To be a good therapist, one must have an emotional appreciation of individual persons as complex wholes—not just their weaknesses but their strengths, not just their pathology but their health, not just their misperceptions but their surprising, unaccountable sanity under the worst of conditions. (Preface)

Introduction

Analogous omissions happen all the time with psychoanalytic data. Information is ignored because it is not “neat,” objectively describable, full of discrete, observable behavioral units (cf. Messer, 1994). Therefore, it is no surprise that we have a lot of empirical data on cognitive-behavioral therapies and far less on psychoanalytic ones. (3)

It is very difficult to do good research on conventional, long-term therapy, and few of us who feel the calling to be therapists also have the temperament of the dispassionate scientist (see Schneider, 1998, on the romantic tradition in psychology). We are not, however, indifferent to science. (3)

Relatively untrained people with good instincts and a good heart can be effective therapists. Highly trained individuals who lack ordinary compassion can be disastrous ones. The art of the clinician is difficult to teach and especially difficult to convey to skeptics. Some people who disparage psychotherapy have no temperamental affinity for the sensibilities it involves. (6)

I suspect that a passionate, perhaps even evangelical, sensibility is not unrelated to a therapeutic calling, and possibly to therapeutic success. This sensibility does not always correlate with evenhandedness. (8)

Ch. 1: The Relationship Between Case Formulation and Psychotherapy

It seems to me self-evident that unless one understands someone’s unique, personal subjectivity, one cannot infer the best treatment approach for that individual. What helps one person can damage another, even if the presenting problems of the two people seem comparable, and even if a particular strategy has reduced target symptoms in a statistically significant number of people in a well-defined pool of subjects with similar problems. (9)

In a reasonable world, however, technique would be derived from an understanding of personality and psychopathology, not from the technical preferences of the practitioner (cf. Hammer, 1990). (10)

In creating a psychodynamic case formulation, the interviewer’s aim is usually to increase the probability that psychotherapy for a particular person will be helpful. There are, of course, other reasons to formulate a case, including a clinician’s effort to give appropriate advice to staff dealing with a patient, or figuring out what to say to a patient’s family, or making a good referral. But they are all related to working out the best intervention for the person whose psychology is being conceptualized. By understanding the idiosyncratic way an individual organizes knowledge, emotion, sensation, and behavior, a therapist has more choice about how to influence him or her in all these areas and to contribute to the improvements in life for which he or she has sought professional help. When we construct a formulation that seems to make sense of the diverse pieces of information we get in an intake interview, we do so with a view to exerting therapeutic influence on the patient’s subjective world. (11)

This vision of the objectives of therapy includes the disappearance or mitigation of symptoms of psychopathology, the development of insight, an increase in one’s sense of agency, the securing or solidifying of a sense of identity, an increase in realistically based self-esteem, an improvement in the ability to recognize and handle feelings, the enhancement of ego strength and self-cohesion, an expansion of the capacity to love, to work, and to depend appropriately on others, and an increase in the one’s experience of pleasure and serenity. (12)

Analytically oriented therapy tends to go on longer than therapy conducted in accordance with other theoretical orientations, because both client and therapist are pursuing goals of general mental health that go beyond the swift removal of a particular disturbance. (13)

People come to analytic therapy not just to get /control/ over a troublesome tendency but to outgrow or master the strivings that are causing such a battle over control. (13)

The analytic emphasis on understanding is partly attributable to the fact that the two participants in the work need something interesting to talk about while the nonspecific relational factors are doing their quiet healing. It may also reflect the fact that the kinds of people who seek to practice or undergo psychoanalytic therapies appreciate insight as a value in itself. Knowledge is thus pursued for its own sake in dynamic therapy, as well as for the sake of specific treatment goals. (15)

In the preceding paragraphs, I mentioned the ancient conviction that knowing the truth sets people free. An internal sense of freedom is probably one of the most precious aspects of anyone’s personal psychology. Most clients come to therapists because something is compromising their subjective sense of agency. They are being controlled by their depression or their anxiety or their dissociation or their obsession or compulsion or phobia or paranoia and have lost the sense of being master of their own ship. Sometimes they come because they have never felt in charge of their life, and they are beginning to imagine that such a state of mind would be possible if they were to get some help. (15)

Part of a good dynamic formulation thus involves an understanding of the ways in which a particular person’s feeling of agency has been compromised. (16)

In these times, experiencing one’s identity solely by reference to connections outside the self is a dangerous practice, as people can attest whose jobs have been eliminated by the company that had defined them, or who have been recently divorced by the spouse who had given life meaning. In the absence of reasonably supportive contexts, people often need a therapist’s help in their efforts to experience and verbalize who they are, what they believe, how they feel, and what they want. The effort to develop a strong and cohesive sense of self may be a person’s primary preoccupation in therapy or it may exist more silently alongside other goals and concerns. (17)

Yet those of us who make our living trying to persuade self-hating people that there is nothing inherently wrong with them do wish we could do it faster. At minimum, we would like to ensure that we avoid doing any further damage to anyone whose self-esteem is already hanging by a thread. (18)

One means by which a client’s self-esteem increases in psychotherapy is the therapist’s willingness to be seen as flawed. Both because it is the truth and because it models adequate self-regard in the context of imperfection, the psychoanalytic therapist conveys a conviction of having the capacity to help the patient despite acknowledged mistakes and limitations. (18)

As the therapist accepts, often without even the need to comment, the client’s most anxious and shame-drenched disclosures, the client starts reframing these areas of personal shortcoming as ordinary rather than terrible. (18)

practitioners want their patients to know what they are feeling, to understand why they are feeling that way, and to have the internal freedom to handle their emotions in ways that benefit themselves and others. (19)

Similarly, if one is angry, the important issue from a psychoanalytic point of view is not to vent the anger in the moment but to notice the feeling and find some way to use its energy in the service of problem solving. (20)

Therapists have always distinguished between intellectual and emotional insight and have known from experience that to transform into verbal expression something that first manifested as an inchoate body sensation or a feeling of impending dread or a behavioral compulsion is the route to understanding and mastery of the problem. Now we have evidence that this process involves, among other things, the differences between emotional memory, stored in the amygdala, and declarative memory, stored in the prefrontal cortex. (20)

One of the frequent background reasons for a person’s seeking psychotherapy is his or her wish to change a tendency to “fall apart” when life gets difficult. The analytic term for the elusive capacity to cope despite adversity is ego strength. (20)

The superego (the “above-myself”) was his term for the moral overseer inside most of us—the conscience, the self-evaluator. It was understood to be partly conscious, as when one congratulates oneself for resisting temptation, and partly unconscious, as when one suffers in some way because of guilt that is out of awareness. Freud’s use of the term ego (literally “I”) was roughly synonymous with what most people mean by “self.” But he also wrote as if the ego comprised a set of functions that operate partly consciously, as in ordinary problem solving, and partly unconsciously, as in people’s use of automatic defense mechanisms. (21)

This hypothetical construct, the ego, theoretically mediates between the demands of the id, the superego, and reality. In analytic parlance, ascribing to someone a strong ego means that he or she does not deny or distort harsh realities but finds ways of prevailing that take them into account. Bellak and Small (1965) described three overlapping aspects of ego strength: adaptation to reality, reality testing, and sense of reality. A person with good ego strength is by definition neither paralyzed by excessive or unreasonable guilt nor vulnerable to acting on passing impulses. (21)

A major nonspecific outcome of good psychotherapy is increased ego strength and self-cohesion. One wants a person to be able to confront difficult challenges without the internal experience of fragmentation or annihilation. One also hopes that after therapy, a person can tolerate temporary states of regression and destabilization in the service of growth, that he or she has developed the knack of “going to pieces without falling apart,” in Epstein’s (1998) felicitous phrase. (22)

Intriguingly, in a 1906 letter to Carl Jung (McGuire, 1974), he did comment that psychoanalysis was essentially a “cure through love,” something he apparently regarded as self-evident. (22) #Freud

When psychotherapy goes well, clients find that they feel more accepting not only of their complex internal lives and their “real” selves but also of the complexities and shortcomings of others. They see their friends, relatives, and acquaintances in the contexts of the others’ situations and histories, and they take disappointments less personally. As they forgive themselves for things they now understand and can control, they forgive others for what they do not understand and cannot control. Having confided their darkest secrets to a therapist who has not been shocked, they become less afraid of intimacy, of being deeply known by another person. Having explored their hostile and aggressive side, they become less afraid that it will somehow damage those they care about. Having taken in their therapist’s compassion toward them, they extend it to others. (22)

As Stark explains, the initial phase of therapy involves the client’s slow acceptance of the fact that his or her psychological problems reflect accidents of a complicated fate and endowment, not some personal defect or failure; the second phase involves the painful appreciation that even though this is true, no one but the client can be responsible for solving those problems. (23)

In this paradigm, love is the benign and creative expression of the sexual drive, and work, the positive expression of the aggressive drive. Freud’s successors in the object relations movement have added a critical third “instinct” (if anything so complicated can still be termed as such), namely, dependency (attachment). (23)

Many adults come to therapy feeling like children trapped in destructive relationships and concluding that there is something dangerous about their need for others. Ideally, they figure out during treatment that it is not their basic needs that have been problematic but their handling of them. (24)

Grieving over what is not possible sets the stage for enjoying what is. (25)

Subjectivity is critical for discerning the meaning of a particular behavior. (26)

Researchers in the empirical, positivistic tradition use parsimony as a criterion of explanation, while practitioners are repeatedly impressed with multiple and overlapping causation, or what Waelder (1960) called “overdetermination” (see Wilson, 1995). In other words, in a research project, one tries to isolate variables so that a particular cause-and-effect process can be exposed, uncontaminated by other possible explanations. In understanding the meaning of a problematic behavior, in contrast, one typically finds many contributants, none of which alone would have created the symptom. Anything important enough to have become a major problem to a person is usually overdetermined, not caused by a discrete variable. (26)

For example, an obese patient of mine had to become aware of all of the following contributants to her weight problem before she could successfully diet and keep the pounds off: a probable constitutional inclination toward overweight and some hypoglycemic tendencies; a mother who was overconcerned with her eating habits (beginning with feeding her baby on a rigid schedule and later acting hurt if she failed to eat everything on her plate); a family pattern of using food to distract from anxiety and shame (the mother would bring out a cheesecake whenever someone was upset); an identification with a beloved obese grandmother; a childhood molestation in which she had been victimized but for which she had been blamed (leading her to want to demonstrate graphically in her appearance her lack of seductiveness); a pattern of sadness and loneliness that were assuaged by the ritual of coming home after school and comforting herself with snacks; the development of a defiant self-image as a person whose self-esteem inhered in intelligence rather than in physical vanity; and a witnessing of her father’s wasting death from cancer, an experience that had created in her the unconscious conviction that losing weight was a precursor to and cause of death. (27)

In analytic therapy, it is the unraveling of many different strands of causation that eventually permits patients to get mastery over patterns they seek to change. (27)

Usually, a therapist has a few interconnected ideas about the sources of a particular client’s suffering and finds that while investigating in those areas, all kinds of other realms open up. A dynamic formulation is only the roughest kind of mapping of someone’s individuality, but it is essential to have some kind of map before we invite a person into a terrain where both parties could otherwise get lost. (28)

Summary: Psychodynamic case formulation attempts an understanding of a person that will inform the direction and tone of treatment. It is a more inferential, subjective, and artistic process than diagnosis by matching observable behaviors to lists of symptoms. It assumes a concept of psychotherapy as involving not only symptom relief but also the development of insight, agency, identity, self-esteem, affect management, ego strength and self-cohesion, a capacity to love, work and play, and an overall sense of well-being. I have argued that an interviewer can generate a good tentative formulation of a person’s personality and psychopathology if he or she attends to the following areas: temperament and fixed attributes, maturational themes, defensive patterns, central affects, identifications, relational schemas, self-esteem regulation, and pathogenic beliefs. (28)

Ch. 2: Orientation to Interviewing

The back-and-forth quality of an early session, in which the therapist not only asks questions but also defers to the patient’s agenda for the meeting, militates against a slavish adherence to a format. (29)

The question about how the prospective patient feels talking to me, in addition to its concrete objective of our deciding whether or not to work together, is intended to send the message that I will be interested in how he or she experiences our relationship. (32)

When people come to a therapist, they are usually afraid of being judged, misunderstood, or treated with a subtle professional contempt. They often regard their own symptoms with bewilderment and shame, seeing them as evidence of a vague craziness that makes no sense. One of the first things I try to convey is that their problems are not incomprehensible. (32)

In an initial session, one wants to get some sense of how interpretations will be received, so that one can adjust one’s style of clinical interaction to the particular needs of the patient. (34)

It is also important that the therapist not offer an appointment that he or she will begrudge keeping, such as very early in the morning or very late in the evening. (35)

From my perspective, the operative rule in choices about practice arrangements is that the therapist needs to protect against resenting the patient. It is very hard to have a sincere will to help a person by whom one feels demeaned or exploited. (38)

I feel strongly that the diagnostic process should be as consensual as the therapy process. A professional may have greater expertise and general knowledge of psychology than patients do, but patients’ specific knowledge about themselves is the material on which diagnoses are based. (40)

I also treat the diagnostic issue as a kind of necessary evil, explaining that no one is an exact fit with any of the available categories, and that they are only the roughest approximations of very complex conditions. (40)

Anything significant to the client’s psychology will reappear many times in the transference, whether or not it has been addressed realistically in an early meeting. Often, though, I handle such inquiries by saying something like, “I’ll be glad to answer your question, but first, could you tell me why it’s important to you to know that?” Because these early questions usually constitute tests (Weiss, 1993), it helps to know the client’s thinking behind the request for information. (41)

A lot of what happens in therapy goes on between the actual sessions. (42)

It is important to keep one’s inferences tentative, to be aware of their limitations, to check them out with the patient, and to engage mutually in an ongoing process of revision and elaboration of the ways the two parties understand the person’s psychology. Although the sharing of a dynamic formulation should be mediated by timing and tact, clients have the right to know the therapist’s working assumptions about the nature of their difficulties. In fact, the therapist’s communication of his or her provisional conclusions about the origins and functions of the patient’s problems typically becomes the cornerstone of the working alliance. (43)

“I know it’s strange to be asked to be so direct, and it must feel awkward, especially when some of your responses to me are negative. But in a way, therapy is a microcosm, a chance to study a relationship at close range, and by investigating what happens between you and me, we have an opportunity to scrutinize some emotional things that may happen to you elsewhere, things no one talks about in social situations. You may find yourself feeling toward me the way you feel or have felt toward other people, and our comprehension of that should be very useful in your efforts to understand yourself and change.” (44)

I comment that, very often, people carry around a lot of unconscious apprehensions about what other people’s reactions to them will be, and they learn to scan others’ faces and disconfirm their fears before they even know they have them. The patient’s use of the couch will bring such anxieties into awareness. I also say that I like to work using the couch because, like Freud, I find it tiring to be scanned, and I enjoy sitting back, not making eye contact, and thinking about how the client’s words are stirring up my own associations. (45)

If the therapist is doing his or her job properly, the client will be repeatedly correcting and revising the formulations that the therapist offers. The realization that the therapist is frequently wrong is one of the great therapeutic revelations. Patients will forgive almost anything except arrogance, and they are grateful for models of nondefensiveness. (45)

 

Ch. 3: Assessing What Cannot Be Changed

Nonetheless, for many reasons, we need to acknowledge and appreciate the significance of those aspects of a person’s situation that are not amenable to therapeutic influence. A person’s basic temperament is one thing that therapy does not change, and numerous other fixed aspects of people’s individual psychologies also set limits on, and provide a context for, our therapeutic efforts. (48)

pursuing the unattainable inevitably creates shame about failure. (49)

A generation of developmental scholarship has convincingly demonstrated that human beings are anything but blank slates at birth. From shyness to stimulation seeking, we know that people’s attributes are genetically influenced and cannot be seen as sheerly the result of their upbringing. (50)

Typically, the youngster whose temperamental proclivities are alien and problematic to his or her parents develops the conviction that there is just something “wrong” with the self. (50)

Understanding the plain facts of a situation tends to take the stigma out of it. (51)

For example, many adults coping with previously undiagnosed attention deficit disorder have found both solace and practical help in the aptly titled You Mean I’m Not Lazy, Crazy, or Stupid?! (Kelly & Ramundo, 1995). (51)

I strongly recommend that both medical and nonmedical therapists obtain James Morrison’s (1997) useful guide, When Psychological Problems Mask Medical Disorders, for help in disentangling somatic and psychological issues. (52)

A person’s sense of the integrity of his or her body is a natural basis of self-esteem and emotional health. (56)

The conscious renunciation of futile strivings would set people free to spend more psychological energy on what was realistically achievable and gratifying. (58)

Critical to a client’s initial willingness to work with a particular therapist is his or her feeling that the therapist does not flinch from talking about the ruthless realities the person faces. (60)

In part it is wishful: People hope to evade their own suffering by identification with someone who presumably “has it all together.” While most of us enjoy idealization, it does not come without the price tag of the patient’s contrasting demoralization. Therefore, it is clinically advisable to assess the ways in which any individual client feels inferior or at a disadvantage compared to the therapist and to explore what that means for the person. Of course, this has to be done with tact, and with a sensitivity to the possibility of the client’s feeling exposed and humiliated. In this process, it is important that the therapist be open to admitting that there are areas where his or her life is easier than the client’s and also that there are areas where the client has the edge. (61)

Sometimes, especially among patients with particularly terrible histories, it takes months or years for them to assimilate the fact that therapy is not about airing grievances and getting others to make restitution but about solving their current problems. Therapists who join in their patients’ fantasies about getting perpetrators to compensate for their historical crimes are courting disaster. (62)

It may be true in a legal sense that criminals should be held responsible for their crimes, but in psychotherapy, the important message for patients to get is that the power to change their lives inheres within them, unrelated to whether their childhood mistreaters admit to responsibility for their traumatization. (62)

It is critical even in the briefest therapeutic intervention for a clinician to “get” what someone wants to avoid facing about the consequences of his or her personal background. The patient will profit in direct proportion to the degree to which the therapist can facilitate mourning, either immediately or eventually, when the client reflects on the therapeutic interaction. It is usually something of a revelation to patients, especially younger ones, that even if their parents were able at this point to change, they themselves would still have to deal with the outcomes of who their parents were when they were younger. In other words, the important “parent” to confront is the internalized person, not the living relative. (63)

Among those aspects of a person’s psychology that a therapist must respect as “givens” are his or her temperament; congenital conditions; irreversible effects of physical trauma, illness, or addiction; unchangeable physical realities; unchangeable life circumstances; and personal history. Even though those features of someone’s situation that are fixed and unchangeable are by definition not “dynamic,” they have significant effects on an individual’s psychodynamics and responsiveness to psychotherapy. (63)

Ch. 4: Assessing Developmental Issues

We may ask for the person’s earliest memory and for family stories about him or her. (Alfred Adler, 1931, observed that the first memory contained the major themes of an individual’s personality. I know of many first memories that seem to confirm this, though I am not aware of research in this area. Many therapists have followed Adler on this point because their experience also attests to the richness of this line of inquiry.) (65)

Consonant with the Piagetian concepts of assimilation and accommodation (Piaget, 1937; Wolff, 1970), analytic developmental theory assumes that the maturational stage of the individual both determines that person’s experience of a given stressor and constructs the template for his or her interpreting the meaning and implications of future stressors. In adulthood, depending on what maturational issues have been more and less well worked out, specific stresses affect people in very different ways because they have radically different unconscious meanings. (66)

Under stress, people tend to revert to the methods of coping that characterized an earlier developmental challenge that felt similar to their current situation: They “regress” to a point of “fixation.” There is a more or less tacit assumption in psychoanalytic theory that the earlier a person has been faced with neglect or abuse or other overwhelming experience, the more vulnerable he or she is, and the more catastrophic and eventually cumulative are the effects of the traumatic circumstances. (67)

Some children with constitutional advantages and empathic responsiveness can compensate remarkably for early deprivation and trauma. (68)

Thus, the fact that a man’s mother was in a severe postpartum depression for most of the first year of his life should appropriately prompt an interviewer to ask him about first-year issues such as trust, capacity to soothe himself, capacity to regulate affect, and possible conflicts about closeness. But the information that a man has a problem with trust, self-soothing, affect regulation, and closeness should not automatically evoke the conclusion that his early mothering was faulty. Such leaps foreclose real understanding, substituting a derived model for important information. (69)

Every interviewer needs to try to understand with every patient how much of his or her suffering results from some immediate stimulus to unconscious, conflicted material, and how much of it reflects a kind of arrested psychological development. We also must keep in mind that maturation can be markedly uneven; that a person can have extraordinarily well-developed capabilities yet suffer from a crippling deficit in the area of, say, sexuality or the ability to be alone or the capacity to mourn, or comfort with competitiveness. “Fixation” is not a simple, unidimensional thing. (72)

Guilt and projected guilt, as in bedtime anxieties about hidden attackers, are typical. Fears of retribution for hostile wishes are eventually resolved by identification with primary caregivers, especially the parent with whom the child feels most competitive (“I can be like Daddy and have someone like Mommy when I grow up”). (74)

In assessing the psychology of any individual client, one must appreciate not only the nature of the person’s current developmental challenges but also the nature of the earlier tasks to which they hearken back. (76)

A central diagnostic task of a clinical interview is assessing the developmental level at which a person is characterologically organized. Are the main issues with which the person repeatedly struggles those of the earliest phase of life, the one Freud called oral and Mahler called symbiotic? If so, the interviewer will hear themes such as the Eriksonian conflict between basic trust and distrust, the Sullivanian confusion of “me versus not me,” R. D. Laing’s (1965) “ontological insecurity,” and other derivatives of the infant’s struggle to define a sense of existence and personhood. The client will seem confused about what thoughts and feelings are inside him or her versus what is coming from outside. Reality testing will be problematic. Affect regulation may be difficult. One will have a hard time getting a picture of the main people in the client’s world, as they will be described in vague or global ways that make them seem more like shadowy concepts than living beings. The patient may express uncertainty about his or her basic nature, including whether he or she is male or female, straight or gay, omnipotent or impotent, good or evil. The interviewer tends to feel overwhelmed in a vague and disturbing way. (76)

Or is the person preoccupied with the themes and conflicts of the phase Freud called anal and Mahler called separation-individuation? If so, the clinician will feel a sense of dyadic struggle, of Erikson’s (1950) “autonomy versus shame and doubt,” of Sullivan’s (1947) “good me versus bad me,” of Mahler’s (1971) “coming closer and darting away,” of Masterson’s (1976) engulfment versus abandonment depression, of Kernberg’s (1975) alternating ego states. The existence of the self will not seem fragile, but the struggle between infantile helplessness and aggressive empowerment will be intense, and will induce in the interviewer very strong countertransference reactions (hostility, demoralization, and rescue fantasies are common). The images that the interviewer will derive of the people in the client’s life will be stark and unnuanced; they will tend to appear as all-good and all-bad actors on the person’s subjective stage. There may be evidence that the major players change frequently but always inhabit these all-good and all-bad roles. Reality testing will be adequate, but identity will seem tenuous, and primitive defenses such as denial, splitting, and projective identification will predominate in the person’s efforts to solve problems. (77)

Or does the person see the world through the lens of the oedipal phase? If so, one notes the client’s susceptibility to conflicts about sexuality, aggression, and/or dependency in the context of an overall capacity for object constancy, an appreciation of the complexity of self and others, a tolerance for ambivalence, an ability to take an observing position toward his or her affective life, and a capacity to feel remorse and a sense of responsibility. Reality testing will be secure. The person’s relationships will others will be marked by devotion, consideration, and the appreciation of the complexity of others. When speaking of the main people in his or her life, the patient will bring them alive as three-dimensional human beings in the diagnostician’s mind. The oedipally organized individual comes across as a separate person with a strong sense of I-ness, and his or her suffering seems well demarcated into a particular area. The interviewer’s countertransference tends to be benign. (77)

Annihilation anxiety survives in the psychology of most adults in residual fears of intimacy. One can easily find evidence of people’s anxiety that closeness with another person will threaten their independent existence. (79)

The second kind, separation anxiety, affects all of us to some degree, as separations inevitably stimulate unconscious memory traces of frightening infantile disconnections, but it is an especially intense and central part of the experience of people organized at a borderline level of development. (79)

The third kind of anxiety, oedipal or superego anxiety, involves fears of punishment for unacceptable sexual, aggressive, or dependent strivings. There is no threat to the perception of reality and identity of the self, but one’s feeling of personal good-enough-ness may be seriously compromised. (79)

What kind of anxiety a person is suffering cannot be inferred automatically from his or her manifest situation. (80)

Depending on the internal meanings of various stresses, it is not uncommon for someone to withstand gracefully what seem to observers to be major traumas, such as the deaths of several close relatives, and then to fall apart psychologically under the stress of what appears to other people to be a minor nuisance, such as an angry outburst from a competitive colleague. (81)

A very frequent precipitant to seeking mental health services is an unconscious anniversary reaction—for example, the tenth year after a parent’s death (the unconscious minds of people in our culture seem to go by the decimal system) or the client’s reaching the age the parent had attained when he or she died. (81)

Another common time for adults to seek therapy is the year that one of their children reaches the age at which they themselves had a traumatic experience. (82)

Some stressors have a natural tendency to activate the issues of a particular developmental phase. The experience of being arbitrarily oppressed or mentally played with and confused (“gaslighted” as per Calef & Weinshel, 1981) is likely to bring up the earliest questions about one’s existence and sense of reality—that is, issues from the psychotic–symbiotic phase. The experience of losing a beloved person or being rejected by someone important will predictably stimulate the issues of the separation–individuation phase. The experience of sexual temptation or triangular competitive relationships will tend to bring up oedipal issues. It behooves us to understand this process so that we neither underpathologize nor overpathologize a patient on the basis of the developmental themes that have been catalyzed by a given stress. (82)

In the late 1970s, on the basis of a series of ingenious experiments inspired by Bowlby’s (1969, 1973, 1980) work on attachment and separation, Mary Ainsworth and her colleagues (Ainsworth, Blehar, Waters, & Wall, 1978) delineated three distinct individual styles of attachment: secure (by far the largest category), avoidant, and ambivalent–resistant. All were seen as in the normal range of individual difference, except at the extreme ends of the avoidant and ambivalent continua.
Later research (Main & Solomon, 1986) established the existence of a fourth group, with a maladaptive style the researchers called disorganized–disoriented attachment. About eighty percent of maltreated infants (Osofsky, 1995) and forty to fifty percent of children with depressed or alcoholic mothers (Hertsgaard, 1995) fit this pattern. (82)

 

Ch. 5: Assessing Defense

People come to therapists with a potent combination of hope and shame. They want to reveal the psychological issues they are struggling with and, at the same time, they want to minimize them so that the therapist will not be as negative toward them as they themselves tend to be. They are simultaneously striving to be nondefensive and being propelled by their anxieties into being more defensive than usual. (85)

Some of the specific questions that might highlight defensive functioning, however, include the following: What do you tend to do when you’re anxious? How do you comfort yourself when you’re upset? Are there any favorite family stories about you that claim to capture your basic personality? What kinds of observations or criticisms or complaints do other people tend to make about you? How do you find yourself reacting to me? (85)

I have noted (McWilliams, 1994, p. 98) that the defenses we tend to consider more archaic involve the boundary between the self and the outer world, whereas those we consider higher-order processes deal with internal boundaries, such as those between the ego or superego and the id, or between the observing and experiencing parts of the ego. (87)

In order to help a person, we need to appreciate the particular way in which he or she is using thoughts, feelings, and actions to relieve upsetting internal states. (87)

Just as a person’s reliance on omnipotent control in the interview situation alerts a therapist to a possible psychopathic streak in the interviewee, habitual reliance on another defense or constellation of defenses has been associated with (or, in my way of thinking, is definitional of) certain characterological tendencies. Each tendency has a distinguished history of clinical and theoretical investigation. Reliance on splitting, projective identification, and other “primitive” defenses is associated with borderline-level personality organization (Kernberg, 1975); idealization and devaluation suggest narcissism (Kohut, 1971; Kernberg, 1975; Bach, 1985); withdrawal into fantasy indicates schizoid tendencies (Guntrip, 1969); reaction formation and projective defenses constitute a paranoid process (Meissner, 1978; Karon, 1989); regression, conversion, and somatization indicate a psychosomatic vulnerability and associated alexithymia, the inability to put words to feelings (Sifneos, 1973; McDougall, 1989); introjection and turning against the self are implicated in depressive and masochistic psychologies (Menaker, 1953; Berliner, 1958; Laughlin, 1967); denial is the hallmark of mania (Akhtar, 1992); displacement and symbolization suggest phobic attitudes (MacKinnon & Michels, 1971; Nemiah, 1973); isolation of affect, rationalization, moralization, compartmentalization, and intellectualization are definitional of obsessional tendencies (Shapiro, 1965; Salzman, 1980); undoing is an essential defense in compulsivity (Freud, 1926); repression and sexualization imply hysterical issues (Shapiro, 1965; Horowitz, 1991); dissociative reactions characterize posttraumatic states of mind (Putnam, 1989; Kluft, 1991; Davies & Frawley, 1993). (90)

A man who is characterologically paranoid will use projection in almost every circumstance. (90)

Ch. 6: Assessing Affects

Ch. 8: Assessing Relational Patterns