m p atib le w ith g e n e ra l social w o rk th e o ry

(R a p a p o rt, 1962). In m a n y cases social case
b ro u g h t h im to th e clin ic. T h e th e r a p is t e n
c o u ra g e s th e p a tie n t to d iscu ss th e p re c ip ita t
w o rk by itself is m o re a d e q u a te ly d esig n ed for
in g fa c to r, th e ev en ts o f th e crisis a n d w h a t
c e r ta in p ro b le m s th a n p s y c h ia tr y . T y h u r s t
m e a su re s h a v e been ta k e n to solve it. T h e

g r o u p e x p lo r e s a l t e r n a t e c o p in g m e a s u re s .
(19 5 7 ) h a s re m a rk e d th a t tu r n in g to th e p sy
c h ia tris t m ay re p re se n t a n im p o v e rish m e n t of
reso u rces in th e re le v a n t social e n v iro n m e n t as
G r o u p s u p p o rt a n d th e e x p re ssio n of o p in io n s
a re o ften h e lp fu l. U n lik e tra d itio n a l g ro u p
m u ch as a n in d ic a tio n of th e ty p e of se v erity of
th e r a p y th e re is n o a n a ly sis m a d e of th e g ro u p
d is o rd e r.
p ro cess. M o s t o f th e tim e is sp e n t fo cu sin g on

each in d iv id u a ls p re s e n tin g p ro b le m . A go-
Is b e h a v i o r t h e r a p y e v e r u s e d in f a m i l y
t h e r a p y f o r c risis?
in g - a ro u n d
p ro c e d u re is em p lo y ed to give
used sh o w in g in te ra c tiv e sequences.
each p e rs o n a ch a n c e to ta lk . T ra n s fe re n c e in
te r p re ta tio n is m in im iz e d d u e to th e la c k of
tim e. In re v ie w in g re s u lts w ith 1 ,3 0 0 p a tie n ts
it is c la im e d th a t a n u m b e r o f a d v a n ta g e s a re
a v a ila b le to a c risis g ro u p as c o m p a re d to in d i
v id u a l th e ra p y . G r o u p s u p p o r t a n d r e a s s u r
a n c e h a v e been v a lu a b le . S ocial re la tio n s h ip s
W h a t t e a m m e m b e r s a r e b e s t in c r is i s i n
te rv e n tio n ?
h a v e d ev elo p e d b etw e e n th e m em b e rs a n d good

a lte rn a te c o p in g m e a s u re s seem to be m o re p a
la ta b le to a p a tie n t w h e n offered b y a m e m b e r
A w ide v a rie ty of te c h n iq u e s h av e been used

m a n y of th e m b e h a v io ra lly o rie n te d , fo r e x
am p le , feedback, m o d e lin g a n d ro le p la y in g ,
re h e a rs a l, a n d re c ip ro c a l re in fo rc e m e n t (E isle r
& H e rso n , 1 9 7 3 ). V id e o ta p e re p la y s a re also
In a clinic se tu p a te a m a p p ro a c h is id eal. A
good te a m fo r th e h a n d lin g o f em erg e n c ie s is a
p sy c h ia tric n u rs e , a p sy c h ia trist, a n d a p sy
c h ia tric social w o rk e r w h o h av e h a d tr a in in g
in em erg en cy p sy c h ia try a n d crisis in te rv e n
tio n . A m u ltid is c ip lin a ry te a m can also in clu d e
p sych ologists a n d m e m b ers o f o th e r d iscip lin e s,
w h o com es fro m th e sa m e s u b c u ltu ra l m ilie u

w ith k n o w led g e o f p ro b le m s a n d d efen ses e x
p lo ite d w ith in th e c u ltu re th a t a re b e tte r
k n o w n to th e g ro u p m e m b e rs th a n to th e th e r
a p is t. E x p r e s s io n o f s ig n if ic a n t fe e lin g s is
g r e a t e r in th e g r o u p th a n in in d iv id u a l
th e ra p y . T h e forces of m o d e lin g a n d d e se n s iti
CRISIS INTERVENTION
z a tio n a re also m o re p o te n t. O n e d isa d v a n ta g e
is th e g re a te r difficulty o f k e e p in g d iscu ssio n s
in focus.
217
D o e s n t a s h o r t p e r i o d o f h o s p i t a l i z a t i o n
p ro v id e a b re a th in g space fo r th e p a tie n t
i n a crisis?
H o s p ita liz a tio n sh o u ld be re s o rte d to o n ly as
Is it p o s s i b le to se lec t t e c h n i q u e s i n c r is i s
in te r v e n tio n th a t are specially su ite d fo r
ce rtain p atients?
a la st re s o rt re c o g n iz in g th a t it w ill solve little
S om e a tte m p ts hav e been m a d e to c o rre la te
th e ir in v o lv em e n t in th e c risis a n d fro m a lte r
resp o n ses to stressfu l even ts w ith th e c h a ra c te r
in g th e fam ily c lim a te th a t sp o n so re d th e crisis
stru c tu re s of th e victim s (S h a p iro , 19 6 5 ) a n d

th e n to choose te c h n iq u e s best su ite d for c h a r
in th e first p lace.
a c te r styles. H o ro w itz (1 9 7 6 , 1977) h a s o u t
S in c e c ris is i n t e r v e n t i o n is a k i n d o f
in g o p e r a t i o n to d e f u s e a c r i t i c a l
t i o n , s h o u l d n t a ll ca se s r e c e i v e
t h o r o u g h t r e a t m e n t a f t e r t h e c r is is
so lv e d ?
lined th e v a rio u s w ay s th a t h y ste ric a l, o b

sessio n al, a n d n a rcissistic p e rs o n a litie s re sp o n d
to stress as a co n seq u en ce o f th e ir u n iq u e c o n
flic ts , n e e d s, a n d d e fe n s e s. F o r e x a m p le ,
p re fe rre d te c h n iq u e s in th e h y ste ric a re o r
in th e lo n g ru n . In d e e d , it w ill p ro b a b ly be
used by th e fam ily a s a n esc ap e fro m facin g
h o ld
situ a
m ore
is r e
It is a m isc o n c ep tio n to conceive o f c risis in
g an iz e d a ro u n d d e a lin g w ith im p e d im e n ts to
te rv e n tio n a s a h o ld in g o p e ra tio n . L im ite d as it
p rocessing ; in th e obsessive, w ith m e th o d s th a t
seem s, it is a s u b s ta n tia l fo rm o f tr e a tm e n t in
its o w n rig h t, a n d it m ay fo r m a n y p a tie n ts be
su p p o rt m a in te n a n c e o f c o n tro l a n d s u b s titu
tio n of re a listic for m ag ical th in k in g ; in th e
th e tre a tm e n t o f choice. T h e e x p e rie n c e is th a t
n a rc is s is tic p e r s o n a lity , w ith in te r v ie w in g

tactics th a t ca u tio u sly d eflate th e g ra n d io sity of
o n ly a sm all n u m b e r o f p a tie n ts receiv in g a d e

q u a te crisis in te rv e n tio n n eed seek m o re in te n
th e p a tie n t a n d a t th e sam e tim e b u ild u p self
sive th e ra p y , sa tisfa c to ry re s u lts h a v in g been
esteem .
o b ta in e d w ith crisis th e r a p y alo n e . In d e e d ,

th e re is evid en ce th a t in som e in sta n c e s deep
In m an y cases, h o w ev er, it is d ifficu lt, p a r

h a b itu a l p e rs o n a lity styles th a t w o u ld m a k e
a n d la s tin g p e rs o n a lity c h a n g e s h a v e been

b ro u g h t a b o u t by w o rk in g th r o u g h a crisis.
p re fe rre d te c h n iq u e s p o ssib le since th e p a tie n t
O fte n th e p a tie n t h a s g a in e d en o u g h so th a t
m ay be re s p o n d in g w ith e m e rg en cy re a c tio n s
th a t c o n ta m in a te o r conceal h is basic p a tte rn s .
th e re is n o fu tu re in cid en ce o f crises.
A ll th a t th e th e ra p is t m a y be a b le to d o is to
try to h e lp th e p a tie n t d ev elo p a c le a re r id ea of
D o e s c r is i s t h e r a p y r e q u i r e s p e c i a l t r a i n
in g ?
th e stress in c id en t a n d its m e a n in g to h im ,
w ith th e h o p e of h e lp in g h im u n d e rs ta n d h is
T h e key fa c to r in th is m o d el o f m e n ta l
h e a lth service is th e a v a ila b ility o f tra in e d a n d
d e fe n s iv e m a n e u v e rs . T h e p a ti e n t is e n
co u rag ed to p u t in to w o rd s h is feelings a n d a t
titu d e s a b o u t th e tr a u m a tic in c id e n t a n d its
im p lic a tio n s fo r h im . S u p p o rt, re a s su ra n c e ,
sk illed p e rs o n n e l. U n fo rtu n a te ly , c risis in te r

v e n tio n h a s b een re g a rd e d a s a seco n d -b est
fo rm of tr e a tm e n t th a t can be d o n e by r e la
tiv e ly u n tr a in e d p a r a p r o f e s s io n a ls . A p p r o
p ria te p ro fe ssio n a l tr a in in g in th is m o d el is
tic u la rly in severe crises, to d e lin e a te sh a rp ly
c o n fro n ta tio n , in te rp re ta tio n , a n d o th e r te c h

n iq u e s a re u tiliz e d in re la tio n to e x istin g n eed s
a n d a s a w a y o f c o u n te r in g o b s tru c tiv e
defenses. T h e a im is to p u t th e p a tie n t in to a
p o sitio n w h e re he can e m b a rk o n a c o n stru c
tive course of a ctio n in lin e w ith th e ex istin g
re a lity situ a tio n , h o p in g th a t h e w ill accep t th e
th e r a p is ts offerings irresp e ctiv e o f h is p e r
so n ality style.
ra re ly given a n d is a n e sse n tia l n eed in p sy

c h ia tric a n d p sy ch o lo g ical tr a in in g p ro g ra m s.
T h e u su a l tr a in in g does n o t e q u ip a p ro fe s
sio n a l to d o crisis in te rv e n tio n . A d d itio n a l
sk ills re la te d to th e crisis m od el a re re q u ire d .
A s a m a tte r o f fact, th e c risis m o d el is best
le a rn e d by p ro fe ssio n a ls a t a n a d v an ced stag e
o f tr a in in g a n d su p e rv isio n . E xcessive an x ie ty
218
an d a n erosion of confidence is often p re c ip i

ta te d in stu d e n ts a t lo w er levels of tr a in in g
th e r a p is t w ill be w ise to su m m o n se cu rity p e r

so n n el to aid h im if vio lence b re a k s th ro u g h .
w h en h a n d lin g th e p ro b le m s of h ig h ly d is
T h is m e a s u re n o t o n ly can a lla y th e th e r a p is ts
tu rb e d p eo p le in crisis. S u p erv isio n by e x p e ri
fears, b u t also th e p a tie n t o ften re a liz e s th a t he
enced crisis th e ra p is ts is also m ost im p o rta n t.
w ill be p ro te c te d fro m a c tin g o u t h is im p u lse s,
S om e lite ra tu re on tra in in g m eth o d s a n d d ire c
a n d th is h e lp s ca lm h im d o w n . T h e g re a te st
tio n s m ay be found in th e w ritin g s of B a ld w in
h e lp is re n d e re d by th e p a tie n ts a b ility to
(1 9 7 7 ), K a p p a n d W eiss (1 9 7 5 ), a n d W a lla c e
c o m m u n ic a te to a n
a n d M o rle y (1970).
th e re fo re , p rio r to giv in g th e p a tie n t in ten siv e
I s n t t h e m a i n g o a l o f c ris is i n t e r v e n t i o n
n a m e l y t h e b r i n g i n g o f a p e r s o n b a c k to a
p r e v i o u s d u b i o u s p r e c r i s i s s t a b i l i t y to o
s u p e r f ic ia l?
u n d e r s ta n d in g p e rs o n ;
tr a n q u iliz a tio n , h e sh o u ld be allo w ed to v e rb a

lize freely. H o s p ita liz a tio n m u st be co n sid ered
to p ro te c t th e p a tie n t sh o u ld v io len t ten d en c ies
re a p p e a r . T o o fre q u e n tly th e p a tie n ts th re a ts
o ne co n sid ers th a t a p a tie n t m ay
a r e ta k e n lig h tly . T h e p a ti e n t s h o u ld be
a ssu re d th a t it is essen tia l th a t he be te m p o
re a c h h a b itu a l sta b ility in from o n e to six

sessions, w e m ay co n sid er su ch a goal q u ite an
r a r ily h o s p ita liz e d for h is o w n p ro te c tio n an d
W hen
ach iev em en t. T h is is u su ally all a p a tie n t seeks

from th e ra p y . B u t in a c o n sid e ra b le n u m b e r of
p a ti e n ts th e w o r k in g - th r o u g h o f th e c ris is
sta rts a p ro cess th a t can lead to ex ten siv e
c h an g e in p a tte rn s of b e h a v io r a n d p e rh a p s
even in a lte ra tio n s of th e p e rs o n a lity stru c tu re .
A nd th e fact th a t a p a tie n t sto p s th e ra p y in six
sessions o r less does n o t m e an th a t he c a n n o t
la te r seek fu r th e r tre a tm e n t a im ed a t m o re e x
tensive goals, sh o u ld h e so desire.
I s n t t h e t i m e d e v o t e d to t h e r a p y
l i m i t e d in c ris is i n t e r v e n t i o n ?
to o
th a t he w ill n o t n eed to stay in a h o sp ita l

lo n g e r th a n is n ecessary . E v en w h e re th e p a
tie n t does n o t a g re e to h o s p ita liz a tio n , h e m ay
still be w illin g to accep t it if h e feels th a t th e
th e r a p is t is sin ce re a n d c o n c ern e d a b o u t his
w elfare. T r a n s p o r ta tio n
to a n o th e r h o sp ita l
sh o u ld be d o n e by a m b u la n c e w ith en o u g h se
c u rity a tte n d a n ts to m a n a g e v io len t d isp lay s
sh o u ld th e y o ccu r. A p ro p e r d ia g n o sis is neces
sa ry .
Is th e
vio len ce a
m a n ife sta tio n
of a
n e u ro lo g ic a l co n d itio n like a b ra in tu m o r or
ep ile p sy , a b re a k th ro u g h of psy ch o sis, a c o n se
q u e n c e of a re c e n t h e a d in ju ry , a n in d ic a tio n of
E x p e rie n c e show s th a t m ost p e o p le can be

h elp ed to resolve a crisis w ith in th e tra d itio n a l
excessive alco h o l o r d ru g in ta k e ? C o n tin u in g

th e r a p y w ill be c o n tin g e n t on th e p ro p e r d ia g
tim e lim ita tio n of six sessions. A good th e ra p is t
nosis.
can accom plish m o re w ith a p a tie n t in six

s e s sio n s th a n a b a d t h e r a p is t c a n in six
h u n d re d .
If a p a t i e n t c o m e s to a n e m e r g e n c y r o o m
in a h o s p i t a l i n a n a g i t a t e d sta te s a y in g h e
is a f r a i d o f g i v i n g in to a n i m p u l s e to k ill
s o m e o n e , w h a t is t h e b e s t w a y o f h a n d l i n g
this?
F irs t, a ss u re th e p a tie n t th a t he w ill receive
h e lp to p ro te c t h im from th e se fears. In an
a c u te sta te it is obvio u sly d ifficult to p ro b e th e
sources of his fears of violence. B rin g in g h im to
som e im m ed iate sta b ility is th e aim . F o r th is
p u rp o s e n e u ro le p tic s sh o u ld be a d m in is te re d in
p ro p e r dosage to calm th e p a tie n t d o w n . T h e
E v e n in c ris is t h e r a p y o f a v e r y b r i e f n a
t u r e s o m e t h e r a p i s t s c l a i m t h a t it is p o s s i
b l e to i n f l u e n c e d e e p e r p a r a m e t e r s o f
p e rs o n a lity . A re th e re te c h n iq u e s th a t can
b r i n g th is d e s i r e d r e s u l t a b o u t ?
N o b e tte r w a y ex ists th a n to stu d y th e re a c
tio n s of th e p a tie n t to th e te c h n iq u e s th a t a re
b ein g u tiliz ed in th e effort to resolve th e crisis.
T h e p a t i e n t s r e a c tio n s to th e th e r a p e u ti c
s itu a tio n , irresp e ctiv e of th e specific te c h n iq u e s
e m p lo y ed , w ill reflect basic n eed s, defenses,
a n d re a c tio n p a tte rn s th a t em b o d y in te r p e r
so n al in v o lv em en ts d a tin g back to fo rm ativ e
e x p e rien c e s in th e p a st. R e sp o n ses to th e c u r
re n t tre a tm e n t e x p erie n c e, if o n e u n d e rs ta n d s
CRISIS INTERVENTION
219
p sy ch o an aly tic th eo ry a n d m e th o d o lo g y a n d
h as th e m o tiv a tio n to use th is k n o w led g e, a re
g o als a re to o a m b itio u s a n d w ill re q u ire e x te n

sive tim e to re a c h , o r w h e re th e y a re u n re a c h a
like a biopsy of th e sm o ld e rin g p sy c h o p a th o l
ble
ogy. P a tte rn s excited by th e r a p y a n d th e th e r a
u n d e rs h o o t h is m a rk a n d a t te rm in a tio n be left
p ist w ill reveal b o th th e sources a n d effects of

fau lty e arly p ro g ra m m in g . T h e s e effects a re
w ith a d is g ru n tle d a n d a n g ry p a tie n t.
often ex p ressed in th e form of re s ista n c e . B e
If o n t e r m i n a t i o n t h e p a t i e n t still h a s u n
reso lv ed p ro b le m s, w h a t do you do?
cause th e p a tie n t h a s le a rn e d to o p e ra te w ith a

social facade a n d b ecause th e m o re fu n d a m e n
irre sp e c tiv e
The
goal
o f tim e,
of crisis
th e th e r a p is t
in te rv e n tio n ,
m ay
fro m
ta l o p e ra tio n s of re p re ssio n sh ield h im from
p u re ly p ra g m a tic v ie w p o in t, is to b rin g a p a
a n x ie ty ,
tie n t to p re c risis e q u ilib riu m .
he
m ay
not
m a n ife s t
re s is ta n c e s
o p en ly . It is h e re th a t th e tra in e d a n d e x p e ri
O n c e th is is
ach ie v ed , th e c h ie f a im of th is m odel o f th e ra p y
enced th e ra p is t o p e ra te s w ith a d v a n ta g e . F ro m
has
th e p a tie n ts g estu res, h e sita tio n s, m a n n e r of
e sp ecially h av e difficulty d is c h a rg in g p a tie n ts
ta lk in g , slips of speech, d re a m s, a n d a sso ci
b ecau se
atio n s, one m ay g a th e r sufficient in fo rm a tio n
p ro b le m s a t te r m i n a ti o n . W h ile g o a ls a re
m o d est in crisis th e ra p y , a n d w h ile w e m ay
been
re a c h e d .
th e
p a tie n ts
In e x p e rie n c e d
h av e
th e ra p is ts
som e u n reso lv ed
to h e lp identify a n d d eal d ire c tly a n d ac

tively w ith resistan ces to te c h n iq u e s. T h e s e
te rm in a te th e r a p y a b ru p tly , it is often g ra tify
resistan ces em b o d y fu n d a m e n ta l defensive o p

e ra tio n s, a n d th e ir re so lu tio n m ay in flu en ce
a c tu a lly o c c u rre d a fte r tr e a tm e n t a s a re s u lt of
in g to see on fo llo w -u p h o w m u ch p ro g re ss h as
m an y in tra p sy c h ic elem en ts, in itia tin g a c h a in
th e le a rn in g s a c q u ire d d u rin g th e active tr e a t
re actio n th a t u ltim a te ly re s u lts in re c o n s tru c

tive ch an g e. T h is c h an g e, sta rte d in re la tiv e ly
le a rn to h a n d le h is o w n se p a ra tio n sy m p to m s
b rie f th e ra p y focused on th e ex istin g crisis,
a n d fea rs a n d let th e p a tie n t go a t th e p ro p e r
m ay go on th e re m a in d e r of th e in d iv id u a ls
tim e. N a tu ra lly , if th e p a tie n t is still serio u sly
m e n t p e rio d . T h e th e ra p is t, th e re fo re , sh o u ld
life. If th e p a tie n t h as been ab le to e sta b lish a
a n d d a n g e ro u s ly sick, fu r th e r tr e a tm e n t w ill be
c o n tin u ity b etw een th e crisis situ a tio n , h is a c

tive p a rtic ip a tio n in b rin g in g it a b o u t, th e
n ecessary .
forces in h is c h a ra c te r o rg a n iz a tio n th a t su s
D o e s n t t h e t r a d i t i o n a l l i m i t e d g o a l o f
c ris is i n t e r v e n t i o n in i t s e l f c i r c u m s c r i b e
th e th e r a p e u ti c effort a n d p r e v e n t m o re
extensive p e rso n a lity grow th?
ta in his m a la d ju s tm e n t, a n d th e ir o rig in in his

e arly c o n d itio n in g s, th e o p p o rtu n itie s for c o n
tin u e d p e rs o n a lity m a tu ra tio n a re good.
S h o u l d t i m e l i m i t s b e set i n a d v a n c e in
c ris is i n t e r v e n t i o n e v e n if y o u d o n t k n o w
t h e d i r e c t i o n t r e a t m e n t w i l l ta k e ?
D efin itely . C ris is in te rv e n tio n is o n e s itu a
tio n w h e re ad v an ce settin g of th e n u m b e r of
sessions is re q u ire d . In e x p e rie n c e d th e ra p is ts
a re u su a lly h e sita n t ab o u t d o in g th is. W h e re a
te rm in a tio n d a te is not a g ree d o n , th e p a tie n t
w ill u su ally settle back an d w a it for a m ira c le
to h a p p e n no m a tte r how lo n g it tak es.
W h a t a b o u t t h e a d v a n c e s e ttin g o f g o a ls
in c r isis i n t e r v e n t i o n ?
It is im p o rta n t to p ro jec t ach ie v a b le go als
a n d to get th e p a tie n t to ag re e to th ese. W h e re
T h is is a n im p o rta n t p o in t. T h e g oal of
p re c risis h o m eo stasis is, for b e tte r o r w o rse,
p ra g m a tic ; cost effectiveness is th e cu rsed te rm .
B eing p ra g m a tic , h o w ev er, does n o t m e a n th a t
o n e c a n n o t p ro ceed b ey o n d th e p a tie n ts es
ta b lish e d p re c risis n e u ro tic h o m eo stasis. If one
accep ts th e d ic tu m th a t a c risis is a n o p p o rtu
n ity for g ro w th , a m e a n s of tra n sg re s sin g
m o d es of c o p in g th a t have failed , a n d a n in
v ita tio n to re le a se sp o n ta n e o u s g ro w th p ro c
esses, it is p o ssib le w ith in th e p re s c rib e d f e w
session s a v a ila b le to b rin g a n in d iv id u a l in
crisis as w ell as th e fam ily to n ew
tia litie s.
p o te n
I believe th is is w h e re a d y n a m ic
o rie n ta tio n is so h elp fu l. It is n o t n ece ssa ry to

delve too d e e p ly in th e u n co n scio u s d u rin g
220
crisis; th e unco n scio u s w ith its w e a lth of e n

cru sted needs a n d conflicts is a lre a d y n e a r th e
surface w ith th e defenses sh a tte re d a s th e y a re .
A nd la te n t creativ e d riv es m ay also be try in g to
surface. T h e th e ra p is t c a n , if a le rt, h a rn e s s
th ese forces a n d b rin g th e p a tie n t to a n a w a re
ness of h ow a n d w h y he is b ein g v ictim ized by
som e of h is d is to rtio n s a n d in te rp e rso n a l s h o r t
com ings. If in te rp re ta tio n s a re p re se n te d sk ill
cidal p a tie n ts a t th e em erg en cy d e p a rtm e n t of

a la rg e g e n e ra l h o sp ita l o v er a 2 -y e a r p e rio d ,
56 p e rc e n t o f w h o m acte d im p u lsiv ely a n d h a d
n o p re v io u s h is to ry o f a n e m o tio n a l p ro b le m .
H e su g g ests th a t tw o -th ird s o f su icid al p a tie n ts
a re ex cellen t c a n d id a te s for crisis in te rv e n tio n .
In th e e v e n t o f an a c tu al suic id a l a tte m p t
h o w sh o u ld o n e proceed?
fully in th e co n tex t of th e h ere a n d n o w , an d
A n a ssessm en t o f th e su ic id a l a tte m p t is n ec
identified u n d e rly in g n u c le a r p ro b le m s a re r e
essa ry . W a s it m o tiv a ted by a tru ly g e n u in e
la te d to th e crisis situ a tio n , th e th e ra p is t m ay

p ro m o te c h an g es fa r b ey o n d p ra g m a tic b a r
d e sire to kill o n eself o r w a s it a n a p p e a l for
riers.
u n d e rs ta n d in g o r h e lp ? W a s th e re a rev en g e
m o tif? If so, a g a in s t w h o m th e p e o p le th e p a
H a v e te le p h o n e h o t- lin e s fo r crises
p r o v e n su c c e ssfu l? H a v e a n y b o o k s b e e n
w r i t t e n o n t h i s s u b je c t ?
O n th e w h o le, yes. B u t th e a d e q u a c y o f th e
tie n t is liv in g w ith , p a re n ts , o r w h o m else?

H a d th e re been th r e a ts o f su icid e p r io r to th e
a tt e m p t ? W h a t im m e d ia te e v e n ts , if a n y ,
p ro m p te d th e a tte m p t? If th e p a tie n t suffered a
loss, is th e loss p e rm a n e n t (such as th e d e a th of
service is e n tire ly d e p e n d e n t on th e q u a lity of
a m a te )? Is th e r e a c h ro n ic d e b ilita tin g p h y si
v o lu n te e r h e lp a v aila b le . W h e re v o lu n te e rs a re
u n tra in e d a n d u n sk ille d , th e effect can be a n ti-
cal illn ess p re s e n t, a d e sire to escap e in tra c ta

ble p a in , o r ev idence of a te rm in a l illn ess like
th e r a p e u tic .
has
c a n c e r? W a s th e m eth o d e m p lo y ed a w ell-
been edited by D . L e ste r a n d G . W . B ro c k o p p

(C r is is In te r v e n tio n a n d C o u n se lin g b y
d esig n ed a n d tr u ly le th a l m e th o d ? O r w a s it
book
on
th e
s u b je c t
T eleph on e, S p rin g fie ld , 111., T h o m a s , 1976).
p o o rly o rg a n iz e d , a n d if so, w as th e a tte m p t

m a d e w ith a h o p e to be re sc u e d ? H o w d eep ly
d e p ressed is th e p a tie n t n o w ? Is th e d e p re ssio n
W h a t is t h e b e s t ta ctic in t h e case o f a s u i
c i d e risk ?
A p erso n w h o re a lly is in te n t o n ta k in g
h is life w ill m a n a g e to d o so s te a lth ily .
E n d o g e n o u s d e p re s s io n s a r e e s p e c ia lly d is
p o se d to do th is ; th e r e f o r e , w h e re in a
d e p ressio n th e re is a p a st h isto ry o f a g e n u in e
su icid al a tte m p t, o r th e p a tie n t h as e x p ressed a
th r e a t o f s u ic id e , e le c tro c o n v u ls iv e th e r a p y
sh o u ld be in s titu te d w ith o u t delay . T e m p o ra ry
h o s p ita liz a tio n m ay be esse n tia l in th ese cases
u nless th e p a tie n t is co n sisten tly w a tc h e d 24
h o u rs a d ay. S uicid e is esp ecially p o ssib le as
th e p a tie n t beg in s to feel b e tte r an d h a s m o re
en erg y a t h is disp o sal.
D o e s a s u i c i d e t h r e a t c a ll f o r i m m e d i a t e
u s e o f crisis i n t e r v e n t i o n ?
S uicide is often a n a n g ry c o m m u n ic atio n
a n d reflects a n in a b ility to resolve a p e rso n a l
crisis. R u b en (1 9 7 9 ) re p o rts a stu d y o f 151 su i
re c e n t, o n e of lo n g -sta n d in g , o r o n e th a t p e ri
o d ically a p p e a rs ? H a s th e p a tie n t received p sy
c h ia tric h e lp in th e p a st, a n d if so, w h a t k in d
o f h e lp a n d for w h a t? W h a t k in d o f s u p p o r t is
n o w a v a ila b le to th e p a tie n t (relativ es, frien d s,
o rg a n iz a tio n s, e tc .)? Is it p o ssib le for th e th e r
a p is t to esta b lish a good c o n tac t w ith th e p a
tie n t a n d to c o m m u n ic a te w ith h im ? H o w a re
re la tiv e s a n d frie n d s re a c tin g to th e p a ti e n ts
a tte m p t (a n g ry , frig h te n e d , d e sire to be h e lp
fu l, e tc .)? O n c e a n sw e rs to th ese q u e stio n s a re
o b ta in e d , th e th e ra p is t w ill be in a b e tte r p o si
tio n to d eal c o n stru c tiv e ly w ith w h a t is b e h in d
th e a tte m p t. S h o u ld h o sp ita liz a tio n be decided
o n , as w h e n th e re is a p o ssib ility th a t th e a t
te m p t m a y be re p e a te d , th e th e r a p is t sh o u ld
see to it th a t a re sp o n sib le m e m b e r of th e
fam ily is b ro u g h t in to th e p ic tu re im m e d ia te ly
a n d follow s th r o u g h o n re c o m m e n d a tio n s p ro
te c tin g th e p a tie n t fro m a n y le th a l o bjects
(d ru g s, knives, ra z o rs , etc.) a n d n p t p e rm ittin g
CRISIS INTERVENTION
221
th e p a tie n t to be a lo n e u n til th e p a tie n t is
d rin k in g te m p o ra rily a b a te s h is su fferin g w ith
a c tu a lly h o sp ita liz e d . In th e event h o s p ita liz a
th e c o n seq u en ce th a t h e becom es a n alcoholic.
tio n is n o t deem ed n ecessary , th e p rin c ip le s o f
A d e p ressed w o m a n w h o seeks c o m p a n io n sh ip
gets h e rs e lf involved w ith a n d so d e p e n d e n t on
crisis in te rv e n tio n w ith th e p a tie n t a n d th e

fam ily sh o u ld im m ed iately be in stitu te d .
A re th e re a n y d a ta o n w h a t h a p p e n s to p a
t i e n t s in a c ris is w h o c a n n o t b e s e e n i m
m e d i a t e l y a n d a r e p u t o n a w a i t i n g list?
a re je c tin g e x p lo ita tiv e p sy c h o p a th th a t she

c a n n o t b re a k th e re la tio n s h ip . A m a n h av in g
e x p e rie n c e d
s e v e ra l e p is o d e s o f im p o te n c y
d e ta c h e s h im se lf fro m w o m e n to avoid th e
c h a lle n g e o f se x u a lity . A y o u th o u t o f college
A ccording to on e stu d y , fully o n e -th ird to
fearfu l o f fa ilin g in a n ex ecu tiv e p o st w ith a
o n e -h a lf of th e p a tie n ts on a w a itin g list w h e n

co ntacted la te r on w ill n o lo n g e r be in te re ste d
o f w o rk a s a la b o re r. T o fo re sta ll su ch co m
in tre a tm e n t (L a z a re et a l, 1972). T h e re aso n s

for th is g en e ra lly a re th a t th e p a tie n t h av in g
com e for h elp in a crisis finds o th e r reso u rc es
to q u ie t h im d o w n o r h e w o rk s o u t th e p ro b
good fu tu re d ecid es to give u p h is jo b in favor

p ro m ise s it is im p o rta n t to in te rv ie w th e a p p li
c a n t if po ssib le w ith in 2 4 h o u rs o f th e re q u e s t
fo r h e lp . O n e w a y o f c irc u m v e n tin g a w a itin g
list is to o rg a n iz e a n in ta k e g ro u p p e n d in g an
lem s by h im self even th o u g h som e of th e so lu
o p e n in g in a th e r a p is ts sch ed u le. S u ch a n in
tio n s p ro v e to be p o o r co m p ro m ise s. T h u s a
te rim p ro v isio n m a y su rp ris in g ly be all th a t

som e p a tie n ts need.
m a n suffering from in ten se a n x ie ty fin d s th a t
Conclusion
D isru p tiv e as a sta te of c risis m ay be, it can
offer th e victim a n o p p o rtu n ity to develop n ew
bles. T h e m o re flex ib le th e p e rso n , th e m o re

v e rsa tile th e m a n e u v e rin g . A b a te m e n t o f te n
a n d h e a lth ie r co p in g m ec h a n ism s. In in itia tin g
sio n
a sta te of d is e q u ilib riu m th a t fails to c le a r u p

w ith h a b itu a l p ro b lem -so lv in g m eth o d s, th e
e v e n tu a lly
crisis m ay e n e rg ize old u n reso lv ed conflicts,
and
c e ssatio n
re s u lt
of th e
in
th e
c risis sta te m a y
re s to ra tio n
o f th e
p re v io u s a d a p tio n a l level a n d h o p efu lly in th e
r e a c tiv a tin g re g re s s iv e n e e d s a n d d e fe n s e s.
le a rn in g o f m o re p ro d u c tiv e p a tte rn s of b e
h a v io r. F a ilu re to reso lv e th e crisis, h o w ev er,
W o rk in g o u t so lu tio n s fo r th e crisis often w ill
o r c o n tin u a n c e of u n re so lv e d conflicts m ay u lti
e n co u rag e m o re a p p ro p r ia te w ay s o f co p in g .
m a te ly lead to m o re se rio u s n e u ro tic o r p sy
T h u s , th e crisis w ith its m o b iliz a tio n of

e n erg y o p e ra te s as a second c h a n c e in c o rre c t
ing e a rlie r fa u lty p ro b le m -so lv in g (R a p a p o rt,
1962).
S tu d ies of crisis states in d ic a te th a t th e y u s u
c h o tic s o lu tio n s . T h e r a p e u t i c in te r v e n tio n

th ro u g h c risis in te rv e n tio n is re q u ire d w h en
p a tie n ts c a n n o t ov erco m e d ifficu lties by th e m
selves a n d b efo re th e re is e n tre n c h m e n t in
ally last no lo n g e r th a n 6 w eeks, d u rin g w h ich

tim e som e so lu tio n , a d a p tiv e o r m a la d a p tiv e , is
found to b rin g ab o u t e q u ilib riu m . T h e in itia l
d azed shock re a c tio n to a crisis is u su a lly fol
low ed by g re a t ten sio n a n d m o b iliz a tio n of
w h a te v e r reso u rces in d iv id u a ls h av e a t th e ir
co m m an d . S h o u ld efforts a t re so lu tio n fail,
th ey w ill ex p lo it w h a te v e r co n triv a n ce s o r s tr a t
agem s they can fa b ric a te to resolve th e ir tr o u
C ris is th e r a p y in c o rp o ra te s a n u m b e r of ac
tive te c h n iq u e s im p le m e n te d in th e m e d iu m of
a d irectiv e th e r a p is t re la tio n s h ip w ith th e p a
tie n t. It is e sse n tia lly sh o rt te rm , o rie n te d
a ro u n d tw o g o als: (1) th e im m e d ia te objective
o f m o d ify in g o r re m o v in g th e c ritic a l s itu a tio n
o r sy m p to m c o m p la in t fo r w h ic h h e lp is b ein g
s o u g h t, a n d (2 ) th e h o p e d -f o r o b je c tiv e o f
in itia tin g som e c o rrectiv e in flu en ce o n th e in d i
p a th o lo g ic a l so lu tio n s.
222
v id u a ls an d fa m ily s c u sto m a ry b eh av io r. T h e
in to m o tio n c e rta in resista n c e s a n d defensive
u n b a la n c in g of th e fam ily e q u a tio n w ill o p ti

m istically in s titu te ch an g es in th e b e h a v io ra l
o p e ra tio n s th a t if d etec ted m u st be m a n a g e d to

p re v e n t sa b o tag e o f th e tr e a tm e n t p ro cess. In
p a tte rn s th a t have led u p to th e crisis. T h e
o th e r w o rd s, even th o u g h th e tactics m a y be
th e o retical fra m e w o rk g o v e rn in g th e a p p ro a c h
is p ro b le m solving. T h e m eth o d o lo g ic s tr a t
n o n a n a ly tic , th e p a tie n ts re sp o n se to th e te c h
egies a re eclectic in n a tu r e a n d re c ru it su n d ry
n iq u e s a n d to th e th e r a p is t becom e a focus for

e x p lo ra tio n fo r th e p u rp o s e o f d etec tin g a n d
tactics in clu d in g in te rv ie w in g , c o n fro n ta tio n ,
reso lv in g re sista n c e s to c h a n g e . E x ten siv e p e r
e n v ir o n m e n ta l m a n i p u la t io n , d ru g th e r a p y ,
hy p n o sis, g ro u p th e ra p y , fam ily th e ra p y , a n d
b eh av io r th e ra p y , d e p e n d in g o n th e n eed s a n d
p ro b le m s of th e p a tie n t a n d th e p a rtic u la r a p
so n a lity m o d ifica tio n s a re n o t ex p ected , b u t

som e m o d ific a tio n s m ay e v e n tu a te as a se r
e n d ip ito u s d iv id e n d , w h ic h o ften e x p a n d s a fte r
titu d e for w o rk in g w ith a selected m eth o d .
th e r a p y h a s en d ed . F o llo w -u p in terv ie w s over

a p erio d of y e a rs h av e sh o w n th a t th is a p
T h e te c h n iq u e o r te c h n iq u e s e m p lo y e d ,
w h ile aim ed a t reliev in g th e im m e d ia te crisis
p ro a c h can score su sta in e d sy m p to m a tic relief,

freed o m from fu r th e r crises, a n d in som e cases
s itu a tio n o r sy m p to m a tic u p se t, w ill often set
a c tu a l co n stru c tiv e p e rs o n a lity a lte ra tio n s.
CHAPTER 15
Making a Relaxing and

Ego-Building Tape
O n e of th e sim p lest w ay s o f p ro m o tin g re
sive c o n tact w ith a n e x ten sio n of th e th e ra p ist.
la x a tio n a n d e n h a n c in g m o ra le is th r o u g h th e
(3) T e n sio n s a n d a n x ie tie s becom e allev ia ted
em p lo y m en t of a cassette re co rd in g . A m o n g th e
ad v an ta g es of th is a d ju n c t is th a t th e p a tie n t
th ro u g h re la x in g a n d re a s s u rin g su g g estio n s.
T h is su b d u e s defensive m a n e u v e rs th a t have
can use it aw ay from th e th e r a p is ts office. T o o
d iv erted th e p a tie n t fro m p u ttin g in to p ra c tic e
often tre a tm e n t begins a n d en d s w ith each

w eekly o r b iw eekly th e ra p e u tic session. T h e
m o re a d a p tiv e p a tte rn s . (4) A m o re c o n stru c
only c a rry o v er is th e m em o ry of th e p a tie n t,

w hich ten d s to be b lu n te d by re sista n c e a n d by
tive self-im ag e is e n c o u ra g e d th ro u g h positive

p e rsu a siv e su g g estio n s n e u tra liz in g n eg ativ e
su g g estio n s w ith w h ich th e p a tie n t h a s been
th e in tr u s io n of e v e ry d a y d is tr a c tio n s a n d
h a b itu a lly p re o c c u p ie d . (5 ) T e r m i n a t i o n is
resp o n sib ilities. By p la y in g th e ta p e a t least
m o re easily ach iev ed since a to k en o f th e th e r a
tw ice d aily , th e p a tie n t reen fo rces a n d c o n so li

d ates th e lessons le a rn e d in th e th e ra p e u tic
session.
th e p a tie n t, a n d th is a m e lio ra te s s e p a ra tio n

a n x ie ty . (6) A fter th e ra p y th e p a tie n t h a s a
O th e r ta n g ib le d iv id en d s a ccru e too: (1) T h e

ta p e is m a te r ia l e v id e n c e t h a t s o m e th in g
definite an d p a lp a b le is b e in g d o n e for th e
p a tie n t. Som e p erso n s co n sid e r th e ta lk in g
p ist, em b o d ied in th e ca ssette , re m a in s w ith
h e lp in g re so u rc e to tu r n to in th e ta p e sh o u ld
a n x ie ty em erg e , sy m p to m s re tu rn , o r critic al
s itu a tio n s a rise th a t th re a te n
c o p in g cap acities.
to o v e rw h e lm
c u re te m p o ra ry a n d flim sy. T h e y seek som e
U n d e rs ta n d a b ly , several q u e stio n s a rise r e
th in g m o re s u b s ta n tia l. T h is , in p a rt a t least,
is w hy d e m o n stra b le tec h n iq u e s, such as th o se
g a rd in g lim ita tio n s, d is a d v a n ta g e s, a n d d a n

g ers o f s u p p ly in g th e p a tie n t w ith a n e rsa tz
th e ra p is t in th e fo rm of a ta p e .
used in b eh av io r th e ra p y , m a k e a g re a te r im
p act on ce rta in p a tie n ts th a n sim p ly v e rb a liz
ing. It m ay be th a t th e p laceb o effect is also
en h an ced th ro u g h th e in s tru m e n ta lity of a
tap e. (2) A re la tio n sh ip w ith th e th e r a p is t b e
com es m o re in ten sified . L iste n in g to som eone
w ho soothes, q u ie ts, relax e s, a n d re a ssu re s so
lid ifie s r a p p o r t . T h e id e a liz e d im a g e o f
em p a th ic a u th o rity is au g m e n te d . E ven w h en
th e voice on th e ta p e is n o t th a t o f th e th e r a
p ist, it becom es iden tified w ith th e th e ra p is t. A
re la tio n sh ip th a t m ay n o t dev elo p in th e b rie f
tim e devoted to tre a tm e n t w ill have a b e tte r
chance of evolving because of th e m o re in te n
D o e s n o t a t a p e e n h a n c e t h e p a t i e n t s d e
p e n d e n c y a n d p ro v id e h im w ith a cru tch
h e c a n u se i n s t e a d o f s t a n d i n g o n h i s o w n
f eet?
In fo llo w -u p s, w h ich have ex ten d e d in som e
cases o v er 15 y ea rs, I h av e n o t e n c o u n te re d a
single p a tie n t w h o h as b ecom e d e p e n d e n t on a
ta p e o r in w h o m d ep e n d e n c y h a s in c rea se d as
a c o n seq u en ce o f h a v in g a ta p e a v a ila b le to
h im o r h er. T h e p ro b le m is n o t th a t p a tie n ts
w ill ov eru se th e ta p e ; ra th e r, it is th a t th ey
w ill sto p u sin g it w h en th ey s ta rt feeling bet-
223
224
te r, p u ttin g it asid e before th e y have achieved
a n a lte re d sta te of co n scio u sn ess th a t in v ig o
its full benefit. S om e ta p e su g g estio n s a re a k in

to form s of assertiv e tra in in g , a n d th ey lead to
ra te s reg ressiv e p h e n o m e n a . H o w o n e h a n d le s
tra n sfe re n c e , re sista n c e , e m erg en ce o f a rc h a ic
g re a te r, n o t lesser, self-sufficiency.
e m o tio n s , a n d
th e e lic ita tio n o f m e m o rie s
sh o u ld th e se e r u p t w ill d e te rm in e w h e th e r o r
D o e s n t a t a p e , w h i c h c o n t a i n s s u p p o r t i v e
a n d r e e d u c a t i v e s u g g e s tio n s , t a k e a w a y
fro m a d y n a m ic a p p r o a c h th a t d eals w ith
d e e p e r a n d m o r e f u n d a m e n t a l issu es?
n o t a th e ra p e u tic effect w ill be re g iste re d . O f

co u rse, th e th e r a p is t m a y choose to ig n o re
O n th e c o n tra ry , it a d d s to a d y n a m ic
a p p r o a c h . T r a n s f e r e n c e m a y be e n h a n c e d
fo rt, le a rn in g a b o u t th e m e x p e d itio u sly (w h ich
th ro u g h th e p a tie n ts re a c tio n s to th e ta p e (as

w ill be illu s tra te d la te r in th e c h a p te r), a n d
to th e ta p e ) m a y e n a b le th e th e r a p is t to d eal
ch a ra c te ristic resistan c e s m ay su rface th a t is,

if on e w atch es fo r th ese re sp o n se s a n d if th e
p a tie n t is e n c o u rag ed to re p o rt d re a m s. S everal
re aso n s acco u n t fo r th is. C o n ta c t w ith th e th e r
a p is t th ro u g h th e ta p e is o n a d a ily b asis, th u s
p r e v e n tin g
th e
p a ti e n t
fro m
a v o id in g
or
th ese m a n ife sta tio n s. B u t w h e re re s ista n c es a re

p o w e rfu l e n o u g h to b lock th e th e ra p e u tic ef
can o ccu r by stu d y in g th e p a tie n ts resp o n se s
w ith th e m a n d th u s salv ag e tr e a tm e n t th a t
o th e rw ise w o u ld en d in fa ilu re .
I n t h e e v e n t t h e t a p e b r e a k s o r is lo s t,
w o n t t h e p a t i e n t s s y m p t o m s r e t u r n ?
A n a d ju n c tiv e cassette ta p e is n o s u b s titu te
fo r p s y c h o th e ra p y .
It su p p le m e n ts a n d
ex
re p re ssin g em erg in g d e stru c tiv e feelings, w h ich
p e d ite s p sy c h o th e ra p y . T h e r e is n o re a so n w h y
can h a p p e n w h en th e ra p e u tic c o n tac t is m in i

m al. M o re o v e r, in d u c in g re la x a tio n re s u lts in
d e a lt sa tisfa c to rily w ith th e p a tie n ts p ro b le m s.
sy m p to m s sh o u ld re tu r n if p s y c h o th e ra p y h a s
Preliminary Preparations
T h e e q u ip m e n t for m a k in g a ta p e is sim p le.
A good cassette re c o rd e r a n d a m ic ro p h o n e
th a t h as a s ta rt a n d sto p sw itch a re e sse n tia l. It
is best not to rely o n th e p a tie n ts re c o rd e r,
w ith w h ich id io sy n crasies th e th e r a p is t m ay
n ot be a c q u a in te d . A m e tro n o m e is o p tio n a l. I
use a n electonic m etro n o m e th a t is tu n e d to a
b ase to n e a t a speed o f a b o u t o n e b e at p e r
second. A m e tro n o m e m a y be p u rc h a s e d in an y
m usic store. A sm all b o ttle o f ru b b in g alco h o l,
som e Q -tip s a n d a n eed le sh o u ld be a v a ila b le
in th e event th e th e ra p is t w ish es to test for
glove a n a e sth e sia . In m a k in g a ta p e th e su g
g estio n s should be given flu e n tly , w ith con v ic
tio n an d w ith o u t stu m b lin g for w o rd s. T o
p rev en t o m issio n s a n d e m b a rra ss in g speech
b lu n d e rs, a p re p a re d sc rip t is e sse n tia l, one
th a t is sufficiently g e n e ra l so th a t it a p p lie s to
p ra c tic a lly all p a tie n ts , yet in to w h ic h th e th e r
a p is t can in te rp o la te sp ecial su g g estio n s th a t
a re a p p lic a b le to specific p a tie n ts . T h e sc rip t
in th is c h a p te r h a s been tested o v er a n u m b e r
o f y ea rs, a n d it h a s m a n y a d v a n ta g e s. T h e
th e r a p is t m ay c o p y it o n c a rd s a n d e x p e rim e n t
w ith it. It is b est to re h e a rse th e m a k in g of a
ta p e w ith p a u s e s a n d e m p h a s is a t c e r ta in
p o in ts so th a t w h e n it is p lay e d b ack it so u n d s
lik e n a tu r a l ta lk . P e rfo rm e rs o n ra d io o r telev i
sion h av e m a ste re d th e skill of re a d in g a sc rip t
so th a t it so u n d s sp o n ta n e o u s. T h e th e ra p is t
sh o u ld p ra c tic e by d ic ta tin g sev eral ta p e s , tr y
in g to a rtic u la te n a tu r a lly , th e n liste n in g to
w h a t h a s been d ic ta te d , a n d c o n tin u in g to
recite u n til th e a r t of ta lk in g ca su a lly fro m
sc rip t h as b een m a ste re d . S om e th e ra p is ts
p re fe r to give th e ir p a tie n ts a p re re c o rd e d ta p e
m a d e by a n o th e r p e rso n .* It m ay also be h e lp
* A
p re re c o rd e d
r e l a x in g a n d e g o - b u ild in g t a p e w a s
m a d e f r o m th e s c r ip t in th is c h a p te r a n d m a y b e o b ta in e d
f r o m E l b a I n d u s tr ie s , 4 9 1 S e v e n th A v e ., N e w Y o r k , N .Y .
10018.
M AKING A RELAXING AND EGO-BUILDING TAPE
225
ful for a th e ra p is t to secu re a ta p e th a t can
p h e n o m e n o n in h y p n o sis, w h ich w h e n n o t e x
serve as a m odel to follow .

W h e n to in tro d u c e th e d e s ira b ility o f m a k
p e rien ce d w ill in s p ire d is a p p o in tm e n t a n d a
ing a ta p e is a concern. 1 u su a lly decid e to do
th e r e la x in g
th is if I have th e tim e a t th e en d of th e first

session a fter collecting d a ta a b o u t th e p a tie n t
a c tu a lly e n te r a s ta te of h y p n o sis. F o r p ra c tic a l

p u rp o s e s it is n o t n ecessary to d iffe re n tia te r e
a n d p re s e n tin g a h y p o th e sis o f th e p ro b le m .
H o w ev er, it m ay be d o n e a t th e second o r a
th e su g g estio n s th a t a re g iven a re effective in
sense of fa ilu re . In th e co u rse of re s p o n d in g to

e x e rc is e s m a n y p a ti e n ts w ill
la x a tio n fro m h y p n o sis in m a k in g a ta p e since
la te r session. T h e p a tie n t m ay be a p p ro a c h e d
b o th states. In d e e d , it m a y be w ise to m in im iz e
as in th e follow ing ex cerp t:
th e need for h y p n o sis by s ta tin g th a t a ll w e

w ish to do is to p ra c tic e re la x a tio n . If th e p a
T h . I b eliev e y o u w o u ld b en efit if I m a k e a r e la x
tie n t ask s w h e th e r w h a t w ill be d o n e is a form
in g c a s se tte ta p e fo r y o u . U n d e r s ta n d a b ly , w ith
of h y p n o sis, he m ay be ad v ised : S om e p eo p le
w h a t y o u h a v e g o n e th r o u g h , yo u h a v e a lot of
re la x so d ee p ly th a t th e y m a y go in to h y p n o sis,
a n d som e a c tu a lly doze off. B u t th is is n o t im
te n s io n , a n d th e ta p e s h o u ld h e lp .
Pt. I see.
T h . H a v e y o u ev er n o ticed h o w m u c h b e tte r you
feel w h e n y o u a r e free fro m te n s io n a n d r e
la x e d ?
Pt. Y es, b u t t h a t s th e tro u b le . I c a n t re la x .

T h . F o r th a t re a so n I m g o in g to te a c h yo u a
p o rta n t. H o w d e e p you go m ak es little d iffe r

ence. T h e su g g estio n s I w ill give y o u can be
e q u a lly effective w h e th e r y o u a re lig h tly r e
lax e d o r close to sle e p .
It is often e x p e d ie n t a t th e e n d of th e in itia l
m e th o d th a t w ill h e lp yo u re la x . Y ou k n o w
in te rv iew to h av e a p re p a r a to ry session o f r e
w h e n y o u a r e ten se, every o r g a n in y o u r body
la x a tio n as a p re lim in a ry to m a k in g a ta p e ,
is k eyed u p . T h is m a k e s it h a r d fo r y o u to
w h ich is d o n e a t th e n e x t session. T h e re aso n
h e a l. By le a r n in g h o w to r e la x y o u r m u scles
th is is h e lp fu l is th a t it e n a b le s th e th e r a p is t to
a n d b r e a th e e asily y o u s h o u ld b e g in to n o tice
observ e h o w th e p a tie n t re s p o n d s to su g g es
a n im p ro v e m e n t. T h is w ill give y o u th e best
tio n s. It also p re p a r e s th e p a tie n t fo r w h a t w ill
c h a n c e to o v erco m e te n s io n .
Pt. T h a t s g o o d . Is th a t lik e m e d ita tio n ?

T h . M e d ita tio n is o n e fo rm o f re la x a tio n . H y p n o s is
h a p p e n a t th e ta p e -m a k in g session.
T h e p a tie n t is m a d e c o m fo rta b le in a c h a ir
sh o w y o u o n e th a t s h o u ld be s u ita b le for you.
th a t sh o u ld be su fficien tly h ig h so th a t it p ro
vides su p p o rt for th e h e a d . A n o tto m a n , if
Do
a v a ila b le , p ro v id e s su p p o rt for th e feet. T h e
is a n o th e r . T h e r e a r e o th e r fo rm s to o . I w ill
you
have
a ta p e
r e c o r d e r a c a s s e tte
re c o rd e r? [ I f th e p a tie n t h a s no re co rd er, it is
p a tie n t m ay be to ld th e follo w in g :
b est th a t h e p u r c h a s e o n e, p r e fe r a b ly o n e th a t
h a s a n a u to m a tic s h u t o f f w ith th e e n d in g o f th e
ta p e.]
Pt. Y es, I p la y m u sic o n it.

T h . F in e , I ll m a k e a re la x in g ta p e for y o u th a t
T h . P r io r to m a k in g a re la x in g ta p e fo r y o u , w h ic h
w e w ill d o n e x t tim e , I w o u ld lik e to see h o w
yo u re la x . W h a t I w o u ld lik e to h a v e yo u do is
j u s t le a n b a c k , close y o u r e y e lid s a n d k eep
sh o u ld b e of h e lp . T h e n e x t tim e yo u com e
th e m clo sed u n til I give y o u th e c o m m a n d to
h e re b rin g a b la n k 1 -h o u r ta p e , th a t is, 3 0
o p e n th e m . R e m e m b e r y o u w ill n o t be asle e p
m in u te s o n each sid e. G e t a good q u a lity ta p e
a n d y o u w ill n o t be h y p n o tiz e d , j u s t p le a s a n tly
so th a t it w ill la st. It is n o t n e c e s sa ry to b rin g
re la x e d .
y o u r re c o rd e r sin c e I ll u se m in e.
Pt. A ll rig h t.
It is u su a lly best to em p lo y th e w o rd r e
la x a tio n r a th e r th a n h y p n o sis since th e la t
te r m ay have co n n o ta tio n s for th e p a tie n t th a t
w ill co m plicate m a tte rs. P eo p le a re a c q u a in te d
w ith th e sy m p to m s of re la x a tio n , b u t th e y m ay
a n tic ip a te so m e m y s te rio u s , e x tr a m u n d a n e
T h e fo llo w in g sc rip t is th e n slo w ly re a d in a

k in d o f d ra w lin g , c h a n tin g to n e as if lu llin g a
p e rso n to sleep.
N o w j u s t s e ttle b a c k a n d s h u t y o u r eyes. L is te n
c o m fo rta b ly to th e s o u n d of y o u r b r e a th in g . B re a th e
in r ig h t d o w n in to th e p it o f y o u r sto m a c h . D -e -e -p 1-y, b u t g e n tly , d -e -e -p -l-y . J u s t d e e p ly e n o u g h so
226
t h a t you feel th e a ir so a k in g in. In . . . a n d o u t.
tie n t m a y
D -e -e -p -l-y , d -e -e -p -l-y . In . . . a n d o u t. A n d a s you
m e tr o n o m e a n d ev ery b e a t o f th e m e tro n o m e w ill
feel th e a i r so a k in g in , yo u b e g in to feel y o u rse lf g e t
se n d yo u in d e e p e r a n d d e e p e r . ] A s yo u v isu a liz e
tin g p le a s a n tly tire d a n d r-e - l- a -x - e - d , v ery r-e -l-a -x -
th is q u ie t sc en e, I s h a ll c o u n t fro m o n e to tw e n ty ,
e -d . E v e n d - r - o - w - s - y , d - r - o - w - s - y a n d r e la x e d .
a n d w h e n I re a c h th e c o u n t o f tw e n ty , yo u w ill feel
D ro w s y a n d re la x e d .
be
told,
I am
g o in g
to
tu r n
on
y o u rse lf in d e e p , su fficien tly d e e p to a b s o rb th e s u g
N o w I w a n t y o u to c o n c e n tra te o n th e m u sc le
g e s tio n s I m g o in g to give y o u . O n e , d e e p e r a n d
g ro u p s th a t I p o in t o u t to y o u . L o o se n th e m , re la x
d e e p e r.
th e m , a ll w h ile v isu a liz in g th e m . Y o u w ill no tice
T h r e e . . . d ro w s ie r a n d d ro w s ie r. F o u r, d e e p e r
th a t y ou m ay be ten se in c e rta in a r e a s a n d th e id ea
a n d d e e p e r. F iv e . . . d r o w s ie r , a n d d ro w s ie r, a n d
is to re la x y o u rse lf c o m p le te ly . C o n c e n tra te on y o u r
d ro w s ie r. S ix . . . seven, v ery tire d , v ery re la x e d .
fo re h e a d .
L o o se n
and
d eep er,
and
d e e p e r.
E ig h t, d e e p e r a n d d e e p e r. N in e . . . te n , d ro w s ie r
N o w y o u r eyes. L o o se n th e m u sc le s a r o u n d y o u r
a n d d r o w s ie r . E le v en , tw e lv e , th ir te e n , d e e p e r a n d
eyes. Y o u r ey elid s re la x . N o w y o u r face, y o u r face
d e e p e r, d - r- o -w -s -i- e - r a n d
r e la x e s.
te e n , d r o w s ie r , a n d d r o w s ie r , a n d d ro w s ie r. F iftee n
your
m u sc le s in
d e e p e r,
y o u r fo re h e a d .
A nd
th e
Tw o,
m o u th . . . re la x
th e
m uscles
d - r- o -w -s -i- e - r.
F o u r
a r o u n d y o u r m o u th . Y o u r c h in ; le t it sa g a n d feel
. . . six te e n . . . se v e n te e n , d e e p e r a n d d e e p e r. E ig h
h eav y . A n d as y o u re la x y o u r m u sc le s, y o u r b r e a th
te e n . . . n in e te e n . . . a n d fin a lly tw e n ty , (p a u se)
in g
c o n tin u e s
r-e -g -u -l-a -r-l-y
and
d - e - e - p - l- y ,
I w a n t you (th e p a t i e n t s fi r s t n a m e m a y be m e n
tio n e d ) fo r th e n e x t few m in u te s , to c o n tin u e v is
d e e p ly w ith in y o u rself.
N o w y o u r n e c k , y o u r n eck re la x e s. E v e ry m u scle,
u a liz in g a q u ie t a n d w o n d e rfu lly r e la x e d scen e, a n d ,
ev ery fib e r in y o u r neck re la x e s. Y o u r s h o u ld e rs
a s y o u d o , y o u w ill g et m o re , a n d m o re , a n d m o re,
r e la x . . . y o u r a r m s . . . y o u r e lb o w s . . . y o u r fo re
a n d m o re r e la x e d . Y o u r b o d y w ill b e g in to g et m o re
a r m s . . . y o u r w ris ts . . . y o u r h a n d s . . . a n d y o u r
p le a s a n tly tire d a n d m o re r e la x e d , a n d y o u w ill get
fin g e rs re la x . Y o u r a rm s feel loose a n d re la x e d ;
d ro w s ie r a n d d r o w s ie r ; y o u r a r m s m a y feel h eav y ,
h ea v y a n d
re la x e d . Y o u r w h o le body
y o u r h a n d s tin g ly . W h e n I ta lk to yo u n e x t, y o u ll
b e g in s to feel loose a n d re la x e d . Y o u r n eck m u scles
be m o re d e ep ly r e la x e d . D e e p , d -r-o -w -s -y a n d r e
lo o se a n d
r e la x ; th e fro n t o f y o u r n eck ; th e b ack m uscles. If
la x e d ; d -r-o -w -s -y , a n d d e e p , a n d re la x e d ; d e e p ,
y o u w ish , w ig g le y o u r h e a d to g et all th e k in k s o u t.
d -r-o -w -s -y , a n d r e la x e d ; r e la x e d , a n d d e e p , a n d
K e e p b r e a th in g d e e p ly a n d re la x . N o w y o u r chest.
d ro w sy , (p a u se f o r a b o u t 3 0 se c o n d s)
T h e fro n t p a r t o f y o u r ch est re la x e s . . . a n d th e
N o w I d lik e to h a v e yo u c o n c e n tr a te o n y o u r left
b a c k p a r t of y o u r ch est re la x e s. Y o u r a b d o m e n . . .
a r m . I a m g o in g to s tro k e th e a r m a n d as I s tro k e it,
th e p it of y o u r s to m a c h , th a t re la x e s . T h e sm a ll of
th e m u sc le s get firm a n d rig id a n d th e a r m s get stiff.
y o u r b a c k , lo o sen th e m u scles. Y o u r h ip s . . . y o u r
E v e ry m u sc le , every fib e r in th e a r m stiffen s, a n d
th ig h s . . . y o u r k n ees re la x . . . even th e m u scles in
th e a r m w ill feel a s if it is g lu e d r ig h t d o w n to th e
y o u r legs. Y o u r a n k le s . . . y o u r feet . . . a n d y o u r
sid e of th e c h a ir . ( T h e th e r a p is t a t th is p o in t m a y
to es. Y o u r w h o le b o d y feels loose a n d re la x e d . A n d
w a lk o v e r to th e p a ti e n t a n d w h ile su g g e stio n s are
n o w a s y o u feel th e m u sc le s r e la x in g , yo u w ill n o tice
g iv e n s tr o k e th e le ft a rm .
t h a t y o u b e g in to feel re la x e d a n d p le a s a n tly tire d
n o w c h a n g e f r o m a lu llin g c h a n t to a f i r m e r m o r e
a ll
feel
c o m m a n d in g to n e .) E v e ry m u sc le , ev ery fib e r feels
v -e -r-y , v -e -r-y re la x e d . . . a n d y o u a r e g o in g to feel
stiff a n d firm a n d rig id . T h e a r m feels a s if a 100-
o v e r.
Y our
body
b e g in s
to
T h e in to n a tio n s h o u ld
d -r-o -w -
p o u n d w e ig h t p re ss e s o n th e a r m (th e th e r a p is t m a y
s-i-e -r, fro m th e to p o f y o u r h e a d r ig h t d o w n to
p r e s s th e a rm d o w n ) a s if a s u c tio n p a d h o ld s th e
y o u r to es. E v e ry b r e a th yo u ta k e is g o in g to so a k in
a r m d o w n , a s if steel b a n d s b in d th e a r m d o w n to
d e e p e r a n d d e e p e r a n d d e e p e r, a n d yo u feel y o u r
th e c h a ir . T h e a r m se em s g lu e d to th e c h a ir , a n d
b o d y g e ttin g d ro w s ie r a n d d ro w s ie r, (p a u se)
w h e n I tr y to lift it, it feels h eav y a n d rig id , g lu e d
d -r-o -w -s -i-e -r,
and
d - r-o -w -s -i-e -r,
and
A n d n o w I w a n t y o u to im a g in e , to v isu a liz e th e
a g a in s t th e c h a ir . ( T h e th e r a p is t th e n lig h tly tries to
m o st re la x e d a n d q u ie t a n d p le a s a n t scene im a g in a
lift th e a r m .) H e a v y a n d stiff a n d rig id . [ T h is is th e
b le. V isu a liz e , a re la x e d a n d p le a s a n t q u ie t scene.
f i r s t test as to w h e th e r th e p a tie n t is r e s p o n d in g to
A ny
su g g e stio n s. T h e g r e a t m a jo r ity o f p a tie n ts w ill e x
sc e n e t h a t
is c o m f o r ta b le .
D ro w s ie r, a n d
d r o w s ie r , a n d d r o w s ie r . Y o u a r e v -e -r-y w e a ry , a n d
h ib it a s tiffn e s s o f th e a rm . T h o s e w h o s h o w no
e v e ry b r e a th w ill se n d yo u in to d e e p e r a n d d e e p e r
stiffn e s s a n d r ig id ity a re r e s is tin g f o r so m e reason.
a n d d e e p e r. [ I f a m e tr o n o m e is to be u se d th e p a
In th e la tte r e v e n t th e th e r a p is t m a y r e m a r k , I t is
227
MAKING A RELAXING AND EGO-BUILDING TAPE

a little h a r d to d o th is th e first tim e . N e x t tim e you
i-n -g in y o u r e a r s . A s soon a s th a t h a p p e n s , a s soon
w ill p ro b a b ly fin d it e a s ie r . T h e n th e th e r a p is t
a s you see th e bell m ove, lift y o u r fin g e r. [It is p o s s i
m a y g o on u n in te r r u p te d ly .] A n d n o w I m g o in g to
b le th a t th e p a ti e n t m a y be an e x c e lle n t h y p n o tic s u b
stro k e th e a r m , a n d w h a te v e r stiffn ess is th e r e w ill
j e c t a n d a c tu a lly h a llu c in a te rin g in g o f th e b ell a t th is
leav e. In fact, th e a r m w ill feel lig h t a s a fe a th e r.
p o in t. T h is is, h o w e v e r , n o t q u e s tio n e d so th a t in th e
( T h e a rm is s tr o k e d a n d th en r a p id ly lifte d .)
e v e n t no a u d ito r y h a llu c in a tio n s e x is t th e p a tie n t
F eel
your
ey elid s
g lu ed
to g e th e r
now .
Y our
d o e s n o t in fe r h e h a s fa ile d . A c tu a lly , it m a k e s no d if
ey elid s feel tig h t, tig h t a n d w h e n yo u tr y to lift
fe r e n c e w h e th e r o r n o t th e p a tie n t h a llu c in a te s in
th e m , th ey feel a s if th e y a re g lu e d to g e th e r. T ig h t,
s o fa r as th e la te r m a k in g o f th e ta p e is c o n c e rn e d .)
tig h t, tig h t. [ T h is is th e n e x t test, a n d m o s t p a tie n ts
(p a u se , u n til th e fi n g e r lifts)
w ill c o m p ly w ith th e su g g e stio n s. In th e e v e n t th e
T u r n a w a y fro m th e c h u rc h b u ild in g n o w a n d see
p a tie n t is in re sista n c e a n d lifts th e ey e lid s, s im p ly
y o u rse lf w a lk in g b ack th r o u g h th e c o u r ty a rd in to
p r e s s th e m d o w n to close th e m a n d sa y, It is a lit
th e a lle y . O v e r th e r ig h t- h a n d side o f th e a lle y , on
tle d ifficu lt n o w . N e x t tim e it w ill be e a s ie r , a n d
th e g r o u n d , yo u see a p a il w ith ste a m in g w a te r . L ift
c o n tin u e w ith th e su g g e stio n s.]
y o u r fin g e r w h e n you see th is, (p a u se , u n til f in g e r
N o w w h a t I d like to h a v e you do is to p ic tu re
th in g s in y o u r m in d a s I d e sc rib e th e m , a n d , a s you
d o , in d ic a te it b y liftin g th is fin g e r a n in ch o r so in
th e
a ir.
(T h e
in d e x fi n g e r o f th e
le ft h a n d
lifts)
N ow
see y o u rse lf ta k in g y o u r rig h t h a n d a n d
w a v in g it th r o u g h th e s te a m . A s y o u d o th is , y o u r
is
h a n d w ill get tin g ly a n d te n d e r a n d se n sitiv e as if it
to u c h e d .) F o r e x a m p le , im a g in e y o u rse lf w a lk in g
h a s b een so a k e d in s te a m . W h e n yo u see y o u rse lf
o u tsid e o n th e s tre e t, a n d w h e n yo u see y o u rse lf
d o in g th is , lift y o u r fin g e r. In a m o m e n t y o u r h a n d
w a lk in g o n th e s tre e t, in d ic a te th is by liftin g u p
w ill b eco m e se n sitiv e a n d te n d e r a s if yo u h av e
y o u r fin g e r. \T h e s e su g g e stio n s a re a im e d a t tr a in
w a v e d it in s te a m , (p a u se , u n til f i n g e r lifts)
in g th e p a tie n t in im a g e ry . M o s t p a tie n ts e a s ily v is

u a liz e
th e m s e lv e s
w a lk in g
on
th e
stre e t.
In c o n tr a s t to y o u r se n sitiv e r ig h t h a n d , y o u r left
O cca
h a n d is g o in g to get n u m b a n d in se n sitiv e . It w ill
sio n a lly , a p a tie n t w ill b lo ck d o in g th is f o r o n e
feel a s if I h a v e c re a te d a w ris t b lo ck w ith n o v o cain e
W h e re th is o ccu rs a n d a fte r a
( T h e th e r a p is t m a y to u c h th e p a t ie n t's le ft w r is t
m in u te o r so h a s p a s s e d w ith o u t th e fi n g e r liftin g ,
w ith h is fi n g e r in a n u m b e r o f s p o ts , c ir c lin g it as i f
th e th e r a p is t m a y say: It is a d ifficu lt to do th is. So
n o v o c a in e is b e in g in je c te d .) A s a m a tte r o f fact, you
n o w p ic tu re y o u rse lf s ittin g in th e c h a ir a n d you a re
a r e n o w g o in g to im a g in e y o u rse lf w e a r in g a th ic k
rea so n o r a n o th e r .
in lo o k in g a t m e. In y o u r im a g in a tio n see m e a s I
h ea v y le a th e r glove on y o u r left h a n d , a n d as soon
ta lk to y o u , a n d w h e n y ou d o , lift th e f in g e r. T h is
a s y o u see y o u rse lf in y o u r im a g in a tio n w e a r in g a
u s u a lly b rin g s a p o s itiv e re sp o n se sin c e th e im a g e o f
th ic k h ea v y le a th e r glove on y o u r left h a n d , in d ic a te
th e th e r a p is t is fr e s h in th e p a t i e n t s m in d . O n ce th e
it by liftin g y o u r fin g e r, (p a u se, u n til fin g e r lifts)
p a tie n t h a s lifte d th e fin g e r , th e su g g e stio n a b o u t
N o w I a m g o in g to sh o w yo u th e d ifferen ce be
p ic tu r in g o n e s e lf w a lk in g on th e str e e t is m a d e a n d
tw e e n th e se n sitiv e r ig h t h a n d a n d th e left h a n d e n
s h o u ld be su c c e ssfu lly e x e c u te d . In th e v e r y u n u s u a l
v elo p ed in a glove. | In m o s t cases a p a r tia l g lo v e
e v e n t th e p a tie n t re sists a ll th ese su g g e stio n s, or
a n a e s th e sia w ill be o b ta in e d , a n d th is m o r e th a n
la te r su g g e stio n s d u r in g th e se ssio n , th e th e r a p is t
a n y o th e r p h e n o m e n o n d u r in g th e p r e s e n t re la x in g
m a y say: It is a little d ifficu lt n o w . Y ou w ill fin d it
sessio n w ill im p r e s s th e p a tie n t th a t s o m e th in g im
e a s ie r n e x t tim e . T h e h o p e is th a t th e p a tie n t w ill
p o r t a n t m a y be a c c o m p lis h e d w ith su g g e stio n . A fte r

th e sessio n is over, m a n y p a tie n ts e x p r e s s su r p ris e
e v e n tu a lly w o r k th ro u g h th e resista n c e.)

V isu a liz e y o u rse lf w a lk in g in to a n a lle y w a y b e
o r in c r e d u lity th a t a n a e sth e sia h a s occu rred . S o m e
tw e e n tw o b u ild in g s. See y o u rse lf s te p p in g in to th is
d o u b t th a t th e th e r a p is t a c tu a lly to u c h e d th e h a n d
a lle y w a y .
A nd
you
w a lk
r ig h t
in to
an
open
w ith
th e n e e d le , a n d th e th e r a p is t w ill h a v e to
c o u r ty a rd . S ee y o u rse lf w a lk in g in to th is c o u rty a rd ,
a ss u re th e m th is w a s ro .] I a m g o in g to to u c h y o u r
a n d rig h t in fro n t o f y ou you see a ta ll c h u r c h th e
left h a n d w ith a s te riliz e d n e e d le , a n d it w ill feel as
ste e p le , s p ire , a n d bell. T h e n lift th e fin g e r. ( T h e
if I a m to u c h in g it th r o u g h a th ic k , h eav y le a th e r
th e r a p is t c o n tin u e s su g g e stio n s.) N o w w a tc h th e bell.
glove. Y o u w ill feel to u c h , b u t no p a in ; to u c h b u t no
N o w w a tc h th e bell. It w ill b eg in to m ove fro m o n e
p a in . T o u c h , b u t no re a l p a in . (A n e e d le , a s m a ll
sid e to th e n e x t, fro m o n e sid e to th e n e x t, a n d a s it
b o ttle o f a lc o h o l a n d a sw a b o f c o tto n o r Q -tip b ein g
d o es, you get th e s e n sa tio n o f a c la n g in g , c -l-a -n -g -
a v a ila b le, th e n e e d le is w ip e d w ith a lco h o l, a n d th e
228
a lc o h o l-so a k e d sw a b is a p p lie d to th e b a ck o f th e
d a n g e ro u s a u th o r ity w h o , if he re la x e d his
h a n d in th e tria n g le b e tw e e n th e th u m b a n d fo r e
g u a rd , m ig h t in ju re h im .
fin g e r .
T h e th e r a p is t s h o u ld th e n
to u c h th e sk in
In m ost cases re sista n ce s w ill n o t be e n
w ith th e n e e d le lig h tly to a v o id d r a w in g b lo o d ). O n
co u n te red a n d th e th e ra p is t m a y th e n p ro ceed
th e c o n tr a ry , th e o th e r h a n d , th e r ig h t h a n d , w ill be
w ith th ese in stru c tio n s: T h e n e x t tim e you
v ery se n sitiv e a n d te n d e r a n d p a in fu l even to th e

slig h te s t to u c h . ( T h e sa m e p ro c e ss w ith th e n e e d le is
re p e a te d w ith th e b a ck o f th e rig h t h a n d to d e m o n
str a te th e d iffe re n c e in se n sa tio n b e tw e e n th e tw o
h a n d s .)
W h a t w e h a v e d o n e is to p r o d u c e a n a n e s th e sia ,
com e h e re b rin g a 1 -h o u r b la n k cassette ta p e of

good q u a lity , 3 0 m in u te s on each side. It is n o t
n ecessary to b rin g y o u r re c o rd e r since I w ill
use m y o w n m a c h in e .
A t th e n e x t session, if th e p a tie n t do es n o t
w h ic h is so m e tim e s u sed in m in o r su rg ic a l o p e r
sp o n ta n e o u sly
a tio n s . B u t w h a t it in d ic a te s is th e p o w e r of th e
sh o u ld in q u ire a b o u t th e m . F o llo w in g th e r e
re p o rt
d re a m s,
th e
th e r a p is t
m in d in c o n tro llin g p h y sic a l fu n c tio n s. A n d if th e
la x in g sessio n , m a n y p a tie n ts a re a p t to have
m in d can d o th is w ith a fu n d a m e n ta l fu n c tio n like
d re a m s th a t re la te to th e ir re la x a tio n e x p e ri
p a in , it ca n also c o n tro l y o u r s y m p to m s (th e se m a y
ence a n d th a t ex p o se tra n sfe re n c e as w ell as
be m e n tio n e d ).
re sista n c e m a n e u v e rs. T h e s e re a c tio n s m a y be

very im p o rta n t becau se n o t o n ly do th ey o p en
I a m n o w g o in g to c o u n t slo w ly fro m o n e to five.

W h e n I re a c h th e c o u n t of five lift y o u r eyes a n d
you
w ill be o u t o f it. O n e . . . tw o . . . th r e e . . .
fo u r . . . five.
a w in d o w in to th e u n d e rly in g d y n a m ic s, b u t
th ey a re w a rn in g sig n a ls of p ro b le m s th a t w ill
hav e to be h a n d le d th a t m ay sa b o tag e th e
ben efits of th e re c o rd e d ta p e .
M o st p a tie n ts w ill slow ly lift th e ir eyelids

a n d sp o n ta n e o u sly co m m e n t on how re la x ed
T h u s a m ale p a tie n t b ro u g h t in th is d re a m
a fte r th e first session: I w as ill in bed.
th ey feel. T h e y m ay in q u ire if th e th e ra p is t
F rie n d s w e re v isitin g m e. I t s g r a n d p a s h o u se,
re a lly to uched th e left h a n d w ith a need le. If
a n d m y m o th e r is th e re . S h e ta lk s a b o u t h e lp
th e p a tie n t does n o t p re s e n t his c o m m en ts
in g m e, b u t sh e gets m e p in k rib b o n s for m y

bed a n d tells m e to sleep. I say, T h is is for
sp o n tan eo u sly , th e th e ra p is t m a y in q u ire a b o u t

resisted ce rta in su g g estio n s (w h ich as h a s been
g ir ls . S h e trie s to p e rs u a d e m e i t s all rig h t.

B u t I d o n t w a n t to believe h e r. T h e n I h a d
m en tio n ed before is n o t u n u s u a l), th e th e ra p is t

m ay ask w h e th e r th e p a tie n t w as u p set o r h ad
p en is; it c h a n g e d to rib b o n s a n d it w as ch o k in g
his p e rso n al reactio n s. In th e event th e p a tie n t
a n o th e r d re a m . T h e r e w a s a ro p e a ro u n d m y
a n y o th e r feelings o r th o u g h ts d u rin g th e re
m y p e n is . T h e tra n sfe re n c e ele m e n ts cam e
lax in g exercises.
In one p a tie n t, for e x a m p le , w h en asked
w h a t th o u g h ts cam e to h im w h en he c o u ld not
v isu alize a ch u rc h w h en ask ed to d o so, he r e
plied: I h ad a p e c u lia r fa n ta sy , visionlike.
T h e re w as a m a n h o le in th e stre e t, a n d I w as
w a lk in g to w a rd it. A nd th e re w a s a m a c h in e
w ith teeth in it read y to g rin d m e u p . A t th is
o u t ra p id ly a fte r th e re la x a tio n session. H a d I

n o t been a le rte d to th e p a tie n ts fe a r of c a s tra
p o in t, th e p a tie n t sm iled a n d h e said; I knew

a m an w ho w e n t for a n a ly sis a n d re fe rre d to
his a n a ly s ts office as a hell h o le . T h e fan tasy
an d his asso ciatio n p ro v id ed a d y n a m ic focus
for o u r in terv iew s, w h ich d ea lt w ith tr a n s
ference feelings th a t I, like his fa th e r, w as a
tio n (w h ich a p p a re n tly stem m ed fro m h is u n

reso lv ed o e d ip a l fan ta sie s a n d w h ich he w as
p ro je c tin g o n to m e) I w o u ld no t h av e been a b le
to d eal w ith h is core p ro b le m . I d elay e d th e
m a k in g of th e ta p e u n til w e h a d w o rk e d suffi
cien tly o n th is m a te ria l so th a t h e w o u ld no t
in te rp re t m y ta p e -m a k in g activ ities as a ca s
tr a tin g th re a t.
In th e g re a t m a jo rity o f p a tie n ts th e d re a m s
a n d fa n ta sie s th a t follow th e first re la x in g
session a re p le a s a n t on es a n d do n o t in d ic a te
an y need for d e la y in d ic ta tin g th e cassette .
229
M aking the Tape

T h e p a tie n t is m ade c o m fo rta b le in a c h a ir
(som e p a tie n ts p refer lyin g on a couch since
th ey a re m o re rela x e d in it), a n d th e b la n k
cassette is p u t in to th e th e r a p is ts re c o rd e r. It
is w ise to test th e voice level, c o u n tin g from
one to ten in th e m ic ro p h o n e , a t th e v o lu m e
fo re h e a d .
L o o se n
th e
m u sc le s in
y o u r fo re h e a d .
N o w y o u r eyes. L o o se n th e m u sc le s a r o u n d y o u r
eyes. Y o u r ey elid s r e la x . N o w y o u r face, y o u r face
re la x e s.
A nd
your
m o u th . . . r e la x
th e
m uscles
a r o u n d y o u r m o u th . Y o u r c h in ; le t it sa g a n d feel
h ea v y . A n d a s y o u re la x y o u r m u sc le s, y o u r b r e a th
in g
c o n ti n u e s
r-e -g -u -l-a -r-l-y
and
d - e - e - p - l- y ,
th a t on e w ill use d u rin g th e d ic ta tio n , a n d th e n

listen in g to th e p lay b ac k . A fter th e p ro p e r a d
d e e p ly w ith in y o u rself.
ju s tm e n ts h av e been m ad e, th e th e ra p is t says
e v e ry
to th e p a tie n t, If you h e a r som e ru s tlin g it is

b ecause I m ay refer to m y c a rd s a n d to th e case
d e rs r e la x . . . y o u r a r m s . . . y o u r e lb o w s . . . y o u r
reco rd to m ake su re I in c lu d e all th e m a te ria l

th a t is im p o rta n t. N o w I w a n t you to sh u t
y o u r fin g e rs re la x . Y o u r a r m s feel loose a n d r e
y o u r eyelids a n d keep th e m sh u t u n til I give
b o d y b e g in s to feel loose a n d r e la x e d . Y o u r neck
you th e co m m an d to o pen y o u r e y e s.
T h e scrip t, w h ich h a s been copied on card s,
m u sc le s r e la x ;
is essen tially sim ila r to th a t in m y book, T h e

T echn iqu e o f P sych o th era p y (1 9 7 7 , p p . 7 9 5 -
N o w y o u r n e c k , y o u r n eck re la x e s . E v ery m u scle,

f ib e r
in
y o u r n e c k r e la x e s . Y o u r s h o u l
f o r e a r m s . . . y o u r w r is ts . . . y o u r h a n d s . . . a n d
la x e d ; h e av y a n d loose a n d r e la x e d . Y o u r w h o le
th e fro n t of y o u r n eck ; th e b ack
m u sc le s. If y o u w ish , w ig g le y o u r h e a d to g et all th e
k in k s o u t. K e e p b r e a th in g d ee p ly a n d re la x . N o w
y o u r c h est. T h e fro n t p a r t of y o u r ch e st re la x e s . . .
and
th e
back
p art
of y o u r c h e s t re la x e s.
Y our
7 9 6 ). T h e first p a r t is id e n tica l w ith th a t of th e
a b d o m e n . . . th e p it o f y o u r sto m a c h , th a t re la x e s.
b eg in n in g of th e p re lim in a ry session, b u t to
T h e sm a ll of y o u r b a c k , lo o sen th e m u scles. Y o u r
avoid con fusion th e co m p lete sc rip t w ill be in

cluded here. D ic ta tio n sh o u ld be slow , w ith
h ip s . . . y o u r th ig h s . . . y o u r k n e e s re la x . . . even
th e m u sc le s in y o u r legs. Y o u r a n k le s . . . y o u r feet
p ro p e r p au ses a n d em p h a se s m u c h as in th e
. . . a n d y o u r toes. Y o u r w h o le b o d y feels loose a n d
first session. T h e p a tie n ts first n a m e m a y be
r e la x e d . A n d n o w as y o u feel th e m u sc le s re la x in g ,
in te rp o la te d in c e rta in sp o ts to m a k e th e ta p e
m o re p e rso n al. T h e p a tie n t h a v in g sh u t th e
y o u w ill n o tic e th a t you b eg in to feel re la x e d a n d
eyes, th e re c o rd e r is tu rn e d o n a n d th e sc rip t
p le a s a n tly tire d a ll o v er. Y o u r b o d y b e g in s to feel

v -e -r-y , v -e -r-y re la x e d . . . a n d y o u a r e g o in g to feel
d - r-o -w -s -i-e -r,
d ictated.
and
d - r- o -w -s -i- e - r,
and
d -r-o -w -
s-i-e -r, fro m th e to p of y o u r h e a d r ig h t d o w n to y o u r

to es. E v e ry b r e a th
N o w j u s t se ttle b a c k a n d sh u t y o u r eyes. L is te n
c o m fo rta b ly to th e so u n d of y o u r b r e a th in g . B re a th e
yo u ta k e is g o in g to so ak in
d e e p e r a n d d e e p e r a n d d e e p e r, a n d you feel y o u r
b o d y g e ttin g d ro w s ie r a n d d ro w s ie r, (p a u se)
in r ig h t d o w n in to th e p it of y o u r s to m a c h . D -e -e -p -
A n d n o w I w a n t yo u to im a g in e , to v isu a liz e th e
1-y, b u t g e n tly , d -e -e -p -l-y . J u s t d e e p ly e n o u g h so
m o st re la x e d a n d q u ie t a n d p le a s a n t scene im a g in a
th a t you feel th e a ir so a k in g in. In . . . a n d o u t.
ble. V isu a liz e , a re la x e d a n d p le a s a n t q u ie t scene.
D -e -e -p -l-y , d -e -e -p -l-y . In . . . an d o u t. A n d a s you
A ny
feel th e a i r so a k in g in , you b eg in to feel y o u rse lf g e t
d ro w s ie r, a n d d ro w s ie r. Y ou a r e v -e -r-y w e a ry , an d
tin g p le a s a n tly
and
th a t
is c o m f o r ta b le .
D r o w s ie r , a n d
r-e - l- a -x - e - d , v ery r-e -
ev ery b r e a th w ill sen d yo u in to d e e p e r a n d d e e p e r
1-a-x-e-d. E v en d -r-o -w -s -y , d -r-o -w -s -y a n d re la x e d .
a n d d e e p e r. [ I f a m e tr o n o m e is to be u se d th e p a
D ro w s y a n d re la x e d .
tie n t
N ow
tire d
scene
m ay
be
to ld , I a m
g o in g
to
tu r n
on
I w a n t you to c o n c e n tra te on th e m u scle
m e tro n o m e a n d ev ery b e a t of th e m e tro n o m e w ill
g ro u p s th a t I p o in t o u t to you. L o o se n th e m , re la x
se n d yo u in d e e p e r a n d d e e p e r . ] A s yo u v isu a liz e
th e m , all w h ile v isu a liz in g th e m . Y ou w ill n o tice
th is q u ie t scene, I s h a ll c o u n t fro m o n e to tw e n ty ,
th a t y ou m ay b e te n se in c e r ta in a r e a s a n d th e idea
a n d w h e n I re a c h th e c o u n t of tw e n ty , you w ill feel
is to re la x y o u rse lf c o m p le te ly . C o n c e n tra te on y o u r
y o u rse lf in d e e p , su fficien tly d e e p to a b s o rb th e su g
230
g estio n s I m g o in g to give you. O n e , d e e p e r an d
[.sp ecific s y m p to m s th a t h a v e b u r d e n e d th e p a tie n t
d e e p e r.
m a y be m e n tio n e d h e r e i f d e s ir e d ]. E v e ry d a y . . .
Tw o,
d e e p e r,
and
d e e p e r,
and
d e e p e r.
T h r e e . . . d ro w s ie r a n d d ro w s ie r. F o u r , d e e p e r a n d
y o u w ill b eco m e . . . S O D E E P L Y I N T E R E S T E D
d e ep er.
IN
F iv e . . . d r o w s i e r ,
and
d ro w s ie r,
and
W HATEVER
Y O U A R E D O IN G
. . .
SO
d ro w s ie r. S ix . . . sev en , v ery tire d , v ery re la x e d .
D EEPLY
E ig h t, d e e p e r a n d d e e p e r. N in e . . . te n , d ro w s ie r
G O IN G O N . . . T H A T Y O U R M IN D W IL L B E
a n d d ro w sie r. E le v en , tw elv e, th ir te e n , d e e p e r a n d
COM E
d e ep er,
YO U RSELF AN D YO U R P RO B LEM S . . . AND
d -r-o -w -s -i-e -r
and
d -r-o -w -s -i-e -r.
F o u rte e n , d ro w s ie r, a n d d ro w s ie r, a n d d ro w sie r.
F if te e n . . . s ix te e n . . . s e v e n te e n ,
d e ep er.
deeper
E ig h te e n . . . n i n e te e n . . . a n d
tw e n ty , {p a u se)
IN
W H ATEVER
M U C H L E S S P R E O C C U P IE D
IS
W IT H
Y O U R O W N F E E L IN G S .
and
f in a lly
IN T E R E S T E D
E v e ry d a y . . . Y O U R N E R V E S
COME
STRO N G ER
AND
W IL L B E
S T E A D IE R
. . .
Y O U R M IN D W IL L B E C O M E C A L M E R A N D
I w a n t y ou {th e p a t i e n t s fi r s t n a m e m a y be m e n
C LE A R E R . . . M O R E CO M PO SED . . . M O R E
tio n e d ) fo r th e n e x t few m in u te s, to c o n tin u e vis
P L A C I D . . . M O R E T R A N Q U I L . Y o u w ill b e
u a liz in g a q u ie t a n d w o n d e rfu lly re la x e d scene, a n d ,
com e M U C H
a s y ou d o , y ou w ill g et m o re , a n d m o re , a n d m o re,
M U C H L E S S E A S IL Y A G IT A T E D . . . M U C H
L E SS E A S IL Y
W O R R IE D
. . .
a n d m o re re la x e d . Y o u r body w ill b eg in to g et m o re
LESS FEARFUL
p le a s a n tly tire d a n d m o re re la x e d , a n d yo u w ill get
M U C H L E S S E A S I L Y U P S E T . Y ou w ill be ab le
d ro w s ie r a n d d r o w s ie r , y o u r a rm s m a y feel heav y ,
to T H I N K M O R E C L E A R L Y . . . Y ou w ill be ab le
y o u r h a n d s tin g ly . W h e n I ta lk to yo u n e x t, y o u ll
to
be m o re d eep ly re la x e d . D e e p , d -r-o -w -s -y a n d r e
M E M O R Y W I L L I M P R O V E . . . a n d y o u w ill be
la x e d ;
d -r-o -w -s -y
and
deep
and
r e la x e d ;
deep,
d -r-o -w -s -y , a n d re la x e d ; re la x e d , a n d d e e p , an d
d ro w sy , (p a u se f o r a b o u t 3 0 se co n d s)
R e la x a n d feel d ro w sy . A s y o u b e g in to feel m o re
d ro w sy , y o u h a v e a so rt of flo a tin g s e n sa tio n a n d
AND
CONCENTRATE
A P P R E H E N S IV E . . .
M ORE
a b le to S E E T H I N G S I N
S P E C T IV E
. .
E A S IL Y .
T H E IR
W IT H O U T
TRU E PER
M A G N IF Y IN G
T H E M . .. W IT H O U T A L L O W IN G T H E M T O
G E T O U T O F P R O P O R T IO N .
E v e r y d a y . . . y o u w ill b e c o m e E M O T I O N
y o u re la x m o re. T h in g s seem to fad e a little a n d lose
ALLY MUCH
th e ir im m e d ia c y a n y a n x ie ty a n d d e p re ss io n fade.
SETTLED
A so rt o f fu z z y a n d tin g lin g s e n sa tio n a n d a feelin g
T U R B E D . E v e ry
of w e lc o m in g sle ep , yet d iffe re n t fro m th e re a c tio n
G R E A T E R F E E L IN G O F P E R S O N A L
to o r d in a ry sleep .
B E IN G . . .
T h e m in d is lik e a sp o n g e . It so a k s u p su g g e s
CALM ER
. . . M UCH M ORE
. . . MUCH
day
LESS
.
E A S IL Y D IS
you
w ill
feel
W ELL
A G R E A T E R F E E L IN G O F P E R
S O N A L S A F E T Y . . . A N D S E C U R IT Y A N D
tio n s. In y o u r case it h a s b een filled w ith n e g a tiv e
CO NTROL
su g g e stio n s th a t h a v e p iled u p in y o u o v er th e y ears.
tim e .
[ T h e s e m a y be e n u m e r a te d . F o r e x a m p le , i f th e p a
YO U R
th a n y o u h a v e felt fo r a lo n g , lo n g
E v e ry d a y . . .
Y O U w ill b eco m e . . . a n d Y O U
tie n t h a s a fe e lin g th a t h e c a n n o t g e t better, o r is

u n a b le to su c ceed a t a n y th in g o r i f h e h a s a d e v a lu e d
P L E T E L Y R E LA X E D . . . AN D LE SS TEN SE
s e lf-im a g e ,
EACH
th ese
m ay
be m e n tio n e d as n eg a tiv e
th o u g h ts. ]
w ill r e m a in
DAY
. . . M ORE
. . . BO TH
P H Y S IC A L L Y . . . A nd,
I sh a ll n o w giv e y o u a n u m b e r o f su g g e stio n s an d
AND
M ORE
M ENTALLY
COM
AND
y o u b eco m e . . . a n d ,
d-S1 y o u r e m a in . . . M O R E R E L A X E D . . . A N D
y ou m ay u tiliz e th o se th a t a p p ly to y o u a t th is m o
LESS TEN SE E A C H D A Y . . .
m e n t an d p u t asid e th o se th a t do n o t, w h ic h m ay
v elo p M U C H M O R E C O N F I D E N C E I N Y O U R
a p p ly a t so m e o th e r m o m e n t.
S E L F . M U C H m o re co n fid en ce in y o u r a b ility to
E v e ry
day
STRO N G ER
. . . y o u w ill b e c o m e p h y s ic a lly
and
F IT T E R .
Y o u w ill b e c o m e
S O , y o u w ill d e
D O . . . N O T O N L Y w h a t yo u H A V E to do each
d a y , . . . b u t M U C H m o re co n fid en ce in y o u r a b il
M O R E A L E R T . . . M O R E W ID E A W A K E . . .
ity to d o w h a te v e r y o u O U G H T to be a b le to
M O R E E N E R G E T I C . Y ou w ill b eco m e M U C H
do . . . W I T H O U T F E A R O F C O N S E Q U E N C E S
L E S S E A S IL Y T IR E D . . . M U C H L E S S E A S-
. . . W IT H O U T U N N E C E S S A R Y A N X I E T Y . . .
IL Y F A T IG U E D . . . M U C H L E S S E A S IL Y D E
W I T H O U T U N E A S I N E S S . B e c a u se of th is . . .
P R E S S E D . . . M U C H L E S S E A S IL Y D IS C O U R
e v e ry d a y . . . y o u w ill feel M O R E A N D M O R E
AGED.
IN D E P E N D E N T . . . M O R E A B L E T O S T A N D
B e c a u s e o f r e s o lu tio n o f y o u r tr o u b le s
231
U P O N YO U R O W N F E E T W IT H O U T P R O P S
I w a n t y o u to c o n tin u e to liste n to th is re c o rd in g
[ I f th e p a tie n t is u tiliz in g p r o p s , lik e tr a n q u iliz e r s
a s o ften as p o ssib le a n d a s p r a c tic a l. It m a k e s no
o r p ills , th ese m a y be m e n tio n e d , L ik e tr a n q u i l
d iffe re n c e h o w d e e p you go. E v en if y o u feel you a re
iz e r s
co n scio u s, o r if y o u r m in d w a n d e r s o ff w h ile liste n
and
s le e p in g
p ills . ] A N D
W O R R Y IN G . T O H O L D
W IT H O U T
YOUR O W N . . .
no
in g ,
or
if y o u
fall
a s le e p ,
th e
su g g e stio n s w ill
p e n e tr a te , (p a u se)
m a tte r h o w d ifficu lt o r tr y in g th in g s m a y be.

b eg in to
R e la x a n d re st a n d , if you w ish , give y o u rse lf a n y
h a p p e n . . . E X A C T L Y a s I tell y o u th e y w ill h a p
a d d itio n a l su g g e stio n s to y o u rse lf to feel b e tte r, o r
A n d , b e c a u se all th e s e th in g s
W IL L
H A P P IE R
su g g e stio n s to h a n d le a n im m e d ia te p ro b le m , u sin g
. . . M U CH M O RE CO NTENTED . . . M UCH
th e w o rd y o u a s if you a r e ta lk in g to y o u rself.
M O R E C H E E R F U L . . . M U C H M O R E O P T I
T h e n r e la x , go to sle e p o r a r o u s e y o u rse lf. T a k e as
p e n , you
w ill b eg in to feel M U C H
M IS T IC . . . M U C H L E S S E A S I L Y D IS C O U R -
lo n g a s y o u lik e. W h e n yo u a re re a d y yo u w ill
A G E D . . . M U C H L E S S E A S IL Y D E P R E SSE D .
a r o u s e y o u r s e lf n o m a tte r w h e n th a t is by c o u n tin g
N o w re la x a n d rest fo r a m in u te o r so, g o in g
slo w ly to y o u rs e lf fro m o n e to five. Y ou w ill be co m
d e e p e r, d -e -e -p -e -r, d -e -e -p -e -r, a n d in a m in u te o r
p le te ly o u t of it th e n a w a k e a n d a le r t. R e m e m b e r
so I sh a ll ta lk to y o u , a n d y o u w ill be m o re d eep ly
th e m o re you p ra c tic e th e m o re in te n se w ill be y o u r
re la x e d , (p a u se a b o u t 10 se co n d s)
re sp o n s e , th e m o re e a sily w ill y o u r re sis ta n c e s give
T h e r e a r e fo u r th in g s w e a r e g o in g to acco m p lish
a s a re s u lt of th e s e su g g e stio n s. I c a ll th e m th e fo u r
S s: sy m p to m relief, se lf-co n fid e n ce, s itu a tio n a l c o n
tr o l,
and
s e lf-u n d e rs ta n d in g .
F ir s t,
w ay .
K eep o n p ra c tic in g : a n d n o w go a h e a d . . . re la x
. . . a n d w h e n yo u a re re a d y . . . w a k e y o u r s e lf u p.
y o u r v a rio u s
sy m p to m s (e n u m e r a te ) a r e g o in g to be less a n d less
A fter th e p a tie n t lifts th e eyelids, h e m a y be
u p s e ttin g to y o u . Y o u w ill p a y less a n d less a t t e n
ask ed ho w he feels. G e n e ra lly , th e re p ly w ill

be R e la x e d . T h e th e r a p is t th e n p la y s back
tio n to th e m b ecau se th e y w ill b o th e r y o u less a n d

less. Y o u w ill fin d th a t y o u h a v e a d e s ire to o v e r
co m e th e m m o re a n d m o re. A n d a s w e w o rk a t y o u r
p ro b le m s, you w ill feel th a t y o u r self-confidence
g ro w s a n d e x p a n d s . Y o u w ill feel m o re a s se rtiv e a n d
stro n g e r. Y o u w ill be ab le to h a n d le y o u rse lf b e tte r
in a n y s itu a tio n s th a t co m e a lo n g , p a r tic u la rly th o se
th a t te n d to u p se t y o u (e n u m e ra te ). F in a lly , a n d
m o st im p o rta n tly , y o u r u n d e r s ta n d in g o f y o u rse lf
w ill im p ro v e , (p a u se)
th e last sen ten ce a n d th e n re w in d s to th e b e

g in n in g a n d p la y s back th e first few w o rd s to
m a k e su re th e ta p e c o n ta in s th e s ta rt a n d end
of th e sc rip t. T h e p a tie n t is g iven th e ta p e w ith
th e in ju n c tio n ; If you can b o rro w a n o th e r
re c o rd e r, it is best to copy th e ta p e . U se th e
copy so th a t if th e ta p e b re a k s o r is lost you
h a v e a m a s te r to copy fro m .
Reactions to the Tape

T h e p a tie n ts ex p erie n c e s in p la y in g th e
ta p e sh o u ld be review ed a t th e n ex t session. A
n u m b e r of q u e stio n s m ay co n cern th e p a tie n t,
such as th e follow ing:
Q . S u p p o s in g so m e o n e is a t th e d o o r b u z z in g o r th e
te le p h o n e r in g s w h ile th e ta p e is p la y in g , w h a t
do I d o ?
A. If yo u w ish to in te r r u p t th e se ssio n , j u s t c o u n t
to y o u rs e lf fro m o n e to five a n d tell y o u rse lf to
Q . I fall asleep b efo re th e ta p e e n d s. D o e s th is m a t

te r?
A. N o . T h e su g g e stio n s w ill still g e t th r o u g h . A ll it

m e a n s is th a t you a r e a good su b je ct.
lift y o u r ey elid s.
Q . A t th e e n d o f th e ta p e b efo re I com e o u t of it,
w h a t su g g e stio n s s h o u ld I give m yself?
A. W h a te v e r y o u r im m e d ia te p ro b le m s a re , tell
Q . S h o u ld I c o u n t o u t lo u d b efo re I com e o u t o f it?
y o u rse lf y o u w ill w o rk th e m o u t. If y o u a r e a n
A. It is best to c o u n t to y o u rself.
tic ip a tin g d iffic u ltie s in fa c in g a s itu a tio n , tr y to
232

o u tlin e in a d v a n c e th e b est w a y of h a n d lin g it
Q . If m y m in d w a n d e r s a n d I a m n o t c o n c e n tra tin g
o n w h a t th e ta p e sa y s, w h a t th e n ?
A. L e t it w a n d e r . S o m e of th e su g g e stio n s w ill still

g et th r o u g h even if y o u fall a s leep . T h e r e a re
p e rip h e ra l
a r e a s o f a tt e n t i o n
p o in ts e n u m e r a te d so fast. A rm s n e v e r feel loose.

N e c k is m o st d ifficu lt. A n d h o w c a n a n y o n e re la x
a n d te ll y o u rse lf y o u w ill do it.
t h a t s till a r e
a b s o rb in g th e su g g e stio n s th a t a r e b e in g m ad e.
Q . W h a t a r e th e best tim e s to u se th e ta p e ?
A. If c o n v e n ie n t th e firs t th in g in th e m o rn in g a n d
th e la s t th in g a t n ig h t befo re g o in g to sleep.
S o m e p e o p le p u t th em se lv e s to sle ep w ith th e
ta p e . T h e ta p e sh o u ld be p la y e d d aily .
Q . W h e n I use th e ta p e a t n ig h t m y w ife liste n s to
it. I th in k sh e g ets a s m u c h o u t o f it a s I do.
A. Y o u r p ro b le m s a r e d iffe re n t th a n h e rs. B u t you

p ro b a b ly d o s h a re som e c o m m o n p ro b le m s. Y ou
can g et a n e a r p lu g [o n e u s u a lly co m e s w ith a
recorder] to let y o u liste n p riv a te ly w ith o u t d is
t u r b in g y o u r w ife.
o n o r d e r?
C a n t w rig g le m y h e a d if I lie d o w n .
E n u m e ra tio n o f p a r ts o f b o d y is felt lik e p h y sic a l
to u c h a n
in tru s io n ,
an
in v a sio n
o f m y p riv a te
self w ith e ro tic u n d e r to n e s a n d re se n te d .

C a n n o t v isu a liz e a p le a s a n t, q u ie t, w o n d e rfu lly
re la x e d s c e n e . E v e ry tim e re s p o n d w ith b itte rn e s s
I ve n e v e r e x p e rie n c e d one.
W h e n yo u m e n tio n m y n a m e it a lw a y s s u rp ris e s
a n d to u c h e s m e a re c o g n itio n of m e (u n w o rth y of
n o tice).
F lo a tin g se n sa tio n . . . th in g s fa d e a little a n d
lo se th e ir im m e d ia c y . A n x i e ty a n d d e p re ssio n fa d e
. . . a so r t o f f u z z y a n d tin g lin g se n sa tio n a n d a fe e l
in g o f w e lc o m in g s le e p . It d o es n o t h a p p e n . A lso
s le e p . W h y sle ep ?
N e g a tiv e su g g e stio n s th a t p il e d u p in y o u o v e r
Q . H o w o ften sh a ll I u se th e ta p e ?
th e y e a r s . If th e th o u g h ts a n d fe e lin g s a r e su g g e s
A. A t least tw ice a d a y , every d ay .
tio n s, th e y
m u st h a v e co m e fro m
so m e w h e re o r
so m e o n e. F ro m w h e re ? F ro m w h o m ?
T h e p a tie n ts re a c tio n s to th e ta p e a re im
W e m u s t re p la ce th e m
w ith p o s itiv e su g g e s
p o rta n t because th e y m a y rev eal som e basic
tio n s . M y r e a c tio n a b itte r a n d a n g r y th e p o w e r
p ro b lem s, tra n sfe re n c e m an ife sta tio n s, re s ist
o f p o sitiv e th in k in g , ev ery d a y in every w a y I get
ances, a n d th e m o v em en t in th e ra p y . O c c a
b e tte r a n d b e t te r .
sio n ally a p a tie n t w ill becom e q u ite a r g u

m en tativ e a fte r liste n in g to th e ta p e a few
p o i n t o f te a r s .
tim es. F o r e x a m p le , o n e p a tie n t a t th e th ird
p ro m is e s th a t a r e n o t b e in g fu lfille d (too good to be
session (the ta p e h ad been m a d e a t th e second
tr u e , u n a t ta i n a b le to m e). N o n e o f it is h a p p e n in g .
session) h a n d e d m e th e follo w in g ty p e w ritte n
H o w lo n g m u s t it ta k e to ta k e effect?
com m ents:
T h e ta p e q u e s tio n s a n d re a c tio n s.
L e a n b a c k M u s t I sit? I h a v e no c h a ir w h e re I
c a n re st m y h e a d . If I do get d ro w sy I g et to be like
a J a p a n e s e w o b b le h e a d d o ll, a n d th e su d d e n j e r k of
th e h e a d d is tra c ts . C a n I lie d o w n ? ( T h e n I te n d to
fall a sle e p .)
In a n d o u t " I d o n t b r e a th e th a t fast, a n d th e
in a n d o u t n e v e r co in cide.
T ir e d a n d rela xed . V e ry tire d , v ery r e la x e d . A
to ta l c o n tra d ic tio n , a n d I m u st a d d p le a s a n tly ,
a n d i t s d is tra c tin g . T o m e tir e d m e a n s e x tre m e
te n s io n a n d c o lla p se , te n s io n to th e p o in t o f v io len t
p a in .
C a n n o t re la x , n o t m ost o f th e tim e (o r m u c h of
th e tim e . N o t re a lly re la x ). A n d c a n n o t follow th e
D e s c rip tio n o f h o w
Y o u ll
be
I ve felt b r in g s m e to th e
E v e ry
m uch
d a y n o w , e tc ., e t c .
less e a s ily
tir e d .
T ire d
a g a in . C o n tr a d ic tio n is d is tu r b in g . I w a s u rg e d to
feel t i r e d
b e f o re .
A re th e re
d if f e r e n t k in d s o f
t i r e d ? E v e ry d a y , y o u w ill b eco m e so d e e p ly in
te re s te d . . . F e lt a s a d e ro g a tio n . I ve a lw a y s b een
d e e p ly in te r e s te d in w h a t I w a s d o in g , in p e o p le ,
in so m a n y th in g s , e x c e p t w h e n th e d e p re ss io n g ot
so b a d th a t I d id n t w a n t to do a n y th in g o r see
a n y o n e . A n d th is p e rsis ts, even th o u g h to a lesser
d e g re e . E n o u g h to k e e p m e stu c k a n d p a ra ly z e d .
T h e w h a t th e h ell f o r ? still o p e ra te s . I d o n t, o r
a lm o st d o n t w o rk . I c a n n o t a n s w e r le tte rs . I a m n o t
f u n c tio n in g fr o m
w ith in (o n ly , to som e e x te n t, in
re s p o n s e to o u ts id e stim u li a n d p e o p le ), e ith e r e m o
tio n a lly o r c re a tiv e ly . W h a te v e r p o te n tia l is th e r e , is
still locked u p tig h t. A n d w h e n I sa y I a m n o th in g ,
I a m n o t se lf-d e p re c ia tin g , I a m m e re ly d e s c rib in g
th e a w fu l se n se o f e m p tin e s s w ith in .
M AKING A RELAXING AND EGO-BUILDING TAPE

I d o n t w a n t to be m u c h less c o n sc io u s o f m y s e lf
a n d m y fe e lin g s . I w a n t to be co n scio u s, b u t I w a n t
233
fig h tin g off closeness to m e as in d ica ted in th is

d re a m :
th e feelin g s to c h a n g e . I w a n t to f e e l (a n d n o t o n ly
p a in a n d ra g e ). I w a n t to b e a b le to feel love. T o feel
P t.
jo y . T o h a v e a feelin g o f p e rs o n a l w e ll-b e in g . S ee
A h e rd o f w ild h o g s a c ro ss th e field, m o v in g
r a p id ly , full of w ild a n g r y e n e rg y , b u t r a th e r
th in g s in th e ir tr u e p e rs p e c tiv e . W h a t th e devil is
sm a ll. I w o n d e r I th o u g h t th e y w e re b ig g er.
tr u e p e rs p e c tiv e ? T h e r e is no su c h th in g .
A fo re re la x e d , less ten se each d a y . It is n t h a p
T h e y a r e d a n g e ro u s .
B a ck to w h e re I ca m e fro m . M o th e r sa y s I
p e n in g .
s h o u ld n t h a v e g o n e. T h a t a r e a is v ery d a n
" N o t o n ly w h a t yo u h a v e to do each d a y , b u t
g e ro u s. I a m frig h te n e d in re tro s p e c t. I look
w h a t yo u o u g h t to be a b le to d o . ( M e a n in g ? B u t,
ac ro ss th e w a te r a t th e d is ta n t, g re e n la n d . It
of co u rse, I a m to s u p p ly th e m e a n in g .)
se em s p eace fu l fro m h e re . B u t n o , it is v ery d a n
W ith o u t fe a r of c o n s e q u e n c e s . ( M e a n in g ? )
g e ro u s.
M o r e a n d m o re a b le to s ta n d o n y o u r o w n feet
T o ta l lo n e lin e ss. I c a n see s tr a n g e r s to w h o m
w ith o u t p r o p s . Is th e ta p e a p r o p ? A re th e W s
I m e a n n o th in g . A sid e fro m t h a t n o th in g . I
p ro p s ?
ca n r u n a n d r u n . W h e n I sto p , th e r e is n o th in g .
T h e y w ill h a p p e n , ex a c tly a s I tell you th e y w ill
I love no o n e , a n d no o n e loves m e.
h a p p e n . W h e n ?
I w a lk w ith m y h a n d in D r . W o lb e r g s a rm .
C a n n o t s ta n d / ca ll th e m th e f o u r S s . I can
S o m e w h a t b e h in d us w a lk s h is w ife. W ill she
sc re a m w h e n e v e r I h e a r a fo rm u la . C a n it be o m it
feel j e a lo u s ? I a m m ild ly a n x io u s . ( T h e r e w a s
ted , p le a se ? (If a n o th e r ta p e is m a d e ).
m o re , b u t I c a n t re c a ll it.)
" A s w e w o r k o n y o u r p r o b le m s (? D o w e?)
I w a s lis te n in g to th e ta p e a n d I k e p t th in k in g
" I n situ a tio n s th a t u p se t y o u . S itu a tio n s d o n t
m a y b e you d i d n t h a te m e. B u t I p u s h e d it o u t
u p se t m e. (O f co u rse n o t. I av o id w h a t I fe a r).
o f m y m in d . B e cau se I c o u ld n t to le r a te th a t b e
" I t m a k e s no d iffe re n c e h o w d e e p y o u g o . E v e n i f
c a u s e it w o u ld m a k e m e v u ln e r a b le . I sa id , I m
y o u f e e l y o u a re c o n s c io u s (A m I su p p o s e d to be
g o in g to a s k h im if h e is s u re he a p p ro v e s m e . I
u n c o n s c io u s? I a m co n scio u s ev ery tim e n o t every
h a d a n o th e r d re a m :
I w a s o n a sta g e g iv in g a p e rfo rm a n c e , a n d I
tim e o r a ll th e tim e. A t tim e s I ve fa lle n asle e p ).
felt I co u ld do it. I w a n te d e v e ry b o d y to lik e m e,

"M ake
your ow n
s u g g e s tio n s . A m o n g th e m :
and
I w a n te d
to
put
on
p o se
of c o n fi
S to p re je c tin g y o u rself. S to p re je c tin g life. Be g lad
d en ce. I k e p t sa y in g , D r . W o lb e rg sa y s I m
yo u a r e aliv e.
F eel aliv e. D o n t feel
n o t b a d . T h e n I w a s in a n e m b ry o n ic sa c lik e a
w o rth le ss . Y o u a r e w o rth w h ile . Y o u a re in te llig e n t.
F eel good.
b a llo n lik e I w a s g iv in g b ir th to a b a b y . A m a n
Y o u a r e ta le n te d . Y o u h a v e a c c o m p lis h e d m u ch .
w a s b lo w in g on it as if h e w a s h e lp in g m e.
R e la x , feel re ste d . F eel b r ig h t. F eel a le rt. F eel. R e

m e m b e r th is o r th a t.
"G o
to sleep .
O r a ro u se y o u r s e lf. C o n fu sin g
each tim e. Is th is d e lib e ra te ?
F o rtu n a te ly , it is ra r e th a t o n e e n c o u n te rs so
n eg ativ e a re a c tio n . In th is case I listen ed
silently to h e r o bjections a n d m e re ly to ld th e
p a ti e n t to c o n tin u e lis te n in g to th e ta p e ,
p ro m isin g th a t if she needed a n ew ta p e in th e
fu tu re I w o u ld m a k e one. I th e n d iscu ssed h e r
d re a m s a n d h e r fe e lin g s a b o u t m e . H e r
resp o n se w as a good o n e, a n d sh e did no t
req u est a n o th e r ta p e , b e n e fitin g fro m th e o n e I
h ad dictated to w h ich o rig in a lly she h a d so
m an y negative re actio n s. S h e seem ed to be
T h e positive aspects o f th e d re a m p re d ic ted

th e resp o n siv e re la tio n s h ip
veloped w ith m e.
th e
p a tie n t
de
A n o th e r p a tie n t w ith a stro n g fear of a u

th o rity h a d th e fo llo w in g re a c tio n a n d d re a m
a fte r th e p la y b a c k of th e tap e .
P t.
I felt c o m fo rta b le a n d p ro te c te d a n d I th o u g h t
m a y b e I c a n s ta n d u p to m y su p e rv is o r. T h a t
n ig h t I d r e a m e d , th a t th e r e w a s a w o m a n a t a
c a m p s ite . S h e w a s a cro ss b e tw e e n a fu ry a n d a
w itc h . T h e r e w a s also a m a n a n d a c h ild . I
w a s c o m in g for h e lp . A s I a p p r o a c h e d th e
c a m p s ite , th is w o m a n ca m e f o rw a rd . I w a s
s u p p o s e d to h a v e in n e r c o n v ic tio n , th e s tre n g th
o f w ill to o v erco m e th is sp e c te r. S h e com es
234

to w a r d m e a w fu l lo o k in g , p a le . I a w o k e in a
tio n o f m y m o th e r, th e w o m a n a n a ly s t I h a d
cold s w e a t. T h e n I fell a s le e p a g a in a n d th e
o n ce
d ream
s u r e m y s te p fa th e r ? T h e d ire c to r looks lik e
re su m e d . T h e
d ir e c to r c a m e
in a n d
se en ,
and
m yself.
The
m an
I m
not
sa id : T h is th in g is n o t r e a l a ll im a g in a r y
you a n d th e m a n I live w ith . T h is w e e k I w as
n o r e a l i t y . I w e n t in a g a in to th e c a m p site .
a b le to face a n d ta lk to m y s u p e rv is o r w ith o u t
T h is tim e it is n o t so b a d , b u t I s w e a t a n d h av e
s h a k in g .
a n x ie ty a n d I w o k e u p . A g a in I w e n t to sleep
a n d th e d r e a m c o n tin u e d . T h e d ir e c to r sa id ,
O .K . L o o k a t it a s it is. R e co g n ize th e re a lity
fo r w h a t it is a n d face i t . I d id it a n d th a t w a s
it. I looked a t th e visio n a n d th e d r e a m en d e d .
I a w o k e re la x e d a n d h a p p y . P la y e d th e ta p e
It m ay n o t a lw a y s be p o ssib le to get d re a m s
o r asso ciate d feelings fro m p a tie n ts in re p o n se
to th e ta p e , b u t th e th e r a p is t w ill be a b le to
d e d u ce th e re sp o n se s fro m b e h a v io ra l an d
o th e r clues. In th e event th e p a tie n t does n o t
o f a c h ild o r b a b y . M u s t be som e asp e c t of
b rin g u p th e m a tte r, th e th e r a p is t sh o u ld in
q u ir e a s to h o w th e p a tie n t feels liste n in g to
a g a in . I h a v e h a d r e c u r re n t d r e a m s a ll m y life
m yself, I m su re . T h e ch ild is u s u a lly d y in g o r
th e ta p e . It is r a r e th a t o b jectio n s to som e
sick o r in d a n g e r. A b u rd e n . A n d I a s a n a d u lt
a sp ects o f th e ta p e a re so stro n g th a t a n ew
am sa v in g it. T h e w o m a n in th is d r e a m , th e
ta p e d e le tin g th ese sections w ill be n eeded.
fu ry -w itc h , th e a w fu l looked lik e a c o m b in a
Conclusion
A cassette ta p e c o n ta in in g re la x in g a n d egob u ild in g su g g estio n s offers th e p a tie n t a c o n
tin u in g m e a n s of su p p o rtiv e an d e d u c a tio n a l
h e lp aw ay from th e th e r a p is ts office. R e
sponses to th e ta p e p ro v id e tra n sfe re n c e a n d
re sista n c e m a te ria l for a d y n a m ic focus th a t

m ay be e x p lo re d a n d in te rp re te d . U p o n te r m i
n a tio n o f th e r a p y th e ta p e m ay serve as a n im
p o r ta n t aid to w a rd fu rth e rin g th e objectives of
tre a tm e n t.
CHAPTER 16
Homework Assignments
O n e of th e m ost neglected asp ects o f s h o r t
te rm th e ra p y is assig n in g h o m e w o rk th ro u g h
2.
W h a t p a tte r n s o f b e h a v io r w o u ld y o u lik e to
c h a n g e , p a tte r n s th a t s h o u ld be c h a n g e d ? H o w far
w h ich p a tie n ts can facilita te m e an s o f c o n tro l
b a c k do th ey g o ? D o yo u see a n y c o n n e c tio n b e
lin g o r e lim in a tin g self-d efeatin g p a tte rn s . It is

often assum ed th a t th e lessons a b so rb e d in th e
tw e e n th e s e p a tte r n s a n d th in g s t h a t h a p p e n e d to
th e r a p is ts office w ill a u to m a tic a lly c a rry over

in to ev eryday life. T h is c h e rish e d h o p e does
n ot a lw ay s com e to pass. T h e av e ra g e p a tie n t
g e n e ra lly d issociates th e le a rn in g s in th e th e r a
p is ts office from b e h a v io r a t h o m e, a t school,
a t w o rk , an d in th e c o m m u n ity . A fter p sy c h o
y o u a s a c h ild ? R e a liz e th a t yo u m a y n o t h a v e been

re s p o n s ib le for w h a t h a p p e n e d to y o u a s a c h ild , b u t
y o u a re re s p o n s ib le fo r p e r p e tu a tin g th e s e p a tte r n s
n o w , for le ttin g th e s e p a tte r n s r u in y o u r h a p p in e s s
a t th e p r e s e n t tim e . Y o u can do s o m e th in g a b o u t
th e m . W h e n y o u o b se rv e y o u rse lf a c tin g th e se p a t
te r n s o u t, S T O P . A sk y o u rse lf a r e y o u g o in g to let
th e m c o n tro l y o u ? S ay to y o u rse lf, I a m a b le n o w
to sto p th is n o n s e n s e , a n d do it. F o r e x a m p le ,
logically s trip p in g oneself d u rin g a sessio n ,

o u tsid e th e p a tie n t p u ts b ack o n th e fa m ilia r
e v e ry tim e yo u b e a t y o u rse lf a n d d e p r e c ia te y o u rself,
n e u ro tic su it of clothes.
It can be h e lp fu l,
o r act o u t a b a d p a tte r n a n d say y o u a r e h e lp le ss to
th erefo re, in c o n so lid atin g th e ra p e u tic g a in s to
c o n tro l it, a r e y o u d o in g th e s e th in g s to p ro v e th a t
insist th a t th e ra p y does n o t sto p w ith th e ex it

from th e tre a tm e n t ro o m . T h e p a tie n t m u st
p u t in to p ra c tic e w h a t is le a rn e d d u rin g th e
sessions in o rd e r for an y c h a n g e to re g iste r it
y o u a r e d efen se le ss a n d th a t th e re fo re so m e b o d y
s h o u ld co m e a lo n g a n d ta k e c a re o f y o u ? A re you
p u n is h in g
y o u rse lf b e c a u se you feel g u ilty a b o u t
so m e th in g ? It is easy to say y o u a r e a c rip p le d c h ild

a n d th a t so m e k in d p e rso n m u st ta k e c a re of you.
self p e rm a n e n tly . A nd w h en tre a tm e n t h as

ended, th e p a tie n t w ill c e rta in ly need to r e in
force new m odes of co p in g by c o n tin u in g
p e n d e n c y by g e ttin g d e p re ss e d , fe e lin g p h y sic a lly ill,
h o m e w o rk ; o th e r w is e , in r e t u r n i n g to th e
y o u c o n tro l a b a d p a tte r n , r e w a r d y o u rse lf by d o in g
cu sto m ary e n v iro n m e n t, re la p se m ay b e in
s o m e th in g n ice fo r y o u rse lf, s o m e th in g you e n jo y an d
evitable.
th a t is g o o d fo r you.
In s tru c tio n s m ay th u s be given th e p a tie n t

a lo n g th e follow ing lines:
d e v e lo p th a t a re c o n s tru c tiv e ? W o u ld you lik e to be
B u t re m e m b e r y o u p a y a n a w fu l p ric e fo r th is d e
a n d d e s tro y in g y o u r feelin g s of s e lfw o rth . E v e ry tim e
3. W h a t p a tte r n s o f b e h a v io r w o u ld y o u lik e to
m o re
1.
a s s e rtiv e
for
in s ta n c e ?
If
so,
p la n
to
do
L o o k sq u a r e ly a t y o u r im m e d ia te life s itu a s o m e th in g th a t c a lls fo r a s se rtiv e n e ss each d a y .
tio n . W h a t e le m e n ts a r e to y o u r lik in g ? A re th ese

e le m e n ts good fo r you a n d c o n s tru c tiv e , a n d do th e y
n eed re in fo rc e m e n t? O r sh o u ld th e y be m in im iz e d
o r e lim in a te d b ecau se th e y get yo u in to p ro b le m s?
W h a t e le m e n ts a r e d e s tru c tiv e ? W h a t can y o u d o to
m a k e th e m less d e s tru c tiv e ? S h o u ld th e y be e lim i
n a te d c o m p le te ly ? H o w
ca n y o u go a b o u t d o in g
th is ? O n c e y ou h a v e d ecid ed on a p la n of a c tio n ,
p ro ceed w ith it a ste p a t a tim e , d o in g s o m e th in g
a b o u t it each d ay .
T h e s e a ssig n m e n ts m a y be given v e rb a lly to

th e p a tie n t in th e th e r a p is ts o w n w o rd s. If a
re la x in g a n d e g o -b u ild in g cassette ta p e (see
p re c e d in g c h a p te r) h a s been m ad e , re m in d th e
p a tie n t th a t re s u lts a re c o n tin g e n t on u tiliz in g
th e ta p e p re fe ra b ly a t least tw ice d aily .
In a d d itio n to th e above, som e p a tie n ts m ay
b en efit fro m a p rin te d o r ty p e w ritte n set of d i
235
236
rectio n s, such a s suggested below . T h e s e m ay
4. O b s e r v in g d a y d r e a m s o r n ig h t d re a m s. A u se
be ad a p te d to specific p ro b lem s. T h e list m ay
ful o u tlin e fo r o b se rv in g th e m e a n in g o f o n e s d a y o r
be given to a n d discussed w ith th e p a tie n t

s h o rtly before te rm in a tio n .
n ig h t d r e a m s in c lu d e s th e s e th r e e q u e s tio n s : W h a t
is y o u r fe e lin g a b o u t y o u rse lf in th e d r e a m ? W h a t
p ro b le m a r e y o u w re s tlin g w ith in th e d r e a m ? By
w h a t m e a n s do y o u re a c h , o r fail to r e a c h , a s o lu
1. W h e n e v e r y o u g e t u p s e t o r y o u r s y m p to m s
r e tu r n o r g e t w o rse, a sk y o u r s e lf w h y th is is so. T r y
tio n
to
th e
p ro b le m
th a t
p r e s e n ts
itself in
th e
d re a m ?
to e s ta b lis h a r e la tio n s h ip b e tw e e n th e sy m p to m s
R e c u rr in g d r e a m s a r e p a r tic u la r ly sig n ific a n t b e
a n d h a p p e n in g s in y o u r e n v iro n m e n t. D id so m e
c a u s e th e y re p re s e n t a c o n tin u in g co re p ro b le m in
t h in g o c c u r th a t m a d e yo u feel g u ilty o r a n g e re d you
o n e s life. A g a in , w h e n e v e r p o ss ib le , y o u s h o u ld a t
o r th a t y o u d i d n t lik e ? A re yo u p u n is h in g y o u rse lf
te m p t, if yo u c a n , to r e la te th e c o n te n t o f y o u r
b e c a u se y o u feel g u ilty ? Is so m e th in g g o in g o n in
d r e a m s to w h a t is h a p p e n in g in y o u r life a t th a t
y o u r re la tio n s h ip w ith a p e rso n w h o is close to you
tim e . O n e m a n fo u n d th a t h e h a d r e c u r r in g d re a m s
o r w ith th e p e o p le w h o a r e a r o u n d yo u th a t is h a rd
o f b lo o d sh e d b u t th a t th o se d r e a m s o n ly o c c u rre d
fo r you to ta k e ? O r is so m e th in g b o th e r in g you th a t
a f te r h e h a d m a d e a n a tte m p t to a s s e rt h im se lf by
y o u find d ifficu lt to a d m it even to y o u rse lf? It is
a s k in g fo r a r a is e in p a y o r by g o in g o u t w ith a g irl
o fte n h e lp fu l to k eep a w r itte n re c o rd of th e n u m b e r
th a t h e lik e d . H e w a s m u c h s u r p r is e d to d isc o v er
o f tim e s d a ily th a t y o u r s y m p to m s r e tu r n a n d a p
t h a t h is frig h te n in g d r e a m s w e re a c tu a lly ev id en ce
p ro x im a te ly
w hen
th e y
s ta rte d
and
w hen
th e y
sto p p e d . If y o u j o t d o w n th e th in g s th a t h a p p e n e d
th a t h e still h a d so m e o ld c h ild ish fe a rs a b o u t s ta n d

in g u p fo r h im self.
im m e d ia te ly b e fo re th e s y m p to m s s ta rte d , a n d th e
5. O b s e rv in g re sista n c e s to p u t t i n g u n d e r s ta n d
c irc u m sta n c e s , if a n y , th a t re lie v e d th e m , yo u m ay
in g in to a ctio n . E x p e c t in e v ita b le re sis ta n c e w h e n
b e a b le to le a rn to c o n tro l y o u r s y m p to m s o r e lim i
y o u tr y to sto p n e u r o tic p a tte r n s . A n d th e r e ca n be
n a te th e m .
2. W h a t are th e c irc u m sta n c e s th a t b o o st a n d th e
te n s io n a n d f e a r w h e n o n e faces a c h a lle n g e th a t fo r
th in g s th a t d im in is h
th e fe e lin g s a b o u t y o u rse lf?
an c e c o n tin u e to o c c u r, it is w ell to q u e s tio n th e
W h e n do y o u feel g o o d a b o u t y o u rse lf a n d w h e n do
re a s o n s fo r th e d e la y a n d a sk w h y o n e is a f r a id
y o u feel b a d ? A re th e s e feelin g s c o n n e c te d w ith y o u r
a n d th e n to ta k e h e a r t a n d d e lib e ra te ly c h a lle n g e th e
successes o r y o u r fa ilu re s ? W h a t m a k e s yo u feel in
fe a r to see if it c a n be o v erco m e.
m e rly h a s b een ev a d e d . W h e n d e la y in g a n d a v o id
fe rio r, a n d w h a t m a k e s you feel s u p e rio r ? D o you

feel b e tte r w h e n
you a r e a lo n e a n d
a w a y fro m
p e o p le , o r d o y o u feel b e tte r w h e n you a r e w ith

p e o p le ? W h a t k in d of p e o p le ?
3. O b serve th e f o r m
p e o p le .
o f y o u r r e la tio n s h ip w ith
W h a t te n s io n s do yo u g et w ith
p e o p le ?
W h a t k in d of p e o p le do y o u lik e a n d d islik e ? A re
th e s e te n s io n s w ith all p e o p le o r c e r ta in k in d s of
p e o p le ? W h a t d o p e o p le do to u p s e t y o u ? In w h a t
w a y s d o you g e t u p s e t? W h a t do y o u d o to u p se t
th e m o r to get y o u rse lf u p se t w h e n y o u a r e w ith
th e m ? W h a t d o y o u do a n d w h a t do th e y d o th a t
te n d s to m a k e y ou a n g r y ? W h a t p ro b le m s do you
h a v e w ith y o u r p a r e n ts , m a te , c h ild r e n , boss, asso c i
a te s a t w o rk , a u th o r itie s , p e o p le in g e n e ra l? D o you
te n d to t r e a t a n y o n e in a w a y s im ila r to th e p a tte r n s
th a t y o u e s ta b lis h e d w ith y o u r f a th e r, m o th e r, s ib
lin g s? H o w is y o u r r e a c tio n to p e o p le ab o v e y o u ,
b elo w y o u , e q u a l to y o u ? W h a t a r e y o u r e x p e c ta
T h e d is c ip lin ed p ra c tic e o f th ese p rin c ip le s

o f s e lf-o b s e rv a tio n c a n le a d to p ro g r e s s iv e
g ro w th . P a tte rn s h av e to b e reco g n ized a n d
rev ised if o n e is to ach ieve m o re satisfy in g
g o als in life. B u t as ev ery o n e k n o w s, th e h a b its
of y e a rs give g ro u n d g ru d g in g ly a n d slow ly.
Id e a lly , h o w e v er, th e p ro cess of p e rs o n a lity
u n d e r s ta n d in g a n d g r o w th is m a r k e d by
sev eral d iscrete fe a tu re s: T h e r e is th e a w a re
ness th a t o n e s p ro b le m s do n o t o c cu r fo r
tu ito u s ly b u t a re in tim a te ly co n n ected w ith th e
events (esp ecially th e h u m a n in te ra c tio n s) of
o n e s life. F o r a given in d iv id u a l th e re is a
c e rta in q u a lity of h u m a n ev en t th a t g e n e ra te s
a n x ie ty , co n flict, a n d stress. T h e s e p h e n o m e n a ,
once d e tected , m a y lead n e x t to a se a rc h in g for
o p p o s ite sex ? D o you tr y to m a k e y o u rse lf too d e
th e o rig in a n d h isto ry o f th ese p a tte rn s . It is

n o t im p o ssib le to see h o w th ese p a tte rn s o p e r
p e n d e n t o n c e rta in p e o p le ?
a te d as fa r b ack as a p e rso n can re m e m b e r
tio n s w h e n you m eet a very a ttr a c tiv e p e rso n of th e
237
HOMEWORK ASSIGNMENTS
p e rh a p s even th e very e a rlie s t m em o ry c o n
In c re a sin g ly , w e c a n e x p re ss a claim to a new
ta in s so m eth in g of th e sam e th in g . S eein g th e
life; w e find o u rselv es ab le to be m o re ex
c o n d itio n s u n d e r w h ich fea rs o rig in a te d , an d
p ressive. S e lf-re c rim in a tio n s d im in ish . O u r ca
u n d e r w h ich th ey a re n o t re trig g e re d , o n e m ay
n e x t d e te rm in e w h e th e r o n e c a n be m o re th e
p a c itie s e x p a n d , a n d w e g ra tify m o re o f o u r
m a s te r of o n e s life r a th e r th a n a v ictim o f it.
th e re fo re less a n g ry , w e c a n e n te r in to re la
C o u ld w e be d ifferen t fro m th e w ay w e h av e
a lw ay s k n o w n ou rselv es to b e? A n d ever so
tio n sh ip s w ith p eo p le w ith m o re o p e n n e ss an d
n e e d s. F e e lin g le ss f r u s tr a te d
in life , a n d
slow ly, w e m ay ch allen g e o n e h a b itu a l c h ild ish
a g re a te r a b ility to sh a re .
T h e s e a re id e a listic g o als, b u t th e y re p re se n t
fear a t a tim e, p u sh in g o u rselv es to b re a k o u t
a g u id e alo n g th e w ay to w a rd g re a te r self
o f th e p riso n of o u r n e u ro tic self-d efeatin g p a t

te rn s. Success b reed s success, a n d v icto ry lead s
o b se rv a tio n a n d ric h e r living. F id e lity to th e
to victory. D efeats a re re a n a ly z e d in acco rd
p ra c tic e o f se lf-o b se rv a tio n , to g e th e r w ith th e

a c tu a l tr a n s la tio n of u n d e rs ta n d in g in to a c tio n ,
w ith
c a n be a lifelo n g q u e st m a rk e d by h ig h a d v e n
th e ir
p lace
in
th e
S eeing ou rselv es defeated
psychic
s tru c tu re .
by th e sam e old
en em ies, w e a re b u oyed u p in k n o w in g th a t
fo rm u la tio n s a b o u t o u r p e rs o n a litie s a re c o r
rect, a n d w e a re th e n en c o u ra g e d to fig h t on.
tu r e a n d n o ta b le re su lts.
T h e k n o w le d g e of o n eself a n d
how
one
re a c ts c o n tin u e s to c o n stitu te th e su re st p a th to
h e a lth a n d to m a tu re b e h a v io r.
Evolving a More Constructive Life Philosophy

O n e o f th e w ay s p sy c h o th e ra p y in flu en ces
p eo p le is by h e lp in g th e m to d ev elo p new
sh o rt-te rm p ro g r a m is: C a n w e a s th e ra p is ts
v alu es a n d p h ilo so p h ie s of liv in g . H o w e v e r,
e x p e d ite m a tte rs by a c tin g in a n e d u c a tio n a l
th e h isto ry of th e m a jo rity o f p a tie n ts , p rio r to

th e ir seeking th e ra p y , a tte sts to fu tile g ro p in g s
c a p a c ity , p o in tin g o u t fa u lty v a lu e s a n d in d i

c a tin g h e a lth y o n es th a t th e p a tie n t m a y a d
for som e k in d of p h ilo sp h ic a l a n sw e r to th e ir
v a n ta g e o u s ly
d ile m m a s .
v ie w p o in ts to be stre sse d ?
The
se a rc h
m ay
p ro c e e d
fro m
C h ris tia n to O rie n ta l p h ilo so p h ie s, fro m p r u

rience to m o ra lism , from se lf-cen tered n ess to
c o m m u n ity m in d ed n ess. W h a t a t first seem s
firm ly e stab lish ed soon becom es d u b io u s as
new ideas a n d co n cep ts a re p ro ffe re d by d iffe r
e n t a u th o ritie s. It is fa r b e tte r to evolve p h ilo s
o p h ies th a t a re an c h o re d in som e re a listic c o n
c ep tio n of o n e s p e rso n a l u n iv e rse th a n to
accept fleeting cosm ic se n tim e n ts a n d s u p p o s i
tio n s no m a tte r how sou n d th e ir so u rce m ay
seem . E ven a b rie f p erio d of p sy c h o th e ra p y
m ay till th e soil for th e g ro w th of a h e a lth ie r
sense of values. W e m ay be ab le d u rin g th is
sp an to in cu lcate in th e p e rso n a p h ilo so p h y
p red icted on science r a th e r th a n o n cu ltism .
T h e q u e stio n
th a t n a tu r a lly follow s in a
a d o p t?
If so ,
w hat
a re
th e
A c tu a lly , n o m a tte r h o w n o n d ire c tiv e a th e r

a p is t m a y im a g in e h im se lf to be, th e p a tie n t
w ill soon p ick u p fro m e x p lic it o r im p licit cues
th e te n o r o f th e th e r a p is ts p h ilo so p h ie s a n d
v alu es. T h e k in d s of q u e stio n s th e th e ra p is t
a sk s, th e focus o f h is in te rp re tiv e a ctiv ities, his
c o n fro n ta tio n s a n d acq u ie scen ces, h is silences
a n d e x p re ssio n s of in te re st, a ll d e sig n a te p o in ts
o f view c o n ta g io u s to th e p a tie n t, w h ich he
te n d s to in c o rp o ra te , co n scio u sly a n d u n c o n
sciously, u ltim a te ly e sp o u sin g th e very co n
c e p tu a l c o m m o d itie s th a t a re p riz e d by th e
th e ra p is t. W h y n o t th e n o p e n ly p re s e n t new
p re c e p ts th a t can serve th e p a tie n t b e tte r?
S u p e rfic ia l as th e y so u n d , th e few p re c e p ts th a t
238
can be te n d ered m ay be in s tru m e n ta l in ac

ce le ra tin g a b e tte r a d ju s tm e n t. A m o n g p o ssib le
p ro p o sitio n s a re th e follow ing:
Handling Tension and Anxiety

T h e p a tie n t m ay b e re m in d e d th a t te n sio n
a n d a n x ie ty m a y a p p e a r b u t th a t h e c a n do
so m e th in g p o sitiv e a b o u t th e m .
Isolating the Past from the Present

A ll p erso n s a re v ictim ized by th e ir p a st,
T h . E v e ry tim e yo u e x p e rie n c e te n s io n , o r a n y o th e r
w h ich m ay o p e ra te as m isch ief m o n g e rs in th e
sy m p to m s fo r th a t m a tte r , a sk y o u rse lf w h y ? Is
p re se n t. A good a d ju s tm e n t p re su p p o se s m o d u
la tin g o n e s activ ities to p re s e n t-d a y c o n sid e ra
s o m e th in g w h ic h h a p p e n e d b e fo re th a t is s tir
tio n s r a t h e r th a n r e s ig n in g to p r o m p tin g s
in sp ire d by ch ild ish n eed s a n d m is in te rp r e ta
tions.
In
th e ra p y
th e
p a tie n t
m ay
becom e
a w a re o f w h a t e a rly p a tte rn s a re re p e a tin g
it th e im m e d ia te s itu a tio n y o u a r e in ? Is it
r in g y o u u p ? Is it so m e th in g yo u b elieve w ill
h a p p e n in th e f u tu re ? O n c e y o u h a v e id e n tifie d
th e so u rc e o f y o u r te n s io n o r tr o u b le , y o u w ill
be in a b e tte r p o sitio n to h a n d le it. T h e least
t h a t w ill o c c u r is th a t y o u w ill n o t feel so h e lp
them selves in h is a d u lt life. T h is m ay p ro v id e

h im w ith a n in cen tiv e fo r c h an g e. O n th e o th e r
Y o u w ill th e n be in a b e tte r p o sitio n to do
h a n d , it m ay give th e p a tie n t a n excuse to r a
t h in g s to c o rre c t y o u r tro u b le .
tio n a liz e
h is d e fe c tio n s o n
th e
less sin c e yo u k n o w a little a b o u t its o rig in s .
b a s is t h a t
u n a lte ra b le d a m a g e h as been d o n e to h im by
h is p a re n ts, w h o a re re sp o n sib le for all of his
tro u b le . T h e th e ra p is t m ay re m in d th e p a tie n t
th a t he, like a n y o n e else, h a s a te n d e n c y to
p ro ject o u tm o d ed feelings, fears, a n d a ttitu d e s
in to th e p re se n t. H is e a rly h u rtfu l e x p erien ces
u n d o u b te d ly c o n trib u te to h is in sec u rity a n d to
T h e id ea th a t one need n o t be a h elp less

v ictim o f sy m p to m s te n d s to re s to re feelings of
m a ste ry . A p a tie n t w h o h a s g iven th is su g g es
tio n w e n t to a n ew class. W h ile liste n in g to th e
le c tu re r, she b eg a n to e x p e rie n c e te n sio n an d
to
a n x ie ty . A sk in g h e rs e lf w h y , she re a liz e d she

w a s re a c tin g to th e p re se n c e of a c la ssm a te
he,
w h o cam e fro m h e r o w n n e ig h b o rh o o d a n d
th erefo re, m u st try to o vercom e th e m . T h u s ,

th e th e ra p is t w o u ld m a k e a sta te m e n t sim ila r
to th e follow ing:
felt g u ilty a b o u t h e r in te re st in o n e of th e m en
in th e class. T h is h a p p e n e d to be th e re al
T h . R u m in a tin g o n y o u r u n f o rtu n a te c h ild h o o d
re a so n w h y sh e re g iste re d fo r th e co u rse. S he
re a liz e d th a t sh e feared th e n e ig h b o rs re v e a l
his d evalued
self-esteem .
c o n ta m in a te
h is a d ju s tm e n t n o w , a n d
T hey
c o n tin u e
a n d b itte r p a s t e x p e rie n c e s a r e in d u lg e n c e s you

c a n n o t a ffo rd . T h e s e ca n p o iso n y o u r p re s e n t
life if y o u let th e m do th is. It is a c re d it to you
as a p e rs o n
fo rtu n e s .
to rise ab o v e y o u r e a rly
A tte m p t to r e s tr a in
m is
y o u rse lf w h e n
y ou fall b a c k in to th in k in g a b o u t p a s t ev en ts
y ou n o lo n g e r ca n c o n tro l o r w h e n y o u find
y o u rse lf b e h a v in g ch ild ish ly . R e m e m b e r, you
m ay n o t h a v e b een re s p o n s ib le for w h a t h a p
p e n e d to y o u w h e n you w e re a c h ild , b u t you
a re re s p o n s ib le for p e r p e tu a tin g th e s e p a tte r n s
k n ew h e r fam ily . S he th e n rec o g n ized th a t she
ing h e r in te re st in th e m a n to h e r p a re n ts if she
sa t n e a r h im o r w as frien d ly to h im . S h e th e n
th o u g h t a b o u t h e r m o th e r w h o w a s a r e
p ressiv e, p u n itiv e p erso n w h o h ad w a rn e d h e r
a b o u t se x u a l activities. W ith th is u n d e rs ta n d
in g , sh e s u d d e n ly b e c a m e a n g r y a t h e r
c la ssm ate . W h e n sh e ask ed h e rse lf w h y she
w as so fu rio u s, it d a w n e d o n h e r th a t she w as
a c tu a lly e m b itte re d a t h e r o w n m o th e r. H e r
te n sio n a n d h o stility d is a p p e a re d w h e n sh e r e
re le a se m y se lf fro m th e b o n d s of th e p a s t .
solved to follow h e r im p u lses on th e b asis th a t

she w a s n o w old e n o u g h to do w h a t she
A n d w o rk a t it.
w ish ed .
in th e p re s e n t. S ay to y o u rse lf, I m g o in g to
Tolerating a Certain Amount of

Tension and Anxiety
239

Frustration and Deprivation
Som e tension a n d an x ie ty a re in h e re n t p a rts
N o p erso n c a n ev er o b ta in a full g ra tific a
of living. T h e re is no escap e fro m th e m . T h e
tio n o f all o f h is n eed s, a n d th e p a tie n t m u st

com e to th is re a liz a tio n .
p a tie n t m u st be b ro u g h t a ro u n d to a ccep t th e
fact th a t he w ill have to to le ra te a n d h a n d le a
T h . It is im p o r ta n t to re m e m b e r th a t y o u still can
c e rta in a m o u n t of an x iety .
d e riv e a g r e a t d e a l o f jo y o u t o f e ig h ty p e r cen t
T h . E v e n w h e n y ou a r e fin ish e d w ith th e r a p y , a
r a th e r th a n o n e h u n d r e d p e r c e n t. E x p e c t to be
c e rta in a m o u n t o f te n s io n a n d a n x ie ty a r e to be
f r u s tr a te d
ex p ected . A ll p e rso n s h a v e to live w ith som e
w ith it.
to so m e e x te n t a n d
le a r n to live
a n x ie ty a n d te n s io n , a n d th ese m a y p r e c ip ita te
v a rio u s sy m p to m s fro m tim e to tim e . If y o u do
get so m e a n x ie ty n o w a n d th e n , rid e it a n d try
to fig u re o u t w h a t is s tir r in g it u p . B u t, r e
Correcting Remediable Elements

in O ne's Environment
m e m b e r, y o u a re n o w o rse off th a n a n y o n e else

sim p ly b ecau se you h a v e so m e a n x ie ty . If you
a r e u n a b le to reso lv e y o u r te n s io n s e n tire ly
th r o u g h se lf-o b se rv a tio n , try to in v o lv e y o u rse lf
in a n y o u ts id e ac tiv itie s th a t w ill get y o u r m in d
T h e p a tie n t m a y be re m in d e d of h is re
sp o n sib ility to re m e d y a n y a lte ra b le facto rs in
h is life s itu a tio n .
off y o u r te n sio n s.
T h . O n c e yo u h a v e id e n tifie d a n y a r e a o f tro u b le ,

Hostility
tr y to fig u re o u t w h a t c a n b e d o n e a b o u t it.
L a y o u t a p la n o f a c tio n . Y ou m a y n o t be ab le
to im p le m e n t th is e n tire ly , b u t do a s m u c h o f it
a s yo u c a n im m e d ia te ly , a n d th e n ro u tin e ly
If th e p a tie n t can be m a d e to u n d e rs ta n d
k e e p w o r k in g a t it. N o m a tte r h o w h o p eless
th a t he w ill occasio n ally get re se n tfu l a n d th a t
th in g s se em , if y o u a p p ly y o u rse lf, yo u c a n do
if h e ex p lo res th e re aso n for th is, he m a y be

a b le to avoid p ro je c tin g h is a n g e r o r c o n v e rtin g
c o u ra g e d . J u s t k e e p w o rk in g a w a y .
m uch
to
rectify
m a tte r s .
Do
not
get
d is
it in to sym ptom s.
T h . If y ou feel te n se a n d u p se t, a s k y o u rse lf if you

a r e a n g ry a t a n y th in g . See if yo u ca n fig u re o u t
w h a t is c a u s in g y o u r r e s e n tm e n t. P e r m it y o u r
Adjusting to Irremediable
Elements in One's Life Situation
self to feel a n g ry if th e o ccasio n ju s tif ie s it; b u t

e x p re ss y o u r a n g e r in p ro p o rtio n to w h a t th e
N o m a tte r h o w m u ch w e m a y w ish to co r
s itu a tio n w ill to le ra te . Y o u d o n o t h a v e to do
rect c e rta in c o n d itio n s, p ra c tic a l c o n sid e ra tio n s

m a y p re v e n t o u r d o in g m u c h a b o u t th e m . F o r
e x a m p le , o n e m a y h av e to le a rn to live w ith a
a n y th in g th a t w ill re s u lt in tr o u b le for you;

n e v e rth e le ss , see if you can re le a se som e of
y o u r a n g e r. If y o u can do n o th in g m o re, ta lk
o u t lo u d
a b o u t it w h e n
y o u a re a lo n e , o r
en g a g e in m u s c u la r ex e rc ise s to p ro v id e a n
o u tle t fo r a g g re ss io n , lik e p u n c h in g a p illo w .
In sp ite o f th ese ac tiv itie s y o u m a y still feel
a n g r y to a c e rta in d e g re e . So lo n g a s you k eep
it in h a n d w h ile re c o g n iz in g th a t it e x ists, it
n eed n o t h u r t yo u . A ll p e o p le h a v e to live w ith
a c e rta in a m o u n t of a n g e r.
h a n d ic a p p e d c h ild o r a sick h u s b a n d o r w ife.

O n e s fin an c ia l situ a tio n m a y be irre p a ra b ly
m a rg in a l. T h e r e a re c e rta in th in g s all p eo p le
h av e to cope w ith , c e rta in situ a tio n s fro m
w h ic h th e y c a n n o t escap e. If th e p a tie n t lives
in th e h o p e of e x tric a tin g h im se lf fro m a n u n
fo rtu n a te p lig h t by m ag ic, he w ill be in co n
s ta n t fru s tra tio n .
240
T h . T h e r e a r e c e rta in th in g s e v e ry p e rso n h a s to
tw o o f h e r fr ie n d s h u sb a n d s. S h e fo u n d h e rse lf
le a rn to ac c e p t. T r y y o u r best to a lte r th e m as
u n a b le to re sist th e ir ad v an c es, even th o u g h
m u c h a s y o u c a n . A n d th e n if som e tro u b le s
th e se x u a l e x p e rie n c e s w e re n o t p a rtic u la rly
c o n tin u e , j u s t tell y o u rse lf y o u m u st live w ith
fu lfillin g . S h e felt a sh a m e d a n d w as g u ilt- rid
so m e of th e m , a n d reso lv e n o t to let th e m te a r
d e n by h e r a ctio n s. T h e r e w as obviously som e

d e e p e r m otive th a t p ro m p te d th e p a tie n t to act
y o u d o w n . It ta k e s a good d e a l of c o u ra g e a n d
c h a r a c te r to live w ith y o u r tro u b le s , b u t you
m a y h av e a re s p o n s ib ility to c a r r y th e m . If you
s ta r t feelin g so rry for y o u rself, you a r e b o u n d
to be u p se t. So j u s t p lu g a w a y a t it a n d b u ild
o u t se x u a lly , b u t th e th r e a t to h e r m a rria g e
a n d re la tio n s h ip w ith h e r h u s b a n d re q u ire d an
im m e d ia te h a ltin g of h e r activ ity . I re m a rk e d
y o u rself: I a m n o t g o in g to re s p o n d to tro u b le
to h er: U n til y o u fig u re o u t som e of y o u r u n

d e rly in g feelings, it is best fo r you to sto p y o u r
lik e a w e a th e r v a n e . I w ill re m e d y th e tro u b le
a ffa irs rig h t n o w . H o w w o u ld you feel a b o u t
u p in s u la tio n
to h e lp yo u c a r r y o n . S ay to
if I ca n . If I c a n n o t, I w ill a d ju s t to it. I w ill
sto p p in g rig h t n o w ? L e ts give o u rselves a
c o n c e n tra te o n th e good th in g s in m y life a n d
c o u p le o f m o n th s to fig u re o u t th is th in g .
m in im iz e th e b a d .
F ra n k ly ,
Using Will Power to Stop Engaging

in Destructive Activities
d o n t
see
how
we
can
m ake
p ro g re ss u n le ss you d o . T h e p a tie n t r e
lu c ta n tly ac q u ie sced ; b u t soon sh e w as reliev ed
th a t som eb o d y w as s u p p o rtin g h e r in n e r re so
lu tio n to resist. T h e in te rv a l e n a b le d us to e x
p lo re h e r d is a p p o in tm e n t w ith h e r h u sb a n d ,
O n e of th e u n fo rtu n a te co n seq u en ces of a
h e r re s e n tm e n t to w a rd h im , a n d to find o u t
d y n am ic a p p ro a c h is th a t it gives th e p a tie n t
le ts fo r h e r d e s ire s fo r fre e d o m
th e idea th a t he is u n d e r th e in flu en ce of u n
e x p re ssio n in m o re a p p ro p r ia te c h a n n e ls th a n
conscious m o n sters he c a n n o t co n tro l. H e w ill,

th e refo re, ju s tify th e a c tin g -o u t on th e b asis of
se x u a l a c tin g -o u t. If th e p a tie n t h a s been given
and
self-
r e p e t itio n - c o m p u ls io n s .
a c h a rt d e ta ilin g th e in te ra c tio n of d e p en d e n cy ,
low feelings o f in d e p e n d e n ce , h o stility , d e
A ctu ally , once he h a s a g lim m e r of w h a t is

h a p p e n in g to h im , th e re is no re a so n w h y he
v a lu e d s e lf-e s te e m a n d d e ta c h m e n t, th e i r
m a n ife sta tio n s as w ell as re a c tio n fo rm a tio n s
c a n n o t en list th e co o p e ra tio n of h is w ill p o w e r
to n e u tra liz e th e m , h e m a y be e n jo in e d to
to h elp in h ib it him self.
stu d y th e c h a rt a n d see h o w h is o w n d riv es a n d

n eed s, w ith th e ir co n seq u en ces, fit in to th e
h is
a u to m a tic
T h . If y o u k n o w a s itu a tio n w ill be b ad for y o u , try

to d iv e rt y o u rse lf fro m a c tin g it o u t even if you
h av e to u se y o u r w ill p o w e r. T h e r e
is no
r e a s o n w h y y ou c a n t w o rk o u t s u b s titu te so lu
tio n s th a t
are
o v erall desig n .
less d e s tru c tiv e to y o u even
th o u g h th e y m ay n o t im m e d ia te ly be so g r a t i
Stopping Unreasonable Demands

on Oneself
fy in g . R e m e m b e r, a c e rta in a m o u n t of d e p r iv a
tio n a n d fru s tra tio n is n o rm a l, a n d it is a co m
If th e p a tie n t is p u s h in g h im se lf b ey o n d th e
p lim e n t to y o u a s a p e rso n to be ab le to give u p
lim its of h is ca p a c itie s o r se ttin g too h ig h

s ta n d a rd s fo r h im self, it w ill be esse n tia l for
h im to assess h is actio n s. A re th ey to satisfy his
a m b itio n s o r th o se of h is p a re n ts ? A re th e y to
g ra tific a tio n s th a t
are
u ltim a te ly
h u r tfu l
to
y ou. R e m e m b e r, to o , th a t so m e of th e ch ief
b en efits y o u g et o u t o f y o u r sy m p to m s a re
m a so c h istic , a k in d of need to p u n is h y o u rself.
Y o u ca n le a rn to o v erco m e th is to o . W h e n you
o b se rv e y o u rse lf a c tin g n e u ro tic a lly , sto p in
y o u r tr a c k s a n d fig u re o u t w h a t you a r e d o in g .
A w o m an , living a co n v e n tio n a l life as a

hou sew ife, w as invo lv in g h e rse lf se x u ally w ith
do th in g s p e rfe c tio n istic a lly ? If so, does he feel

h e can achieve g re a te r in d e p e n d e n c e o r s ta tu re
as a p e rso n w h e n he succeeds?
T h . A ll p e o p le h a v e th e ir asse ts a n d lia b ilitie s . Y ou
m a y n e v e r be a b le to a c c o m p lis h w h a t som e
241
p e rs o n s ca n do; a n d th e re a r e som e th in g s you
fo r o th e rs th a t b u ilt u p a m o re e stim a b le feel
can do th a t o th e rs w ill find im p o ssib le . O f
in g a b o u t h erself.
c o u rse , if y o u try h a r d e n o u g h , yo u can p r o b a
L ogic o b v io u sly c a n n o t co n v in ce a p erso n

w ith d ev alu e d self-esteem th a t h e h a s m e rit.
bly d o th e im p o ssib le, b u t y o u ll be w o rn d o w n

so it w o n t m e a n m u c h to y o u . Y ou ca n still
live u p to y o u r c re a tiv e p o te n tia ls w ith o u t g o
in g to e x tre m e s. Y o u ca n re a lly w e a r y o u rse lf
o u t if you p u sh y o u rse lf too h a r d . So ju s t tr y to
U n less a p ro p e r a ssessm en t is m a d e of his e x

istin g v irtu e s, h o w ev er, th e p e rso n w ill be
re ta rd e d in c o rre c tin g h is d is to rte d self-im age.
re la x a n d to en jo y w h a t you h a v e , m a k in g th e
m o st o u t o f y o u rse lf w ith o u t te a r in g y o u rse lf to
T h . Y ou do h a v e a te n d e n c y to d e v a lu e y o u rse lf as
pieces. J u s t d o th e b est yo u c a n , a v o id in g u sin g
a re s u lt o f e v e ry th in g th a t h a s h a p p e n e d to
p e rfe c tio n is m as a s ta n d a rd fo r y o u rself.
yo u . F ro m w h a t I ca n o b se rv e , th e r e is n o re a l
re a s o n w h y y o u sh o u ld . If y o u d o , yo u m a y be
u s in g s e lf-d e v a lu a tio n as a w a y of p u n is h in g
Challenging a Devalued Selfimage
y o u rse lf b e c a u s e o f g u ilt, o r o f m a k in g p eo p le
feel so rry
for y o u , o r o f r e n d e r in g y o u rse lf
h e lp le s s a n d d e p e n d e n t. Y ou k n o w , a ll p eo p le
a r e d iffe re n t; e v e ry p e rs o n h a s a u n iq u e n e s s ,
O ften a n in d iv id u a l re tire s on th e in v e st
m e n t o f h is c o n v ic tio n o f s e lf-d e v a lu a tio n .
W h a t need is th e re for h im to m a k e a n y effort
if h e is so c o n stitu tio n a lly in fe rio r th a t all of
his best in te n tio n s a n d w e ll-d ire c te d a c tiv ities
w ill lead to n a u g h t? It is e x p e d ie n t to show th e
p a tie n t th a t he is u tiliz in g h is self-d e v a lu a tio n
lik e ev ery th u m b p r in t is u n iq u e . T h e fact th a t

you do n o t p o ssess som e q u a litie s o th e r p eo p le
h a v e d o es n o t m a k e y o u in fe rio r.
Deriving the Utmost Enjoyment

from Life
as a d estru ctiv e im p le m e n t to b o lster h is h e lp

lessness an d p e rh a p s to sp o n so r d ep en d en cy .
In th is w a y he m a k e s c a p ita l o u t o f a
h a n d ic a p . P o in tin g o u t re a listic assets th e p a
tie n t possesses m ay n o t succeed in d e stro y in g
th e v itiated im age of h im self; b u t it does h elp
h im to re e v a lu a te h is p o te n tia litie s a n d to
avoid th e d e sp a ir of c o n sid e rin g h im se lf co m
p letely hopeless. O n e m ay p o in t o u t to th e p a
tie n t in stan ces of his successes. In th is resp ect,
e n co u ra g in g th e p a tie n t to a d o p t th e idea th a t
he can succeed in a n activ ity in w h ich h e is in
te reste d , a n d to e x p a n d a p re s e n t asset, m ay
prove to be a saving grace. A w o m a n w ith a
d eep sense of in fe rio rity a n d lack of self-co n
fidence w as ex h o rte d to ad d to h e r k n o w led g e
o f h o rtic u ltu re w ith w h ich she w as fascin ated .
A t g a th e rin g s she w as e m b o ld en ed to ta lk
ab o u t h e r sp ecialty w h en a n a p p ro p r ia te occa
sion p re sen ted itself. S h e fo u n d h e rs e lf th e
c en te r of a tte n tio n a m o n g a g ro u p of s u b u r
ban ites w h o w ere eag er to a c q u ire e x p e rt in
fo rm atio n . T h is p ro v id ed h e r w ith a m e a n s of
social contact a n d w ith a w ay of d o in g th in g s
F o c u sin g on tro u b le s a n d d is p le a su re s in
o n e s ex isten ce can d ep riv e a p e rso n o f jo y s
th a t a re h is rig h t as a h u m a n b eing. T h e need
to d evelop a sen se of h u m o r a n d to get th e
g rim n e ss o u t of o n e s d aily life m ay be stressed .
T h . T r y to m in im iz e th e b a d o r h u r tf u l e le m e n ts
a n d c o n c e n tra te o n th e good a n d c o n stru c tiv e
th in g s a b o u t y o u rse lf a n d y o u r s itu a tio n . It is
im p o rta n t fo r ev ery p e rs o n to r e a p o u t o f each
24 h o u r s th e m a x im u m of p le a s u re s p o ssib le.
T r y n o t to live in r e c r im in a tio n s o f th e p a s t
a n d in fo re b o d in g s a b o u t th e f u tu re . J u s t co n
c e n tr a te o n a c h ie v in g h a p p in e s s in th e h e re
an d now .
Accepting One's Social Role

E v e ry a d u lt h a s a re sp o n sib ility in assu m in g
a v a rie ty o f social ro les: a s m a le o r fem ale, as
h u s b a n d o r w ife, as a p a re n t, a s a p e rso n w h o
m u st re la te to a u th o r ity a n d o n occasio n s act
as a u th o rity , as a c o m m u n ity m e m b e r w ith o b
242
lig atio n s to society. T h o u g h he m ay feel im m a
g o in g o n in h is ]h er] m in d ? H o w w o u ld I feel
tu re , d e p e n d e n t, h o stile, a n d h y p o c ritic a l, th e
if I w e re in h is [her] p o s itio n ? A t a n y r a te , if
in d iv id u al still m u st try to fill th ese ro le s as

com pletely as he can . If th e p a tie n t is d e s tru c
tively involved w ith a n o th e r p e rso n w ith w h o m
yo u ca n re c o g n iz e w h a t is g o in g o n , c o rre c tin g
he m u st c a rry on a re la tio n sh ip , like an e m

p lo y er, for e x a m p le , he m u st a tte m p t to u n d e r
s ta n d th e forces th a t serve to d is tu rb th e r e la
m a tte r s th a t ca n be reso lv e d , a d ju s tin g to th o se

th a t c a n n o t be c h a n g e d ; if you a r e a b le to
r e la te to th e g o o d r a t h e r th a n to th e b a d in
p e o p le , y o u s h o u ld be a b le to get a lo n g w ith
th e m w ith o u t to o m u c h d iffic u lty .
tio n sh ip . A t th e sam e tim e, h o w ev er, he m u st

try to keep th e re la tio n sh ip g o in g in a w ay th a t
co nvention
d ictates so th a t
he w ill n o t do
T h e form by w h ic h th e ab o v e g u id e lin e s a re
v e rb a lly o r g ra p h ic a lly c o m m u n ic a te d to th e
p a tie n t
a n y th in g d estru ctiv e to h is secu rity .
w ill
v a ry ,
and
each
th e ra p is t m ay
decide w h e th e r th e y a re useful in w h o le o r in
T h . O n e w a y o f tr y in g to g et a lo n g w ith p e o p le is
p a r t for specific p a tie n ts . R e a d in g a ssig n m e n ts
to a tte m p t to p u t y o u rse lf in th e ir p o sitio n a n d
m ay also be given a n d su g g estio n s for c o n
to see th in g s fro m th e ir p o in t o f view . If y o u r
tin u e d self-e d u c a tio n m a d e a fte r th e r a p y h a s
h u s b a n d [w ife, c h ild , e m p lo y e r, etc.] is d o in g
e n d ed . A full list of re a d in g m a te ria ls w ill be
so m e th in g
fo u n d e lse w h ere
83 3 ).
th a t
is
u p s e tttin g ,
ask
y o u rself:
W h a t is h e [she] feelin g a t th is tim e ; w h a t is
(W o lb e rg ,
1977, p p .
816-
Conclusion
It is im p o rta n t to su p p ly p a tie n ts w ith
h o m e w o rk assig n m e n ts to rein fo rc e th e v alu e
lo w er self-esteem , stu d y in g o n e s re la tio n s h ip s

w ith p eo p le, e x a m in in g d re a m s a n d fa n ta sie s,
of th e ir sessions. T h e s e ta sk s a re u su a lly r e
o r seein g w h a t re sista n c e s block th e p u ttin g of
lated to w h a t is im m e d ia te ly g o in g o n in th e r
ap y , w h e th e r th ey involve e x p lo rin g th e n a tu r e
u n d e rs ta n d in g in to p ro d u c tiv e ac tio n . P ra c tic e
of o n e s p ro b le m s, c h a rtin g th e freq u en cy of
sessions d ev o ted to a sse rtiv e a n d o th e r c o n

stru ctiv e fo rm s of b e h a v io r a re esp ecially h e lp
sy m p to m s
circ u m sta n c e s
ful. S om e of th e assig n ed exercises striv e to in
u n d e r w h ich th ey a p p e a r, re c o g n iz in g th e co n
stru ctiv e a n d d e stru ctiv e e lem en ts in th e im
m e d ia te e n v ir o n m e n t, o b s e rv in g b e h a v io r a l
p a tte rn s an d re in fo rc in g th o se th a t a re a d a p
c o n trib u te to a m o re p ro d u c tiv e a d ju s tm e n t. A
re la x in g a n d e g o -b u ild in g c a sse tte ta p e as w ell
and
re c o rd in g
th e
tive, p ick in g o u t situ a tio n s th a t en h a n c e o r
c u lc a te
new
v a lu e s
and
p h ilo s o p h ie s
th a t
a s assig n ed re a d in g s a re a d d itio n a l u seful ac

cessories.
CHAPTER 17
Termination of Short-term Therapy
P ro p e r te rm in a tio n of tr e a tm e n t is o n e of
re fe rra ls a re sp arse . S o m etim es th e p ro jected
th e m ost neglected aspects o f th e th e ra p e u tic

process. Id eally , it sh o u ld s ta rt in th e in itia l in
g o als of th e ra p y h av e been set too h ig h , a n d

b o th p a tie n t a n d th e r a p is t a re d is a p p o in te d
terview d u rin g w h ich th e lim ite d tim e sp a n is
w ith w h a t seem m e a g e r re su lts. T h e y w ill th en
e m p h a s iz e d .
ea g erly cancel th e te rm in a tio n c o n tra c t a n d
m ed iately
m en t,
E v e n th o u g h
a rra n g e
h o p efu lly e m b a rk o n a se a rc h for a cu re w ith a
as th e th e ra p e u tic re la tio n s h ip
fre sh se rie s o f se s sio n s t h a t w ill u s u a lly

ev e n tu a te in lo n g -te rm a n d in som e cases in te r
accepts
la te r,
th e p a ti e n t im
th is
p ro v isio n al
cry stallizes, its en d in g can pose a th re a t.

T e rm in a tio n of th e ra p y is n o p ro b le m in
m ost p a tie n ts w h o a re a d e q u a te ly p re p a re d for
it, o r w ho a re ch a ra c te ro lo g ic a lly n o t too d e
p e n d e n t, o r w ho a re seen for o n ly a few
sessions an d d isch arg ed before a stro n g r e la
tio n sh ip w ith th e th e ra p is t develops, o r w h o
a re so d etac h ed th a t th e y w a rd off a close
m in a b le tre a tm e n t.
T h e w o rd c u re
is a n
a m b ig u o u s
ex
p re ssio n w h en re la te d to e m o tio n a l p ro b le m s.
M o s t o p tim istic a lly it d e sig n a te s an e lim in a
tio n of p a th o lo g y a n d th e in d u c tio n of a to tal
a n d ro b u s t sta te of w e ll-b ein g . T o a n tic ip a te
th e ra p e u tic co n tact. It m ay , h o w ev er, b ecom e a
su ch a goal in s h o rt-te rm th e r a p y excites u n

re a listic h o p e a n d o p tim ism . M a n y of th e im
d ifficult p ro b le m in o th e r cases. P a tie n ts w h o

in e a rly ch ild h o o d hav e suffered re je c tio n o r
p rin ts of u n fo r tu n a te life e x p e rien c e, p a r tic u

la rly th o se c o m p o u n d e d in e a rly c h ild h o o d , a re
a b a n d o n m e n t by o r loss o f a p a re n t, o r w h o
m o re o r less in d e lib le a n d c a n n o t be e lim in a te d
have h ad difficulties in w o rk in g th ro u g h th e
co m p letely by a n y m e th o d k n o w n to d ay . N o r
s e p a r a tio n - in d iv id u a tio n d im e n s io n s of th e ir
d ev elo p m en t a re especially v u ln e ra b le a n d m ay
react w ith fear, a n g e r, d e sp a ir, a n d grief. A
c a n a ll c h a r a c te r o lo g ic d e fic its be to ta lly

re g e n e ra te d , re s id u a l d is to rtio n s often o b tr u d
r e tu rn of th e ir o rig in a l sy m p to m s w ill ten d to
in g th em selv es im p e rtin e n tly a t u n g u a rd e d m o

m e n ts even in th e m ost successfully tre a te d in
confound th e p a tie n t a n d in s p ire in th e th e r a
d iv id u a l. O n th e o th e r h a n d , it is p o ssib le to
p ist fru s tra tio n , d is a p p o in tm e n t, g u ilt feelings,

a n d a n g e r a t th e p a tie n t for h a v in g failed to r e
spo n d to th e ra p e u tic m in is tra tio n s .
R esistan ce to te rm in a tio n affects n o t o n ly th e
p a tie n t; it is p re se n t also in th e th e ra p is t
w ho for conscious o r unco n scio u s re a so n s m ay
n ot be w illin g to let h is p a tie n t se p a ra te .
T h e ra p is ts c o u n te rtra n s fe re n tia lly fo rm a tta c h
m en ts to som e of th e ir p a tie n ts , an d th ey
m ay resen t sen d in g th em a w ay . S o m etim es
m o n e ta ry facto rs influence d elay s in te r m in a
n e u tra liz e th e effects of in im ic a l p a s t e x p e ri

e n c e , to e n h a n c e s e c u r ity , to b o ls te r se lf
esteem , a n d to im p ro v e a d a p ta tio n a n d p ro b
lem solving th r o u g h w e ll-co n d u cted sh o rt-te rm
tio n , p a rtic u la rly d u rin g p e rio d s w h en
p a tte r n s in d u lg e d th a t sp o n s o r sy m p to m s , sa b o ta g e
new
p sy c h o th e ra p y . T h e o bjectives th a t w e m ay
p ra c tic a lly ach iev e a re these:
1. M o d if ic a tio n o r re m o v a l of sy m p to m s a n d re lie f
of su fferin g .
2. R e v iv a l of th a t level of fu n c tio n in g th a t th e p a
tie n t p o ssessed p r io r to th e o u tb r e a k o f th e illn ess.
3. P ro m o tio n of a n u n d e r s ta n d in g th a t th e re a re
243
244
fu n c tio n in g , a n d in te rfe re w ith a m o re
c o m p le te e n -
jo y m e n t of life.
4.
5. P ro v is io n o f u se fu l w a y s o f d e a lin g w ith such

p a tte r n s a n d th e ir effects in o r d e r to rectify a n d
A tta in m e n t o f so m e id e a of h o w to re c o g n iz e
th e ex iste n ce o f se lf-d e fe a tin g p a tte r n s a n d h o w to
r e p la c e
th e m
w ith
m o re
c o n s tr u c t i v e
c o p in g
m e a s u re s ,
e x p lo re th e ir c o n s eq u en ces.
Termination Procedures
F o llo w in g th e su g g estio n s d e ta ile d in C h a p
It is m a n ife stly im p o ssib le to u p ro o t p e r
te r 4 A G e n e r a l O u tli n e o f S h o r t- te r m
T h e r a p y , th e p a ti e n t is a p p r is e d of th e
so n a lity d ifficu lties th a t d a te b ack to c h ild h o o d
lim ited n u m b e r of sessions th a t w ill c o n stitu te
sive p ro lo n g e d
tr e a tm e n t, e ith e r by d e s ig n a tin g th e e x a c t
n u m b e r in ad v an ce a n d se ttin g a te rm in a tio n
som e p a tte rn s . T h e p a tie n t w ill th e re fo re h av e

to be p r e p a r e d fo r te r m i n a ti o n w ith th e
d a te o r, a fte r in d ic a tin g th a t th e n u m b e r of
a ch ie v e m e n t o f o n ly less th a n a co m p lete cu re.
sessions w ill be c ircu m sc rib e d , by p o stp o n in g
A p a tie n t w h o c a m e for tre a tm e n t w ith a p ro b

lem o f o b esity , d e p re ssio n , a n d stro n g feelings
a n n o u n c in g th e e n d in g d a te u n til a fte r th e ra p y
h a s sta rte d . O n c e th e ta rg e t d a te is se ttle d , th e
p a tie n t is p erio d ic ally re m in d e d o f it an d
resp o n ses to th is b riefin g h a n d le d (see p p . 4 5 -
in a sh o rt p e rio d , a n d q u ite lik ely even in te n

tre a tm e n t w ill fail to b u d g e
of in fe rio rity w a s h elp ed in 10 sessions to c o r

rect h is food h a b its a n d to lose w e ig h t. H is
d e p ressio n lessen ed to a g re a t e x te n t, b u t th e re
4 6 ). W ith ra r e ex ce p tio n s th e ra p y sh o u ld be
w a s no c h a n g e in th e sleazy im ag e he h a d of
end ed on th e a g re e d -u p o n d a te (p. 4 6 ). T h e
him self. I re m in d e d h im th a t o u r a g re e d -u p o n
g oal in th e ra p y w a s to h elp h im dev elo p b e tte r
need to w o rk on o neself is stressed (p. 4 7 ), an d

a rra n g e m e n ts fo r fu rth e r tre a tm e n t m ad e if
food h a b its a n d m o d e ra te his d e p re ssio n . A n e x
necessary (p. 47).
c e rp t follow s:
T h e q u e stio n is often ask ed as to w h e th e r

sy m p to m atic im p ro v e m e n t by itself w ith o u t
som e u n d e rs ta n d in g of th e u n d e rly in g sources
of th e c u rre n t u p set is sufficient ju s tific a tio n for
th e te rm in a tio n of th e ra p y . Id e ally th e a n sw e r
w o u ld be no. S y m p to m a tic re lie f m ay o c cu r as
Pt.
I feel a lot b e tte r, th e w e ig h t a n d a ll, b u t I still

feel lik e I d o n t a m o u n t to m u c h .
T h . W e ve g o n e o v er som e o f th e re a s o n s w h y you
a lw a y s h a v e felt th is w ay .
Pt. B u t c a n t I be c u re d of th is?
T h . Y o u r p ro b le m goes so f a r b a c k th a t a c o m p le te
a consequence of th e p lace b o effect a n d m ay

e x p e n d its e lf r a p i d ly u n le s s c h a n g e s a re
b ro u g h t a b o u t in th e e n v iro n m e n t as w ell as in
th e self. N ev erth eless, w e sh o u ld n o t m in im ize
th e im p o rta n c e of sy m p to m rem o v al since
c u re w o u ld ta k e a lo n g tim e . E v en th e n a few
w ith o u t it no th e ra p y can ju s tify itself. R elief

of sy m p to m s ca n re sto re im p o rta n t defenses
th a t a re a p a r t of th e in d iv id u a ls h a b itu a l
ad a p tiv e m a c h in e ry . In th is w a y w e m ay best
th e r a p y .
achieve th e objective of re s titu tin g th e o p tim a l

p a s t a d ju s tm e n t. M o s t p a tie n ts a re satisfied
w ith th is a cco m p lish m e n t, b u t o ccasio n ally
som e in d iv id u als exp ect m o re ex ten siv e re su lts
w ith in a few sessions.
re s id u e s o f y o u r c h ild h o o d m a y p o p u p fro m
tim e to tim e . T h is is n t im p o r ta n t b e c a u se you
ca n still k e e p g ro w in g a n d d e v e lo p in g o n y o u r
o w n w ith w h a t yo u h a v e a lr e a d y le a rn e d in
R ig h t n o w yo u ca n o v erco m e y o u r
sy m p to m s , lik e o v e re a tin g a n d d e p re ss io n , a n d
fu n c tio n a lot b e tte r in sp ite o f h o w y o u feel
a b o u t y o u rse lf. T h e r e a lity is th a t y o u a r e n o t
a n in f e rio r p e rs o n even th o u g h y o u feel you
a re . O v e r a lo n g p e rio d a p p ly in g th e u n d e r
s ta n d in g y o u n o w h a v e w ill w e a r o u t th is d e lu
sion a b o u t y o u rself. B u t e x p e c t no m ira c le s. It
w ill ta k e tim e . T h e im p o r ta n t th in g is to k eep
w o rk in g a t y o u rself. S u p p o s e y o u try th in g s on
245
TERMINATION OF SHORT-TERM THERAPY

your ow n, and
Pt.
in a b o u t 3 m o n th s w e w ill
to c o n tin u e w o rk in g on h is o w n
(w ith th e
m a k e a n o th e r a p p o in tm e n t to see h o w y o u a re
a ssig n e d h o m e w o rk ) liste n in g re g u la rly to th e
d o in g .
c assette ta p e if o n e is given h im , a n d re p o rtin g
T h a t s g r e a t. M a y b e
can w o rk a t th is by
m yself, a n d if I n eed f u rth e r h e lp , I ll call you.
T h . F in e . D o n t h e s ita te to call m e if a n y f u rth e r

p ro b le m s d ev elo p .
back for a session in 2 w eek s, th e n once a

m o n th , a n d a fte r a w h ile once every 3 m o n th s.
It is n o t u n u s u a l for a p a tie n t to h av e achieved
c o n sid e ra b le p ro g re ss by h im se lf a fte r fo rm al
th e ra p y h a s en d ed once th e m o m e n tu m h as
In av o id in g th e p a tie n ts re q u e st for lo n g erte rm th e ra p y , w e in d ic a te th a t it is esse n tial for
been
s ta r te d
S h o u ld
d u r in g
th e
s h o r t- t e r m
n o p ro g r e s s h a v e o c c u rr e d
sp an .
se v e ra l
th e p a tie n t to try to resolve his p ro b le m s by
m o n th s a fte r te rm in a tio n , a n d sh o u ld th e p a
him self. T h is is d one w ith no illu sio n th a t a
tie n t be d issatisfied w ith h is s ta tu s, a n o th e r in
c u re w ill com e a b o u t in a n y c h a ra c te ro lo g ic d is
ten siv e sh o rt-te rm tre a tm e n t can be in s titu te d ,
to rtio n s, b u t r a th e r to avoid b eco m in g d e
d u rin g w h ich a n assay is m a d e of th e k in d of
p e n d e n t on th e ra p y . P ro ce e d in g on o n e s o w n ,
p ro g ress m ay be m ad e w ith in te rim sessions of
th e r a p y best to use, th e c a p a c ity of th e p a tie n t
sh o rt-te rm th e ra p y if n ecessary . In th is case tw o
ach iev ed . S o m etim es th e second b rie f tre a tm e n t
such b rief p e rio d s of five a n d six sessions each

w ere used th e first y e a r a n d th re e sessions th e
tr ia l does th e jo b w ith o u t fu r th e r fo rm al th e r
ap y b ein g n eed ed . O n th e o th e r h a n d , w e m ay
second y ear. S ingle fo llo w -u p sessions th e th ird
n o t be ab le to avoid re s o rtin g to lo n g -te rm
to c h an g e , a n d
re a listic g o als th a t m a y be
a n d fifth y ears revealed ex ten siv e a n d g ra tify in g
th e ra p y , a n d h e re th e k in d o f th e r a p y a n d th e
p e rs o n a lity changes.
T h is does n o t im p ly th a t lo n g -te rm th e ra p y
d e p th of th e r a p y w ill su g g est itself fro m th e
m ay not be th e tre a tm e n t of choice in som e

cases. B ut th e selection of p a tie n ts m u st be
W e m u st, n ev erth eless, b ra c e o u rse lf to th e

p o ssib ility o f fa ilu re n o m a tte r w h a t w e do.
carefu lly m ade.

A n o th e r com m on q u e stio n th a t co n fro n ts th e
w ell w ith a n y k in d of th e ra p y . M a n y o f th ese
th e ra p is t is if a t th e end of th e a llo te d tr e a t
m en t tim e a p a tie n t feels b e tte r b u t h a s n o t
reach ed the goals set by th e th e r a p is t o rig i
d a ta a lre a d y o b ta in e d .
In e v ita b ly th e re w ill be p e rso n s w h o do not

in d iv id u a ls go on to p ro lo n g e d tre a tm e n t w ith
th e object of a ch iev in g re c o n stru c tiv e ch an g e
th ro u g h th e alch e m y o f tim e. T h e idea th a t
n ally , should te rm in a tio n th e n be d e la y e d ? It is
lo n g - te rm
difficult to g e n e ra liz e an a n sw e r to th is q u e s
tio n o th e r th a n to say th a t c e rta in p a tie n ts w ill
w h e re s h o rt-te rm a p p ro a c h e s hav e failed is d e

ceptive. T h e r e a re som e p a tie n ts w h o seem
th e r a p y
w ill
in e v ita b ly
su cceed
benefit from f u r th e r th e ra p y a n d o th e rs w ill
d oom ed to a p e rp e tu a l im m a tu re a d ju s tm e n t,
not. M u c h as w e w o u ld like to c o n tin u e w o rk

ing w ith a p a tie n t, th e d a n g e r of in te rm in a b le
th e ra p y m u st be kep t in m in d . S om e p a tie n ts
w ill n o t, for su n d ry reaso n s, be a b le to achieve
th e objectives th a t th e th e r a p is t h as a n tic ip a te d
o r th a t they th em selves covet, no m a tte r how
long w e keep th em in tr e a tm e n t. In d eed ,
c lin g in g to a p a re n ta l fig u re in a d e p e n d e n t
w a y th e re m a in d e r of th e ir lives. S om e th e o rie s
o f w h y th is is so have been p re se n te d . O n e
sp e c u la tio n for a c e rta in ty p e o f p a tie n t is th a t
in tre a tm e n t th e p a tie n t is u n a b le to b rin g
a b o u t th e in te rn a liz a tio n of th e th e ra p is t as an
o b je c t-a n c h o r a ro u n d w h ich th e p a tie n t can o r
g a in s
g a n iz e h im se lf o r to m a in ta in an e q u ilib riu m
achieved in th e p re lim in a ry sh o rt-te rm tr e a t

m en t p e rio d , th e p a tie n t b eco m in g steep ed in a
n e g a tiv e tr a n s f e r e n c e a n d in c r i p p li n g d e
in th e face of th e a n x ie ty released by in te rp re
tive w o r k (A p p e lb a u m , 1972). T h e r e a re
c o n tin u ed
th e ra p y
m ay
d issip a te
th e
p e n d e n c y fro m w h ic h h e c a n n o t li b e r a te
him self. T h e w ay th is p ro b le m is best h a n d le d
is to te rm in a te th e ra p y , e n jo in in g th e p a tie n t
o th e r su rm ise s too, b u t som e sick er p a tie n ts

w ill re sp o n d m u ch m o re to a d ju n c tiv e e n v iro n
m e n ta l m a n ip u la tio n , re h a b ilita tiv e tr e a tm e n t,
social th e ra p y , a n d p h a rm a c o th e ra p y th a n to
246
fo rm al p sy c h o th e ra p y , a lth o u g h p erio d ic p sy
c h o th e ra p e u tic sessions w ith a skillful an d
c h a ra c te r p a tte rn s a re d islo d g ed re lu c ta n tly ,

h o w e v e r m a la d a p tiv e th e y m a y b e, it is
e m p a th ic th e ra p is t a lo n g w ith a d ju n c tiv e a p
a s s u m e d th a t c h a r a c t e r a lt e r a t io n s w h ile
in itia te d d u rin g th e fo rm al tre a tm e n t p erio d
p ro a c h e s sh o u ld p ro d u c e o p tim a l re su lts.
M o s t p a tie n ts , fo rtu n a te ly , m ay be h e lp e d
w ill need to c o n tin u e to develo p in th e p o st-
an d sig n ifican tly h e lp e d by d y n a m ic s h o r t
th e ra p e u tic sp a n over an e x ten d e d in te rv a l,
te rm th e ra p y . E ven d eep p e rs o n a lity d ifficu l
even over y e a rs, before p e rm a n e n t a lte re d im
ties m ay be in flu en ced . B ecau se e n tre n c h e d
p rin ts a re etch e d in to th e p e rs o n a lity stru c tu re .
Managing Untoward Reactions to Termination

In p a tie n ts w ho have been in th e ra p y for
w ay th a t th e p a tie n t w as p re p a re d for te r m in a
m o re th a n a h a n d fu l of sessions a n d w h o have
estab lish ed a good th e ra p e u tic a llia n c e , sto rm y
tio n , a n d b rin g in g in to th e o p e n th e p a tie n ts

feelings a b o u t te rm in a tio n . O ften th ese feelings
clouds m ay g a th e r as th e te rm in a tio n
d a te
a re n o t e x p licit, th e p a tie n t b ein g a fra id to e x
d ra w s n e a r. T h e fact th a t th e e n d in g o f th e r
p ress a n g e r o r g rie f o p e n ly a n d th e th e ra p is t
a p y b rin g s out u n reso lv ed issues re la ted to th e
a v o id in g a re a s th a t m ig h t be u p se ttin g o r e m
se p a ra tio n -in d iv id u a tio n th e m e is no t e n tire ly
b a rra s s in g
a liab ility . In d eed , as R a n k (1 9 3 6 , 1947)

insisted y ears ago it m ay becom e th e m ost im
se q u e n tly , to face th e fact th a t te rm in a tio n can

be difficult for th e th e r a p is t also a n d b e cau se of
th is m a y r e q u ire som e soul se a rc h in g o n his
p o rta n t aspect of th e h e lp in g p ro cess by forcin g
to
h im .
It
is im p o r t a n t,
con
th e p a tie n t to face p a ra ly z in g d ep en d en c ie s a n d
p a rt. W ill th e th e ra p is t be reliev ed in g e ttin g
to assu m e th e resp o n sib ilitie s of in d iv id u a tio n .
rid of a b u rd e n so m e p a tie n t a n d c o n se q u en tly
M a n y o th e r a u th o ritie s a ffirm R a n k s b elief

th a t th e w o rk in g -th ro u g h o f resid u es o f ch ild
fice? W ill he feel g u ilty a t d is c h a rg in g a p a
ish h elplessness is esse n tia l to w a rd sp o n so rin g
fa c ilita te th e easin g o f th e p a tie n t o u t of his of
g re a te r p e rs o n a lity m a tu ra tio n . It is, how ev er,
tie n t w h o still suffers fro m re s id u a ls o f th e

p ro b le m for w h ich h e lp w a s o rig in a lly so u g h t?
naiv e to assu m e th a t a d u lth o o d w ill b re a k o u t
W ill he re se n t th e fin a n c ia l loss c re ate d by a
in a flash solely as a co n seq u en ce of b eing

evicted from th e ra p y . It w ill re q u ire p e rh a p s
years before th e fru its of m a tu rity can m ellow .
T h e th e ra p is t sh o u ld n o t deceive h im self in to
believing th a t in d iv id u a tio n is easy to achieve
hole in h is c a se lo a d ? W ill h e h im se lf suffer

se p a ra tio n a n x ie ty cau sed by h is o w n u n r e
solved se p a ra tio n -in d iv id u a tio n p ro b le m s? It
w ill ta k e a good d eal of c o u ra g e to face u p to
th ese issues.
a n d th a t w ith te rm in a tio n th e p a tie n t, sw o rd

in h a n d , can h a p p ily s a u n te r o u t to c o n q u e r
W h e re d re a m s a n d e x p lo ra tio n of ac tin g -o u t
ten d e n c ies a re em p lo y ed , th e p a tie n ts feelings
th e w o rld . N ev erth ele ss, th e seeds of selfre lia n c e have a g re a te r ch an ce o f g e rm in a tio n

in th e soil p ro v id ed by th e p ro p e r m a n a g e m e n t
a b o u t te rm in a tio n w ill be m ost re a d ily a v a il

ab le. A p a tie n t w as ask ed a t th e te n th session
of th e te rm in a l p h ases of th e p a tie n t- th e r a p is t
re la tio n sh ip .
H o w in ten se th e re a c tio n s to te rm in a tio n b e
com e w ill d ep en d on th e p a tie n ts re s id u a l d e
p en d en cy n eeds, how th o ro u g h ly th ese needs
have been s u p p o rte d d u rin g tr e a tm e n t, th e
h o w she felt a b o u t te rm in a tin g tr e a tm e n t th e

fo llo w in g m o n th . S he a d m itte d feeling b e tte r
a n d said th a t she w as h a p p y th a t I co n sid ered
h e r w ell e n o u g h to be on h e r o w n . T h e n ex t
session she a d m itte d feelin g a b it s h a k y
a b o u t h a n d lin g m a tte rs by h e rse lf a n d th a t th is
re a c tio n lasted for sev eral h o u rs a fte r she left
247

my office. S he denied a n y feelings of re s e n t
b ecom e so a n g ry o r d is tru s tfu l as to b re a k a p
m ent o r d ep ressio n . A t th e fo llo w in g session

she b ro u g h t in th is d re a m : I am a tte n d in g a
c o n ta c t th e p a tie n t by te le p h o n e a n d discuss
fu n e ra l. A girl w ith a rm s cu t off in a coffin.

S he looks like m e. I am frig h te n e d a n d ru n
p o in tm e n ts. If th is occu rs, th e th e ra p is t sh o u ld

w h a t is h a p p e n in g . T h e fact th a t sufficient in
te re st ex ists to in d u ce th e te le p h o n e call in all
h o m e . F o r th e n ex t few sessions w e focused
p ro b a b ility w ill m o tiv a te th e p a tie n t to re tu rn
on h e r feelings of h elp lessn ess a n d fea rs of
for th e re m a in in g sessions.
w h a t m ig h t h a p p e n to h e r a fte r she sto p p e d , as
I h av e fou nd th a t th e use o f a cassette ta p e
w ell as h e r a n g e r a t m e. E a rly d ep en d e n c ies
h elp s th e te rm in a tio n p ro cess im m e a s u re a b ly
fostered by a n o v erp ro tectiv e m o th e r w e re e x
p p . 2 2 3 -2 3 4 ). T h e p a tie n t d o es n o t e x p e ri
p lo red . N o revision of th e te rm in a tio n tim e

w as m ade. A t th e fo u rte e n th session sh e a d m it
ted fe e lin g a g r e a t d e a l b e tte r , a n d sh e
p re sen ted th is d re a m : I a m slid in g d o w n a
ence th e shock of b ein g left alo n e o n h is o w n

devices. H e h a s a tool th a t he can u tiliz e by
h im se lf to e x p a n d th e g a in s th a t h e h a s d eriv ed
fro m tre a tm e n t. T h e ra p is ts w h o im ag in e th a t
c h u te an d fallin g d o w n , th e n sta n d in g u p , th e n
fallin g d o w n , th e n sta n d in g u p , th e n fallin g
th e in d iv id u a tio n p ro c e s s is e x p e d ite d by
a b ru p tly to ssin g p a tie n ts o u t o f tre a tm e n t after
d o w n . M o th e r a n d fa th e r r u n u p to p ick m e
th e last session on th e th e o ry th a t th e ab sen ce
up. I p u sh th em a w a y a n d I sta n d a lo n e. I
w a lk u n ste a d ily b u t u n d e r m y o w n p o w e r. In
o f th e th e ra p is t a n d th e p rese n c e of in sig h t a re
h e r asso ciatio n s she state d th a t a t w o rk she
a d q e q u a te fo llo w -u p s a re d o n e. A su rp ris in g ly
h a d ta k e n a d efin ite sta n d . S he w a s p ro u d of

h e rse lf because she refused to go to h e r e m
la rg e n u m b e r of p a tie n ts , w h o p re s u m a b ly h ad
p lo y er for advice. I kno w m o re a b o u t th ese

th in g s th a n he d o e s. T e rm in a tio n o ccu rred
a fte r th e n ex t session. A 2 -y e a r fo llo w -u p
re m e d ia l w ill e n c o u n te r a ru d e shock w h en
ach iev ed m a tu rity at d isc h a rg e , so o n er o r la te r

lo ck th e m s e lv e s in to n e w p a r a l y z in g d e
p en d en c ie s w ith som e s u rro g a te p a re n ta l figure
show ed c o n tin u in g a n d ex ten siv e im p ro v e m e n t
o r e x p lo it successive offbeat tr e a tm e n t m o
d a litie s o n c e th e y re e x p e r ie n c e te n s io n o r
in h e r a d ju stm e n t.
a n x ie ty . T h e use o f th e ta p e m a k e s th ese feck
T h e im p o rta n c e of a llo w in g p a tie n ts to e x
less re so u rce s u n n e ce ssary . S p e c u la tio n
th a t
p ress th e ir feelings of d is a p p o in tm e n t, a n g e r,
th e p a tie n t m ay get d e p e n d e n t on th e ta p e a n d
a n d sad n ess c a n n o t be o v erem p h a siz ed . T h e
th a t th is w ill th w a rt th e in d iv id u a tio n p rocess
th e ra p is t w ill esp ecially be a le rte d for p ro b

lem s w h ere, as h a s been m e n tio n ed b efore, th e
is co m p letely g ro u n d le ss. O n th e c o n tra ry , th e

ta p e en jo in s th e p a tie n t to c o n tin u e th e w o rk
p a tie n t as a child e x p e rien ce d a d e a th o f o r

s e p a ra tio n from a p a re n t o r w h e re in la te r life
in g -th ro u g h p ro cess to w a rd g re a te r self-suffi

ciency.
a c a ta stro p h ic re a c tio n follow ed th e loss o f o r

s e p a ra tio n from a p a re n t o r m a te . P a tie n ts
p le te w ith o u t som e p ro v isio n for th is o r som e
w ith a h ig h level of ch a ra c te ro lo g ic d e p e n d e n c y
m ay re g a rd te rm in a tio n as a p e rso n a l in ju ry ,
an u n w a rra n te d d e se rtio n , o r a sign of th e ir
o th e r ty p e of self-h elp as w ell as m a in te n a n c e

of p ro p e r v ig ilan ce to p re v e n t slip p in g b ack to
th e p re v io u s sta te . T h e p a tie n t sh o u ld be e n
lack of im p o rta n c e o r self-w o rth . It is esse n tia l

n ot to act defensive o r g u ilty a b o u t te rm in a tin g
tre a tm e n t. E x p la n a tio n s sh o u ld focus on th e
need to p ro tect th e p a tie n t fro m g e ttin g locked
in to a d ep en d en cy situ a tio n in tre a tm e n t th a t
w ill prov e c rip p lin g a n d in fa n ta liz in g . M o st
jo in e d to p u rs u e h o m e w o rk a ssig n m e n ts
given h im d u rin g th e active tre a tm e n t p erio d
p a tie n ts w ill h a n d le th e te rm in a tio n e x p e rie n c e

w hen given a ch an ce to e x p ress th em selv es
A n a sp ect in th e r a p y th a t is also n eg lected is

p ro v id in g p a tie n ts w ith som e m e an s of c o rre c t
in g d isto rte d co g n itio n s. S u p p ly in g th e m w ith
freely. O ccasio n ally , th o u g h , th e p a tie n t m ay
N o s h o rt-te rm tr e a tm e n t p ro g ra m is co m
(see C h a p te r 16) a n d in v ited to re tu rn to see

th e th e ra p is t b rie fly sh o u ld se rio u s p ro b le m s
d evelop in th e fu tu re th a t h e c a n n o t m a n a g e by
h im self (p. 46).
248
a w ay of loo k in g a t life a n d a t th e ir o w n e x
th a t th e se tb a c k s w ill get s h o r te r a n d s h o r te r
p erien ces, in sh o rt w ith a p ro p e r life p h i
a s y o u a p p l y y o u r u n d e r s t a n d i n g to w h a t
losophy, m ay ad d to th e ir e n h a n c e m e n t of
p ro d u ced
w ell-b ein g . W e m ig h t co n sid e r th is a k in d of

cognitive th e ra p y . T h e sp o n ta n e o u s ev o lu tio n
r e s tr u c tu r e y o u rself. In a w a y it is good if a se t
of m o re w h o leso m e w ay s of lo o k in g a t th in g s
often occurs su b tly as a re s u lt of th e cog en t a p
p lic a tio n
of p rin c ip le s th a t th e p a tie n t h a s
th e s e tb a c k . G r a d u a l l y
y o u w ill
b a c k o c c u rs, fo r th e n y o u w ill h a v e a n o p p o r tu
n ity to co m e to g rip s a g a in w ith y o u r b asic
p ro b le m s to see h o w th e y w o r k . T h is ca n b u ild
u p y o u r s ta m in a . It is lik e ta k in g a vaccine.
R e p e a te d d o se s p ro d u c e a te m p o r a r y p h y sic a l
le a rn e d in th e ra p y . L ife is a p p ro a c h e d fro m an
u p s e t, b u t c o m p le te im m u n iz a tio n e v e n tu a lly
alte re d
p erspective. W h a t w as a t o n e tim e
r e s u lts . In o th e r w o rd s, if y o u r sy m p to m s com e
frig h te n in g o r g u ilt in s p irin g is no lo n g e r d is
b a c k , d o n t p a n ic . It d o e s n t m e a n a n y th in g
un
m o re th a n th a t so m e th in g h a s s tirre d u p p o w e r
d erm in es self-esteem ceases to re g iste r su ch ef
ful te n s io n s . A sk y o u rse lf w h a t h a s c re a te d y o u r
fects. T h is re v o lu tio n ta k e s tim e. V a lu e c h a n g e

m ay n o t be d is cern ib le u n til y e a rs h av e passed
te n s io n s . Is th e r e a n y th in g in y o u r im m e d ia te
tu r b in g ;
w hat
b r in g s
in s e c u rity
and
s itu a tio n t h a t trig g e re d th in g s ? R e la te th is to

w h a t y o u k n o w a b o u t y o u rse lf, a b o u t y o u r p e r
beyond th e fo rm al tre a tm e n t p erio d .

It is often h elp fu l to w a rn th e p a tie n t th a t,
w h ile o ne m ay feel b e tte r, th e re w ill be r e
s o n a lity in g e n e r a l. E v e n tu a lly , yo u w ill be a b le

to s to p y o u r re a c tio n . B u t be p a tie n t a n d k e e p
w o r k in g a t it.
q u ire d a co n sisten t a p p lic a tio n of w h a t h as

been lea rn e d in th e ra p y to in s u re a m o re
p e rm a n e n t re so lu tio n of d e e p e r p ro b le m s. T h e
A n o th e r n eg lected a sp ect o f th e ra p y a re fol
need for self-o b serv atio n a n d for th e active
lo w -u p sessions. P rio r to h is d isc h a rg e th e p a

tie n t m ay be to ld th a t it is c u sto m a ry to h av e a
c h a lle n g in g of n e u ro tic p a tte rn s is stressed .
fo llo w -u p session 1 y e a r a fte r tr e a tm e n t, th e n
T h e p a tie n t is also en jo in ed n o t to get u p se t if

a setback is ex p erien ced .
y e a rly th e re a fte r fo r a few y ears. M o s t p a tie n ts

do n o t object to th is; in d eed , th e y a re fla tte re d
T h . S etb a c k s a r e n o rm a l in th e c o u rse o f d e v e lo p
a session is b est m a d e by a p e rs o n a l te le p h o n e
call. W h e re th e p a tie n t, fo r a n y re a so n , fin d s it
by th e th e r a p is ts in te re st. A n a p p o in tm e n t for
m e n t. A fte r a ll, so m e o f th e s e p a tte r n s a r e as

th e m se lv e s even w h e n yo u h a v e a n u n d e r s ta n d
im p o ssib le to k eep th e a p p o in tm e n t, a frie n d ly

le tte r m a y be se n t a sk in g h im to w rite th e th e r
in g of th e ir n a tu r e . B u t w h a t w ill h a p p e n is
a p is t d e ta ilin g h is feelin g s a n d p ro g re ss if an y .
old
as
you
a re .
T hey
w ill
tr y
to
rep eat
Conclusion
T h e te rm in a tio n p h a ses o f s h o rt-te rm tr e a t
m e n t a re often m in im iz e d , m a n y th e ra p is ts
im a g in in g th a t th e en d of th e ra p y w ill com e
a b o u t a u to m a tic a lly . L eft to th e ir o w n r e
sources, a c o n sid era b le n u m b e r of p a tie n ts , if
th e y can afford it, o r if tre a tm e n t is p a id for by
a th ird p a rty , w ill w a n t to c o n tin u e in tr e a t
m e n t in d efin itely . T h e go als of sh o rt-te rm
th e ra p y a re often set too h ig h by b o th p a tie n ts
a n d th e ra p ists. R ealistic ally , it is a fo rlo rn
h o p e th a t p a tie n ts can u n d o in a few sessions a
life tim e b u n d le o f p e r s o n a lity im m a t u r i tie s

th e y could n o t e lim in a te w ith lo n g -te rm tr e a t
m e n t o v er a n in d efin ite p e rio d . It w ill be
e sse n tia l, th e re fo re , fo r th e th e r a p is t to accep t
m o d est a tta in a b le g o als w ith in th e b rie f sp a n
of tre a tm e n t, w h ile a le rtin g th e p a tie n t to
p ro b le m s to be w o rk e d o n by o n eself a fte r th e r
a p y h a s en d ed . T h e r a p y w ith a few ex c ep tio n s
sh o u ld be te rm in a te d a t th e d esig n a te d set tim e
lim it.
T e rm in a tio n , h o w ev er, c a n be a p ro b le m for
249

b o th p a tie n t a n d th e ra p is t. A s th e te rm in a tio n
te rm in a te w ith th e last in te rv iew . T h e fact th a t
d a te a p p ro a c h e s , th e p a tie n t m a y e x p e rien c e a
reg ressio n w ith sy m p to m rev iv al. T h e th e r a
o v er 6 0 p e rc e n t of p a tie n ts w h o h av e com
p ist w ill th e n be te m p te d to p ro ceed b ey o n d
tr e a tm e n ts (P a tte rs o n
th e te rm in a tio n d a te h o p in g th a t a few m o re
sessions w ill save th e d ay . In s te a d o f y ield in g
th a t a n o n g o in g th e ra p e u tic e x p e rie n c e of som e
to th is te m p ta tio n , th e th e ra p is t m o re p r o p i
tio u s ly sh o u ld e x a m in e w h a t te r m i n a ti o n
m ean s to th e p a tie n t a n d to him self. U s u a lly it
w ill h a v e s tir r e d u p th e o ld d e p e n d e n c y a u to n o m y conflict in th e p a tie n t. A n d th e fact
th a t th e p a tie n t h a s n o t achieved th e e n tire
h o p ed -fo r c u re m ay , in tu r n , o p e n o ld u n
h e a le d w o u n d s in th e t h e r a p is t , in c lu d in g
g ra n d io sity an d n arcissistic need to p ro v e in
v incibility as a th e ra p is t. It m a y also k in d le th e
s e p a ra tio n an x ie ty sp a rk e d by th e p a tie n ts
th re a te n e d d e p a rtu re . B o th tra n sfe re n c e a n d
c o u n te rtra n sfe re n c e w ill re q u ire e x p lo ra tio n a t
th is p o in t to h e lp th e s e p a r a tio n p ro c e s s
to w a rd allo w in g p a tie n ts to sta n d on th e ir o w n
feet, p u ttin g in to p ra c tic e th e lessons le a rn e d in
p le te d
sh o rt-te rm
th e ra p y
seek o u t fu rth e r
et a l,
1977) in d icates
k in d , fo rm a l o r in fo rm a l, is d eem e d n ecessary
by th e g re a t m a jo rity . If th e th e r a p is t does n o t
p ro v id e a d ire c tio n , th e p a tie n t w ill se a rc h for
o n e p e rso n a lly , p e rh a p s b lu n d e rin g in to a d v e n
tu re s th a t a re u n re w a rd in g to say th e least.
O n e w ay to fo ster c o n tin u e d im p ro v e m e n t is
to p re p a r e th e p a tie n t to w o rk to w a rd a lte rin g
a d e stru c tiv e e n v iro n m e n t so th a t it ceases to
im p o se stra in s o n a d ju s tm e n t. T h e lin es alo n g
w h ic h su ch m o d u la tio n s m a y be m a d e w ill be
d e te rm in e d d u rin g th e active tre a tm e n t p h ase .
H o m e w o rk sh o u ld be e n c o u ra g e d . T h e se
m ay em b o d y (1) te n sio n re d u c tio n a n d egob u ild in g th r o u g h self-re la x a tio n exercises o r
liste n in g to a c assette ta p e , (2) in c u lc a tio n of a
p ro p e r p h ilo so p h ic a l o u tlo o k by im p a rtin g new
m e a n in g s to o n e s ex isten ce, (3) o b se rv a tio n of
th e ra p y . T h e th e r a p is t m u st accep t th e fact
th a t no p a tie n t can be co m p letely c u re d a t th e
o n e s b e h a v io r to d etec t p a tte rn s th a t p ro v o k e
te rm in a tio n of sh o rt-te rm th e ra p y . T h e m ost
c o n stru ctiv e m o d es of c o p in g w ith esse n tial
th a t can be h o p ed fo r is th a t en o u g h h a s been
g a in ed in tre a tm e n t to h av e achieved sy m p to m
relief, a b a n d o n m e n t of a n old d e stru ctiv e p a t
re sp o n sib ilities.
L e s t w e c h id e o u rs e lv e s a t
te rn o r tw o o r a t least som e u n d e rs ta n d in g of
these p a tte rn s , a n d ideas o f h o w o n e can k eep
w o r k in g o n o n e s e lf to a s s u r e c o n tin u in g
im p ro v em en t.
T h e ra p e u tic c h an g e does n o t cease a t th e
te rm in a tio n of th e ra p y . It m ay c o n tin u e lo n g
a fter tre a tm e n t h a s en d ed , p e rh a p s th e r e
m a in d e r of th e in d iv id u a ls life. In d e e d , follow u p stu d ies of p a tie n ts w h o sto p p e d th e r a p y in a
sta lem ate o r because of no a p p a re n t im p ro v e
m en t have rev ealed g ra tify in g a lte ra tio n s th a t
seem to hav e re q u ire d th e rip e n in g effects of
tim e.
Too
fr e q u e n tly
th e r a p y
is p re s u m e d
to
p ro b le m s, a n d (4) th e stu d ied p ra c tic e o f m o re
n o t h a v in g
ach iev ed w ith d y n a m ic s h o rt-te rm th e r a p y a

co m p lete ly a n a ly z e d p a tie n t o n te rm in a tio n ,
w e m ay heed th e w ise w o rd s o f F re u d w h o
w ro te : O u r a im w ill n o t be to r u b off every
p e c u lia rity of h u m a n c h a ra c te r fo r th e sak e of
a sc h em atic n o rm a lity , n o r yet to d e m a n d th a t
th e p e rso n w h o h a s been th o ro u g h ly a n aly z ed
sh all feel n o p a ssio n s a n d d ev elo p n o in te rn a l
conflicts. T h e b u sin ess of th e a n a ly sis is to
secu re th e best p o ssib le p sy ch o lo g ical c o n d i
tio n s for th e fu n ctio n s o f th e ego; w ith th a t it
h a s d isc h a rg e d its ta s k . W e a re , of co u rse,
h o p e fu l th a t w ith c o n tin u e d w o rk o n th e m
selves o u r p a tie n ts w ill p ro ceed b ey o n d th is o b
jectiv e.
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c o m b in e d
w ith
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in
HA:
JS ,
d is li k e d
A
H a th a w a y
K e ll n e r
m e d ic a l
R:
JA M A
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RM :
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(e d ): S h o r t- te r m
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M a c h o v e r K : P e r s o n a li ty P r o je c tio n in th e D r a w in g s o f
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(A ls o
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M a la n
DH:
T o w ard
th e
V a li d a ti o n
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P sy
M a la n
DH,
B acal
p s y c h o d y n a m ic
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A s tu d y o f
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B rie f p s y c h o th e r a p y in th e h o s p ita l s e ttin g :
T e c h n iq u e s a n d
g o a ls.
P s y c h ia tr Q
4 7 :3 4 1 -3 5 2 ,
19 7 3 .
n a m ic c r i te r ia . B r J P s y c h ia tr y 1 1 4 :5 2 5 , 1 9 6 8 .
M a la n D H . H e a t h E S , B a c a l H A , e t a l: P s y c h o d y n a m ic
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in
u n tr e a te d
n e u r o tic
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A rc h
G en
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L e w is J , M i d e r P A : E ffec ts o f le a d e r s h ip s ty le c o n te n t a n d
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M a ltz
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E n g l e w o o d C li f f s , N J ,
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L ib e r m a n R A : B e h a v io ra l a p p r o a c h to g r o u p d y n a m ic s . I.
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A r c h G e n P s y c h ia tr y 2 4 :2 2 , 1 9 7 1 .
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The
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P s y c h ia tr y 1 6 :1 2 3 - 1 2 7 , 1 9 6 3 .
M a rtin
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R e s is ta n c e to in n o v a tio n
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L e v in R E , R iv e lis d e P a z , L : C o n tr i b u tio n s to th e th e o ry
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N e w Y o rk , G r u n e & S tr a t to n , 1 9 6 7 .
U s d in
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P s y c h ia tr y :
E d u c a ti o n
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Im a g e .
N e w Y o rk , B r u n n e r / M a z e l , 1 9 7 3 .
M a r t i n R C : T h e a c u te s itu a tio n a l c ris is a n d c o m m u n ic a
L u r i a A : H ig h e r C o r tic a l F u n c tio n s in M a n . N e w Y o rk ,
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p s y c h o th e r a p y :
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c o m p a r is o n
C om p G ro u p
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M L.
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C h a n g in g
C la s s r o o m
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M e a r s E : S e x u a l p r o b le m c lin ic s: A n a s s e s s m e n t o f th e
w o rk
of 26
d o c to r s
tr a in e d
by
th e
in s ti tu ti o n
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P itt m a n
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Q u a y tm a n W : I m p r e s s io n s o f th e E s a le n (S c h u tz ) p h e
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Exp
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S p ie g e l H , S p ie g e l D : T r a n c e a n d T r e a t m e n t : C lin ic a l
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C ib a
F o u n d a tio n
S y m p o s iu m .
L o n d o n , C h u r c h i ll, 1 9 6 8 , p 8 7 (b ).
S ifn e o s
PE:
S h o r t- te r m
P s y c h o th e r a p y
in d ia g n o s is ? A m J P s y c h ia tr y 1 3 1 :5 2 3 , 1 9 7 4 .
S p itz e r R L , W ils o n
and
E m o tio n a l
C r is is . C a m b r id g e , H a r v a r d U n iv e r s ity P re s s , 1 9 7 2 .
P T : N o s o lo g y a n d th e o ffic ial p s y
c h i a tr i c n o m e n c la t u r e , in F r e e d m a n A M , K a p la n H I ,
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260

c h ia tr y , V o l 2 , 2 n d e d . B a ltim o r e , W i lli a m s & W i l
k in s , 1 9 7 5 , p p 8 2 6 - 8 4 5 .
S w a r tz J :
HH
S p iv a c k G , P la t t J J , S h u r e M B : T h e P ro b le m -S o lv in g A p
p r o a c h to A d ju s tm e n t; A G u id e to R e s e a rc h a n d I n
te r v e n tio n . S a n F ra n c is c o , C a lif , J o s s e y - B a s s , 1 9 7 6 .
b r ie f p s y c h o th e r a p y , in
B r ie f T h e r a p i e s . N e w
B a r te n
Y o rk , B e h a v io r a l
P u b lic a tio n s , 1 9 7 1 .
S w e n s o n W M , M a r t i n H R : A d e s c r ip tio n a n d e v a lu a tio n
o f a n o u tp a t i e n t in te n s iv e p s y c h o th e r a p y c e n te r . A m J
S p r in c e M P : W o r k w ith a d o le s c e n ts : B rie f p s y c h o th e r a p y
w ith a lim ite d a im . J C h ild P s y c h o th e r 2 (2 ):3 1
T im e - l im i te d
(e d ):
37,
1968.
P s y c h ia tr y 1 3 3 :1 0 4 3 - 1 0 4 6 , 1 9 7 6 .
S zasz
TS:
The
M y th
o f M e n ta l
I lln e s s .
N ew
Y o rk ,
H a rp e r & R ow , 1961.
S p r in g m a n R R : S in g le s e s sio n p s y c h o th e r a p y in s e c o n d a ry
T a ft J
m a le im p o te n c e . M e n t H e a l th S oc 5 : 8 6 - 9 3 , 1 9 7 8 .
S ta in b r o o k E : T h e h o s p ita l a s a th e r a p e u ti c c o m m u n ity ,
in
F reed m an
AM,
K a p la n
H I,
S adock
C o m p r e h e n s iv e T e x tb o o k o f P s y c h ia tr y .
BJ
(ed s):
B a ltim o r e ,
CT,
S e m ra d
EV:
s y lv a n ia P r e s s , 1 9 4 8 .
T e ic h e r A , d e F r e it a s L , O s h e r s o n A : G r o u p p s y c h o th e r
a p y a n d th e in te n s iv e g r o u p e x p e rie n c e : A p r e l im i
W illia m s & W ilk in s , 1 9 6 7 , p p 1 2 9 6 - 1 3 0 0 .

S ta n d is h
(e d ): F a m ily C a s e w o r k a n d C o u n s e lin g : A F u n c
tio n a l A p p r o a c h . P h ila d e lp h i a , U n iv e r s ity o f P e n n
G r o u p p s y c h o th e r a p y
w ith
n a r y r a t io n a l e fo r e n c o u n te r a s a t h e r a p e u ti c a g e n t in
p s y c h o tic s , in R o s e n b a u m M , B e rg e r M (e d s ): G r o u p
th e
2 4 :1 5 9 - 1 7 3 , 1 9 7 4 .
and
G ro u p
F u n c tio n .
N ew
Y o rk ,
T e rm an
B a sic B o o k s , 1 9 6 3 .
S te in C : H y p n o tic p ro je c tio n in b r ie f p s y c h o th e r a p y . A m J
a p y o f p s y c h ia tr ic re a c tio n s to p h y s ic a l illn e s s . A m J
S te k e l W : C o n d it io n s o f N e r v o u s A n x ie ty . N e w
Y o rk ,
g r o u p s in a g r o u p th e r a p y p r o g r a m . I n t J G r o u p P s y
S tr a k e r M : B r ie f p s y c h o th e r a p y in a n o u tp a tie n t c lin ic :
e v a lu a ti o n .
Am J
P s y c h ia tr y
124:
B io f e e d b a c k
tr e a tm e n t
in
m e d ic in e a n d p s y c h ia tr y : A n u lt im a te p la c e b o ? S e m in
P s y c h ia tr y 5 : 3 7 9 - 3 9 3 , 1 9 7 3 .
G e n P s y c h ia tr y 2 6 : 2 7 0 - 2 7 8 , 1 9 7 2 .
d is c o rd . J C o n s u lt C li n P sy c h o l 3 3 : 6 7 5 - 6 8 2 , 1 9 6 9 .
w ith
s u b p ro fe s s io n a ls . J
C lin
P sy c h o l
SS:
The
T h e m a t ic
A p p e r c e p tio n
T e st:
The
T h e o r y a n d T e c h n iq u e o f I n te r p r e ta t io n . N e w Y o rk ,
G ru n e & S tra tto n , 1947.
c h i a tr N u r s M e n t H e a l th S e rv ic e s 8 ( 3 ) : 1 1 1 2 , 1 9 7 0 .
T r a k a s D , L lo y d G : E m e r g e n c y m a n a g e m e n t in a s h o r t
b e h a v io r a l tr e a tm e n t fo r p r e d e l in
d e l in q u e n t s ,
in
open
g ro u p .
C om pr
P s y c h ia tr y
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1971.
G e n P s y c h ia tr y 2 3 : 6 5 - 6 9 , 1 9 7 0 .
T y h u rst J S :
The
ro le s
of
t r a n s i tio n
s ta t e s in c lu d in g
R u b in
and
S o c ia l
P s y c h ia tr y .
W a s h i n g to n ,
DC,
W a lte r
RD,
U p h a m F : E g o A n a ly s is in th e H e lp i n g P ro fe s s io n s . N e w
Y o r k , F a m i ly S e rv ic e A s s o c ia tio n o f A m e r ic a , 1 9 7 3 .
S t u a r t R B , T r i p o d i T : E x p e r im e n t a l e v a lu a tio n o f th r e e
and
T e a c h e r s e v a lu a tio n o f c h i ld r e n in s h o r t- te r m
R e e d A r m y I n s tit u te o f R e s e a rc h , 1 9 5 7 .
S t u a r t R B : O p e r a n t- i n te r p e r s o n a l tr e a tm e n t fo r m a r ita l
tim e - c o n s tr a in e d
In te llig e n c e .
d is a s te r s in m e n ta l illn e s s . S y m p o s iu m o n P r e v e n tiv e
S t r u p p H H : O n th e te c h n o lo g y o f p s y c h o th e r a p y . A rc h
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M e a s u rin g
T u c k m a n A J: B r ie f p s y c h o th e r a p y a n d h e m o d ia ly s is . A rc h
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BC:
MA:
P s y c h o th e r
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te r m
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S tr ic k le r M , A llg e y e r J : T h e c risis g r o u p : A n e w a p p l ic a
G lu e c k
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T r a c e y J : P a r e n t g u id a n c e g r o u p s : Is th i s th e r a p y ? J P sy -
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CF,
In t J
v ia p s y c h o s y n th e s is . R o c h e R e p o r t 2 ( 1 8 ,1 9 ) , 1 9 7 2 .
T o lo r A
T o m k in s
L iv e r ig h t, 1 9 5 0 .
S to n e A , P a rlo ff M , F r a n k J , e t a l: T h e u s e o f d ia g n o s tic
S tr o e b e l
M e rr ill
fie ld .
B o s to n , H o u g h to n , M if f lin , 1 9 3 7 .
tre a tm e n t
P s y c h ia tr y 1 2 5 :1 0 4 0 - 1 0 4 9 , 1 9 6 9 .
and
LM ,
h e a lth
T i e n H C : F r o m c o u c h to co ffee s h o p : A n e w p e r s o n a l ity
C lin H y p n 1 4 :1 4 3 - 1 5 5 , 1 9 7 2 .
S te in E H , M u r d a u g h J , M a c L e o d J A : B rie f p s y c h o th e r
E v o lu tio n
m e n ta l
B ra d y J P
U r s a n o R M , D r e s s ie r D M : B r ie f vs. lo n g - te r m p s y c h o
th e r a p y :
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(e d s ): A d v a n c e s in B e h a v io r T h e r a p y , V o l 4 . N e w
Y o rk , A c a d e m ic P re s s , 1 9 7 3 .
V e r h u ls t J : M a r i t a l c h a n g e : A n in te n s iv e , s h o r t- te r m a p
S u e s s J F : S h o r t- te r m p s y c h o th e r a p y w ith th e c o m p u ls iv e
p e r s o n a lity
and
th e
o b s e s siv e -c o m p u ls iv e
n e u r o tic .
A m J P s y c h ia tr y 1 2 9 : 2 7 0 - 2 7 5 , 1 9 7 2 .
S u in n
RM ,
et
a l:
A c c e le ra te d
m a ss e d
d e s e n s itiz a tio n :
1 .3 0 3 - 3 1 1 , 1 9 7 0 .
MG,
u n m o tiv a te d
W o o ls o n
p a t ie n t .
1975.
V e r n a ll is F F , e t a l: S a t u r a t i o n g r o u p p s y c h o th e r a p y in a
U n m o tiv a tio n in s h o r t- te r m tr e a tm e n t. J B e h a v T h e r
S w a n so n
p r o a c h . I n t M e n t H e a l t h R e s N e w s l e tt e r 1 7 ( 2 ) :7 10,
w eekend
c l in ic :
An
o u tc o m e
s tu d y .
P s y c h o th e r
T h e o r y R e s P r a c 7 :1 4 4 - 1 5 2 , 1 9 7 0 .
V e r n a ll is F F , e t a l: T h e t r e a tm e n t p ro c e s s in s a tu r a tio n
AM:
P s y c h o th e r , T h e o r y
w ith
th e
R es P rac
1 0 :1 7 5 - 1 8 3 , 1 9 7 3 .
S w a r tz J : T im e - l im i te d b r ie f p s y c h o th e r a p y . S e m in P s y
c h i a tr y 1 :3 8 0 - 3 8 8 , 1 9 6 9 .
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V is h e r J S , O S u lliv a n M : N u r s e a n d p a t ie n t r e s p o n s e s to
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C o p y rig h t 1980 Louis R Wolberg

D y n a m ic Focus: A. P r o b i n g into th e P a st, 101

10. C h o o sin g a D y n a m ic Focus: C . P re s e n tin g I n t e rp re t a ti o n s , 125

d a te d a n asto n ish in g ly larg e p e rc e n ta g e of th e

Y ork C ity , d u r i n g w h ich a n u m b e r of p a r

re latively recently, h ow e v e r, th a t th e r e has

tic ip a n ts p resen ted m a te ria l d e ta ilin g th e ir

id eas a n d o b se rv a tio n s of th is s em in ar. It is

as a n e x p ed ie n t. E ven n a tio n a l p sy ch o an aly tic

revealed the res u lts of a p ro ject th a t lasted tw o

m e n t, have b e g u n to p re a c h its v irtu es and

psy chiatrists tre a te d p a tie n ts o n a s h o r t-t e rm

M a s s e r m a n detailed the h isto ric a l-c o m p a ra tiv e

ceeded differences. N ev erth eless, a g re a t n u m

p hilo so p h ies, goals, selection p ro c e d u r e s a n d

p resen ted m a t e r i a l on m o tiv a tio n a l factors th a t

O n e of th e m ost critical q u e stio n s is re lated

th e charac teristic s of s h o r t-t e rm versus lo n g

cho analytic c o n tr ib u tio n s to s h o r t- t e r m th e r a p y

ficulties th a t s h a d o w o u tc o m e stu dies te n d to

o b scu re results. Yet w ith all o u r skepticism

A le x a n d e r W o lf d ealt w ith s h o r t-t e rm g r o u p

a b o u t q u a n tify in g brief clinical o p e ra t io n s suf

p sy ch o th erap y . M o lly H a r r o w e r described a

ficiently to satisfy th e c rite r ia of objectivity,

research p roject related to o u tco m e of lo n g

te r m s w ith his p ast, as in insig ht th e r a p y , or

HANDBO OK OF SHORT-TERM PSYCHOTHERAPY

search of p a tie n ts w h o h a d been tre a te d in a

techn iq ues, o r co rrec ting h a b itu a l p a st m odes

c o m p a r is o n stu d y w ith tw o fo rm s of b rief psy

design to follow in all form s of p s y c h o th e ra p y ,

not hav e a n im m e d ia te d r a m a ti c influence on

the p e rs o n a lity stru c tu re , it can catalyze such

low b ecau se m a n y d is ch arg ed p a tie n ts w h o do

n ot seek fo rm al t h e r a p y u tilize o th e r form s of

In this v o lu m e I h ave a tt e m p t e d to b rin g

b etter th e i r a d ju s tm e n t. Life, after satisfactory

to g eth er co m m o n elem ents in th e chief m odels

evolve p rinc iple s th a t can be em p lo yed by in d i

can ta x co p in g capacities of even c u r e d p a

retical biases a n d styles of o p e ra tio n . H o w a

tients. T h i s is n o t a lto g e th e r bad , for in m e e t

trodu ced in an y form of p s y c h o th e ra p y is one

describe is no t p res e n te d w ith illusion t h a t it is

m u c h like a boo ster shot can e n h a n c e th e effect

N o r m a y it p ro ve e q u a lly helpful to all t h e r a

p re p a r e s th e p a ti e n t for a n tic ip a te d events an d

pists o r cu rativ e in every case. It is, n e v e rth e

con tin gen cies a n d te aches a w a y of d e a lin g

ble for the g re a t m a jo rity of p a tie n ts seen in

if no t a lr e a d y a c q u a i n te d w ith som e tech n iq u e s

o th e r form s of help. U n d e r these c ir c u m

W h a t e v e r g a in s m a y accrue from a n y evolving

ing tech niqu es (pp. 3 6 0 - 3 8 2 ) a re in d ispen si-

insights a re n e u tr a liz e d by th e crip p lin g influ

ence of th e p ro lo n g e d sh elte re d relatio n sh ip .

A final w o rd of cau tio n m a y be indicated.

m en t. B ut, for the g re a t m a jo rity of pe op le

S u ch disc on certing p h e n o m e n a give im p e tu s

seeking help for em o tio n al p ro b le m s, th e tim e

w ith o u t d e v italizin g its effect. T h i s is n ot to