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The History and Empirical Status of Key Psychoanalytic


Article  in  Annual Review of Clinical Psychology · February 2006

DOI: 10.1146/annurev.clinpsy.2.022305.095328 · Source: PubMed


23 526

2 authors, including:

Marna S Barrett
University of Pennsylvania


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Annu. Rev. Clin. Psychol. 2006. 2:1–19

doi: 10.1146/annurev.clinpsy.2.022305.095328
Copyright  c 2006 by Annual Reviews. All rights reserved
First published online as a Review in Advance on November 28, 2005


Lester Luborsky and Marna S. Barrett
Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania 19104;
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Key Words psychoanalytic theory, empirical support, therapy outcome

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■ Abstract Over the past century, the ideas set out in psychoanalytic theory have
permeated the field of psychology as well as literature, art, and culture. Despite this
popularity, analytic theory has only recently received empirical support. In this chapter,
we seek to highlight several fundamental concepts of analytic theory (the unconscious,
drives, defenses, object relations, Oedipus complex) and psychodynamic treatments
(transference, countertransference, interpretations, resistance). The first section of the
chapter offers a comprehensive definition and historical background for each concept.
This foundation is followed by a review of the empirical evidence supporting the
reliability and validity of these concepts, their impact on treatment, and their broader
influence on the future of psychology.

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
PSYCHOANALYTIC CONCEPTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Unconscious . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Drives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Parent-Infant and Parent-Child Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Oedipus Complex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Defenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
PSYCHOANALYTIC CONCEPTS IN THERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Transference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Countertransference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Accuracy of Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Evidence for the Unconscious . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Evidence for Drives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Evidence for Parent-Infant and Parent-Child Relationships . . . . . . . . . . . . . . . . . . 9
Evidence for the Oedipus Complex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Evidence for Defenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Evidence for Transference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

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Evidence for Countertransference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Evidence for Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Evidence for Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Evidence for the Accuracy of Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
THE IMPACT OF PSYCHOANALYTIC CONCEPTS . . . . . . . . . . . . . . . . . . . . . . . . 14

Psychoanalytic concepts are prevalent throughout the field of psychology as well
as in literature, art, and popular culture. For example, the Oedipus complex is a
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primary theme in Shakespeare’s Hamlet and in later plays such as Eugene O’Neill’s
Morning Becomes Electra. Many of these concepts, however, originate in the
theoretical writings of Freud and the developments of psychoanalysis. In this
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chapter, we want to highlight the impact of several psychoanalytic concepts on the

field of psychology.
To this end, we have divided the chapter into two parts: Part one offers a com-
prehensive definition and understanding of the key concepts as well as a review of
each concept’s historical roots. Part two provides empirical documentation of the
reliability and validity of these psychoanalytic concepts and describes their use-
fulness in future endeavors. Although psychoanalytic therapists have been reticent
and even resistant to empirical investigations of analytic theory, several rigorous
studies of key concepts have been conducted.

Psychoanalysis and psychoanalytic theory have evolved considerably since the
1930s. For instance, rather than focusing on a distinct tripartite personality struc-
ture (i.e., id, ego, superego), theorists have shifted their attention to the role of
affect and motivation as determinants of personality (Westen 1998). Despite this
evolution, criticism continues to be leveled against many of the original con-
cepts, particularly about the issue of falsifiability (Macmillan 2001; see also
Wallerstein 1986, Weinberger & Westen 2001). Although certain aspects of Freud’s
concepts are not strictly speaking falsifiable (e.g., id, ego, Oedipus complex), a
number of them are accessible to empirical investigation. The psychoanalytic con-
cepts described in this chapter are especially well known, they form the basis
of modern psychoanalytic theory and dynamic therapy, and their importance in
our understanding of personality development has been demonstrated. However,
due to practical limitations, we have chosen to omit some concepts that, although
key to original psychoanalytic thinking, have been extensively discussed and re-
searched (e.g., id, ego, superego).1 The concepts highlighted in this chapter include

See Filsinger & Stilwell (1979), Stephenson (1982), and Tangney (1994) for empirical
discussions of the validity of these concepts.
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the unconscious, drives, parent-infant and parent-child relationships (object rela-

tions), Oedipus complex, defenses (repression, projection, fantasy, identification,
and intellectualization), interpretations (including the accuracy of interpretations),
transference, countertransference, and resistance.

One of the main underpinnings of analytic theory is that painful or unacceptable
feelings are pushed out of the realm of awareness (by defenses). In order to avoid
pain or discomfort (according to the pleasure principle), a person will fight to
keep these feelings out of awareness or out of consciousness. However, life ex-
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periences will often cause a reawakening of the underlying conflict, resulting in

a psychological struggle to block the emotional discomfort from awareness. Rec-
ognizing distress, a person may work to avoid underlying pain by consciously or
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unconsciously withholding important information from the therapist and deflect-

ing attention to less painful topics. Although the foregoing explanation defines
the typical role of the unconscious, a fundamental assumption of psychoanalytic
theory is that the unconscious exists and allows resolution of the discontinuity
between mental health symptoms and causation (Shevrin et al. 1996).
The unconscious, internal conflicts are theorized to result from poorly resolved
developmental issues, such as parent-infant and parent-child interactions, drives,
trust, autonomy, or security, to name a few. In the life of an adult, experiences occur
that are thought to trigger an early, unresolved issue. Touching on this “nerve” or
emotional hotspot heightens the person’s anxiety and distress, which then sets
off myriad efforts to block it. When the defenses break down and can no longer
effectively block the distress from awareness, neurosis or even psychosis results.2

A second concept central to analytic theory is the role of instinctual drives in de-
termining human development. Historically, a drive or instinctual urge has been
defined as an internal force or tension that propels an individual to act in ways that
reduce tension. This tension is influenced not only by internal strivings (motiva-
tion) but also by environmental or experiential factors acting upon the individual.
The original drive concepts included hunger, sex, aggression, and control, but
more recent models (see Compton 1983, Kernberg 2001) center on the general
notion of a need for pleasure (sex and hunger) and the instinctual response that
occurs when that need is blocked (aggression and control). From a developmental
perspective, the manner in which an infant’s need for comfort is met by a signif-
icant other (object) influences the way in which future relationships are defined

Several books highlight quite nicely the concept of the unconscious and the characteristic
ways in which it is evident (see Davanloo 1990; Fisher & Greenberg 1985, 1996). Fisher
and Greenberg (1996) also offer an excellent summary of psychoanalytic studies and their
usefulness in validating key analytic concepts.
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(internalized object relations). According to Kernberg’s (2001) integrated model

of affect, drive, and object relations, affects are the prime motivators of behavior
and influence communication in the infant/caregiver relationship such that positive
and negative affects combine to form the drives or motivational systems of plea-
sure and aggression. Moreover, affect can be modified and elaborated by internal
object relations, resulting in changes in the drives or in motivation.
Schwartz (1987), who not only suggested that affects are the prime factors of
human motivation but also saw affect as a neurophysiologically based factor, has
made a similar argument. It was the neurologically generated affect evident in
motor behavior (i.e., facial features) that communicated emotions and empathy
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to others. Thus, he argued that the nonverbal behavior and communication of

parents (or caregivers) elicited certain affect in the child that resulted in personality
development and defense structure.
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Parent-Infant and Parent-Child Relationships

In much of the psychological literature, the importance of early parent-child re-
lationships (object relations) was referred to in terms of generalizing explanatory
sentences, such as “early patterns influence later patterns” or “a child who is ad-
vanced early will be a child who is advanced later.” Freud (1909/1955) offered
more specific explanations of developmental patterns using case examples. For
instance, he described a child who was afraid to walk along the streets for fear
of being bitten by a horse. Freud interpreted this behavior as representative of
the close yet fearful relation between a child and his father. Because of the early
physical connection with mother (through breast-feeding), Freud theorized that
children sought an intimate emotional relationship with mother. Unfortunately,
that intimate relationship was shared between mother and father, thus putting the
child in competition with father for mother’s love. In this example, the young boy
sought his mother’s love but feared retribution from his father through castration.
The horse was simply an acceptable conscious representation of the unacceptable
unconscious conflict with the father.
What is most striking about this example (even more than the illustration of
parent-child relationship patterns) is that the information was obtained through
regular observation of the child for many months. Such observation represents a
major tenet of most medical and psychological inquiry; that is, a critical event
causes a particular course of action (an effect). From an understanding of cause
and effect, an intervention or treatment can be developed to block or change the
causative agent with resulting changes in effects or symptomatic outcome. Al-
though Freud did not present these data as a scientific study, observational data
formed the foundation for early verification of many psychoanalytic concepts as
well as stimulating new ideas about human development.
More recently, theorists have described these early developmental patterns in
terms of how individuals relate to a central object (person or thing) in their life.
In contrast to the motivating force of drives, object relations theorists focus on the
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role of interpersonal relationships as the motivation for human behavior. These

objects and the way in which a developing child relates to them form the basis for
the sense of self or individual personality.

Oedipus Complex
Freud’s original Oedipus concept developed from his observations of interactions
between parent and child (see example above). He concluded that any child (boy
or girl) had a twofold attitude toward the parents; that is, (a) a wish to eliminate
the father and take his place in a sexual relationship with the mother and (b) a wish
to eliminate the mother and take her place with the father (Brenner 1955). Most
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dynamic theorists today accept a broader interpretation of the Oedipus complex

encompassing the idea that there is an active competition between two people for
the affection of a third person. Fear of retaliation is often embedded in the dynamic
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between the competing individuals.

As discussed in the section on the unconscious, an assumption of analytic theory
is that anxiety results from an internal perception of danger or threat to the self.
The self (or ego) will utilize whatever is available to defend against this anxiety
and decrease the perceived threat (i.e., a move to make it unconscious). Defenses,
therefore, represent the mechanisms by which we keep anxiety, fear, or discomfort
out of conscious awareness. The frequency and types of defenses are determined
by the strength of the ego (self), and they occur in response to and are the effect
of distress brought about by an internal unconscious psychological event. Once
unique to psychoanalytic theory, the concept of defenses has now been examined
in other areas (Caspar 1995), and we review a few of the more long-standing
defenses for which there is empirical support (Perry 1993).
1. Repression, one of the earliest defenses described by Freud, is a defensive
strategy that keeps from consciousness unpleasant or unacceptable memo-
ries, emotions, desires, or wishes. The concept involves the act of pushing
down memories and restricting their access to awareness. A repressed mem-
ory is one that is forgotten from the subjective perspective of the person in
whom the repression occurs.
2. Denial, a somewhat similar yet better-known defense, involves the act of
keeping from conscious awareness an unacceptable behavior or idea.
3. Projection, also among Freud’s earliest list of defenses, occurs when one
sees into another person but what one sees really comes from the self.
In other words, in an effort to avoid discomfort or anxiety as a result of
personal wishes or impulses, an individual will unconsciously see in an-
other that which she is unable to see in herself. By projecting her unaccept-
able wishes or impulses onto another, the individual is able to criticize that
which is discomforting about her without experiencing the associated pain.
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For example, after a particularly stressful discussion, one person may re-
spond to another, “I am not angry, you are!”
4. Fantasy is a state of mind, much like a waking dream, in which conscious
memories and wishes, about personally important people, are reexamined in a
less threatening way. Such memories and wishes become less threatening due
to a decreasing need for being exact. The resulting fantasy is a “makeover”
of personally important people in terms of the individual’s conscious or
unconscious wish. Although having its historical basis in dream analysis,
fantasy was first discussed as a defense mechanism in the work of A. Freud
and M. Klein (Drapeau et al. 2003).
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5. Identification, a defense later identified by object-theory psychoanalysts

(Drapeau et al. 2003), involves the development of a self-identity that is
based on a copying by the self of the other person’s qualities. Frequently
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identification has been viewed as a turning against the self because the ob-
ject of the identification is often seen as the aggressor. The only way in which
the conscious mind can deal with the unacceptable feelings toward another
person is to identify with that person and strike out against one’s self as if
one’s self was the other.
6. Intellectualization, a more recently articulated defense and one considered
of higher order, involves the avoidance of disturbing feelings or conflicts
through a pseudo-objective stance. Such distancing from discomforting sit-
uations relies on abstract thinking and results in a somewhat cold, aloof


The concepts that follow, i.e., transference, countertransference, resistance, and
interpretation (including accuracy of interpretation), better reflect the process of
psychodynamic therapy than developmental concepts of psychoanalytic theory.
However, they are included in this discussion because of their acceptance through-
out psychology, psychiatry, and associated disciplines as well as in literature and
the media.

Transference was described in Freud’s early writings (Freud 1912/1958) and rep-
resents the process by which the patient is not satisfied with seeing the therapist
as a helper and adviser. Rather, the therapist comes to represent some important
figure out of the patient’s past such that all feelings and reactions related to this
person are consequently transferred to the therapist. Thus, because the therapist
and some important past figure in the patient’s life are seen by the patient as sim-
ilar, the patient relates to the therapist as if the therapist was the significant other.
Within treatment, transference can be critically important because it embodies both
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positive (affectionate) as well as negative (hostile) attitudes toward the therapist

and can be examined for recurring interpersonal themes. One aspect of negative
transference that is essential to keep in mind is that a patient can behave in ways
that stimulate the therapist to respond in a manner consistent with the patient’s
negative transference expectations. Such patient-stimulated countertransference
can then serve to reinforce the negative transference pattern with which the patient
is familiar, distorting the therapist’s understanding of the transference.

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In its basic form, countertransference represents the therapist’s personal and gen-
eral responses to the patient’s transference. That is, countertransference is a pattern
of miscommunication in which the client’s responses—which are based on other
relationships in the client’s life—are responded to by the therapist from the per-
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spective of the therapist’s experience with significant others. Until recently, coun-
tertransference was to be avoided because it meant that the therapist’s personal
experiences were entering into the treatment of the client. However, countertrans-
ference is now seen as inevitable in the treatment process and is embraced as a
way to recognize and better understand the patient’s transference.

Resistance is an in-therapy behavior in which the patient can slow the rate of
change. This concept involves recognition of two competing processes: the move
toward change and the move to block change. Rather than repressing uncomfortable
feelings or anxiety through the use of defenses, resistance involves the conscious
(and sometimes unconscious) act of avoiding the emergence of repressed feelings.
By wanting change yet desiring to do so without emotional discomfort, the client
continually shifts between movement toward change and resistance to issues that
would lead to change. Recently, theorists and researchers have argued that the
movement toward and away from change is representative of the dynamic between
resistance and alliance such that resistance blocks the formation of a good working
alliance (Berg 2000, Callahan 2000, Cho & Lee 1997, Konzelmann 1995, Piper
et al. 1999, Rennie 1994).

Interpretation describes the types of messages within the therapist’s statements
that are shared with the client. The concept involves a search for the essence of
the client’s statements. In other words, interpretation is a means by which the
therapist offers an explanation of cause and effect for events in the patient’s life.
Often, interpretation involves an explanation of the transference and of how it
relates to other patterns of relating in the client’s life. It is through interpretation
that the patient is made aware of previously unrecognized patterns of behavior that
are negatively affecting their interpersonal relationships.
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Accuracy of Interpretation
The degree to which interpretations are accurate depends upon the extent to which
the client agrees with the cause-effect relationship articulated by the therapist as
drawn from client behavior or statements. For example, Kubie (1952) stated that
the accuracy of an interpretation would be evident if the patient’s associations to it
confirmed the content, symptoms were reduced, and future behavior could be pre-
dicted. Although some measures assess the amount or usefulness of interpretations
(see Ogrodniczuk & Piper 1999, Sachs 1983), the measure by Crits-Christoph et al.
(1998) offers the only systematic method for estimating the degree of accuracy for
therapist’s interpretations. In their method, accuracy is determined by the level of
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agreement between the Core Conflictual Relationship Theme (CCRT; a systematic

assessment of interpersonal patterns of relating to others) and observer ratings of
therapist interpretations. The therapist’s most accurate interpretations, defined as
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reasons for the patient’s thoughts, feelings, or behaviors that are congruent with the
CCRT, tend to be followed by the patient’s presentation of increased understanding.


If we listen to current opinions about psychodynamic theory, even from some psy-
choanalysts, it would appear that psychoanalysis has no scientific support or even
that it is not in need of such validation. However, this is not a true representation
of psychodynamic theory (see Holt 2000). Although many therapists are loath to
appreciate the scientific basis to dynamic theory, Freud’s reliance on observational
study of critical concepts was, and is, a scientifically sound avenue for theory
development. Unfortunately, criticism of these early methods, and possibly of the
scientific basis for the therapy, has limited more rigorous investigations of analytic
concepts and fostered a disinterest in and ignorance of current research findings.
We would like to dispel this perception and offer empirical evidence in support of
these concepts.

Evidence for the Unconscious

Our understanding of the unconscious was advanced considerably by the empirical
work of Shevrin et al. (1996). Prior to undertaking their study of the unconscious,
Shevrin and colleagues interviewed 11 patients who suffered from phobias or
pathological grief reactions. These diagnoses were selected because the authors
believed they were clearly in the neurotic range and represented discrete distress.
Each subject completed a battery of tests and four interviews from which the
following were obtained: diagnosis, description of the conscious symptoms of
distress, formulation of the unconscious conflict, and 32 key words used by the
subject that best described the conscious symptoms, unconscious conflict, and
words generally considered to be pleasant or unpleasant. Judgments concerning
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the unconscious conflict or word selections were discussed among participating

clinicians until a consensus was reached.
The central research question was to determine whether evidence for the un-
conscious could be demonstrated by showing differing patterns of brain activity in
response to conscious and unconscious stimuli. Subjects were shown the selected
words first subliminally (1 msec), then supraliminally (30–40 msec), six times, dur-
ing which brain activity and time to response were recorded. Resulting analyses
showed that subjects correctly classified unconscious words more often when pre-
sented subliminally. In contrast, conscious words were classified correctly more
often when presented supraliminally. Ordinary unpleasant words were equally
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likely to be correctly classified regardless of exposure duration. Furthermore, a

significant correlation was found between a measure of repression and response
to unconscious words. That is, subjects relying on repression more often correctly
classified unconscious symptomatic or unconscious conflict words. Taken together,
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these findings suggest that dynamic unconscious processes exist and are confirmed
by brain activity. Moreover, the subjective judgment of the clinician regarding these
conflicts is supported by objective measures of unconscious processes.

Evidence for Drives

Because drives are internal motivational forces, the construct is one that is difficult
to operationalize for investigation. In fact, Compton (1983) suggested that a more
useful conception of drives needed to be developed. Despite these concerns, the
theoretical model of Schwartz (1987) offers one of the best explanations in support
of drives or internal motivational forces. Schwartz not only viewed affect as the
prime factor of human motivation but saw it in neurophysiological terms. He
believed that the development of object relations and patterns of interpersonal
defenses resulted from the presence of affect evident in motor behavior (i.e., facial
features) arising from internal motivation (see also Kernberg 2001).
Research on affect and neurological functioning has provided evidence sup-
porting the notion of internal drives. For instance, emotions have been linked to
subcortical areas of the brain, and damage to the frontal lobe has repeatedly been
shown to cause disturbances in affect and emotions (see Fuster 1989). Whereas
some individuals will show apathy, a lack of initiative, or blunting of affect (i.e.,
no internal motivation) when there is frontal lobe damage, others evidence disinhi-
bition, elevation of mood, and hyperactivity (i.e., excess motivation). Research on
self-stimulation in animals has implicated an area of the brain associated with the
dopaminergic system as a factor in determining drives and motivation (see review
by Gaillard 1992). Thus, neurological factors or changes in brain chemistry can
result in altered motivational forces and underlying drives.

Evidence for Parent-Infant and Parent-Child Relationships

According to object relations theory, conflicts with others and with self are de-
fined by early patterns of relating to others. Therefore, studies on attachment and
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neurological development as well as on the CCRT method offer solid empirical

evidence for the importance of parent-infant and parent-child relationships (i.e.,
object relations). Attachment theory, as described by Bowlby (1988), argues that
individuals form an internal working model of relationships based on their emo-
tional connections with significant others. Furthermore, he states that attachment is
a necessary mechanism for survival (see also Ainsworth 1989). The more a person
has good attachment experiences in childhood (i.e., secure, close, dependable), the
more secure the person is in adulthood (see Feeney 1999). Of course, the issue
of poor attachment experiences is the focus of most research. For example, mal-
treated infants are much more likely to show an insecure, disorganized attachment
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pattern than are infants who not maltreated (Cicchetti & Barnett 1991). In research
with rhesus monkeys, Suomi (1999) found significant differences in attachment
between monkeys raised by peers and those raised by their mothers. Still others
have found that the quality of attachment at one year of age is related to a child’s
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feelings of security at six years of age (Main et al. 1985).

In addition to studies on attachment, research has shown a connection between
emotional experience and brain development that is distinct from genetic influ-
ences (see Bokhorst et al. 2003). For instance, Schore (2002) found a link between
growth of the right hemisphere and attachment experiences. Hofer (1996) has
demonstrated a biological link between mother and child such that in the absence
of mother, the infant will show altered physiological functioning (changes in body
temperature, heart rate, etc.). Because the infant comes to associate these physio-
logical changes with presence or absence of mother, an internal model for relating
to people is laid down in the brain. Based on early patterns of interactions, non-
verbal signals in adult relationships can trigger biobehavioral responses that are
accompanied by distress.
The CCRT method, because it identifies the central relationship pattern evident
in patient’s narratives about their lives, is another way in which early patterns of
relating to people can be shown to affect later patterns. For instance, the central
relationship pattern derived from therapeutic sessions has been found to be con-
sistent across different narratives (Barber et al. 1995) and throughout childhood.
Similar CCRTs were found in a group of children from ages 3 to 5 (Luborsky et al.
1996) and in an adolescent sample from ages 14 to 18 (Waldinger et al. 2002).
Although additional research is needed to document consistency of the CCRT
from early childhood into adulthood, these initial CCRT findings coupled with
those on attachment patterns and neurological development suggest the stability
of interpersonal patterns across development.

Evidence for the Oedipus Complex

The Oedipus complex embodies the libidinal wishes of a child toward one parent
and against the other. However, it is currently regarded as representing any compe-
tition between two individuals for the affection of a third. Although data directly
assessing such competition for affection are absent, a number of theoretical articles
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and single case studies continue to address this issue (see van Dam 1991). Given
that the Oedipus complex is considered an unconscious phenomenon, it might be
inferred from research on dreams using the CCRT method. Recall that the central
relationship pattern is determined from the wishes and interpersonal behaviors (de-
fined in affective terms) evident in patient narratives about relationships. Research
on the CCRT has shown that the wishes and interpersonal responses obtained in
therapy are reliably similar to the wishes and affective responses obtained from
dreams (Popp et al. 1996). Despite the connection of content between dreams and
therapy, specific evidence for recurring relationship patterns involving an Oedipal
triangulation have not been forthcoming.
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Evidence for Defenses

Considerable research is available to demonstrate the accurate and reliable identifi-
by BOSTON COLLEGE on 02/03/10. For personal use only.

cation of one of the best-supported psychoanalytic concepts, defense mechanisms

(Perry 2001, Perry & Cooper 1989, Vaillant 1992). Moreover, defense structures
have been shown to differentiate various Axis I and II disorders as well as severe
psychopathology (Drapeau et al. 2003), and defense structures appear to be mod-
erately stable over time (Perry 2001, Perry & Cooper 1992). In addition, changes
in defense utilization have been identified over a four-session brief treatment
(Drapeau et al. 2003).
Research on interpersonal patterns of relating has also examined the existence
of defenses. Because the CCRT method examines general patterns of relating, it
has been postulated that the defensive structure of an individual would relate to
the CCRT. One of the first studies to examine this connection found significant as-
sociations between defenses and the CCRT (Luborsky et al. 1990). De Roten et al.
(2004) also found correlations between high- and low-level defenses and CCRT
as well as overall defensive functioning. Freni et al. (1998) found that borderline
defenses were higher when there was little desire to help others; neurotic defenses
increased when responses from others were not rejecting, obsessive defenses were
more likely when self-control and self-assurance were minimal, and narcissistic
defenses were more evident when closeness was desired but feelings of being mis-
understood were high. Thus, the concept of defenses and a defensive mechanism
in response to anxiety has solid empirical support.

Evidence for Transference

In transference, the patient sees the therapist and some important past figure in
the patient’s life as similar and thus relates to the therapist as if the therapist
were the significant other. Because the CCRT reflects an underlying schema of
the patient’s experience in relationships, it can be studied as evidence for trans-
ference (i.e., a general pattern for relationships). In a study by Crits-Christoph &
Luborsky (1998), parallels between Freud’s description of transference and the
CCRT were examined. Nearly all of the transference components described by
Freud (1912/1958) corresponded with the components of the CCRT. Moreover,
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the CCRT demonstrated similar patterns of relating with the therapist, others, and
the self.
The CCRT has also found similar patterns of relating to people described prior
to treatment as that found early in therapy (Barber et al. 1998). An examination of
the CCRT in various populations has found that within each person’s narratives a
pattern appears across relationships with different other people. For instance, Fried
et al. (1992) found that in a sample of 35 patients, the CCRT for the relationship
with therapist was significantly similar to the CCRT with other people.
In addition to evidence for the presence of transference in the therapy relation-
ship, research has also found that a better outcome and more positive alliance are
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related to fewer transference interpretations, although a mitigating factor was the

quality of the patient’s patterns of relating (Ogrodniczuk et al. 1999). Moreover,
for transference to be successful there needs to be a supportive environment and
strong therapeutic alliance (Ogrodniczuk & Piper 1999). Thus, there is consider-
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able evidence for the concept of transference, its usefulness in treatment, and the
stability of interpersonal patterns across time, populations, and significant others
in a person’s life.

Evidence for Countertransference

In contrast to transference, countertransference represents the therapist’s responses
to the patient based on significant patterns of relating in the therapist’s life. As
may be expected, research in this area is extremely difficult since treatment is not
focused on therapist interpersonal patterns. In order to examine countertransfer-
ence directly, researchers would need to identify significant interpersonal patterns
evident in the therapist’s experience and then compare these patterns with coun-
tertransference responses made in treatment. Despite this difficulty, a few studies
have examined the management of countertransference and situations in which
it is reduced. For instance, Singer & Luborsky (1977) found that accurate inter-
pretations via CCRT formulations tend to limit the countertransference expressed
in the interpretations. Gelso and colleagues (Gelso et al. 2002) found that a su-
pervisor rating of trainees’ ability to manage countertransference was positively
related to therapist and supervisor ratings of outcome (see also Hayes et al. 1997,
Rosenberger & Hayes 2002). Although the studies are few, the results suggest that
countertransference is a phenomenon that does occur in treatment and that the
ability to manage it is likely to be related to better outcomes.

Evidence for Resistance

In its most basic form, resistance represents the conscious (or unconscious) block-
ing of therapeutic progress; it has broadened in scope to include any mental activity
or behavior that interferes with treatment (see Greenson 1967). In an attempt to
better define the current conceptualization of resistance, several researchers have
conducted quantitative analyses of therapy transcripts. For instance, Schuller et al.
(1991) examined the sessions from 20 patients and found good reliability for four
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subtypes of resistance behavior: abrupt or shifting, flat or halting, oppositional,

and vague or doubting. Mahalik (1994) found evidence for five subtypes of resis-
tance similar to those described theoretically by Greenson (1967). These included
opposition to (a) change, (b) the therapist, (c) insight, (d ) recollection of material,
and (e) expression of painful affect. Thus, there appears to be good evidence for
the concept of resistance.
But does resistance relate to alliance, as some have suggested? Indeed, research
supports the contention that therapeutic resistance is related to the development of
alliance. For example, Callahan (2000) found positive outcomes were related not
only to positive alliance but negatively related to resistance. From a slightly dif-
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ferent perspective, Patton and colleagues (Patton et al. 1997) examined resistance
and alliance across several sessions of treatment. Whereas the working alliance
increased over the course of therapy, resistance decreased. Resistance has also
shown a relation to treatment dropout such that high levels of resistance are as-
by BOSTON COLLEGE on 02/03/10. For personal use only.

sociated with higher rates of dropout (Piper et al. 1999). One explanation for the
connection between resistance, alliance, and outcome is that more directive ap-
proaches increase patient resistance for change, which then negatively affects the
working alliance. For instance, Patterson & Chamberlain (1994) examined studies
of resistance in parent training therapy. They found that parent pathology was as-
sociated with higher levels of resistance, and therapists’ efforts to intervene were
met with immediate resistant behaviors. These findings have been corroborated in
a number of studies reviewed by Beutler et al. (2002). Although there continues to
be debate about the appropriate definition of resistance, research strongly supports
the notion of resistance and its importance in psychotherapy.

Evidence for Interpretation

Interpretation is the therapist’s explanation for events and symptoms in the pa-
tient’s life. As such, research on the Symptom-Context Method for understanding
formation of symptoms represents one of the best avenues for documenting inter-
pretation as a viable concept. First developed in the early 1950s, the Symptom-
Context Method is based on Freud’s observations of patient symptoms within
various contextual settings (Freud 1926/1959). Using patient dialogue from psy-
chotherapy, the Symptom-Context Method seeks to draw connections between the
emergence of a symptom and the context in which it occurs. Luborsky (1996)
offered evidence for the use of interpretation by applying the Symptom-Context
Method to seven psychodynamic therapy cases. Quantifying recurrent symptoms
and preceding events in therapy, he was able to identify eight contexts in which
specific psychological and somatic symptoms followed the pattern.
Despite attention to the concept of interpretation, the vast majority of research
in this area has focused on the connection between use of interpretations and
treatment outcome. Early studies examining the role of interpretation in outcome
showed a positive association (Malan 1976, Marziali & Sullivan 1980), whereas
more recent research has shown an inverse relationship between interpretation and
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outcome (Piper et al. 1991). However, in a review of studies assessing psychother-

apy process and outcome, 63% (24/38) of findings showed that interpretation was
associated with a positive therapy outcome (Orlinsky et al. 1994). Although there
was considerable variability in the scientific and methodological rigor of these
studies, and there remains concern about the impact of high-frequency interpre-
tations (see Connolly et al. 1999, Fisher & Greenberg 1996, Piper et al. 1993),
interpretation clearly has an important place in psychodynamic treatment.

Evidence for the Accuracy of Interpretation

According to Kubie (1952), the accuracy of an interpretation is evident when the
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patient’s associations or connections to the interpretation confirm the content of

the interpretation and future behavior can be predicted (i.e., the cause-effect con-
nection). However, it is not always easy to assess this effect since research has
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shown that individuals will accept bogus interpretations as accurate descriptions

of themselves (Fisher & Greenberg 1985). Despite these caveats, several quite
useful measures exist for assessing the accuracy of interpretations (e.g., Crits-
Christoph et al. 1993b, Ogrodniczuk & Piper 1999). Defining accuracy as the
level of agreement between the CCRT and observer ratings of therapist inter-
pretations, Crits-Christoph et al. (1988) found comparability between the CCRT
and in-session interpretations. Furthermore, it was shown that the accuracy of in-
terpretations predicted outcome (see also Crits-Christoph et al. 1993a,b). In an
examination of the interplay between interpretations, outcome, and personality
traits, Blatt (1998) found that higher accuracy in interpretations was associated
with a better treatment outcome except in highly perfectionist patients.


Evidence of the continuing impact of psychoanalytic concepts throughout psy-
chology can be seen in a number of areas. For instance, several researchers have
argued in favor of a sixth diagnostic axis listing defense mechanisms (Perry et al.
1998, Skodol & Perry 1993). In fact, the feasibility, reliability, and discriminability
of such an axis have been found for seven defenses and three levels of defensive
structure (Perry et al. 1998). Cognitive models have now begun to address the phe-
nomenon of resistance to change, the underlying motivations for resistance, and
the methods for reducing its effects without negatively affecting the therapeutic
alliance (Leahy 2001, Puhl 2003).
Even more striking is the link between neurophysiology and psychoanalytic
concepts. Human psychological functioning can be linked to neurological struc-
ture and functioning by means of information processing (perception, attention,
recognition), prefrontal cortex activity (inhibition, motivation, conscience), the
temporal lobe (memory), amygdala and hippocampus (emotion), and neurochem-
istry (emotional experiences, attachment, object relations) (Hadley 1983, Kandel
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1999, Semenza 2001). And research has begun to demonstrate neurophysiological

correlates of several psychoanalytic concepts, including the defenses, transference,
resistance, object relations, and drives (see review by Kandel 1999).
Taken together, these data offer strong empirical evidence for several key psy-
choanalytic concepts. Though steeped in a tradition of observation as the key
mechanism for scientific validation, current efforts have increased our understand-
ing of personality and encouraged the use of more rigorous experimental designs
to test quantitatively the usefulness and accuracy of these qualitatively generated
concepts. Moreover, these efforts have begun to bring about empirically validated
assessments of treatment that are producing evidence for the general effectiveness
Annu. Rev. Clin. Psychol. 2006.2:1-19. Downloaded from

of dynamic treatments (Fisher & Greenberg 1996).

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son, CT: Int. Univ. Press. 562 pp. formed psychological science. Psychol. Bull.
Waldinger RJ, Diguer L, Guastella F, Lefeb- 124:333–71
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February 24, 2006 16:34 Annual Reviews AR271-FM

Annual Review of Clinical Psychology

Volume 2, 2006

CONCEPTS, Lester Luborsky and Marna S. Barrett 1
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SCHIZOPHRENIA RESEARCH, Gregory G. Brown and Lisa T. Eyler 51

AN ASSESSMENT TOOL, Lorna Smith Benjamin, Jeffrey Conrad
Rothweiler, and Kenneth L. Critchfield 83
Robert F. Krueger and Kristian E. Markon 111
BIOMEDICAL FIELD, Mary C. Blehar 135
TREATMENT OUTCOME, Terence M. Keane, Amy D. Marshall,
and Casey T. Taft 161
David J. Miklowitz and Sheri L. Johnson 199
Anthony Spirito and Christianne Esposito-Smythers 237
DISORDERS, Tyrone D. Cannon and Matthew C. Keller 267
PERSPECTIVES, Marian Sigman, Sarah J. Spence, and A. Ting Wang 327
OBESITY, Anthony N. Fabricatore and Thomas A. Wadden 357
Marilyn S. Albert and Deborah Blacker 379

February 24, 2006 16:34 Annual Reviews AR271-FM



Reichenberg, and Christopher R. Bowie 389
ABUSE, Maxine Stitzer and Nancy Petry 411
Justin MacKenzie 435
RECOVERED MEMORIES, Elizabeth F. Loftus and Deborah Davis 469
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Subject Index 499

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