Experimentation and Innovation in Psychotherapy

Harold Greenwald

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9780202363684
• eBook ISBN: 9781351521048
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

After a long period of relatively slow change and development, the practice of psychotherapy entered a phase of vigorous experimentation in the 1960s. Greatly increased public recognition of the role of psychological approaches has brought about a dramatic upsurge of demand for mental health services on the part of broader segments of the population than ever before. Many kinds of people now seek aid, and display a greater variety of symptoms and life problems than are recorded in the earlier case-history literature.The professional response to this new demand markedly increased the professions creativity and imagination, as this volume outlines. While it is difficult to devise a precise category to cover all forms of such experimentation in psychotherapy, one major characteristic has been an increase in activity. The non-directive or client-centered therapist frequently speaks almost as much as his client, yet he is not considered active, since he attempts to limit his communication to the reflection of the clients feelings.More frequently an attempt is made to distinguish between insight-oriented therapies and active therapies in terms of differing goals.Active psychotherapy is seen as being concerned with techniques that focus directly on the removal of symptoms, such as anxiety or maladaptive overt behavior. The need to establish a clear dichotomy between insight and behavior modification has often been challenged: many of the therapists who stress insight do so in the belief that increased insight, no matter how arrived at, will modify overt behavioral anxiety. Experimentation in Psychotherapy exposes the reader to a wide variety of therapies. Although changes in treatment methods, and a more short-term orientation, have limited some future developments in the field, this volume admirably describes the techniques traditional therapists can effectively employ, given the patient's strengths and limitations.

SIGMUND FREUD

Lines of Advance in Psychoanalytic Therapy

The following address was read by Freud before the Fifth International Psychoanalytical Congress, held at Budapest on September 28 and 29, 1918, shortly before the end of the First World War. It was written during the previous summer, while he was staying with Anton von Freund at his house in Steinbruch, a suburb of Budapest. The paper, in which the main stress is on the “active” methods chiefly associated later with the name of Ferenczi, was the last of Freud’s purely technical works before the two which he published nearly twenty years later, toward the end of his life.

Since much of the opposition to active psychotherapy comes from orthodox Freudians, it is instructive to realize that Freud himself foresaw and even encouraged many of the future developments in activity. It is unfortunate to realize how many analysts prefer to be Freudians rather than Freud-like.

GENTLEMEN: AS YOU KNOW, we have never prided ourselves on the completeness and finality of our knowledge and capacity. We are just as ready now as we were earlier to admit the imperfections of our understanding, to learn new things and to alter our methods in any way that can improve them.

Now that we are met together once more after the long and difficult years of separation that we have lived through, I feel drawn to review the position of our therapeutic procedure—to which, indeed, we owe our place in human society—and to take a survey of the new directions in which it may develop.

We have formulated our task as physicians thus: to bring to the patient’s knowledge the unconscious, repressed impulses existing in him, and, for that purpose, to uncover the resistances that oppose this extension of his knowledge about himself. Does the uncovering of these resistances guarantee that they will also be overcome? Certainly not always; but our hope is to achieve this by exploiting the patient’s transference to the person of the physician, so as to induce him to adopt our conviction of the inexpediency of the repressive process established in childhood and of the impossibility of conducting life on the pleasure principle. I have set out elsewhere¹ the dynamic conditions prevailing in the fresh conflict through which we lead the patient and which we substitute in him for his previous conflict—that of his illness. I have nothing at the moment to alter in that account.

The work by which we bring the repressed mental material into the patient’s consciousness has been called by us psychoanalysis. Why “analysis”—which means breaking up or separating out, and suggests an analogy with the work carried out by chemists on substances which they find in nature and bring into their laboratories? Because in an important respect there really is an analogy between the two. The patient’s symptoms and pathological manifestations, like all his mental activities, are of a highly composite kind; the elements of this compound are at bottom motives, instinctual impulses. But the patient knows nothing of these elementary motives, or not nearly enough. We teach him to understand the way in which these highly complicated mental formations are compounded; we trace the symptoms back to the instinctual impulses which motivate them; we point out to the patient these instinctual motives, which are present in his symptoms and of which he has hitherto been unaware—just as a chemist isolates the fundamental substance, the chemical “element,” out of the salt in which it had been combined with other elements and in which it was unrecognizable. In the same way, as regards those of the patient’s mental manifestations that were not considered pathological, we show him that he was only to a certain extent conscious of their motivation—that other instinctual impulses of which he had remained in ignorance had cooperated in producing them.

Again, we have thrown light on the sexual impulsions in man by separating them into their component elements; and when we interpret a dream we proceed by ignoring the dream as a whole and starting associations from its single elements.

This well-founded comparison of medical psychoanalytic activity with a chemical procedure might suggest a new direction for our therapy. We have analyzed the patient—that is, separated his mental processes into their elementary constituents and demonstrated these instinctual elements in him singly and in isolation; what could be more natural than to expect that we should also help him to make a new and a better combination of them? You know that this demand has actually been put forward. We have been told that after an analysis of a sick mind a synthesis of it must follow. And, close upon this, concern has been expressed that the patient might be given too much analysis and too little synthesis; and there has then followed a move to put all the weight on this synthesis as the main factor in the psychotherapeutic effect, to see in it a kind of restoration of something that had been destroyed—destroyed, as it were, by vivisection.

But I cannot think, gentlemen, that any new task is set us by this psychosynthesis. If I allowed myself to be frank and uncivil I should say it was nothing but an empty phrase. I will limit myself to remarking that it is merely pushing a comparison so far that it ceases to have any meaning, or, if you prefer, that it is an unjustifiable exploitation of a name. A name, however, is only a label applied to distinguish a thing from other similar things—not a syllabus, a description of its content, or a definition. And the two objects compared need only coincide at a single point and may be entirely different from each other in everything else. What is psychical is something so unique and peculiar to itself that no one comparison can reflect its nature. The work of psychoanalysis suggests analogies with chemical analysis, but it does so just as much with the intervention of a surgeon or the manipulations of an orthopedist or the influence of an educator. The comparison with chemical analysis has its limitation: for in mental life we have to deal with trends that are under a compulsion toward unification and combination. Whenever we succeed in analysing a symptom into its elements, in freeing an instinctual impulse from one nexus, it does not remain in isolation, but immediately enters into a new one.²

In actual fact, indeed, the neurotic patient presents us with a torn mind, divided by resistances. As we analyse it and remove the resistances, it grows together; the great unity which we call his ego fits into itself all the instinctual impulses which before had been split off and held apart from it.³ The psychosynthesis is thus achieved during analytic treatment without our intervention, automatically and inevitably. We have created the conditions for it by breaking up the symptoms into their elements and by removing the resistances. It is not true that something in the patient has been divided into its components and is now quietly waiting for us to put it somehow together again.

Developments in our therapy, therefore, will no doubt proceed along other lines; first and foremost, along the one which Ferenczi, in his paper “Technical Difficulties in an Analysis of Hysteria” (1919),⁴ has lately termed “activity” on the part of the analyst.

Let us at once agree upon what we mean by this activity. We have defined our therapeutic task as consisting of two things: making conscious the repressed material and uncovering the resistances. In that we are active enough, to be sure. But are we to leave it to the patient to deal alone with the resistances we have pointed out to him? Can we give him no other help in this besides the stimulus he gets from the transference? Does it not seem natural that we should help him in another way as well, by putting him into the mental situation most favorable to the solution of the conflict which is our aim? After all, what he can achieve depends, too, on a combination of external circumstances. Should we hesitate to alter this combination by intervening in a suitable manner? I think activity of such a kind on the part of the analyzing physician is unobjectionable and entirely justified.

You will observe that this opens up a new field of analytic technique, the working over of which will require close application and which will lead to quite definite rules of procedure. I shall not attempt today to introduce you to this new technique, which is still in the course of being evolved, but will content myself with enunciating a fundamental principle which will probably dominate our work in this field. It runs as follows: Analytic treatment should be carried through, as far as is possible, under privation—in a state of abstinence.⁵

How far it is possible to show that I am right in this must be left to a more detailed discussion. By abstinence, however, is not to be understood doing without any and every satisfaction—that would of course not be practicable; nor do we mean what it popularly connotes, refraining from sexual intercourse; it means something else which has far more to do with the dynamics of falling ill and recovering.

You will remember that it was a frustration that made the patient ill, and that his symptoms serve him as substitutive satisfactions⁶ It is possible to observe during treatment that every improvement in his condition reduces the rate at which he recovers and diminishes the instinctual force impelling him toward recovery. But this instinctual force is indispensable; reduction of it endangers our aim—the patient’s restoration to health. What, then, is the conclusion that forces itself inevitably upon us? Cruel though it may sound, we must see to it that the patient’s suffering, to a degree that is in some way or other effective, does not come to an end prematurely. If, owing to the symptoms having been taken apart and having lost their value, his suffering becomes mitigated, we must reinstate it elsewhere in the form of some appreciable privation; otherwise we run the danger of never achieving any improvements except quite insignificant and transitory ones.

As far as I can see, the danger threatens from two directions in especial. On the one hand, when the illness has been broken down by the analysis, the patient makes the most assiduous efforts to create for himself in place of his symptoms new substitutive satisfactions, which now lack the feature of suffering. He makes use of the enormous capacity for displacement possessed by the now partly liberated libido, in order to cathect with libido and promote to the position of substitutive satisfactions the most diverse kinds of activities, preferences, and habits, not excluding some that have been his already. He continually finds new distractions of this kind, into which the energy necessary to carrying on the treatment escapes, and he knows how to keep them secret for a time. It is the analyst’s task to detect these divergent paths and to require him every time to abandon them, however harmless the activity which leads to satisfaction may be in itself. The half-recovered patient may also enter on less harmless paths—as when, for instance, if he is a man, he seeks prematurely to attach himself to a woman. It may be observed, incidentally, that unhappy marriage and physical infirmity are the two things that most often supersede a neurosis. They satisfy in particular the sense of guilt (need for punishment) which makes many patients cling so fast to their neuroses. By a foolish choice in marriage they punish themselves; they regard a long organic illness as a punishment by fate and thereafter often cease to keep up their neurosis.

In all such situations activity on the part of the physician must take the form of energetic opposition to premature substitutive satisfactions. It is easier for him, however, to prevent the second danger which jeopardizes the propelling force of the analysis, though it is not one to be underestimated. The patient looks for his substitutive satisfactions above all in the treatment itself, in his transference-relationship with the physician; and he may even strive to compensate himself by this means for all the other privations laid upon him. Some concessions must of course be made to him, greater or less, according to the nature of the case and the patient’s individuality. But it is not good to let them become too great. Any analyst who, out of the fullness of his heart, perhaps, and his readiness to help, extends to the patient all that one human being may hope to receive from another, commits the same economic error as that of which our nonanalytic institutions for nervous patients are guilty. Their one aim is to make everything as pleasant as possible for the patient, so that he may feel well there and be glad to take refuge there again from the trials of life. In so doing they make no attempt to give him more strength for facing life and more capacity for carrying out his actual tasks in it. In analytic treatment all such spoiling must be avoided. As far as his relations with the physician are concerned, the patient must be left with unfulfilled wishes in abundance. It is expedient to deny him precisely those satisfactions which he desires most intensely and expresses most importunately.

I do not think I have exhausted the range of desirable activity on the part of the physician in saying that a condition of privation is to be kept up during the treatment. Activity in another direction during analytic treatment has already, as you will remember, been a point at issue between us and the Swiss school.⁷ We refused most emphatically to turn a patient who puts himself into our hands in search of help into our private property, to decide his fate for him, to force our own ideals upon him, and with the pride of a creator to form him in our own image and see that it is good. I still adhere to this refusal, and I think that this is the proper place for the medical discretion which we have had to ignore in other connections. I have learned by experience, too, that such a far-reaching activity toward patients is not in the least necessary for therapeutic purposes. For I have been able to help people with whom I had nothing in common—neither race, education, social position, nor outlook upon life in general—without affecting their individuality. At the time of the controversy I have just spoken of, I had the impression, to be sure, that the objections of our spokesmen—I think it was Ernest Jones who took the chief part⁸—were too harsh and uncompromising. We cannot avoid taking some patients for treatment who are so helpless and incapable of ordinary life that for them one has to combine analytic with educative influence; and even with the majority occasions now and then arise in which the physician is bound to take up the position of teacher and mentor. But it must always be done with great caution, and the patient should be educated to liberate and fulfill his own nature, not to resemble ourselves.

Our honored friend, J. J. Putnam, in the land of America which is now so hostile to us, must forgive us if we cannot accept his proposal either—namely, that psychoanalysis should place itself in the service of a particular philosophical outlook on the world and should urge this upon the patient for the purpose of ennobling his mind. In my opinion, this is after all only to use violence, even though it is overlaid with the most honorable motives.⁹

Lastly, another quite different kind of activity is necessitated by the gradually growing appreciation that the various forms of disease treated by us cannot all be dealt with by the same technique. It would be premature to discuss this in detail, but I can give two examples of the way in which a new kind of activity comes into question. Our technique grew up in the treatment of hysteria and is still directed principally to the cure of that affection. But the phobias have already made it necessary for us to go beyond our former limits. One can hardly master a phobia if one waits till the patient lets the analysis influence him to give it up. He will never in that case bring into the analysis the material indispensable for a convincing resolution of the phobia. One must proceed differently. Take the example of agoraphobia; there are two classes of it, one mild, the other severe. Patients belonging to the first class suffer from anxiety when they go into the street by themselves, but they have not yet given up going out alone on that account; the others protect themselves from the anxiety by altogether ceasing to go about alone. With these last, one succeeds only when one can induce them by the influence of the analysis to behave like phobic patients of the first class—that is, to go into the street and to struggle with their anxiety while they make the attempt. One starts, therefore, by moderating the phobia so far; and it is only when that has been achieved at the physician’s demand that the associations and memories come into the patient’s mind which enable the phobia t...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Contributors
• Introduction
• 1 Lines of Advance in Psychoanalytic Therapy
• 2 The Further Development of an Active Therapy in Psychoanalysis
• 3 The Drive for Superiority
• 4 Psychoanalytic Treatmen t as Education
• 5 The Toxoid Response
• 6 Effect of Paradigmatic Techniques on the Psychic Economy of Borderline Patients
• 7 Recent Developments in “Direct Psychoanalysis”
• 8 The Role of Activity in the Treatmen t of Schizoid or Schizophrenic Patients
• 9 Transactional Analysis
• 10 Reflections on My Method of Grou p Psychotherapy and Psychodrama
• 11 Toward a Holistic Treatmen t Program
• 12 Active Strategies in Marriage Counseling
• 13 The Family Approach to Marital Disorders
• 14 Marriage Therapy
• 15 Methods of Verbal Suggestion
• 16 Reciprocal Inhibition as the Main Basis of Psychotherapeutic Effects
• 17 Implosive Therapy in the Short-Term Treatmen t of Psychotics
• 18 Learning Theory and Psychotherapy Revisited: With Notes on Illustrative Cases
• 19 Neobehavioristic Psychotherapy: Quasi-hypnotic Suggestion and Multiple Reinforcement in the Treatmen t of a Case of Postinfantile Dyscopresis
• 20 The Use of Symptoms as an Integral Part of Hypnotherapy
• 21 The Treatment of Frigidity and Impotence
• 22 Paradoxical Intention: A Logotherapeutic Technique
• 23 Methodology in Short-Term Therapy
• 24 Treatment of the Psychopath
• Index