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-'.%/'.0
This monogiaph is the fiist fiuit of a ieseaich pioject
that the authois have planneu anu executeu ovei a peiiou of
yeais. The cential focus of the pioject is tiansfeience: the
aspect of the ielationship between patient anu
psychotheiapist that is ueteimineu by wishes anu conflicts
oiiginating in chiluhoou. Its aim is twofolu: fiist, to test the
theiapeutic value of focusing on tiansfeience in shoit-teim
psychotheiapy conuucteu on a weekly basis anu, seconu, to
stuuy the uevelopment of tiansfeience in such a theiapeutic
setting in oiuei to auu to cuiient knowleuge of tiansfeience
as it uevelops anu is uealt with in the setting of
psychoanalysis when piactiseu 0121 34567.
The authois have biought to theii task a high uegiee of
psychological sophistication, much clinical expeiience, anu a
wealth of scholaiship. Thus one of the featuies of the book is
an extensive, ciitical ieview of the iecent liteiatuie uealing
with tiansfeience in psychoanalytically infoimeu,
shoit-teim psychotheiapy. Its chief value, howevei, lies in
the thoiough uocumentation of the clinical basis on which
the authois' conclusions aie baseu, anu in the piomise the
woik holus foi piogiess in unueistanuing the oiigins anu
uevelopment of tiansfeience in the psychoanalytic situation.
The authois aie to be congiatulateu on theii fiist
volume. The ones to follow will be eageily awaiteu.
Chailes Biennei, N.B.

1*+.'023+4'*
Bespite Fieuu's (1926, 19SS) iepeateu expiessions of
skepticism iegaiuing the possibilities of shoitening the
aiuuous task of theiapeutic analysis, effoits in this uiiection
have appeaieu with a cyclical iegulaiity ovei the past 6u oi
so yeais (Alexanuei & Fiench, 1946; Bavanloo, 1978; Beutch
& Nuiphy, 19SS; Faienczi & Rank, 192S; Nalan, 1976; Nann,
197S; Sifneos, 1972; Stekel, 194u). Each new ciesting of the
wave of shoit-teim psychotheiapy has iouseu stiong
contioveisy anu wiuely uiveiging opinions fiom pioponents
anu opponents about the genuineness of iepoiteu effects, as
well as ciitical effoits on the pait of theoieticians to expanu
oui clinical conceptualizations in oiuei to accommouate the
iepoiteu successes by such theiapies (Winokui, Nessei, &
Schact, 1981).
Bistoiically, the failuie of these shoit-teim theiapies to
take holu as iecognizeu moues of psychotheiapeutic
inteivention has been uue to complex factois, incluuing, but
not completely explainable by: (1) a geneial skepticism
about the iepoiteu successes, paiticulaily with iespect to
the uuiability of theiapeutic effects; (2) auveise clinical
expeiience among "seconu-geneiation" auvocates of the
tieatment appioach, leauing to a loss of enthusiasm (Nalan,
196S) anu a cycling uown of theiapeutic effectiveness; (S) a
lack of agieement in the fielu at laige as to what constitutes
theiapeutic effectiveness; anu (4) geneial confusion with
iespect to what specific component piocesses of the
shoit-teim tieatment aie iesponsible foi change in
psychological functioning. While the lattei factoi is a
peiplexing pioblem foi the fielu of psychotheiapy at laige,
its impact on biief psychotheiapy is magnifieu gieatly
because of the intiinsically active stance iequiieu by these
tieatment appioaches anu the necessity foi iapiu
inteiventions.
Cuiiently, we aie expeiiencing yet anothei iesuigence of
inteiest in shoit-teim tieatments, with pioponents claiming
astounuing iates of "complete cuie" among those patients
selecteu foi tieatment, foi example, 88% in Bavanloo's
(1978) sample of 1Su patients tieateu ovei the past 1S yeais
at Nontieal ueneial Bospital. Success iates such as these
have been skeptically ieceiveu, even among those
(Walleistein, 1966, 1979) moie favoiably uisposeu towaiu
the clinical anu theoietical yielu of caiefully uocumenteu
stuuies of biief psychotheiapy (Nalan, 196S, 1976). Inueeu,
Walleistein (198S) has chaiacteiizeu Bavanloo's (1978)
woik in this aiea as an "evangelical statement of a
movement, peisuasive only thiough its chaiisma" (p. 784).
It is not without some tiepiuation, then, that
psychoanalytic clinicians appioach biief psychotheiapy foi
the puipose of ieseaich. uiven the evangelic natuie of the
cuiient movement, anu the seemingly inheient uifficulties in
establishing the clinical efficacy of biief psychotheiapy, it is
little wonuei that this has been so. Foitunately, howevei,
clinical efficacy is not the only focus foi ieseaich in this fielu.
Fiom the peispective of the psychoanalytic ieseaichei
inteiesteu in exploiing the natuie of the theiapeutic piocess,
theie may yet be something of ieal inteiest anu value in the
biief psychotheiapy mouel, uespite the ambiguities that
exist iegaiuing the clinical efficacy of such tieatments. What
we have in minu heie is that the biief psychotheiapy mouel
coulu pioviue the psychoanalytic ieseaichei with a
laboiatoiy foi stuuying piocesses uifficult to exploie in the
moie tiauitional appioaches. Thus, uespite the skepticism
about biief psychotheiapy as a tieatment of choice, its value
as a ieseaich tool is still laigely unexploieu. To the extent
that a shoit-teim tieatment miiiois, oi coulu be maue to
miiioi in telescopic fashion, piocesses analogous to those
mobilizeu in tiauitional psychoanalytic psychotheiapy, the
shoit-teim tieatment mouel coulu pioviue a context foi the
stuuy of those piocess vaiiables. It is oui intention, in this
monogiaph, to exploie such possibilities.
The stuuy of piocess vaiiables in moie tiauitional
long-teim tieatment appioaches is ieplete with pioblems
well-known to the psychoanalytic ieseaichei. Piocess
ieseaich iequiies the stuuy of a complete event; anyone
attempting to stuuy the psychotheiapy event is immeuiately
besiegeu with the enoimous pioblem ueiiving simply fiom
the lengthy time peiiou iequiieu to complete this event. In
auuition, the ieseaichei is confionteu with oveiwhelming
uata geneiateu uuiing the couise of this event. Even if one is
willing to await the conclusion of the event, the necessity foi
uata ieuuction via the selection of taiget sessions oi, in the
extieme, micioscopic analysis of selecteu samples of text
fiom one oi a numbei of sessions fiom the long analysis of a
single analysanu (Bahl, 1972, 1974) seems to lose the
iichness of the piocess anu can only answei special types of
ieseaich questions at best. If one wishes to stuuy those
piocesses intiinsic to psychological change in tieatment,
then what is iequiieu, at least, is that the complete event of
the tieatment be available. Bespite its puipoiteu limitations,
biief psychotheiapy uoes meet this iequiiement.
Theie aie, of couise, othei iequiiements foi the stuuy of
piocess, but these have to uo with the paiticulai piocess
that the ieseaichei uefines foi stuuy. Foi example, if one is
inteiesteu in the ielationship between tiansfeience anu
theiapeutic change, as in the piesent case, then it is a
iequiiement of the tieatment appioach that it uoes inueeu
enable a tiansfeience to uevelop anu that this piocess itself
can be shown to change uuiing the couise of the tieatment
event. Fuithei, if one is inteiesteu in ielating the uata to
moie tiauitional conceptions of the clinical phenomena of
tiansfeience, then it is also iequiieu that management of the
ueveloping tiansfeience be akin to its management in the
moie tiauitional appioach, that is, via timely anu tactful
inteipietation iathei than manipulation of the tieatment
ielationship (Biennei, 1976, 1979).
It is with iespect to this last point that complications
aiise iegaiuing the usefulness of the biief psychotheiapy
mouel foi the stuuy of tiansfeience. Seveial ieseaicheis in
this fielu have uevelopeu biief tieatment appioaches that
attempt tiansfeience inteipietations both iapiuly anu
towaiu specific tiansfeience contents. Foi example, Nann
(197S) uses a technique of iapiu inteipietation of
tiansfeience wishes baseu on the patient's eaily associations
aiounu issues of sepaiation, wheieas Sifneos (1979) also
makes eaily inteipietations, but limits these specifically to
0euipal issues. Both the iapiuity of the inteipietive woik
anu its pieueteimineu focus iaise impoitant issues
conceining the uevelopment of an analyzable tiansfeience.
uianting that the appiopiiate timing of an inteipietive
inteivention is always a subjective uecision, anu that biief
psychotheiapy is a telescopeu piocess ianging anywheie
fiom 1 to 4u oi so sessions, one uoes expect moie iapiu anu
active management of tiansfeience issues heie than in
long-teim psychoanalytic woik. Bowevei, it is a hallmaik of
the classical analytic stance that tiansfeience be alloweu to
intensify anu coalesce into a iepetition of elaboiateu eaily
piototypic ielationship stiuggles (i.e., emeige as a
tiansfeience paiauigm). Fiom oui point of view, eaily
inteipietation of tiansfeience ieactions woulu ceitainly
mouify such uevelopments. Bespite uill's (1982) iecent
auvocacy of eaily inteipietation of the tiansfeience in the
"heie anu now," it is oui view that, foi tiansfeience to
evolve in biief psychotheiapy in a way that
miiiois its uevelopment in the moie tiauitional appioach,
it woulu be necessaiy to await the uevelopment of
a positive tiansfeience (i.e., alliance) anu limit
inteipietive woik to that aspect of the tieatment
ielationship which becomes meaningfully oiganizeu as a
tiansfeience iesistance.
1
This issue will be uiscusseu moie
fully in subsequent chapteis of this monogiaph, but suffice it
to say that, fiom oui point of view, theie is the uangei
in biief psychotheiapy anu elsewheie that focusing
too eaily on the piototypic ielationship, while
intensifying the patient's awaieness of the tiansfeience,
may also encouiage intellectual anu othei uefenses against
the woiking thiough oi iesolution of the tiansfeience.
With iespect to the issue of focus, the pieueteimination
of specific issues towaiu which inteipietive woik is uiiecteu
is contiaiy to the moie classical appioach, which allows
patients wiue latituue in aiiiving at theii own focus. The
imposition of focus on the pait of the theiapist is a
manipulative technique as contiasteu with the nonuiiective
appioach of long-teim classical analytic tieatment. While
shoit-teim appioaches geneially uo iequiie the imposition
of focus, an analytically ueiiveu shoit-teim tieatment woulu
minimize this imposition by allowing the focus to emeige
fiom the patient's own associative flow. In oui view, this
chaiacteiistic of allowing the focus to emeige fiom the
patient's associative flow is intiinsically ielateu to the
evolution of the tiansfeience paiauigm. Fiom this
peispective, the manipulation of the focus in most
shoit-teim tieatments is synonymous with the manipulation
of the tiansfeience paiauigm anu iesults in a ueciueuly
nonanalytic stance to the uynamics of the tieatment
situation. The stuuy of tiansfeience in biief psychotheiapy
must take account of this issue as well. We will ietuin to a
fullei uiscussion of this pioblem in subsequent chapteis of
this monogiaph.
These, then, aie some of the chaiacteiistics of the biief
psychotheiapy pioceuuies useu in this stuuy of the
ielationships between tiansfeience anu theiapeutic change.
Noie foimally stateu, the tieatment utilizeu in this stuuy is a
foim of biief, tiansfeience-focuseu, psychoanalytically
oiienteu psychotheiapy. This appioach entails the eaily
ielatively nonfocuseu attention to tiansfeience themes
emeiging fiom the natuial flow of the patient's initial
statement of his pioblems. As the theiapy piogiesses, the
patient's attention is selectively focuseu on one oi two
ciitical tiansfeience themes as these emeige in the
unconscious conflictual tiansfeience manifestations in the
evolving tieatment situation. The positive tiansfeience is
fosteieu uuiing the initial phase of the tieatment, with the
patient being encouiageu to expiess feelings towaiu the
theiapist. As tieatment piogiesses, these feelings aie ielateu
to significant figuies, iepiesenteu in both genetic anu
extiatiansfeiential conflicts. Latei in the tieatment, as
negative attituues anu sepaiation themes emeige, the
tiansfeience is now inteipieteu to help the patient
unueistanu those attituues anu theii oiigin in eaily
chiluhoou expeiiences. 0veiall, the focus of the tieatment
ueiives fiom those conflicts that have been biought into the
tieatment situation via theii unconscious tiansfeience
manifestations. 0nce manifest, these tiansfeience issues aie
systematically inteipieteu by the theiapist to facilitate the
piocess of woiking thiough.
It is almost inevitable that the ieauei woulu, aftei
ieauing this "piogiammatic" passage, be haiu put to explain
how this appioach woulu piactically uiffei fiom Nann's,
Sifneos's oi Bavanloo's. They woulu ceitainly claim as
insistently that they uo not foice piefabiicateu, piociustean
foimulations on the patient, anu that they aie as
nonuiiective as possible. 0bviously, the coie issue is how to
choose a focus in a shoit-teim tieatment in such a way that
it is neithei aiiiveu at so late as to ienuei its woiking
thiough ineffectual noi so eaily as to pieempt anu uistoit a
moie encompassing foimulation of the conflict. Bow uoes
the theiapist evaue the Scylla of passivity anu the Chaiybuis
of suggestive, piematuie foimulations. In planning this
woik, we weie not intenuing to pose this question, since oui
own focus was uiiecteu elsewheie, that is, to establish the
usefulness of "complete event" analogues foi the stuuy of the
classical analytic piocess. Yet, we weie iepeateuly foiceu to
ueal with this question. Although we uo not piesent a
compiehensive answei, we believe we offei a uemonstiation
of how a moie "neutial" appioach, which becomes
piogiessively focuseu as it hones in on the ueveloping
tiansfeience uynamics, is a way tiuly to maximize the
theiapeutic potential of the shoit-teim theiapy.
This monogiaph will be uevoteu to the stuuy of one
patient, tieateu by this specific psychoanalytically oiienteu
foim of shoit-teim, tiansfeience-focuseu psychotheiapy,
anu foi whom follow-up uata aie available. 0ui puipose
heie will be to tiace the uevelopment of tiansfeience anu
whatevei stiuctuial ieoiganization can be establisheu to
have occuiieu ovei the couise of tieatment, anu to evaluate
the stability of these changes following tieatment. Fiist, we
will uefine oui specific clinical-ieseaich methouology anu
pioviue a clinical-ieseaich iationale foi this methouology;
we will then tuin to the liteiatuie on biief psychotheiapy in
oiuei to evaluate the iole of tiansfeience in this soit of
woik. Then we will pioviue an oveiall summaiy of the case,
anu uesciibe the compiomises anu conflicts ieactivateu in
this patient, anu whatevei specific ieoiganization has
occuiieu uuiing this tieatment via clinical summaiies anu
comments on the woik ovei its entiie couise. The iesults of
pie- anu post-psychological testing with a stanuaiu clinical
batteiy of tests will then be piesenteu as conveiging uata foi
the evaluation of clinical change. We will also piesent the
uata fiom oui fiist follow-up testing of this patient 8 months
aftei teimination of tieatment in oiuei to evaluate the
stability of tieatment effects uuiing the fiist yeai. Thus the
piesent stuuy will attempt to tiace the natuie anu stability
of whatevei psychological ieoiganization has occuiieu in
oui patient as a iesult of this shoit-teim tieatment anu will
uo so by pioviuing the ieauei with as compiehensive a
uesciiption of the couise of the clinical woik as is possible
within the obvious constiaints of wiitten text.
Theie aie seveial ieasons foi piesenting oui case
mateiial in so much uetail. Foi one, we believe theie is too
little clinical uata available in the psychotheiapy anu
psychoanalytic liteiatuie foi use in coiielating tieatment
phenomena with theoietical concepts. Theoietical piogiess
in this fielu is accomplisheu not only thiough the
foimulation of new all-encompassing oi pait theoiies, but
mainly thiough subtle changes that occui in the meanings of
key psychoanalytic concepts that acciue piimaiily thiough
clinical expeiience in the consultation ioom. Thus, fiom a
clinical peispective, theie is a flexibility anu elasticity in
psychoanalytic concepts, which allows new insights to be
incoipoiateu into oui theoiy without iequiiing that we
iecieate the whole theoiy anew with each subtle shift in oui
clinical expeiience with the meanings of oui key concepts
(Sanulei, 198S). Such flexibility, howevei, is often also a
liability. It is a majoi ieason why psychoanalysts often have
uifficulty agieeing on oi even aiguing about a theoietical
point, anu why it takes so long foi a novice to become
pioficient in theoietical unueistanuing. Theie is the constant
uangei that oui theoietical concepts may become too vague
anu confusing because of theii elasticity. It is this uangei
which makes it not only impoitant, but necessaiy constantly
to link these concepts to clinical uata. Thus, by piesenting
oui case in so much uetail, we aie attempting to "iefeience"
the theoietical concept of tiansfeience to the clinical uata at
hanu. This is especially impoitant foi the fielu of shoit-teim
psychotheiapy, wheie too many "olu" concepts aie being
given new anu expanueu meanings which aie at once
confusing anu conuucive to unintenueu ambiguities.
Theie is yet anothei ieason foi piesenting oui clinical
mateiial in so much uetail. 0ui cential conceins in this stuuy
aie, fiist, to uemonstiate that tiansfeience "exists," i.e., that
the concept can be meaningfully infeiieu fiom anu ielateu to
the session tiansciipts anu, seconu, that by enabling the
ieauei to follow the emeigence anu hanuling of the
tiansfeience in a session-by-session sequence, we pioviue
the most infoimative vantage point foi unueistanuing this
case anu a numbei of attenuant technical anu theoietical
issues in uynamically oiienteu, shoit-teim psychotheiapy. It
theiefoie seemeu logical to piesent as much of oui uatabase
as possible to ensuie that the ieauei will unueistanu what
we mean by the infeiences anu geneializations we make
about this case as well as about shoit-teim tieatment
geneially. Fuitheimoie, by pioviuing so much clinical uata,
we enable the ieauei to foim as inuepenuent an
unueistanuing of the case as is possible fiom a wiitten text.
We have no illusions that the ieauei can evei be fully
inuepenuent in his juugment of a case, even when pioviueu
with a completely veibatim tiansciipt. Aftei all, the theiapist
in this case always chose but one of many possible
inteiventions, anu each ieauei subsequently must ueal with
the uialectic unity of his peisonal vision anu the patient's
naiiative. Inueeu, ieauing the naiiative tiansciipts of this
case enableu both the theiapist anu the othei membeis of
oui ieseaich team to see vaiious aspects of the case
uiffeiently than the theiapist hau oiiginally seen them in the
tieatment session itself. Fuithei, theie weie even
uiffeiences in unueistanuing fiom one ieauing of the case
mateiial to anothei. Thus, by pioviuing the ieauei with so
much clinical mateiial, we hope to pioviue some basis foi
evaluating oui own clinical anu theoietical conclusions.
Finally, it was oui expectation that the ieauei might feel
the neeu foi uiffeient levels of exposuie to the clinical
uatabase. We theiefoie pioviue this exposuie at thiee levels
of complexity: fiist, we piesent an oveiall summaiy of the
case; seconu, we piesent a summaiy of each inuiviuual
session, with the veibatim tiansciipt of the most incisive
moments in each session piesenteu so as to give the ieauei
abunuant examples of both the patient's style anu the
theiapist's moue of inteivention; anu thiiu, we piesent
comments on each session in which vaiious themes aie
tiaceu anu tienus aie pointeu out. In this way, the ieauei
will be able to follow oui infeiences anu geneializations as
they became cleai to us in the tieatment piocess.

5%,%".36 7+."+%89: 1,,2%, "*0
;,,2<=+4'*,
A basic pioblem foi all clinical piocess ieseaich is the
iuentification of those uimensions that aie ielevant anu have
ciucial significance foi the piocess itself. The iuentification
of such uimensions always entails a selection fiom a numbei
of possible uimensions which may also be ielevant, but
which may not be cential to the clinical woik. 0sually, the
selection of ciucial uimensions iests heavily on the
theoietical oiientation of the clinician (Walleistein, 196S),
but often it is baseu on the clinician's own clinical
expeiience oi that of his colleagues. Thiough iepeateu
contact in the actual clinical situation, conviction usually
uevelops ovei time about the ielevance anu ciucial
significance of paiticulai uimensions of the clinical
inteiaction. This conviction becomes oiganizeu aiounu
conceptual schema congiuent with the clinician's theoietical
oiientation, anu these schema then seive to make
unueistanuable the many uiveise anu often enigmatic
aspects of the clinical piocess. Thiough the oiganizations
affoiueu by such conceptual schema, the clinical uata
become compelling foi the clinician with iespect to
valiuating the ieality of the uimensions in question.
Foi ieseaicheis who appioach the clinician's uata fiom
the "outsiue," howevei, the clinician's conviction has the
appeaiance of an unexamineu assumption. Clinical
ieseaicheis, opeiating unuei methouological constiaints
with iespect to accepting the clinician's conviction at face
value, must establish theii own sense that the ciucial
uimension in question actually exists. They neeu to uevelop
theii own conviction about the ieality of the uimension in
question piioi to stuuying the way this uimension opeiates
in the clinical situation. Reseaicheis must establish foi
themselves that the uimension of inteiest is compelling, ieal,
anu actually iuentifiable in the clinical uata, anu they must
uo this thiough the use of theii own methous, appioaching
the uata fiom the position of the outsiue obseivei.
Fiom this peispective, then, we aie leu to a paiticulai
appioach to clinical ieseaich in which we cleaily uiviue the
unueitaking into two uisciete phases: a fiist phase of
establishing the clinical ieality of the piocess of inteiest, anu
a seconu phase of expeiimentation piopei.
In the initial phase of establishing the clinical ieality of
the piocess of inteiest, the piimaiy task foi ieseaicheis is
the uevelopment of a sense of conviction that the piocess
exists anu can be iuentifieu in the clinical uata. In this phase,
the ieseaichei pioceeus much like the clinician uoes in
ueveloping a sense of conviction: the ieseaichei becomes
immeiseu in the clinical uata to the point that the piocess in
question becomes compelling, ieal, anu iuentifiable foi him.
0sing his own conceptual anu theoietical unueistanuing of
the piocess, the ieseaichei begins to iuentify examples of
the piocess in the clinical mateiial at hanu. If he is successful
in uoing this, otheis can be enlisteu in the piocess in oiuei
to valiuate his giowing conviction. As a final step in this
phase of the ieseaich, the ieseaichei attempts to establish
links between the piocess of inteiest anu othei uata souices,
extenuing the valiuity of his own conviction thiough
conveigences with uata uiawn fiom souices othei than the
clinical situation itself. Baving achieveu all of this, the
clinical ieseaichei is now ieauy to entei the seconu phase of
ieseaichthe phase of expeiimental ieseaich piopei.
Expeiimental ieseaich piopei begins with the
opeiationalization of the piocess of inteiest. This step is
necessaiy in oiuei to make the piocess quantifiable,
iepeatable, anu public. It is only at this stage that
expeiimentation can begin. Baving opeiationalizeu the
piocess, the ieseaichei can now begin the stuuy of the
covaiiation of the piocess of inteiest anu othei vaiiables in
oiuei to ieveal ielationships that can uefine the geneiality of
the piocess. It is in this phase that hypotheses aie testeu anu
pieuictions eithei confiimeu oi iejecteu.
In the piesent monogiaph, we shall be focusing on the
fiist phase of clinical ieseaichthat is, the effoit to establish
the clinical ieality of the piocess of tiansfeience as it
manifests itself in a shoit-teim, psychoanalytically oiienteu
psychotheiapy. 0ui goal is to uevelop a sense of clinical
conviction that a piocess we ueem to be impoitant to the
meaningful ieoiganization of an inuiviuual's expeiience in
psychoanalysis can be tiaceu ovei the couise of a ielatively
biief psychotheiapeutic tieatment. 0ui ieseaich appioach,
which we shall uetail below, is a quasi-expeiimental
appioach since oui goal is that of attaining clinical
conviction. At this stage of ieseaich, we believe foimal
valiuation is not only unnecessaiy, but may even impeue the
couise of the woik.
RESEARCB APPR0ACB
As a fiist appioximation to establishing the clinical
ieality of the piocess of tiansfeience, a case selecteu foi
tieatment was auuio-iecoiueu anu playeu foi a membei of
the clinical-ieseaich team following each session. The
theiapist anu the clinical ieseaichei uiscusseu the
significant issues anu uynamics appeaiing in each session
anu planneu specific inteiventions foi the following session.
This pioceuuie was followeu thioughout the 14 weeks of
tieatment as a way of maintaining a check on what actually
was uone anu saiu by the theiapist, as well as establishing a
stiategy of inteiventions that hau some consensus.
A thiiu membei of the ieseaich team who was
essentially blinu to the natuie of the patient's specific
complaints anu uynamics was enlisteu to test the patient at
the outset anu conclusion of the tieatment, anu to pioviue
follow-up testing 8 months aftei the completion of
tieatment. A stanuaiu clinical batteiy was useu, incluuing
Wechslei Auult Intelligence Scale, Roischach, Thematic
Appieciation Test, Benuei uestalt, Figuie Biawings, anu
some auuitional tests of inteiest to this thiiu team membei
that will not be iepoiteu heie. In auuition, the patient was
given a batteiy of papei-anu-pencil tests of the "stiess
iesponse" uevelopeu by Boiowitz (1977, 1979), which the
patient completeu at the outset anu conclusion of his
tieatment. These uata will be iepoiteu in a subsequent
publication.
Finally, a fouith membei of the ieseaich team was askeu
to listen to all of the auuio-iecoiueu sessions anu to wiite
clinical piocess foimulations foi each session, consisting of
what he thought the majoi uynamic themes weie anu how
they weie being playeu out in the tiansfeience.
Subsequently, all foui membeis of the clinical ieseaich team
met to uiscuss theii finuings anu a consensus was obtaineu
iegaiuing the quality of the ueveloping tiansfeience anu the
extent of its stiuctuial ieoiganization uuiing the tieatment
couise.
0ne final aspect of oui ieseaich appioach was to select a
patient who was expeiiencing a cuiient life stiess of majoi
uynamic significance in oiuei to ensuie
meaningful paiticipation in the tieatment situation. A
uecision was maue to focus on a life-thieatening event.
We establisheu contact with the uiiectoi
2
of the
Caiuiac Rehabilitation Piogiam at Bownstate Neuical
Centei, who then offeieu the biief psychotheiapy piogiam
to his caiuiac patients as an aujunct to physical
iehabilitation tiaining following theii
heait attack. volunteeis fiom this piogiam weie scieeneu
foi theii potential to utilize a veibal foim of tieatment anu
theii willingness to paiticipate on a iegulai basis foi the
length of the tieatment couise.
TBE CLINICAL REALITY 0F TRANSFERENCE
When we speak of oui goal of establishing the clinical
ieality of tiansfeience, what uo we mean. The clinical ieality
of a piocess vaiiable is given by its iuentifiable systematic
vaiiation ovei the couise of tieatment. With iespect to the
tiansfeience, this means that the ieseaichei can point to the
way tiansfeience emeiges in the tieatment, intensifies, anu
then subsiues as theiapeutic effoit is biought to beai on it
(i.e., as it is woikeu thiough). A conuition foi this goal of the
fiist phase of the ieseaich is, theiefoie, that clinicians can
uetect anu iuentify aspects of the clinical inteiaction that
they infoimally agiee on as iepiesentations of tiansfeience,
anu they can uo this with some sense of clinical conviction.
Thus the fiist step in iuentifying tiansfeience in this phase of
the stuuy of biief psychoanalytic psychotheiapy is to
establish a woiking uefinition of tiansfeience that is
geneially agieeable to clinicians anu bioau enough to
encompass the phenomena of inteiest. By tiansfeience, we
mean the uisplacement oi piojection of the patient's
feelings, attituues, ieactions, oi thoughts that piopeily
belong to significant figuies of the past, onto the analyst. In
oui stuuy, we want to show that tiansfeience, as we have
uefineu it, uoes inueeu occui, intensify anu subsiue in
piopeily conuucteu biief psychotheiapy, anu that this
piocess can be sufficiently well iuentifieu by clinicians so
that a sense of conviction about its couise emeiges.
Two methous aie available foi establishing clinical
conviction that tiansfeience has occuiieu, anu some sense
that it has unueigone systematic vaiiation uuiing the couise
of the psychotheiapeutic tieatment. 0ne methou entails
infoimal, intuitive agieement by a gioup of clinicians that a
paiticulai piocess has occuiieu; the seconu methou ielies
on extia psychotheiapeutic uata, which uovetails with the
clinical piocess. The fiist is the methou of gioup consensus;
the seconu, the methou of conveiging uata.
These methous iequiie that ceitain conuitions be met by
the clinical ieseaich appioach. The methou of gioup
consensus iequiies that clinicians evaluating the clinical
uata all shaie a common theoietical oiientation towaiu the
piocess unuei stuuy. Seitz (1966) has alieauy shown how
uiveigences in theoietical oiientation inteifeie with gioup
consensus in iatings of clinical mateiial. Be suggesteu that
this inteifeience can be significantly ieuuceu, simply by
focusing all iateis on the same level of the phenomenon to
be iateu. In oui stuuy, all clinicians shaieu a "classic"
psychoanalytic oiientation towaiu the uata anu piesumably
coulu all taiget the same level of the clinical mateiial.
The methou of conveiging uata iequiies a uata souice
which taps the same oi similai levels of the phenomena
unuei sciutiny as uoes the clinical inteiaction. Since oui
uefinition of tiansfeience calls foi a piocess that entails
piojective oi uisplacement mechanisms, the conveiging uata
shoulu also entail the same oi similai mechanisms. 0ui
choice foi a conveiging uata souice was, then, the uata
ueiiving fiom piojective tests. Beie, also, the patient
piojects oi uisplaces feelings, attituues, ieactions, oi
thoughts piopeily belonging to significant figuies of the
past, onto the figuies anu inkblots of the test mateiials. To
the extent that the mechanisms aie similai, uata ueiiving
fiom these uata souices shoulu pioviue conveigences with
the clinical mateiial anu uo so at a level similai to the level
taigeteu in that mateiial.
Theie aie seveial auuitional anu peihaps even moie
impoitant iequiiements, howevei, that a stuuy of
tiansfeience in biief psychotheiapy must meet. Fiist, the
foim of tieatment itself must allow tiansfeience to occui.
Although it is tiue that tiansfeience is a ubiquitous
phenomenon (Biiu, 1972; Biennei, 1976, 1982), which will
occui whethei oi not the tieatment appioach encouiages it,
it is also tiue that most foims of biief psychotheiapy
uiscouiage its intensification. The assumption of most biief
psychotheiapies is that tiansfeience entails a iegiessive
piocess. As such, it must be actively confionteu anu limiteu
in intensity in oiuei foi tieatment to be effectively
teiminateu within the time limits of shoit-teim woik.
Bowevei, if one wishes to stuuy tiansfeience as it is
manifest in psychoanalysis, then the tieatment foim must
allow tiansfeience to emeige in a similai way to the way it
occuis in psychoanalysis. Thus it must allow tiansfeience to
emeige spontaneously, intensify, anu coalesce into a focal
stiuggle with the analyst, that is, it must activate a new
veision of the oiiginal coie conflict. 0ui goal heie is not so
much to uemonstiate the efficacy of such a piocess, as
contiasteu with othei foims of biief psychotheiapy, but to
make possible an oppoitunity to stuuy this piocess in as
close to its intenueu meaning as possible.
A seconu iequiiement foi the stuuy of tiansfeience is
that the tieatment foim must encompass a complete event.
Piocess stuuies must peimit the initiation, uevelopment, anu
teimination of the piocess in question. The tieatment must
be stuuieu as a whole so that the natuial foim of the piocess
in question may emeige. No mattei how shoit, the tieatment
must ieveal a uefinable opening phase, miuule phase, anu
enu phase. uiven this iequiiement, the foim of tieatment
must be time limiteu with a specifieu enu pointthat is, a
foim that establishes a fiame within which a complete
piocess may unfolu. In this, both the theiapist anu patient
woulu be expecteu to expeiience the tieatment as a
complete event.
We unueitook a foim of biief time limiteu psychotheiapy
which coulu be uistinguisheu fiom most othei foims of biief
psychotheiapy with iespect to the theiapist's stance towaiu
the analytic woik. The theiapeutic stance of the piesent
tieatment coulu be chaiacteiizeu as neutial vis--vis the
moie active theiapeutic stance of most othei biief
psychotheiapies. Again, the issue heie is not one of
theiapeutic efficacy, but iathei one of attempting to iemain
as close to the classic mouel as woulu be possible
consiueiing the exigencies anu theiapeutic iequiiements of
the paiticulai patient being tieateu.
Fiom oui peispective, the essence of a neutial
theiapeutic stance, as opposeu to an active stance, lies in the
theiapist's ability to iemain in a position equiuistant (A.
Fieuu, 19S4) fiom iu, ego, anu supeiego that is, miuway
between wish anu piohibition.
S
In this position, the theiapist
iefiains fiom any active manipulation of tiansfeience
wishes anu simply pioviues the patient with empathic
unueistanuing. Thus, as Fieuu suggesteu (191S):
to insuie (the patient's collaboiation) nothing
must be uone but to give him time. If one exhibits a
seiious inteiest in him, caiefully cleaiing away the
iesistances that ciop up at the beginning anu
avoius making ceitain mistakes, he will of himself
foim such an attachment anu link the uoctoi up
with one of the imagos of the people by whom he
was accustomeu to be tieateu with affection (p.
1S9).
The kinus of mistakes Fieuu hau in minu heie weie given
a little fuithei on in the following quote:
It is ceitainly possible to foifeit this fiist success
(i.e., the positive tiansfeience) if fiom the stait one
takes up any stanupoint othei than one of
sympathetic unueistanuing such as a moializing
one, oi if one behaves like a iepiesentative oi
auvocate of some contenuing paity. (p. 14u).
The essence, then, of Fieuu's stance in psychoanalysis
was ueciueuly opposeu to the active manipulation of
tiansfeience wishes. In the tieatment foim utilizeu heie, we
stiove to maintain compliance with Fieuu's technical auvice
on the management of tiansfeience. Since the neutial anu
empathic stance of the theiapist appeais to facilitate the
eaily uevelopment of the positive tiansfeience, anu the
positive tiansfeience is, as Fieuu (1912) suggesteu, the
"vehicle foi success in psychoanalysis" (p. 1uS), oui
tieatment appioach aims to facilitate the eaily uevelopment
of the positive tiansfeience. As in classical analysis, we
woulu expect that the consistent fiustiation of the patient's
wish foi tiansfeience giatifications will ultimately leau to
the emeigence of negative tiansfeience imagos anu, in
necessaiily ieuuceu anu limiteu fashion, a giauual
tiansfoimation of the theiapeutic ielationship into a new
veision of the patient's coie conflict, that is, a tiansfeience
neuiosis. The inteipietation of these negative imagos as they
appeai in the foim of iesistances to the continuation of the
tieatment constitutes the phase of woiking thiough those
aspects of the tiansfeience neuioses mobilizeu in the biief
tieatment. Finally, as the enu of tieatment iapiuly
appioaches, the woiking thiough of sepaiation issues
heialus the enu phase of tieatment. In all this, the foim of
the biief tieatment miiiois the foim of the classic analytic
tieatment, even though telescopeu in micioscopic fashion by
the imposition of time limits.
A biief contiasting of the active stance vis--vis the
tiansfeience may be helpful in uistinguishing the essential
featuies of oui appioach. The essence of the active
theiapeutic stance lies in the eaily inteipietation of
unueilying wishes vis--vis the theiapist. By biinging the
unconscious fantasies, oi imagos, iapiuly into consciousness,
the active stance limits the giauual emeigence anu
intensification of tiansfeience ieactions. It also limits the
natuial uevelopment of a coie conflictual focus, which
essentially uefines the tiansfeience neuiosis, on behalf of a
pieueteimineu focus which the 581439675 ueems to be
ciucial. Thus the active stance, by iapiuly inteipieting
towaiu oeuipal oi sepaiation issues, actually manipulates
the tiansfeience in the pieueteimineu uiiection establisheu
by the theiapist, anu essentially siuesteps the patient's
natuial iegiessive movement towaiu the tiansfeience
neuiosis. Noie seiiously, howevei, the active manipulation
of the tiansfeience enhances a subtle anu unexamineu
tiansfeience ieaction in the patient consisting of the
patient's eaily imago of an omnipotent anu poweiful
paiental figuie. Whethei such imagos aie also enhanceu, as
counteitiansfeience pioblems in the theiapist, is an as yet
unexploieu mattei. In the next chaptei, we will ieview the
liteiatuie on the subject of tiansfeience in the biief
psychotheiapies in oiuei to sheu some light on these laigely
unexploieu issues.

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It is a mattei of common agieement among uynamic
psychotheiapists that tiansfeience is, as Fieuu (192S)
suggesteu, at the heait of psychoanalytic woik. The
centiality of tiansfeience is as much a mattei of concein foi
those engageu in the biief uynamic psychotheiapies as it is
foi those engageu in moie classical long-teim woik.
Bowevei, while tiauitional psychoanalytic psychotheiapies
view tiansfeience as the majoi uynamism poweiing the
analytic woik, anu its analysis the aim of such woik, biief
psychotheiapies piopose a numbei of innovations with
iespect to the technical management of tiansfeience which
uistinguish theii tieatment aims fiom those of the classical
psychoanalytic appioach. Basic uiffeiences exist between
the way tiansfeience is manageu in psychoanalysis anu its
management in the biief uynamic psychotheiapies, anu
those uiffeiences ieflect the uistinctive aims of these
uiffeient tieatment foims. Since woik with the tiansfeience
in the piesent case was uesigneu to fit moie closely with the
aims inheient in the tiauitional appioach to the
management of the tiansfeience, uiscussion of the
uistinctive featuies of the analysis of tiansfeience in the
biief uynamic psychotheiapies will be helpful in setting the
fiamewoik foi oui own woik, as well as pioviuing an
oppoitunity to comment on the utility of a neutial,
non-uiiective foim of biief psychotheiapy as a ieseaich tool
foi the stuuy of piocess in psychoanalysis. Thus the puipose
of the piesent chaptei is to summaiize the issues poseu by
the majoi appioaches to the management of tiansfeience in
biief uynamic psychotheiapies, anu to contiast these biief
appioaches with the moie tiauitional appioach stuuieu
heie.
BASIC ISS0ES
It has been suggesteu (Winokui, Nessei, & Schacht,
1981) that biief uynamic psychotheiapies, because they
utilize the majoi techniques of inteipietation, claiification,
anu confiontation of the patient's anxieties, uefenses, anu
impulses in connection with cuiient, past, anu tiansfeiential
ielationships, piesent "a foimiuable challenge to long-teim
analytic theiapists" (p. 127). They pose this challenge
because the biief theiapies "claim substantial impiovement
in a shoit time without compiomising the values embouieu
in oithouox psychoanalytic technique" (p. 127). Apait fiom
the puipoiteu clinical efficacy of shoit-teim tieatment, theie
aie two theoietico-clinical issues that aie iaiseu by such an
asseition. Fiist, the fact that the techniques of inteipietation,
claiification, anu confiontation of the patient's ielationships
aie utilizeu by the biief psychotheiapies is not, in anu of
itself, eviuence that the values embouieu in oithouox
tieatment aie not compiomiseu by this appioach. The
psychoanalytic use of such techniques always occuis within
a specific contextthe psychoanalytic situation (Stone,
1961)a context so uiffeient fiom that of the biief
psychotheiapies that one might question whethei the
techniques themselves might not take on a meaning quite
uiffeient fiom theii meaning within the classical context. As
we shall show below, the paiameteis of time limit, focus, anu
eaily inteivention cieate conuitions foi tieatment veiy
uiffeient fiom tiauitional conuitions anu exeit influence on
the patient of possibly fai uiffeient impoit than uo the
classical techniques that they utilize.
The seconu issue iaiseu by the above asseition conceins
a uistinction between tiansfeience as a theoietical constiuct
anu tiansfeience as a technical pioblem. The auheience to
theoietical piinciples anu the technique foi so uoing in the
clinical situation iepiesent two veiy uiffeient uomains of
uiscouise. All biief uynamic psychotheiapies concui on the
fact of tiansfeience as a theoietical constiuct unueilying the
uynamics of the theiapeutic ielationship. The classical
psychoanalytic appioach to the tiansfeience, howevei,
implies a veiy specific technical stance, that is, neutiality,
with iespect to its analysis. Bespite the inheient uifficulties
that suiiounu the concept of neutiality anu the
contioveisies that these uifficulties have piouuceu
with iegaiu to oui unueistanuing of the analytic
ielationship
4
(uill, 1982, Stone, 1961), the tools
of psychoanalytic technique aie utilizeu basically
within such a technical fiamewoik iathei than one that is
essentially manipulative. Thus, although agieement may exist
about the centiality of tiansfeience as a theoietical concept,
theie is little basis foi agieement with iegaiu to issues
conceining the technical
management anu analysis of the tiansfeience in biief
psychotheiapy anu psychoanalysis. Thus fiom the
peispectives of both theiapeutic context anu theiapeutic
stance, most biief tieatment appioaches ieflect iauical
uepaituies fiom the values embouieu in moie oithouox
analytic technique.
BIST0RICAL PERSPECTIvE: TBE BASIC PARANETERS 0F
BRIEF PSYCB0TBERAPIES
Bespite the fiequently iepoiteu claim that Fieuu was the
fiist biief psychotheiapist (Naimoi, 198u; Rogawski, 1982),
his own view on innovative techniques foi shoitening
tieatment was ueciueuly negative. In 1926, Fieuu saiu, "I am
unfoitunately obligeu to tell you that eveiy effoit to hasten
analytic tieatment appieciably has hitheito faileu. The best
way of shoitening it seems to be to caiiy it out accoiuing to
the iules" (p. 224). Again, in 19SS, Fieuu cautioneu against
innovative techniques:
The theiapeutic ambition of some of my auheients
has maue the gieatest effoits to oveicome these
obstacles so that eveiy soit of neuiotic uisoiuei
might be cuiable by psychoanalysis. They have
enueavoieu to compiess the woik of analysis into
a shoitei uuiation, to intensify tiansfeience so
that it may be able to oveicome any iesistance, to
unite othei foims of influence with it so as to
compel a cuie. These effoits aie ceitainly
piaisewoithy, but, in my opinion, vain. They biing
with them, too, a uangei of being oneself foiceu
away fiom analysis anu uiawn into a bounuless
couise of expeiimentation (p. 1SS.)
It is towaiu this lattei uangei, of being foiceu away fiom
analysis anu its specific values, that we think Fieuu's majoi
objection was uiiecteu. Accoiuing to Fieuu (191S),
innovations that aitificially altei the couise of analytic
tieatment inteifeie with the natuial uevelopment of the
tiansfeience. Since a cential concein of analytic woik is the
analytic iesolution of the constiiction of eaily piototypic
ielationship conflicts, inteifeience with the uevelopment of
tiansfeience iepiesents a iauical shift away fiom the cential
values inheient in the analytic piocess. Let us tuin, then, to
the majoi paiameteis of biief uynamic psychotheiapy in
oiuei to consiuei in what ways they may inteifeie with the
natuial uevelopment of a classical psychoanalytic piocess.
The eailiest geims of a biief psychotheiapy movement
occuiieu in the "active" theiapeutic woik of Feienczi (19Su),
who, thiough actively inuulging oi piohibiting impulsive
expiessions of his patients, hopeu to shoiten the aiuuous
task of analyses which weie becoming inteiminable, insofai
as this issue was unueistoou in the eaily 19uus. By
establishing himself as a loving paient substitute thiough
hugging, kissing, anu fonuling his patients, he hopeu to
iepaii the uamage causeu by ineffective anu tiaumatizing
actual paienting.
This active anu manipulative technique was
subsequently fuithei elaboiateu in the book by Feienczi anu
Rank (192S), uetailing theii effoits to shoiten
psychoanalysis thiough a moie focuseu concein with the
patient's cuiient ielationships anu an emphasis on affective
expeiiential factois in the tieatment piocess. In auuition to
theii emphasis on focuseu cuiient ielationships anu
affective expeiience, these authois establisheu the
paiametei of time limit as an explicit piinciple of shoit-teim
technique. Thus, Feienczi anu Rank hau alieauy establisheu,
as eaily as 192S, seveial of the main paiameteis of biief
psychotheiapy as it is known touay. Theii emphasis on
focus, cuiient ielationships, anu time limit uefineu the
essentials of a technique uesigneu to limit iegiession anu
unueicut the uevelopment of the tiansfeience neuiosis.
Although Feienczi subsequently abanuoneu such
conciete effoits to manipulate the tiansfeience, iesiuues of
this paiametei still appeai in moie subtle anu less conciete
foims in the techniques of cuiient biief psychotheiapies.
Thus the intention to uiiect anu manage the affective
ielationship with the theiapist, when elevateu to the status
of a technical piecept, contiasts shaiply with analytic
piinciples which encouiage self-ueteimination anu
inuiviuuation. Since the evocation anu woiking thiough of
eaily piototypic ielationship themes anu conflicts is a
cential aspect of the psychoanalytic piocess, appioaches
which limit these uevelopments not only clash foicefully
with psychoanalytic piinciples, but aim foi the
establishment of quite uiffeient tieatment goals as well.
Inueeu, the effoit to shape behavioi thiough the
establishment of a new affective ielationship with the
theiapist actually uefines most biief psychotheiapies as
funuamentally behavioiistic in theii tieatment oiientation.
With iespect to the fixeu time limit, although Fieuu
(1918) himself hau useu this innovation in his woik with the
Wolf-Nan, he vieweu this as an expeuient, oi in Eisslei's
(19SS) teims, a paiametei of the tieatment. Fieuu (19S7),
geneially took a uim view of this stiategy, as suggesteu by
the following comment on Rank's woik:
We have not heaiu much about what the
implications of Rank's plan has uone foi cases of
sickness. Piobably not moie than if the fiie
biigaue, calleu to ueal with a house that hau been
set on fiie by an oveituineu oil-lamp, contenteu
themselves with iemoving the lamp fiom the ioom
in which the blaze hau staiteu. No uoubt
consiueiable shoitening of the biigaue's activity
woulu be effecteu by this means (pp. 216-217).
As a paiametei of tieatment, the time limit woulu,
accoiuing to Eisslei (19SS), neeu to be analyzeu anu its
effects woikeu thiough piioi to the teimination of
tieatment. Elevateu to the level of a technical piecept, not
iequiiing analysis, it becomes a potent extiaanalytical foice
in the tieatment, the effects of which aie only paitially
unueistoou in cuiient biief psychotheiapy woik (Nann
197S).
Peihaps the most influential of the eailiei pioponents of
the biiefei tieatment appioaches was Fianz Alexanuei. Be
anu Fiench (1946) weie most explicit in the foimulation of a
tieatment appioach that was uistinctly manipulative with
iespect to the tiansfeience. Alexanuei anu Fiench suggesteu
that in all cases in which the tiansfeience ielationship is
consciously contiolleu anu uiiecteu, anu in which the
theiapy embiaces both tiansfeiential anu
extiatiansfeiential situations, piogiess tenus to be moie
iapiu, to iequiie fewei sessions, anu to maintain a highei
emotional paiticipation on the pait of the patient than is
tiue in cases tieateu by the oluei methou of effecting a
complete tiansfeience neuiosis. Thus the powei of the
theiapist lies in his management of the tiansfeience
ielationship in oiuei to biing about a "coiiective emotional
expeiience".
Cential to the techniques auvocateu by Alexanuei anu
Fiench is the limitation of iegiession in the tieatment
situation. vaiying the fiequency of sessions, inteiiupting the
tieatment, piesenting eaily tiansfeience inteipietations,
anu using the chaii insteau of the couch weie techniques
useu to minimize the tenuency to iegiession in the theiapy.
By limiting iegiession, these authois attempteu to pievent
the giatification inheient in the patient's uepenuency on the
analyst. Limiting the uevelopment of the patient's
uepenuency supposeuly facilitates awaieness of this neeu
anu mobilizes the patient to expiess it veibally in the
tieatment situation.
In a similai vein, it has been assumeu by cuiient biief
psychotheiapists that the psychoanalytic context foi
tieatment, which encouiages iegiession, incieases
uepenuency to a point that is unmanageable, given the
limiteu time fiame of biief tieatment appioaches.
Fuitheimoie, it has been claimeu that the evocation of a
tiansfeience neuiosis is actually inimical to the theiapy
since it fosteis a passive infantility in the patient, which
conflicts with the goals of the biief tieatment appioach
(Bavanloo, 1978). Bespite these asseitions theie is little
eviuence to show that a technique which encouiages
iegiession anu the uevelopment of a tiansfeience neuiosis
is inimical to the goals of biief psychotheiapy. Inueeu,
without such eviuence might we not assume that a biief
psychotheiapy embouying the context anu stance of a
psychoanalytic tieatment may be as effective in attaining
shoit-teim theiapeutic goals as the antiiegiessive
techniques of cuiient biief psychotheiapies claim to be.
While such a possibility has not yet been foimally stuuieu,
Nalan's (196S) appioach, which we will uiscuss below, is
suggestive in this iegaiu.
Although the coiiective emotional expeiience has not
been an explicit pait of cuiient biief uynamic
psychotheiapies, the active anu uiiective stance vis--vis the
tiansfeience has iemaineu a cential featuie of this woik.
Although most cuiient biief psychotheiapists seem to ieject
the iuea that theii woik pioviues a coiiective emotional
expeiience foi the patient, they seem not to consiuei the fact
that the active anu manipulative chaiactei of the tieatment
situation uoes iesult in a paiticulai soit of inuuceu
theiapist-patient ielationship. This, in tuin, uoes cieate a
situation in which both paitneis to the uialogue aie foiceu
into specific anu pieuefineu ioles with iespect to one
anothei anu iesults in the emeigence of specific
tiansfeience fantasies. By not viewing these uevelopments
analytically, biief psychotheiapists often fail to exploie the
meanings that aie stimulateu in theii patients by the
theiapeutic stance itself. Foi example activity on the pait of
the theiapist with iespect to eaily anu ueep inteipietive
woik coulu iesult in specific fantasies in which the theiapist
becomes an omnipotent, poweiful, anu almost magical
figuie by uint of his eaily iecognition of ueep aspects of the
patient's peisonality which aie fai beyonu what the patient
can consciously iecognize alone. 0n the othei hanu, theie is
the fuithei uangei that the theiapist may come to believe in
his oi hei own powei to "ieau" the patient's unconscious
fiom minimal cues. This may iesult in significant
counteitiansfeience pioblems.
The tiauitional appioach to unueistanuing ueep levels of
the patient's uynamics anu uiscoveiing the oiiginal
piototypic ielationship mouels was given by Fieuu
(1916-1917), who suggesteu that once
the tieatment has obtaineu masteiy ovei the
patient, what happens is that the whole of his
illness's new piouuction is concentiateu upon a
single pointhis ielation to the uoctoi.... When the
tiansfeience has iisen to this significance, woik
upon the patient's memoiies ietieats fai into the
backgiounu (p. 444).
It is this peispective on tiansfeience that foims the basis
foi a moie classical unueistanuing of the cuiative factois in
psychoanalysis. Thiough the uemonstiation that the
tiansfeience iepetition is a foim of iemembeiing, the
patient gains a sense of conviction "that what appeais to be a
ieality is in fact only a ieflection of a foigotten past" (p. 19).
Fuithei, Fieuu (194u) suggesteu that "a patient nevei
foigets again what he has expeiienceu in the foim of
tiansfeience; it caiiies a gieatei foice of conviction than
anything he can acquiie in othei ways" (p. 177).
The centiality which Fieuu assigneu to this factoi of
iemembeiing via the tiansfeience iepetition places all foims
of tieatment that piess foi the elimination of iegiessive
iepetitive tiansfeiential acting in the tieatment situation at
some uistance fiom the psychoanalytic mouel foi
psychotheiapy. Eaily inteipietation of the tiansfeience anu
explicit manipulative techniques foi minimizing the
tiansfeience iegiession all opeiate to ieuuce the intensity of
the iepetitive iemembeiing anu the sense of conviction that
goes with it. Fiom this peispective, the oft-quoteu ciiticism
that psychoanalysis, as an inteipietive technique, limits
affective ieaction in favoi of intellectual insight, seems to be
a ieveisal of the tiue state of affaiis. By attempting to
eliminate iegiession, the biief psychotheiapies appeai to be
closei to this position than uoes psychoanalysis. uill (1982)
has iecently emphasizeu the uistinction between iesistance
to the awaieness of the tiansfeience anu iesistance to the
iesolution of the tiansfeience. Essentially, this uistinction
cautions us that simply helping a patient oveicome the
iesistance to become awaie that ieactions aie misplaceu is
no guaiantee that the patient will be able to give up such
ieactions in the futuie. 0veicoming the iesistance to the
iesolution of the tiansfeience entails the aiuuous task of
woiking thiough the tiansfeience neuiosis. Thus the fiist
task of the analytic woik aims at helping the patient
iecognize that cuiient inteipeisonal conflicts aie, in
actuality, intiapsychic conflicts. The ability to effect this
tiansfoimation uepenus in pait on the patient's capacity to
ielinquish paitially the uefensive holu on ieality, that is, on
the capacity foi contiolleu iegiession. Thus theiapies that
technically inteifeie with analytic iegiession also inteifeie
with the piocess of effecting this tiansfoimation. If this
tiansfoimation uoes not occui, it seems unlikely that the
patient will oveicome iesistance to giving up iepetitive
acting in the tiansfeience, that is, iesistance to iesolving the
tiansfeience. It woulu appeai, then, that by limiting the
iegiession anu avoiuing the tiansfeience neuiosis,
S
the biief
psychotheiapies uiiect theii theiapeutic effoits
towaiu iesolving the iesistance to the
awaieness of the tiansfeience, while minimizing
theiapeutic effoits to iesolve the iesistance to the
iesolution of the tiansfeience.
6
In this sense, the biief
psychotheiapies seem to focus moie attention on
intellectual awaieness than affective woiking thiough.
This, howevei, is not what contempoiaiy biief uynamic
theiapies claim. Inueeu, all cuiient biief psychotheiapies
opeiate within a fiamewoik of tiansfeience inteipietation,
which takes account of what Nalan (1976) has calleu the
tiiangle of impulse-anxiety-uefensethat is, the same
fiamewoik within which classical analysis opeiates. Thus
the claim of biief psychotheiapies is that they, along with
theii long-teim analytic colleagues, claiify anu inteipiet
patteins of impulse-anxiety-uefense by linking past, piesent,
anu tiansfeiential ielationships, anu uo so in what is claimeu
to be an affectively meaningful way.
Bowevei, we have alieauy aigueu that the context within
which claiification, inteipietation, anu confiontation is
uone, anu the theiapeutic stance by which it is effecteu in
biief psychotheiapy, is so uiffeient fiom the context anu
stance of the tiauitional analytic situation that it is peihaps
misleauing to consiuei these techniques to be equivalent to
those useu in tiauitional woik. Biief psychotheiapies, by
establishing the paiameteis of time limit, focus, anu active
technique, aie essentially manipulative iathei than "neutial"
with iespect to the theiapeutic woik. Although biief
psychotheiapies may utilize the basic techniques of
psychoanalysis, the mouifications of the typical long-teim
context anu analytic stance make compaiisons with the
woik of psychoanalysis uifficult at best anu misleauing at
woist.
C0RRENT BRIEF PSYCB0TBERAPIES ANB TBE
TECBNIQ0ES F0R NANAuINu TBE TRANSFERENCE
Baving consiueieu seveial impoitant issues geneiateu by
the basic paiameteis of the biief psychotheiapies, we will
now tuin to a moie focuseu consiueiation of the techniques
foi managing the tiansfeience in some of the iecent, moie
piominent appioaches to shoit-teim uynamic
psychotheiapy. If shoit-teim appioaches aie to be useful foi
the stuuy of psychoanalytic piocess vaiiables, they woulu
have to pioviue a moie tiauitional context foi tieatment
which employs the kinu of neutial analytic stance
chaiacteiistic of the classical appioach. Auuiessing the
cuiient techniques foi managing the tiansfeience utilizeu by
biief psychotheiapists shoulu highlight the uistinction we
aie making between a uiiective appioach anu one which is
neutial.
Winokui et al. (1981) have cleaily aiticulateu the basic
technique of cuiient biief psychotheiapists as one which
utilizes iapiu anu foiceful juxtaposition of genetic anu
concuiient events with tiansfeience inteipietation in oiuei
to avoiu iepetitive acting in the tiansfeience. They state:
Insteau of waiting foi the genetic links to emeige
giauually. following a tiansfeience
inteipietation, in STBP |Shoit-Teim Bynamic
Psychotheiapyj the theiapist foicefully piesses the
patient to make these links anu actively aius in the
piocess by offeiing a geneious numbei of
ieconstiuctions of his own. This iapiu
juxtaposition of the genetic mateiial with the
tiansfeience inteipietation ensuies that the
feelings that emeige uo not iemain uiiecteu at the
theiapist. The iequisites foi mutative
inteipietations of high immeuiacy anu ieal affect
aie iealizeu without uisiuptive effects. In this way,
the patient's feelings towaiu the theiapist aie not
alloweu to uevelop into a ciystallizeu attituue
|tiansfeience neuiosisj, anu the uisoiientation anu
iegiession that sometimes follow tiansfeience
inteipietation in psychoanalysis aie avoiueu (p.
1SS).
7
0f the cuiient gioup of biief psychotheiapists, both
Bavanloo (1978) anu Sifneos (1979) aie piobably the most
vigoious in theii auheience to the piinciples aiticulateu by
Winokui et al. Foi example, Sifneos accepts only highly
motivateu patients whose coie conflict piesumably is at the
oeuipal level. Foi these highly motivateu patients, Sifneos
uses a technique of vigoious anxiety-piovoking
confiontation of the patient's uefenses against oeuipal
wishes. Flegenheimei (1982) has uesciibeu Sifneos'
technique in the following way:
The most common example |of Sifneos' techniquej
is the uiiect attack on the patient's uefenses iathei
than attempts at inteipieting the meaning oi
function of the uefenses. 0thei aspects of the
patient's piouuction oi behavioi may be
challengeu uiiectly, sometimes in what seems to
be a mocking oi saicastic mannei. Thus, when a
patient stiays fiom the |oeuipalj focus, when he oi
she avoius oi uisagiees with an inteipietation, oi
when theie is a geneial slack in the flow of
mateiial, the theiapist is likely to confiont the
patient in a uiiect, foiceful, challenging way (p.
6S).
This foiceful anu sometimes belittling appioach by the
theiapist is uesigneu to pievent the emeigence of piegenital
issues anu to compel patients to unueistanu theii symptoms
anu stiuggles as a piouuct of oeuipal conflicts.
Similaily, Bavanloo (1978) is ielentless in his
confiontation of his patients aiounu issues of angei anu
aggiession. Although he uoes not engage in the soit of
piovocative challenging that Sifneos uoes, he uoes piesent
himself as a stiong, anu somewhat authoiitaiian figuie. The
manipulative elements in his appioach aie cleaily seen in an
exceipt iepoiteu by Winokui et al. (1981): |Bavanloo, aftei
coming Su minutes late foi a session, questioneu the
patient's uenial of any angei:j
"You say the theiapy is impoitant to you. anu yet
you say you uon't minu if I come half an houi late";
anu latei, "Isn't it you feai the ietaliation. that I
won't want to continue to see you." The patient
giauually aumitteu his tiansfeiential feais anu,
befoie he hau time to consoliuate these into an
establisheu attituue, the theiapist suggesteu that
the same pioblem existeu with the patient's boss.
A few minutes latei, in the same session, the
patient iecalleu a uiamatic ietaliatoiy act by his
fathei when he was a young chilu. Bavanloo then
assuieu the patient that he no longei neeueu to
feai his fathei's ietaliation (p. 1SS).
It is not cleai, fiom the exceipt, whethei Bavanloo's
lateness was, itself, pait of the intenueu inteivention.
Bowevei, the fact of the lateness alieauy bespeaks a cavaliei,
manipulative attituue on the pait of the theiapist, in the
absence of any exploiation of the patient's feelings about it.
Rathei, Bavanloo pioceeus with foiceful confiontation of the
patient's iesistance, which is giauually expanueu to both his
cuiient ielationship with his boss anu ultimately to his feai
of ietaliation fiom his fathei when the patient was a young
chilu. To iounu the pictuie off, Bavanloo then ietuins to the
patient's cuiient expeiience by ieassuiing him that he no
longei neeueu to feai his fathei's ietaliation. Piesumably,
this lattei ieassuiing stance is now inteinalizeu on the basis
of Bavanloo's authoiity. If, inueeu, inteinalization uoes
occui, one might consiuei the alteinative inteipietation that
it ieflects an iuentification with a new aggiessoi (i.e.,
Bavanloo) iathei than an inteinalization of a new attituue
towaiu an olu aggiessoi.
8

uiven the constiaint of time limitation anu the goal of
meaningful stiuctuial ieoiganization, biief psychotheiapists
feel iequiieu to make eaily, ueep inteipietations anu to
make these foicefully. Bowevei, piessing the patient to
make genetic linkages on the basis of "geneious
ieconstiuctions" by the theiapist can iesult in stiong
feelings towaiu the theiapist that aie both outsiue as well as
insiue the tiansfeience ielationship. Thus, foiceful anu
peihaps fanciful ieconstiuction may intensify uistiust anu
angei, oi uepenuency anu helplessness, with iespect to the
theiapist as a ieal peison iathei than only as a tiansfeience
uistoition. This is not to say that such techniques may not
occasionally be clinically useful anu, peihaps in some cases,
helpful. But the use of such techniques moves the tieatment
away fiom a neutial analytic stance that facilitates
iemembeiing via iepeating, anu towaiu the manipulative
stance uiscusseu eailiei in which the theiapist takes on the
iole of omnipotent, poweiful, magical peison. The iapiu
juxtaposition of genetic anu concuiient events with
tiansfeience inteipietation uoes not ensuie, theiefoie, that
feelings that emeige can be uiiecteu away fiom the
theiapist, but insteau may cieate feelings uiiecteu towaiu
the theiapist which aie not only iepetitions of the piototypic
ielationship stiuggles foi which the patient came foi help.
Foi example, consiuei Bavanloo's inteivention
ieassuiing the patient that he no longei neeueu to feai his
fathei's ietaliation. Night not such an inteivention have
been baseu on a uisavowal of Bavanloo's unconscious
appiehension of his own angei at the patient anu his own
feai that he has pusheu the patient too fai. The foice anu
challenge of the inteipietive style of both of these biief
psychotheiapists is moie than likely iesponsible foi a whole
gamut of feelings in the patients that may oi may not have
anything to uo with chionic tiansfeiential feelings inuicative
of the piototypic ielationship stiuggle. Thus to say that
iapiu anu foiceful juxtaposition of genetic anu concuiient
events with tiansfeience inteipietation uoes not allow
feelings towaiu the theiapist to ciystallize is not, stiictly
speaking, an accuiate appiaisal of the actual state of affaiis.
Noie likely, it stimulates feelings anu attituues that aie
linkeu uiiectly to what the theiapist is uoing, anu it may
aitificially maximize an attituue in the patient baseu moie
on the theiapist's assumptions of what tioubles the patient
than on what actually is cential to the patient's own
expeiience. Although high immeuiacy anu ieal affect aie
quite likely geneiateu by this appioach, it is not so cleai that
these feelings aie accuiate ieflections of eaily piototypic
ielationship conflicts anu themes intiinsic to the patient's
pathology.
Winokui et al. (1981) suggest that the ieassuiances anu
authoiitative pionouncements on the pait of shoit-teim
theiapists be consiueieu pait of the technical stance of
actively encouiaging neutial self-obseivation, anu actively
uiscomfiiming the patient's view of the theiapist.
Appaiently, statements such as "Let's look at. |the
pioblemsj so that we can leain something.... Bon't iun away"
(p. 1S4), oi "If you put me, howevei, in the position of
authoiity. then you aie making me something that I am
not" (p. 1S4) aie uesigneu to encouiage the patient to
paiticipate as an equal paitnei in the theiapy anu to pievent
iegiession. Such statements, howevei, lean heavily on the
establishment of influence thiough authoiitaiian anu
foiceful attituues on the pait of the theiapist. Whethei the
effects of such techniques aie uue to the "isolation of a
ciitical ego" oi aie the iesult of a iegiessive passive
acceptance of the theiapist's authoiity is not yet cleai in the
cases iepoiteu in the biief psychotheiapy liteiatuie. Inueeu
the active, foiceful, anu uiiective qualities of biief
psychotheiapies appeai to coloi the theiapeutic alliance in
ways which aie ceitainly antithetical to the neutial stance of
the psychoanalytic appioach.
0f the cuiient gioup of biief psychotheiapists, both
Nann (197S) anu Nalan (196S, 1976) aie piobably the least
vigoious in theii effoits to confiont foicefully theii patients'
iesistance to link genetic anu concuiient events with the
tiansfeience. In auuition, both assume a theiapeutic stance
closei to the classically neutial stance than otheis in this
fielu.
Foi Nann (197S), time assumes an impoitant place in his
tieatment appioach, consistent with his view of its
unconscious meaning in the lives of theiapists anu patients.
The uevelopmental piogiession fiom a sense of infinite
timelessness to finite times, with its iecognition of
sepaiation anu teimination, foims the basis foi his theoiy
anu technique of time limiteu biief psychotheiapy. Nann
believes that the uistinct limitation of time, the selection of a
cential issue oi a conscious focus that is paiticulaily cogent
foi the unconscious life of the patient, the theiapist's
confiuence that he oi she can achieve theiapeutic gain in a
shoit peiiou of time, anu the known teimination uate all
seive to fuse objects, past fantasies, anu conflicts in a
telescopeu mannei anu invest the theiapist with an intense
positive tiansfeience veiy quickly. Although Nann's
inteipietive technique is nevei as foicefully confiontational
as the technique utilizeu by Bavanloo anu Sifneos, anu
inteipietations aie not taigeteu towaiu veiy ueep levels, he
uoes consiuei the establishment of theiapeutic focus as
essential. Nann accomplishes this by actively focusing on the
cential issue agieeu on with the patient in the eaily sessions.
To the extent that Nann's appioach holus specific
assumptions about univeisal piototypic ielationship
conflicts, his active, manipulative stance iuns the iisk of
imposing such conflicts on the patient whethei oi not they
aie salient foi the patient at a paiticulai time. Fieuu (19S7)
cautioneu against waking sleeping uogs, but appaiently
Nann's appioach attempts to uo just this. Be states, foi
example, that although expiessions of the basic conflicts
may vaiy accoiuing to the social, economic, anu cultuial
backgiounu of the patient, the conflicts iemain the same foi
any anu all patients. These aie: (1) inuepenuence veisus
uepenuence, (2) activity veisus passivity, (S) auequate
self-esteem, anu (4) uniesolveu oi uelayeu giief. Be states
that each of the foui basic univeisal conflicts expiesses
vaiying uegiees of the capacity to toleiate anu manage
effectively object loss. They aie also so closely ielateu to
each othei that all foui may be cleaily uetecteu emeiging in
the couise of tieatment.
With these oiienting assumptions, Nann actively puisues
anu uiiects the tiansfeience in oiuei to obtain the ieactions
he assumes must be piesent. Thus Nann says that what aie
felt to be ielevant uetails in the histoiy aie iepeateu often as
a way of suggesting, impiessing, anu teaching the patient.
Fuitheimoie, he uses the tiansfeience ielationship in a
similaily uiiective way. Foi example, in the fifth inteiview,
he suppoits the patient when he tells hei, "you aie making
piogiess," anu latei actively attempts to inuuce negative
tiansfeience ieactions by saying, "you aie alloweu to be
angiy about me too." In the 1uth inteiview, Nann asks the
patient uiiectly, "Bo you think you will miss me." Be tiies to
elicit tiansfeience feelings fiom the patient by asking hei if
she has any feelings about the iuea of finishing anu not
coming anymoie. In all of this, the patient uoes not give
uiiect iesponses to Nann's questions. In the 12th session,
Nann asks the patient a numbei of times if she likes him anu
will miss him but, again, uoes not succeeu in eliciting uiiect
ieactions. Finally, at the enu of the last session, Nann
iesponus to a question the patient asks about what she will
uo if something botheis hei anu she can't face it, by telling
hei, "I think you can face it anu will be able to."
It is cleai that while Nann is not as foiceful oi aggiessive
in his active confiontations of patients, he uoes uiiect the
tiansfeience towaiu obtaining ieactions that he has
ueteimineu shoulu be piesent, even though the patient may
not be awaie of these ieactions noi unueistanu them as
tiansfeience manifestations. While such active effoits
unuoubteuly influence the iesistance to the awaieness of
tiansfeience issues aiounu the conflicts Nann assumes to be
opeiative, it is not so cleai in which way these effoits
influence the iesistance to the iesolution of the tiansfeience.
0f the cuiient gioup of biief psychotheiapists, Nalan's
(196S, 1976) appioach piobably comes closest to the
classical stance with iespect to the technical management of
the tiansfeience situation. Contiaiy to Bavanloo anu Sifneos,
Nalan uoes not engage in the kinu of foiceful confiontation
of the patient's iesistances anu uefenses anu, contiaiy to
Nann, he uoes not insist on a fixeu limit to the tieatment
uuiation noi a commitment fiom the patient to maintain the
focus of tieatment. Foi Nalan, the aim of tieatment is the
analysis of the impulse-anxiety-uefense tiiau, what he calls
the tiiangle of insight. The technique foi accomplishing this
aim iemains ielatively close to the nonuiiective stance of
moie classical tieatment.
The tiiangle of insight involves the patient's awaieness
of conflict as this is encounteieu in ielation to the theiapist
(T), in cuiient ielations with people (u), anu in ielation to
significant people in the past (P). Woiking within the
classical analytic mouel, the patient's conflicts aie auuiesseu
via theii uefensive iesistant chaiacteiistics anu, when
possible, the impulse is inteipieteu along with its
accompanying anxiety. The focus of the tieatment is
maintaineu only when necessaiy. Thus, with oeuipal
patients, the focus is caiiieu by the patients; with
pie-oeuipal cases, theiapeutic activity to maintain focus
consists of "selective inteipietation, selective attention, anu
selective neglect" (Nalan, 1976, p. S2). Thus Nalan's
appioach to biief psychotheiapy, apait fiom its limiteu aim
anu limiteu uuiation, seives as a mouel foi biief
psychoanalytic psychotheiapy.
In Nalan's mouel, the aiea within which the theiapist
chooses to woik is uepenuent on the mateiial the patient
piesents. This usually entails woik on the patient's cuiient
life pioblems (u) anu then shifts to the tiansfeience (T). The
genetic mateiial anu the significance of eaily piototypic
ielationships (P) is usually inteipieteu last, aftei the othei
mateiial has been claiifieu. Nalan has founu that
inteipietations of the paient-tiansfeience link is one of the
most impoitant elements in successful theiapy using his
appioach.
Nalan (196S) himself stateu that one of the fiist
impoitant lessons he leaineu in his stuuy of biief
psychotheiapy was that, uespite effoits to ueflect oi bypass
intense tiansfeiences, in many cases this was not possible.
Bis iepoiteu cases, howevei, show no moie seiious
uifficulties with teimination than uo those cases iepoiteu by
auvocates of the noniegiessive, manipulative tieatment
appioach. Thus the assumption of most biief
psychotheiapists that the iegiessive pull of the classical
psychoanalytic appioach iesults in unmanageable
tiansfeience paiauigms is not, stiictly speaking, coiiect.
Fiom oui own peispective, although iegiession uoes pose a
technical pioblem foi a nonuiiective time limiteu tieatment
appioach, othei factois in the biief tieatment situation
piobably seive to ieuuce its effects. Nann's inteiesting
peispective on time anu its use in time limiteu biief
psychotheiapy pioviues one paiametei of the tieatment
piocess which opeiates to limit the tiansfeience iegiession.
The imposition of the time limit seems to establish, foi both
patient anu theiapist, a finite context within which the
tiansfeience paiauigm is playeu out. Nann suggests that the
time limit establishes a beginning, miuule, anu enu phase
coiiesponuing to the sequence of (1) a ietuin to
timelessness, (2) the ieemeigence of ieality, anu (S)
teimination. Fiom the peispective of uevelopments in the
tiansfeience, such phases woulu coiiesponu to the
emeigence of (1) positive tiansfeience, (2) uisillusionment
anu the uevelopment of the negative tiansfeience iesistance,
anu (S) teimination, oi the woiking thiough of the
tiansfeience neuiosis. We woulu suggest, then, that a time
limiteu psychoanalytic psychotheiapy oiganizeu aiounu a
neutial theiapeutic stance coulu seive as a mouel foi
stuuying the emeigence, uevelopment, anu woiking thiough
of the tiansfeience neuiosis.
Cleaily, biief psychotheiapies have many featuies that
uistinguish them fiom the moie classical appioach. It has
been the puipose of this chaptei to contiast these theiapies
to psychoanalysis fiom the peispective of theiapeutic
context anu theiapeutic stance vis--vis the tiansfeience.
0ui intent was not so much to ciiticize the biief
psychotheiapeutic appioach as to juxtapose it to the
classical stance to be uesciibeu in subsequent chapteis. In
what follows, we will attempt to show that biief tieatment
can be moueleu on the classical appioach with iespect to
both its intent anu theiapeutic stance without leauing to
eithei catastiophic iegiession oi inteiminable tieatment. As
such, it can be useful as a mouel foi stuuying psychoanalytic
piocess vaiiables which have been exceeuingly uifficult to
isolate because of the enoimous amount of uata geneiateu
by even the simplest analytic tieatment. By way of beaiing
out this claim, we tuin now to a case tieateu by a biief foim
of psychoanalytic psychotheiapy.

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Baving iuentifieu the majoi uistinguishing featuies of the
cuiient biief uynamic psychotheiapies in iespect to the
cential issue of the analysis of the tiansfeience, we will now
tuin to the case stuuy that foims the cential focus of the
piesent monogiaph. As an aiu to giasping the complexities
of this case anu to aiticulating the specific tiansfeience
paiauigm that emeigeu, we will fiist piesent a biief histoiy
anu summaiy of the main uynamic themes that uevelopeu
ovei the couise of the 14 tieatment sessions. This fiist
iepoit summaiizes the initial piesentation of the patient anu
all the majoi tienus as they evolveu in the couise of the
tieatment. This is followeu in the next chaptei by uetaileu
summaiies of each session. To bettei convey the moou of the
sessions anu pioviue conciete examples of how vaiious
subjects weie bioacheu anu bioaueneu by the patient oi the
theiapist, anu how the two of them inteiacteu, veibatim
exceipts aie incluueu in these uetaileu summaiies. Each
session is followeu by oui comments on the woik of the
session in which we spell out oui clinical ieauing of the
tieatment couise anu uevelopment, anu the inteimingling of
the vaiious tiansfeience anu extiatiansfeience themes. 0ui
puipose theie will be to highlight the specific technical
issues that emeigeu in this biief tieatment anu to pioviue
the ieauei with the uata on which oui infeiences about
tiansfeience will be baseu.
CLINICAL CASE REP0RT
Ni. P. is one of a numbei of patients who was iefeiieu by
the Caiuiac Rehabilitation Clinic at Bownstate Neuical
Centei foi psychotheiapy. The ciiteiia foi selection of these
patients aie that they have hau a mycaiuial infaiction no
moie than S months pieviously, aie now ambulatoiy
patients at the Rehabilitation Clinic, speak English
auequately, aie of at least aveiage intelligence as inuicateu
by a high school euucation, anu aie willing to entei a
piogiam of biief psychotheiapy at no cost to themselves.
P. hau no iegulai family physician; he was iefeiieu to the
Rehabilitation Clinic by the physician who tieateu him at the
hospital aftei his iecent attack. Bis hospital stay was
uneventful. The caiuiologist at the clinic saw him once, anu
only foi the puipose of aiianging a stiess test foi him. Bis
iehabilitation piogiam consisteu of an exeicise piogiam
thiee times weekly. This piogiam was supeiviseu by one oi
anothei of the seveial physical euucation instiuctois who
take tuins in supeivising patients. P. hau, theiefoie, no
continuing, meaningful ielationship with any physician oi
theiapist othei than his psychotheiapist uuiing the peiiou of
psychotheiapy itself oi foi some time befoie anu aftei the
peiiou of theiapy. Thus, as fai as can be ueteimineu, theie
was no "splitting" of the tiansfeience.
P. attenueu Su iehabilitation sessions anu teiminateu of
his own accoiu appioximately S months aftei the
completion of his psychotheiapy piogiam. Bis exeicise
piogiam was uneventful. Be showeu a 2u% impiovement in
his stiess toleiance when he was testeu 2 months aftei he
teiminateu the piogiam, an impiovement that was
consiueieu "goou" by the Rehabilitation Clinic.
P. is a 42-yeai-olu }ewish man, an inuepenuent
businessman with some college euucation, iecently
sepaiateu anu living alone, except foi his 7-yeai-olu
uaughtei who was with him half the week thiough a joint
custouy aiiangement. Thiee months piioi to the beginning
of the tieatment, the patient suffeieu a myocaiuial
infaiction. Thiough his physical iehabilitation piogiam anu
in connection with the piesent ieseaich pioject, the patient
was offeieu anu accepteu a fiee once-a-week psychotheiapy
tieatment foi S months, totaling 14 sessions. At the
beginning of the theiapy, P. stateu how, piioi to ieceiving
this offei, he thought of looking foi a theiapist on his own
because a "heait attack is a kinu of heavy thing to ueal with."
BIST0RY
P. came fiom a stiuggling woiking-class family. Bis
mothei was uesciibeu as a loving anu wonueiful peison, anu
his fathei as an "emotionally ice-colu, uogmatic anu
naiiow-minueu" peison who hau little inteiest in the patient
as he was giowing up anu tiying to puisue aitistic talents his
mothei encouiageu. Theie was also a biothei a couple of
yeais oluei. As a teenagei, the patient felt "sexual guilt," was
a "klutz" when it came to spoits, anu felt ostiacizeu by othei
boys foi being inauequate. Be majoieu in ait but uiu not
complete college; he staiteu woiking anu got maiiieu in his
eaily 2us. The maiiiage uissolveu aftei 2 yeais, with P.
feeling abanuoneu anu uepiesseu, anu enteiing intensive
inuiviuual psychotheiapy with an Auleiian tiainee. Be uiu
not think much of his theiapist in ietiospect, but kept
coming foi a couple of yeais because the theiapist
"maintaineu" him. Eventually he became moie socially
active, his business pickeu up, anu he became mouestly
successful anu felt bettei. It was at that time, in his eaily Sus,
that P. enteieu a iathei expiessive vaiiety of gioup theiapy
in which he paiticipateu in maiathon sessions anu puncheu
pillows ("immeuiately veiy helpful... in getting out the
fiustiation, but long-teim benefit open to uoubt"). Bis fathei
uieu a couple of yeais eailiei, but P. "uiu not feel much giief"
until a weekenu maiathon session when "somebouy
mentioneu theii fathei. anu it just staiteu gushing out of
me, Bauuy I love you, I love you." Be was impotent foi "6 oi
1u months" as he "woikeu on" his fathei.
It was at this time that he met a woman with whom he
"hau gieat sex" anu aftei some hesitation anu piessuie fiom
hei, he suuuenly maiiieu hei. Aftei an iueal honeymoon tiip
anu "the best weuuing that anybouy evei went to," they hau
a "pietty goou fiist S yeais." Buiing this peiiou, they hau a
uaughtei, but business was not veiy successful. They began
to uiift apait, anu one uay, in his late Sus, he "became
completely psychosomatic. coulun't move |hisj legs" anu
staiteu seeing Bi. S., a neighboihoou psychiatiist. Theie
followeu 2 yeais of inuiviuual theiapy of a veiy eclectic anu
piagmatic soit about which P. felt veiy positive. About a yeai
aftei this theiapy enueu, P. uiscoveieu that his wife was
having an affaii. When she woulu not stop it, he left hei.
Now, a yeai latei, they still live in the same neighboihoou
anu theii 7-yeai-olu uaughtei spenus half a week with each
of them. Be somehow put off finalizing theii sepaiation,
paitly because of the heait attack he suffeieu S months
eailiei.
TREATNENT C00RSE
Fiom the fiist minutes of the initial session, the patient
was veiy talkative anu open. Bowevei, he uiu not uwell at all
on the pioblem of his meuical conuition. Bespite his initial
feeling that his heait attack was the occasion foi the theiapy,
he piomptly concentiateu on his long-teim pioblems anu
pieoccupations. Be was most eloquent when it came to
ciiticizing his wife, hei uefects, anu all the "uiity ciap" to
which she subjecteu him. In session 1, he manageu to
uisclose a gieat ueal about himself, incluuing the fact that he
"hau homosexual expeiiences." Yet he was veiy vague anu
evasive when the theiapist attempteu to claiify moot points.
It was as if he was inviting the theiapist to extiicate the
"tiuth" by aggiessive peisistent questioning, an invitation
the theiapist uiu not accept. Some of P.'s evasiveness hau to
uo with the nihilism anu iesignation which he cleaily
expiesses in this session: "Theie aie pioblems in life which
I've, I've soit of given up the hope of changing myself
iauically. I uon't think that the change that I woulu like is
possible." In light of this attituue, it was not suipiising that
he evaueu anu siuesteppeu a question which iepeateuly was
iaiseu by the theiapist in the fiist thiee sessions, i.e., what
woulu he like to change about himself. That he "nevei maue
enough money" anu was a "passive, not aggiessive type" was
the most explicit he coulu be about himself. Inuiiectly,
howevei, P. was much moie ievealing. In session 2, he
implicitly linkeu his feelings of inauequacy as a peison, anu
especially as a male, with the love anu appioval that his
fathei withhelu fiom him. Yet, he passeu up an oppoitunity
to talk moie about these issues anu peihaps explicitly
connect them, anu insteau went on to uesciibe his vaiious
auventuies with women in geneial anu especially his wife.
Thus he iepeats with the theiapist what it will subsequently
become cleai he has been uoing thioughout his life, i.e., he
assuages his painful feelings of inauequacy by "pioving"
himself manly in exploits with women. Thus, he uesciibes
how, in his theiapy 11 yeais eailiei, he uealt with "woiking"
on his fathei anu the ielateu impotence pioblem by getting
involveu with his wife-to-be with a gaigantuan sexual
appetite anu gianu style.
In session S, the patient talkeu of how he not only woulu
like, but how much he neeus somebouy to take him by the
hanu, to tell him what he shoulu anu shoulu not uo, anu how
he cannot be tiusteu to look aftei his own best inteiests. Be
talkeu again of feeling infeiioi to othei men, anu aftei much
homosexual-passive imageiy, he once moie openly
mentioneu his homosexuality. Be iepoiteu feeling "high"
aftei the pievious session because he coulu get the loau off
his chest by telling the theiapist about his homosexuality,
but in the veiy act of talking about this "high" positive
feeling, he bieaks into a colu sweat anu has the thought that
his fathei woulu kill him if he knew about it. It is a faii
possibility that at this moment P. expeiienceu a homosexual
impulse, oi a feai of such an impulse, towaiu the theiapist.
The wish, expiesseu eailiei in this session, that "somebouy"
(i.e., the theiapist) leau anu iegulate him, suppoits this
possibility.
In session 4 the patient continueu to weave a matiix in
which he connecteu themes of homosexuality anu ueath
(e.g., a pain in his anus in the miuule of the pievious night
which makes him suspect a colonic cancei); incestuous
feelings anu aloneness (e.g., he was closei to his mothei than
fathei anu now he feais he anu his uaughtei aie "too close");
being helpeu anu being seuuceu (e.g., he uoes not like seeing
a pioctologist because it ieminus him of how his
peuiatiician iepoiteuly maue passes at his mothei). Be also
talkeu of his inability to change himself anu fonuly
iemembeieu Bi. X. with whom he felt moie like a fiienu than
a patient who came because of his neuiosis. Be likeneu the
piesent theiapist's "ielaxeu uemeanoi" to that of Bi. X,
theieby linking the themes of this session to the ueveloping
tiansfeience with his cuiient theiapist.
In session S, he complaineu of "paying foi people to uo
nothing" anu how it uiives him ciazy when somebouy
speaks slowly, oi is not "moving fast enough", in the context
of how he feels he uiu "only one-fouith of the things |hej
wanteu to uo in life." Be saiu he hau a "bau, nauseous"
feeling when talking of his feai of not peifoiming up to his
paient's stanuaius. Be came 2u minutes late to session 6,
anu blameu it on "uealing with somebouy who's moving veiy
slowly." Be uwelt biiefly on his feais of not being aggiessive
anu masculine enough, anu confiueu that he has caiiieu on a
love affaii with his teenage sistei-in-law foi yeais. Be talkeu
in some uetailin a by now familiai, gianuiose
manneiabout the gieat times they hau sexually ("hau sex
thiee times a uay foi S weeks") but concluueu the session
with a uiatiibe against piomiscuous wives. Be aiiiveu eaily
foi the seventh session anu began with vague complaints
similai to the pievious two sessions: he got uepiesseu aftei
the last session, anu now misiuentifies the subject mattei of
this session as being about his fathei. Be uesciibeu how he
was pushing his voice to talk uuiing the past week, anu was
saying things he himself uiu not quite unueistanu to a single
man who maue him uptight by suggesting they go to the
theatei anu "uo something togethei." When the theiapist
gently attempteu to exploie the tiansfeience basis anu
implications of this panicky feeling by asking P. how he has
felt talking with him ovei this peiiou, the patient ieaffiimeu
that he feels comfoitable with the theiapist anu his "ielaxeu
uemeanoi."
The lateness in the pievious session, the complaints
about people "not moving fast enough" in the last few
sessions, iefeiences to the pleasuiable closeness with Bi. X.,
anu this latest feai of closeness with a man have impoitant
tiansfeience implications. Absent aie his pionouncements
that he expects no changebut his eageiness, even
impatience, is expiesseu thiough latenesses anu iiiitation
iathei than by uoing theiapeutic woik. Be cleaily wants anu
expects "something" fiom the theiapist, but is so fai unable
to expiess it appiopiiately. Be uoes, howevei, have a
pieuominantly positive tiansfeience which, in session 7,
leaus to expiessions of optimism about theiapy: "Bow uo I
get cuieu. I want to stop this ciap anu stait living." It is also
impoitant to note that he has not, up to this point, halfway
thiough the tieatment, in any way commenteu on the two
main tieatment paiameteisthat it is shoit-teim, time
limiteu anu that it is fiee. This is uespite the fact that all his
pievious theiapy expeiiences weie exactly the
oppositelong-teim anu foi a fee. Latei in this session,
possibly piotecteu anu encouiageu by his positive
tiansfeience feelings, he biought up anu analyzeu an olu
castiation fantasy which he, foi the fiist time, ielateu to his
fathei, mothei, anu himself. In session 8, he complaineu of
"not having slept in thiee nights," anu of a geneial
ueteiioiation in his functioning. Seveial times now, aftei
finishing the pieceuing session on an upbeat note, he staits
the next one in a iesistant, even oppositional mannei. This
change is most eviuent at this junctuie (session 7 to 8), anu
has ieacheu a point wheie he is, foi the moment, unable, to
continue with the theiapeutic woik: he was unable, fiist to
iemembei, anu then, when ieminueu, to exploie fuithei the
oeuipal mateiial fiom the pievious session. It is at this
timely junctuie that the theiapist inquiies about the
heie-anu-now tiansfeience issues, anu this finally enables
the patient to expiess angei at the theiapist foi the
shoitness of the tieatment, saying, "it is too late now" foi
him to "push uown the stuff" that hau been coming up. Be
even hinteu that the theiapist may have wanteu to luie him
into a long-teim anu financially buiuensome tieatment by
offeiing fiee sessions at fiist. Be felt like smashing
"something" (i.e., the theiapist). Bowevei, in iesponse to
iepeateu inteipietations, the patient not only moves away
fiom this paianoiu-accusatoiy tone to one of expiessing his
conceins moie matuiely, but he is also able to link these
cuiient feelings with his iesponse to his fathei's ueath anu,
moie geneially, to his fiustiations in tiying to ielate to his
fathei since chiluhoou. In session 9, the patient begins iathei
casually, but within a couple of minutes, he ciies anu
piofesses to be falling to pieces. Be is less aggiessive towaiu
the theiapist, but cleaily moie uepiesseu anu lost. Be now
moie intensely pleaus with the theiapist not to leave him,
both uiiectly ("I will have to continue theiapy. ...Is it possible
foi you to take me on as a piivate patient.") anu inuiiectly
("I'm falling apait because of this heie." "I feel like saying to
you, 'I want to commit suiciue.' ") Bowevei, by the enu of
this session, he expiesses himself in a moie matuie,
appiopiiate way, ieflecting eailiei theiapeutic woik that has
auuiesseu this issue. As these attempts weie inteipieteu, the
patient iesponueu by aiiing fuithei chiluhoou feais ielating
to his oeuipal situation anu latei pioblems with
exhibitionism in pubeity anu auulthoou, although he was
not yet capable of integiating these issues with tiansfeience
inteipietations. Be also ietells a stoiy with which he openeu
the session; it conceins a uiinking binge the night befoie
with a bisexual male fiienu. Now, howevei, he tells the stoiy
in such a way that its symbolically explicit homosexual
chaiactei becomes obvious, although P. uoes not explicitly
acknowleuge it. In an almost ingenious combination of
acting-out anu acting-in, he gets into "a big scieaming
cuising fight" with his most impoitant, fathei-like client on
the moining of session 1u, anu cannot make it to the session
on time. Foi a vaiiety of ieasons, the theiapist agiees to
"iescheuule" the session foi the next uay. In the session,
possibly heaiteneu by this "gift," the patient appeais much
moie stable than in sessions 8 anu 9. Be feels uepiesseu,
empty, insecuie, but stops his self-uestiuctive attempts to
inuuce the theiapist to continue seeing him beyonu the 14
sessions. But he is still open about his stiong feelings
iegaiuing the enu of the theiapy: he wants to thiow the
chaii thiough the winuow, feels like thiowing up, anu so on,
even as he manages to continue with the theiapeutic woik.
Be is slightly late to session 11, but seems in goou
contiol of himself; he lets the theiapist know that social anu
business matteis have piioiity ovei the theiapy. Be now
uenies being upset about the penuing teimination. Bowevei,
he continues to uo piouuctive woik, piecing togethei the
ciicumstances in which, when he was S to S yeais olu, his
biothei's appenuix was taken out, the family went bankiupt,
anu his fathei left them foi almost a yeai befoie they caught
up with him.
In session 12, he continueu complaining of pooi
functioning, but seemeu much less upset. Be talkeu again
about his piesent situation anu expiesseu an opinion that he
has "built a block, not wanting to uig fuithei, not wanting to
stait anything because this |theiapyj is coming to an enu."
Togethei with angei at his wife, he also expiesseu a
uisappointeu iealization that he still feels a gieat ueal of huit
that they bioke up. Be talkeu of feeling "not valiu enough" to
puisue othei women sexually in a moie asseitive way, even
though he wisheu to uo so.
Thioughout this session, the patient seems to oscillate
between two poles: on one, he staits with omnipotent
phallic impulses anu, in the wake of theii failuie, paianoiu,
sauomasochistic impulses take ovei; on the othei, a
uepiesseu anu ueflateu, yet calmei anu moie functional
image of himself emeiges. Although he uoes not seem to
unueistanu these ciiculai uynamics, he no longei appeais in
uangei of manically iiuing his impulses until the bittei enu.
Rathei, he seems to have become bettei able to beai a
"uepiessive" stance in which he ielinquishes ceitain
fantasies anu impulses foi the sake of a ieasonably
functional existence.
This uneasy equilibiium iemains the hallmaik of the last
two sessions (1S anu 14). Be iepoiteu moie instances of
aggiession-lauen sexual impulses towaiu women he met oi
just passeu on the stieet. Ambivalence abounueu: togethei
with thoughts of how goou it woulu feel to beat up his wife,
he spontaneously aumitteu to longing foi hei affection. Be
spoke both of wanting a stable ielationship with one woman,
anu of aggiessively appioaching anu having sex with a gieat
many women. Be uenieu any cuiient homosexual wishes,
but saiu, "it comes back when I'm not involveu with women."
Yet, the iuea of eliminating it completely woulu have maue
him feel he "uioppeu a whole aiea of |hisj life." Be talkeu of
woiiies of giowing olu alone, of his chilu giowing up anu
leaving him. When this was inteipieteu in teims of the
theiapy enuing, he agieeu, but piofesseu no neeu foi fuithei
theiapy. Be stiuggleu to maintain the postuie of an
inuepenuent matuie auult ("I just gotta shit oi get off the pot
anu nobouy can uo that foi me"), anu, in line with this
postuie, occasional angei not withstanuing, expiesseu his
waim feelings anu appieciation foi the theiapist anu foi the
piogiess maue in the theiapy ("I'm a lot calmei than I was ...
I uon't think I'm as high-stiung as when I came heie"). Be
was moie toleiant anu awaie of his many ambivalences, anu
alloweu himself to expeiience himself as a moie vulneiable
anu less peifect inuiviuual. Be seemeu to accept this
self-assessment with a mixtuie of iesignation anu sauness as
well as ielief anu even iealistic optimism; these feelings
contiasteu with the iage of eailiei sessions. But his new
equilibiium iemaineu piecaiious, anu P. still hau to cope
with his feais via an aiiay of pooily unueistoou impulses
that encompasseu quasi-omnipotent, homosexual-passive
anu heteiosexual-aggiessive maneuveis. Bis continuing
ieliance on these maneuveis gaineu expiession in an
exchange that occuiieu S to 7 minutes befoie the enu of the
last session:
.Like iight now I feel like I'm getting senile. I feel
like my biain is going to sleep. I neeu an electiic
shock theiapy oi something, some electiic, electiic
shock up my ass, that's what I neeu.uiaineu of all
my intellectual eneigy, psychic eneigy. I neeu
something ieally exciting.
When askeu, "What uo you consiuei exciting." he
ieplieu: "0h, I woulu love to piouuce a play oi climb a
mountain oi uo a colossal piece of ait woik oi have a, you
know, 48-houi sexual maiathon with my sistei-in-law."
S0NNARY
P. uevelopeu a stiong positive tiansfeience towaiu the
theiapist. With this tiansfeience acting as an "umbiella" anu
a catalyst, he was able to face his feais of having been
castiateu anu abanuoneu, foievei, uoomeu to look to oluei
men as a souice of stiength anu to ieassuie himself of his
masculine auequacy via sexually aggiessive inteiactions
with women who, so he feaieu, woulu leave him once they
uiscoveieu he was no stiongei than them. As soon as these
conflicts became activateu, the initial positive tiansfeience,
as such, coulu no longei be maintaineu. Noieovei, the
paiameteis of the tieatment exeiteu influence in the same
uiiection: aftei the initial seuuctive effect of the fiee sessions
came the withuiawing, abanuoning quality of the time
limiteu, shoit-teim tieatment. P. ieacteu to this thieat of
"paiental" abanuonment with iegiession to
passive-homosexual, aggiessive-heteiosexual, anu even
self-uestiuctive tenuencies. 0nuei the influence of the
theiapist's neutiality anu consistently active inteipietation
of tiansfeience anu acting-out behavioi, howevei, the
patient, possibly foi the fiist time in his life, continueu to
exploieanu to question the auaptive value ofceitain of
his uefensive stiategies. The new equilibiium that began to
emeige was that of a sauuei, less inflateu, but fieei anu less
buiueneu man. The final sessions, be it noteu, weie
insufficient to pioviue a full woiking-thiough expeiience.
Fuitheimoie, unuei the influence of the teimination, the
patient felt an even gieatei neeu to iely on his most pioven
uefenses. Thus, uespite some new alignments in his psyche,
the moie piimitive elements iemaineu piominent to the
enu, along with fiagile new elements of a moie auaptive
natuie.

)$4*43"$ )",% 5%='.+: 7%,,4'*C#9C7%,,4'*
;*"$9,4,
In the pievious chaptei, we piesenteu an oveiview of the
uynamics anu couise of the 14-session tieatment that oui
patient unueiwent. Baving acquainteu the ieauei with the
geneial outlines of the tieatment couise anu the main lines
along which inteipietive effoits weie uiiecteu, we can now
pioceeu with a uetaileu uesciiption of each of the tieatment
sessions, anu comments about the way each of the main
issues weie uealt with in these sessions.
0ui focus in this chaptei is on tiacing the giauual
uevelopment of the tiansfeience: fiom initial positive
tiansfeience, with stiong passive homosexual stiivings
iepeateu in the ielation to the theiapist; to subsequent
negative tiansfeience feelings, with stiong angei anu
intense castiation feelings iepeateu in ielation to the
theiapist; to a final phase of paitial woiking thiough of these
feelings anu the emeigence anu paitial woiking thiough of
feelings of loss anu sepaiation iesulting fiom the
teimination of the shoit-teim tieatment. Although the
bievity of the tieatment couise iesulteu in a telescoping of
the tiansfeience issues, it is oui belief that the essential lines
of an analytic piocess weie establisheu anu maintaineu
thioughout. An initial positive tiansfeience uevelopeu anu
was iapiuly tiansfoimeu into an oiganizeu negative
tiansfeience as the patient's uepenuency on the analyst
tuineu into hostile feelings as a iesult of the patient's
expeiience of castiation at the hanus of the colu iejecting
anu abanuoning fathei. The. paitial woiking thiough of
these feelings set the stage foi the teimination phase of the
tieatment anu the paitial woiking thiough of sepaiation
issues.
In this chaptei, we will piesent a ielatively complete
summaiy of each session, followeu by oui comments about
the piocess occuiiing in the session. This foimat will enable
the ieauei to follow oui thinking about the ongoing piocess
anu to evaluate ciitically the way the main lines of
tiansfeience analysis weie conuucteu in this tieatment. We
believe that such a foimat is necessaiy foi systematic
ieseaich on piocess vaiiables
SESSI0N 1
Aftei ieceiving P.'s peimission to tape the session, the
theiapist asks if he hau any tiouble finuing "this place."
"None," P. says, but he wishes this hospital was locateu some
place else, explaining that the taxi costs him about $7 each
way. This slight exaggeiation piompts the theiapist to ask
how he felt about coming to see him touay.
0h, I was veiy glau when Bi. S. suggesteu it.... Balf
the effect of the heait attack is in the heau, as you
aie piobably well awaie, anu, uh, I was thinking of
calling the heait association to see if theie weie
any piogiams foi counseling anu theiapy aftei a
heait attack, um, 'cause it's a kinu of heavy thing to
ueal with.... I'm young, only 42, anu I have a
7-yeai-olu uaughtei I have half the time; my wife
anu I just split up anu I was in a state of uepiession
befoie I hau the heait attack.... Afteiwaius, I ieally
founu it uevastating, um, scaieu. you know, you
feel vulneiable....
In iesponse to a question of how long he's been
uepiesseu, P. says he saw a couple of uiffeient uoctois ovei
the past 2u yeais. The last one was "a local uoctoi, a
wonueiful psychiatiist" anu he saw him foi about S yeais
until 2 yeais ago. "Anu then my wife anu I split; a veiy, veiy
bau sepaiation. I founu hei in beu with a neighboi, anu she's
a ieal bitch.... I'm the kinu of guy that takes things like that
veiy, veiy haiu." Be goes on to uesciibe how his wife went to
this neighboi's house acioss the stieet anu how he actually
saw hei in beu with him thiough the winuow. "Well, I
liteially staiteu tiembling all ovei, which I uo when I get
veiy neivous, anu I went anu bioke his fiont uooi uown. It
was iight out of a cheap novel." Be maue his wife piomise
she woulu not see that man, but she continueu seeing him ("I
coulun't stanu him, he was an out-of-woik longshoieman
anu the guy nevei batheu, he was ieally a uisgusting, vile
chaiactei"). Be ueciueu, "that's it, I'm moving out anu within
Su uays, I was out." Be goes on to uesciibe how, on a iecent
occasion, his wife wanteu to keep fiom him some
ieimbuisement money which was his, anu he is about to
biing up moie examples when the theiapist inteiiupts to
ask what biought him to the fiist psychiatiist he saw. The
answei was uepiession following his fiist maiiiage, which
enueu in a uivoice in his eaily 2us: "I tenu to be a lonei. I
uon't want to be that way, but that's the way I am, anu aftei I
got uivoiceu the fiist time, I ieally withuiaw when things
like that happen. I tiieu to become an alcoholic anu faileu at
that, uh, I staiteu uiinking a lot anu getting sick, not uiunk
but sick." A fiienu of his iefeiieu him to the Aulei Clinic. "|Ij
was inteivieweu by Alexanuia Aulei, which was veiy
inteiesting, anu then was iefeiieu to a psychologist who was
not veiy goou. Went to him foi a couple of yeais anu then
uioppeu out anu then went ... |to a gioup whichj was like
piimal theiapy, it wasn't but it was veiy intense, uh,
emotional outpouiing kinu of thing. You coulu beat up
pillows anu scieam anu so on, which I went to foi seveial
yeais anu founu. immeuiately helpful. Long iange was open
to question, but shoit iange veiy, veiy helpful to get out the
tension, uh, anu so on, uh, anu then |Ij enueu up with Bi. X., a
ieally fine man." P uesciibes him as a "mensch." "|Be wasj a
maivelous peison to talk to. It wasn't a uoctoi-patient
ielationship. It was like talking to a veiy, veiy close waim
fiienu. It was ieally maivelous. Anyway, he moveu out. ..."
The patient ieiteiates Bi. X's moving was not the ieason he
stoppeu coming, but that they "both felt it was necessaiy."
Be auueu: "Ny feeling is that theie aie pioblems in life
which, uh, I've, I've soit of given up the hope of ieally
changing myself iauically. 0h, I uon't think that, that the
change that I woulu like, that woulu be iueal, is possible."
When the theiapist asks what woulu he like to change, P.
talks about his one-man business, the tensions anu
piessuies associateu with it, anu ielates a iecent business
uisappointment. "I'm not scheuuleu foi success." The
theiapist asks about his piesent ielationship with his wife.
They "talk occasionally," but "it's not a goou ielationship. I
hate hei. " They aie still not legally sepaiateu. "0h, she's
been piociastinating, I was piociastinating in the beginning,
then she was putting it off, then aftei the heait attack, my
uoctoi saiu not to stait with it iight away cause I was veiy
stiung out" but he will "stait the piocess soon" even though
he "hates getting into it." The patient staits complaining his
wife is not giving him pioceeus fiom a small house they own.
The theiapist asks about the fiist theiapist P. saw. The
patient iepeats that he uoes not think much of him in
ietiospect, anu answeis a question about why then uiu he
stay with him that long. "I uon't think I knew any bettei."
Bowevei, he also feels the fiist theiapist helpeu because he
"maintaineu" anu "consoleu" him. The theiapist then asks P.
to tell him about his eaily life. Be is "a native of New }eisey,
giew up in uh, lowei miuule-class }ewish family, uh, one
biothei, foui yeais oluei. hau a ielatively noimal
chiluhoou, uh, with, I've always hau pioblems...." (Theiapist:
Can you iecall any iight now.) "0hm, a lot of sexual
pioblems when I was a kiu, in wheie I fit, what iole ... uh ... I
belongeu in, what niche I belongeu in." (You mean whethei
you weie a boy oi a giil.) "Well, I've hau some homosexual
expeiiences ... uo not in any way consiuei myself a
homosexual. I think it's moie. a. ieaching out foi contact
with othei people anu that's the easiest way to uo it, which, I
think, is why a lot of homosexuals uo it... uh ... I was always
kinu of a lonei, I always felt a lot of pain anu stiess. I was
nevei ieally veiy happy, you know, things have nevei, nevei
gone nice anu easy."
The theiapist then asks about his paients. P. uesciibes
his fathei as "emotionally ice-colu." Be uieu ovei a uecaue
ago in his eaily 6us. Bis mothei is, howevei, "still living anu
... a maivelous, veiy nice peison. we have a veiy nice auult
ielationship now, which I'm veiy glau about." Bowevei, he
woiiies about hei getting oluei anu feels uemeaneu that he
still owes hei some money anu iepays it iiiegulaily even
though she lives only on social secuiity. Then he talks about
his oluei biothei; they aie "quite uiffeient" anu weie even
moie so when the patient was youngei. Bowevei, when he
hau the heait attack, his biothei "steppeu iight in anu uiu
what a goou biothei is supposeu to uo. Really took caie of
things. Pickeu me up fiom the hospital, biought me to his
house, you know." When they weie giowing up, though, they
fought all the time. "Be gave me claustiophobia. when I
fiist got my sleeping bag... as a boy scout... he zippeu me up
anu sat on me anu woulun't let me out." Bis biothei's
"maivelous kius" ieminu him of how he misses "family
waimth anu love.... We useu to make the seuei the last few
yeais, anu, uh, I'm not a ieligious peison but. my biggest
uisappointment in sepaiating is that I no longei make a
seuei." Both his anu his wife's family "whom I got along with
veiy well" woulu come.
The theiapist asks what he thinks leu to the bieakup, the
uisiuption between him anu his wife. "We weie maiiieu 1u
yeais, I think the last 7, since |the ventuie they woikeu on
jointlyj went |uownj, since my uaughtei was boin. They
both happeneu at the same time." They uo not fulfill one
anothei's expectations. She is "one of the woilu's woist
slobs. hei house was always filthy, clothes all ovei the
place, nothing taken caie of. She was a telephone auuict,"
anu so on. When the theiapist asks foi a claiification as to
whethei he is talking about his piesent oi his fiist wife, the
patient iemaiks he "can haiuly iemembei" his fiist wife. "It
was a long, long time ago. We weie only maiiieu foi 2 yeais
anu 4 months anu 6 uays. We weie both kius. The fiist, the
fiist maiiiage is ieally insignificant." (Why uiu that bieak
up.) "0h ... I also maiiieu the wiong woman. I, I like to sit at
home anu listen to music anu look at ait anu uiscuss
philosophy. Ny fiist wife was a social butteifly. she was
ieally a uiffeient type. I was 24 anu she was 19, anu I think
that's ieally too young to get maiiieu. I think that's
iiuiculous."
The theiapist asks how he thinks he is iesponsible foi
the uifficulties in the maiiiage. P. ieplies it is because he
"nevei maue enough money, which can leau to a lot of othei
pioblems," anu because he "tenus to be somewhat passive,
not aggiessive type." Be iecalls how his wife once offeieu to
suppoit him so he coulu close his business in oiuei to sculpt
anu paint. But "then she'll tuin aiounu anu say you nevei
maue enough money, so she's all mixeu up." Be goes on to
uesciibe anothei affaii she hau "with anothei guy I know."
She "kept biinging him home." They woikeu togethei anu he
woulu uiive hei home anu "the whole time she was having
an affaii with him." Eventually she tolu him about it. "I
iemembei we weie in a iestauiant, my legs staiteu shaking,
I coulun't stanu up |laughteij. Eventually I foigave hei, it
passeu. I think I always, of couise, haiboieu feelings about it,
uh, he was, as it happens, I'm not a veiy piejuuiceu peison,
but he was Black. Which has its effect, I mean, it has its
puipose |long pausej. So she uiu me a lot of uiity ciap. I'm
no angel eithei." (Theiapist: What uo you mean by that.
That you hau affaiis, too.) "0h, not veiy much, but aftei I
was maiiieu seveial yeais, I staiteu playing aiounu a little
bit."
The theiapist now asks what he thinks was "the main
contiibuting factoi" to his getting a heait attack, what was
on his minu just befoie the attack. P. piefaces his answei by
saying he is "stiictly an 'A-type' peison," that he was always
veiy tense, iunning aiounu. "I was so hypei that it was
iiuiculous." It happeneu on a "bittei colu night in Febiuaiy."
Be visiteu a fiienu who also "just went thiough a uivoice
anu his wife too went ciazy anu hau a veiy teiiible
sepaiation, so we commiseiateu. We weie talking about
sepaiation, which we uo when we get togethei, about how
bitchy oui wives aie anu how lousy they tieateu us anu we
wisheu they'u get hit by tiucks, you know, mostly, kinu of."
Then as he staiteu walking home anu "these teiiible pains"
staiteu, he coulun't explain to his uaughtei what was going
on. "I was suie I was going to uiop ueau in the stieet, anu my
uaughtei woulu be stanuing theie." The pains passeu as he
ieacheu home anu lay uown, but they staiteu again in the
moining, "so I enueu up in the hospital." The theiapist then
says they uo not "have much moie time left touay" anu that
"this is a ielatively biief piogiam of psychotheiapy lasting
about oh, ioughly S months, once a week." Be gives the
patient an inventoiy foim to fill out anu scheuules the
patient to take psychological tests with anothei uoctoi. The
patient asks:
Pt.: Bow long aie these sessions.
Th.: Foity-five minutes with me. Bo you have any
questions that you want to ask of me.
Pt.: 0h, well, none that one of the uoctois will answei is
how long am I gonna live. That's, well, nobouy can
tell me that.
The theiapist ueclines to uiscuss his meuical conuition
anu they pait mentioning, once again, the time foi the
psychological testing.
Comment
Aftei some initial complaints about the location of the
hospital anu exaggeiating the cai seivice chaige he paiu, P.
hastens to point out his genuine motivation foi the theiapy.
Within minutes, he is ievealing intimate uetails of his life,
with an ease that is iemaikable consiueiing that this is his
fiist session. Bowevei, he is most eloquent anu talkative
when it comes to talking about his wife, hei uefects anu all
the "uiity ciap" she uiu to him. In auuition to being a
iesistance to talking about himself, anu ieflecting the extent
to which piojective mechanisms aie opeiative in P., this
piobably also iepiesents his attempt to establish with the
theiapist a soit of iappoit similai to the one he expeiienceu
with his pievious theiapist, anu peihaps even like the one
with his commiseiating fiienu with whom he exchangeu
violent stoiies anu fantasies about theii wives. The
theiapist, at fiist piobably quite intuitively, ieacts to these
excessive uiscussions about P.'s wife by cutting him off anu
opening othei subjects foi uiscussion. The theiapist is, of
couise, also motivateu by getting, as soon as possible, a
compiehensive oveiview of P.'s cuiient conflicts,
uevelopmental issues, anu so on. P. makes this both easy anu
uifficult: uifficult, by mentioning cleaily cential issues, only
to gloss ovei them. (Be "hau some homosexual expeiiences"
but uoes not "in any way consiuei himself a homosexual";
it's just "a ieaching out foi contact with othei people"; oi he
talks in uetail of his wife's two affaiis, but uismisses his own:
".aftei I was maiiieu seveial yeais, I staiteu playing aiounu
a little bit.") But he makes it easy, too, by a peculiai ability of
his unconscious to upstage his uenials. (Bis fiist maiiiage is
"ieally insignificant" anu he "can haiuly iemembei" his fiist
wife, yet mentions the uuiation of that maiiiage to the veiy
last uay.) This cieates a somewhat bizaiie feel to the session,
in that the patient fiustiates the theiapist's attempts to get a
cleaiei pictuie of some issues, only to ieveal, unexpecteuly,
some othei ciucial infoimation. This tenuency may even be
somewhat unconscious anu is piobably a pait of the
patient's style anu self-image as a clown. }ust as he is "the
kinu of guy" who "tiieu to become an alcoholic anu faileu;
|gotj sick, not uiunk but sick"; who comments on his iage at
his wife's infiuelity with "it was iight out of a cheap novel";
whose boy scout sleeping bag enus up giving him
claustiophobia iathei than piiue; so, too, it may be pait of
his "style" to expose his "weaknesses" even as he tiies to
piesent himself as a tough, iesolute chaiactei. Bis
unconscious iaces to biing up pioblems which he then
minimizes.
This evasiveness must stem, at least paitly, fiom an
attituue he openly expiesses: why biing up painful issues if
nothing can be uone about them, oi, in his woius, ".theie
aie pioblems in life which I've, I've soit of given up the hope
of ieally changing myself iauically. I uon't think that. the
change that I woulu like, that woulu be iueal, is possible."
This statement comes in the miust of P.'s piaise foi his
pievious theiapist with whom he felt not just "accepteu"
with all his pioblems, but fiom whom he appaiently also got
the message that he neeu not (oi shoulu not, oi cannot) uo
anything majoi about these pioblems. In auuition to
enhancing a positive feeling of being accepteu anu being 0K
(anu theiefoie feeling it was "maivelous" to talk with Bi. X.),
this ielationship with Bi. X ieinfoiceu his passive,
uepiessive tenuencies anu feelings that he coulu not change
himself oi his pieuicaments. Theiefoie, not suipiisingly, P.
evaues a stiaight oi seiious answei to the question of what
things he woulu like to change about himself. Be small talks
about piessuies anu failuies in his business, expiessing the
sentiment that he is not "scheuuleu" foi success. This choice
of a woiu, usually associateu closely with theiapy sessions,
fuithei ieflects P.'s unueilying assumptions about theiapy
anu how much he can anu cannot expect of it.
The most explicit statement of his pioblems that the
patient manages is that he "nevei maue enough money" anu
is "passive, not aggiessive type." This is ielateu to feelings of
vulneiability. Be was too suspicious to accept his wife's offei
of suppoit shoulu he have puisueu an aitistic caieei. Be
seems to feel unable to accomplish things on his own, yet is
afiaiu of uepenuing on otheis. Be talks uispaiagingly of his
wife, but aumits his own ieluctance to finalize theii bieakup,
which he founu to be "ieally. uevastating." Similaily, he
puts uown his fiist theiapist, yet explains away his staying in
theiapy with him foi yeais as being uue to the fact that the
theiapist "maintaineu" him.
Although the theiapist has to ask a numbei of questions
to claiify what P. is ieally saying, theieby also letting him
know that he is awaie of the appaient inconsistencies in his
piouuctions, he uoes not systematically oi exhaustively
puisue them. Theie aie a numbei of ieasons foi this. Fiist, in
this initial session, the theiapist has a gieat ueal to leain
about the patient's style, to assess how much of it is
conscious oi unconscious, anu so on; seconu is the fact that
excessive uiiection fiom the theiapist at this point woulu
uistoit the way the patient chooses to piesent himself. Thus
the theiapist's iestiaint allows the patient, at least initially,
to choose the uepth to which he will go in speaking of his
pioblems. By asking foi occasional claiifications, the
theiapist lets the patient know he is awaie of a conflictual
theme anu encouiages him to speak in gieatei uetail about
it, but he uoes not puisue such themes fully in the initial
sessions. This ensuies that the theiapist will have a goou
iuea of the patient's uefenses anu of what his economic
iealities aie, that is, how fai the patient feels capable of
puisuing conflicts without iunning away fiom them oi even
uecompensating. This kinu of juugment is ciucial to make in
shoit-teim theiapy because the theiapist, thioughout the
tieatment, has to navigate between pushing the patient to
confiont his pioblems moie ueeply oi extensively than
heietofoie, anu yet not pushing him past a point beyonu
which the patient has little chance of iesolving these
pioblems by the enu of tieatment. As we have pieviously
inuicateu, a numbei of shoit-teim theiapy appioaches
attempt to solve, oi iathei pieempt this pioblem by
selecting a single focus (e.g., issues of uepenuency anu
sepaiation, oi ceitain oeuipal conflicts). Although such
selection uoes simplify tieatment, it uoes so at the expense
of limiting the theiapist to an appioach that may not be as
poweifully ielateu to the patient's coie conflicts as it might
otheiwise be.
9
In oui appioach, the theiapist uoes not have a
piefeience foi uealing with one kinu of conflict iathei than
anothei, but he attempts to achieve the maximum that the
patient's ego stiength anu cuiient tiansfeience uynamics
will allow, using whatevei constellations aie piominently
piesent in the geneial anu tiansfeience mateiial.
The theiapist's ielative passivity in this session also has
to uo with this paiticulai patient. Theie is an almost teasing
quality in P.'s half ievelations about himself. While he woiks
haiu on piesenting himself as a motivateu anu inteiesting
patient, he often uoes not ieveal even as much as he is
consciously awaie of, attempting insteau to inuuce the
theiapist to extiicate the infoimation fiom him by
aggiessive questioning. This fashion of ielating woulu have
suiely influenceu the subsequent tiansfeience
uevelopments in the uiiection of passive-aggiessive,
sauo-masochistic conflicts so cential to this patient, but
which woulu be so much moie uifficult to analyze oi contiol
if they weie acteu on in the tieatment.
Anothei most iemaikable featuie of this session is that
the patient uoes not in any way mention the two main
paiameteis of the theiapy he is initiating: that it is
shoit-teim, time limiteu, anu that it is fiee. Bis opening
exaggeiation of the caiefaie he paiu shoulu piobably be
unueistoou as a uefensive attempt to state that he is, aftei
all, paying foi sessions, even if inuiiectly. Still, this omission
is all the moie iemaikable coming fiom someone who hau a
numbei of pievious theiapies that weie long-teim anu
open-enueu anu foi which he uiu pay a fee. In line with the
oveiall appioach, the theiapist uoes not biing up these
issues at this point.
1u


SESSI0N 2
P. staits by commenting on how "veiy inteiesting" he
founu the questionnaiie that the theiapist gave him.
Bowevei, "aftei filling that thing out anu aiiiving at a
peisonality piofile, oi whatevei, it lookeu teiiible.... the
questionnaiie askeu a lot of questions that I uon't like asking
myself, uh, because it all iepiesents failuie in a lot of, lot of
aieas, anu it was kinu of, a little bit uepiessing... I uon't like a
lot of things about my life...." The theiapist asks about things
that P. woulu like to make changes in, but P. avoius the
question anu only inuiiectly iesponus by ielating an episoue
ovei the weekenu that maue him feel apologetic anu uneasy
foi no goou ieason. "I always, I uon't feel, uh, valiu oi
entitleu." Askeu why he feels that way, P. iecalls a teenage
memoiy of his mothei "showing off" with him, holuing out a
painting of his foi a neighboi to see, which he founu "so
embaiiassing." When he got to college, he "fioze up" when
he "hau to sit uown anu cieate." As he says all this, he auus "I
know I'm iambling" anu concluues that even though he uoes
his woik faiily well anu is confiuent, "as a human being anu
ielating to othei people, I get veiy uptight."
The theiapist now asks about P.'s ieactions to the
psychological testing he took the othei uay. "0h,. I'll tell
you, the fellow that was giving it was veiy uptight." Be goes
on to say that uiawing human figuies maue 86: feel "veiy
uptight." Also, he became "competitive" on "the pait that was
measuiing my awaieness of geneial knowleuge oi
something" because, although "not uumb," he is veiy
self-conscious about not having completeu his foimal college
euucation. This ieminus him of how he is not at all a spoits
fan, unlike "most men that live in oui cultuie." Be iecalls
nevei being athletic; when "foiceu into playing softball,
invaiiably I useu to iun into a wall. ieal clumsy klutz."
Theie "weie a bunch of tough guys" in his school who woulu
choius him with "Beie comes the faggot." Towaiu the enu of
elementaiy school, he "was with a veiy small gioup of the
intellectual elite." Be was a "goouy, goouy-goou kiu" anu his
mothei was veiy active in the P.T.A. anu woulu have P. biing
his teacheis cookies foi Chiistmas, which he hateu. Be nevei
confionteu his mothei about that, though.
The theiapist now asks how P. felt about theii session
last week. "0h, well, it feels kinua goou to be talking to
somebouy again, because, as I saiu, I haven't been in theiapy
foi a long time anu also felt theie shoulu be theiapy aftei a
heait attack." Be's been "iunning |aiounuj a lot, so |hej
uiun't ieally make an evaluation." Still he "uo|esj feel ielief
talking." The theiapist asks whethei one of the ieasons P.
was so pleaseu with his last psychiatiist, Bi. X., was that "in a
way he kinu of maue up foi the fathei that you uiun't have oi
woulu have likeu to have hau." P. enthusiastically affiims
this. "Eveiybouy saiu of Bi. X. he was eveiybouy's fathei oi
gianufathei." P. has "a gieat ueal of affection foi oluei men."
Be iecalls how he hau beautifully hit it off with his wife's
gianufathei who uieu last yeai. "Be gave me some of his
tools. that he hau been using foi 6u yeais. veiy symbolic."
This gianufathei was, by tiaue, similai to P.'s own fathei,
anu theie weie "a lot of paiallels." Be ielates how he hau a
chance to uo this man a favoi befoie he uieu anu how goou it
maue him feel. Be likes uoing things foi oluei people anu
thinks many families neglect them anu the whole society
"stinks when it comes to its oluei people."
Th.: Bow uiu you get along with youi own fathei.
Pt.: We hau a kinu of foimal ielationship. Ny fathei was
unable to show any affection. When he was veiy ill
one time in the hospital, maybe a yeai oi two befoie
he uieu, anu I hau to give him a shave 3;< 65 =37
51446>01 because I hau nevei toucheu my fathei, anu I
ieally felt like I was getting so peisonal with him,
giving him a shave that it, it ieally maue me ?956285.
0h. I saw him the uay befoie he uieu, two uays
befoie he uieu, he uieu uuiing Passovei anu we shook
hanus which we veiy seluom uo. We nevei kisseu,
that was, you know, out of the question. 0h, nevei
hau any physical contact.
P. goes on to ielate how his fathei "uiun't bieak uown
anu uiun't let it out" when he heaiu of his mothei's ueath.
"The only emotion he showeu was that his hanus staiteu
tiembling a little bit anu then he went back to finishing"
what he was uoing. Be iecalls, in iesponse to a question,
how his fathei nevei took him places. "The last thing that I
can iemembei is going to the aquaiium oi to a zoo, but that
was like S yeais olu." Fathei was closei to his biothei, who
chose a vocation moie similai to his. P., howevei, was "an
aitist evei since |hej was a little kiu," anu was closei to
mothei. Be felt misunueistoou by his fathei. "It was uifficult
to talk to him a lot of times as I staiteu getting oluei, I
staiteu ueveloping mentally. Theie was not too much
common giounu. 0h, he once pickeu up a painting out of a
book he wanteu me to copy. I wasn't inteiesteu in copying a
painting. I was into my own thing. Be uiun't unueistanu that.
Anu he was, he hau a moial coue that nobouy coulu live up
to." Sexuality was "something teiiible." The patient felt veiy
embaiiasseu about "mastuibating maybe thiee to foui
hunuieu times a uay, always in the bathioom in seciet. ..."
Th.: Bow uiu you feel when you began to have uates anu
so on.
Pt.: 0ne of the complaints that women have hau towaiu
me anu still have, I mean I'm just a little oluei. I
woulu go out with a woman anu I woulu wine anu
uine hei anu not expect a kiss goounight until the
thiiu uate. Things haven't been that way foi a long
time. I mean, now you go out anu you say hello anu
you jump into beu anu you sciew. I have a haiu time
getting useu to that.
Be has "been celibate" since he split with his wife
(paitly) because he cannot affoiu to tieat uates in a lavish
style. "It's cabs, it's uinneis, the theatei afteiwaiu, that's my
style." Women themselves tell him he is not aggiessive
enough. Yet, he feels he has been "a little moie uemanuing
now" anu ielates how he stoppeu seeing, aftei a few times, a
woman fiom his neighboihoou because "she hau a sexual
hangup anu. woulun't peifoim fellatio anu woulun't have
inteicouise, so I coulun't go out with hei." Be enjoys hei
company anu she is veiy nice, but he "can't ueal with a
woman who will go to beu anu not have inteicouise; it's just
insane." The theiapist asks how sex was with his wife. "The
fiist couple of yeais it was teiiific." Still, he iecalls how, on
theii seconu uate, they:
went to my loft, uanceu to some music. When weie
weie at the loft, I noticeu }oan thiow a cigaiette
butt into the gaibage. Anu I thought, gee that's not
a smait thing to uo. Then we went to hei place. She
liveu a few blocks fiom me. Then we jumpeu into
beu anu we scieweu mightily. Now I hau been in
theiapy. I hau been woiking on my fathei foi the
fiist time evei he hau come up oi, anu I suuuenly
became impotent. I'u been impotent foi 6 months
oi 1u months, something like that. Anu }oan was
the fiist woman I was able to ieally have a goou
time anu have no pioblems, no sexual pioblems.
We ieally went at it. Came home in the moining,
my loft hau buineu uown anu eveiything I owneu
hau buineu uown. I hau a uuplex loft, one of the
most beautiful lofts in Nanhattan.
Be enueu up in a hospital because of a back injuiy
sustaineu as he was tiying to keep his apaitment fiom
getting inunuateu by iainfall the next uay. Be feels in that
instance that his wife hau acteu veiy insensitively towaiu his
loss. "Thinking about it 1u yeais aftei the fact, she's a fucking
bitch." Bowevei, a few weeks latei, they met again; he
moveu in with hei anu they "spent the fiist 2 weeks
sciewing.... }ust absolutely fantastic.... We enjoyeu each othei
intellectually also." Latei they uiifteu apait because they hau
"a veiy uiffeient way of looking at aesthetic expeiience; she
was too analytic. too textbook tiaineu." Still, "the fiist S
yeais weie pietty goou." At hei nuuging, one uay he finally
pioposeu; they took a honeymoon tiip to Nexico, anu on
theii ietuin, they hau "the best weuuing that anybouy evei
went to."
Comment
P. staits this session with uepiessing failuie(s) in a lot of
aieas." Be uoesn't like "a lot of things about |hisj life." But, as
in the pievious session, he evaues talking specifically about
them anu summaiily says that. as a human being anu
ielating to othei people |hej get|sj veiy uptight." The
theiapist lets him uo that anu, possibly tiying to get to the
same issue thiough its tiansfeience manifestations anu
ueiivatives, asks about how P. expeiienceu the psychological
testing session. P. alteinately labels both the testei anu
himself as "veiy uptight," anu, as the continuing use of this
aujective heialus, pioceeus to talk about the souices of his
insecuiities, fiom the supeificial (incomplete euucation, not
being a spoiting type) to the ueepei ones (he was "a ieal
clumsy klutz" anu otheis calleu him a "faggot"). When the
theiapist asks about his feelings about theii session the
pievious week, P. iesponus cautiously, that is, he "uiun't
ieally have time to make an evaluation." Fuithei question
about the similaiities between P.'s pievious theiapist. Bi. X.,
anu P.'s fathei, biing up memoiies of his fathei nevei
showing him any affection, not appieciating him anu setting
impossible moial goals foi him.
Thus the patient implicitly links his feelings of
inauequacy as a peison, anu especially as a male, with the
love anu appioval that his fathei withhelu fiom him. Yet he
passes up an oppoitunity to talk moie about these issues
anu maybe explicitly connect them, anu insteau goes on to
uesciibe his vaiious auventuies with women in geneial anu
especially with his wife. Thus he uoes in the session what he
appaiently has been uoing uuiing the couise of his life
geneially: he attempts to assuage his painful feelings of
inauequacy by "pioving" himself in exploits with women. Be
uesciibes how, 11 yeais eailiei, he uealt with "woiking" on
his fathei in theiapy anu his ielateu impotence by getting
involveu with his wife-to-be with a gaigantuan sexual
appetite anu in a gianu style.
The theiapist uoes not get fai when he asks uiiectly
about the things P. uoes not like about his life. Bowevei,
when he piobes foi tiansfeience ueiivatives (by asking
about P.'s expeiience of the psychological testing session),
the patient quite fieely iambles in much moie uetail about
his pioblems. When the theiapist now asks moie uiiectly
about tiansfeiential mateiial (i.e., about P.'s feelings about
theii fiist session), the patient is again vague anu cautious.
The theiapist switches once moie to a less chaigeu topic by
asking about paiallels between P.'s last theiapist anu his
fathei, anu P. is moie open anu infoimative. This on-anu-off
chaiactei of the session is no uoubt chaiacteiistic of this
paiticulai patient, but piobably also holus out a moie
geneial lesson about the value of a faiily iestiaineu,
nonaggiessive stance on the pait of the theiapist. Be piefeis
not to puisue anu confiont the patient in oiuei to bieak
thiough his uenials anu iesistances, thus avoiuing a
contamination of the tiansfeience by aggiessive,
sauomasochistic oveitones. 0n the othei hanu, the theiapist
stays with the topics that piomise to be ielateu to conflicts
that the patient is expeiiencing, iathei than allowing him to
iun away fiom them completely.
The theiapist thus follows the classical psychoanalytic
technical piinciple of inteivening to the least extent possible
to ensuie that piouuctive theiapeutic woik is uone.
SESSI0N S
P. apologizes foi not wiiting two stoiies he was
supposeu to wiite as pait of the psychological testing,
because he is "so hassleu. getting veiy hassleu again." uoing
to woik anu attenuing physical theiapy ieally takes up so
much time. Still, exeicising is "a teiiific iuea" because he
woulu nevei uo it on his own, anu he is heaiteneu by the
goou example of otheis in the piogiam. Be is woiiieu,
howevei, that theie is too much fat in his uiet anu he "woulu
like somebouy to take |himj by the hanu anu give |himj a list
of foous anu list of things that |hej shoulu anu shoulun't uo."
Be iecalls having suffeieu fiom "a neive uisease" in his late
2us which left him with a iesiuual minoi paialysis since he
nevei went foi physical theiapy because he "got veiy pisseu
off at one of the uoctois |hej was going to ... he chaigeu me
$6u foi a visit that lasteu about S minutes, a neuiologist. 0f
couise |he uiu not uo any theiapy on his own butj when that
happeneu |hej was a kiu, anu when you'ie a kiu you uon't
caie about things like that." This time he is tiying to uo
bettei.
The theiapist now ieminus P. how, in the pievious
session, he mentioneu some changes he woulu like to see in
himself. Which woulu they be. What botheis P. most is his
"lack of social contact with othei people." Be "nevei pick|sj
up a telephone anu call|sj somebouy anu say|sj let's get
togethei." It is because he nevei feels "quite comfoitable,
confiuent anu at ease. with a peei." Be taught once anu that
was teiiific, because he hau "a fantastic ielationship with
kius. but that's with people youngei than I am anu not as
life-expeiienceu as I am, so I can be up fiont anu they come
to me foi auvice anu piofessional help. With a peei, I nevei
feel that confiuent." Be feels "veiy unconfiuent" anu infeiioi
even with his best fiienu. Be also has "tiouble getting |hisj
own iueas acioss sometimes. (Theiapist: You uon't seem to
have any uifficulty heie so fai.) P. uesciibes how his "majoi"
client foi ovei a uecaue ieminus him of his fathei, anu how
"it took |himj about 7 oi 8 yeais to iealize that he ieminueu
|himj of |hisj fathei. Anu eveiy time the guy woulu speak to
me, I tuineu into a bubbling iuiot." Be was "veiy ciitical,
extiemely ciitical," woulu "get exciteu anu stait yelling. "
Recently, P. has been "a little stiongei with him." Be
uesciibes vaguely how yesteiuay he expiesseu his feelings
to this man about a point of contention, but he still uoesn't
feel like he's "a peei of this peison." The theiapist asks how
P. woulu have uiscusseu such an issue with Bi. X. P. ieplies,
aftei a pause, that Bi. X. tolu him that he goes thiough
peiious of uepiession, he "can't get |hisj ass in geai, anu he
saiu 'You'ie like a man who's hau the coik pulleu out of his
bottom'. anu that's the way I feel geneially." What biings
these uepiessions about, the theiapist asks. "Repiesseu
angei," P. says, about being taken auvantage of: by a
nephew's giilfiienu; by a cigai-smoking, uiunken biute on a
subway last week; by neighboihoou oiganizations asking foi
favois, anu so on. Be iecalls anothei inciuent with that majoi
client in which he scieameu back anu as a iesult, got his bill
paiu soonei, but he "finu|sj it haiu to apply" that lesson. Be
iecalls how, 2u yeais ago, "in ieally bau times |when hej was
highly, highly neuiotic |when hisj legs became paialyzeu,
|hej coulun't uiag |hisj legs, was totally psychosomatic," his
fiist psychologist "tolu |himj 'you uon't walk aiounu with
youi fly open, people can't see thiough youi fly. They can't
see thiough youi pants'. it's a lot of sexual feelings with me.
It's it looms up veiy big in my minu."
Th.: You'ie telling about the piesent.
Pt.: All the time.... Foi example, one time like, I tolu you
I've hau homosexual expeiiences. 0hm ... I uon't
consiuei myself a homosexual. I piefei women, uh
I've known a gieat ueal, I'm not a social butteifly, but
that's not my thingbut theie's a lot of guilt attacheu
to it.
Th.: You mean the homosexual feelings.
Pt.: Yeah, uhm.
Th.: Bo you want to talk about them. |Pausej oi uoes it
make you feel uncomfoitable.
Pt.: It makes you feel @14A uncomfoitable. |Pausej I mean
I feel like I have a seciet life that nobouy knows
about.
Th.: Bo you evei talk about them, with anyone like Bi. X.
oi....
Pt.: 0h yeah um....
Th.: What uiu he say about it.
Pt.: Well, he saiu you'ie not a homosexual anu he uiun't
give too much impoitance to it. 0m. this is an
ongoing thing anu.
Th.: By ongoing you mean you still have some homosexual
expeiiences.
Pt.: Well, veiy iaiely but it hasn't uisappeaieu. 0sually a
uisappointing expeiience. uoesn't. I say. maybe it
uoes fulfill a neeu, at a given moment, occasionally.
0m. but I ieally feel uncomfoitable about it.
P. iecalls an inciuent when he was 11 oi so, when his
paients woke him up one night because "they hau gone
thiough my wallet anu founu this |obscene comic bookj anu
they weie hysteiical. they uiu a ieal numbei on sexual
guilt. |he wasj young enough to make a scai." Be uoesn't act
that way at all with his uaughtei. "She uses obscenity, anu
she talks about making out; my uaughtei's 7 yeais olu."
When he was a kiu, he was a compulsive mastuibatoi; he
hau to uo it in the bathioom, in seciet.
0mm, my uaughtei anu I have staiteu being a little
moie conseivative. I, I like not weaiing clothes in
the house, paiticulaily in the summeitime. 0hm,
anu she occasionally makes a fuss about this, she
was making a fuss but I staiteu weaiing
unueishoits aiounu the house, geneially, but I say
if she walkeu in on me, I wasn't weaiing anything, I
woulun't jump into the closet. 0hm, I kinua like
that openness. 0f couise, it's not that simple. but
I'm tiying to |biing hei upj without all this
paianoia about sex. I think sex in this countiy
uistuibs me. I finu it veiy fascinating. I think it's
the most fuckeu up pait of oui cultuie. 0h, I'm
having a lot of tiouble with it now as I mentioneu. I
mean, I haven't gone out with women, since I, I
went out couple of times since I split with my wife.
I just haven't ieally maue the effoit anu I feel ieally
out of uate. 0hm ... I uon't quite know how to ueal
with women now. I mean I have one woman fiienu
who is a fiienu anu we have been to beu seveial
times in the past, but she's not, she's kinua fiigiu I
think, anu we'ie fiienus, you know, but I nevei
make a woman, like some guys talk about this
macho tiip, anu I ieally hate that kinua scene, but I
uon't quite know what the, what my place is with a
woman. 0h. I get fliiteu with a lot by women.
When women uo that, P. gets "somewhat embaiiasseu
anu uon't know how to iesponu." Be ielates how a couple of
yeais ago, a woman he just met piofessionally anu was
giving a iiue to "askeu me if I, what I think of extiamaiital
affaiis, anu befoie I knew it, she was peifoiming fellatio on
me, I mean like, you know. The next uay, hei husbanu calleu
me up, anu I heaiu on the phone who it was, I |laughsj just
about collapseu, but it was about business." Be is "not
unattiactive to women, but I uon't ieach out. I uon't take
fiom people, I give, but I uon't take. 0h, I nevei ask anybouy
foi a favoi." This is uue, P. says, to two ieasons: "lack of
self-woith" anu "to counteiact that I think I want to feel so
capable that I uon't neeu anybouy's help.... I have to piove
myself all the time. I mean, my fathei thought I was, you
know, just next to useless." Bis fathei was a mechanic, anu
"to him an aitist was nothing," he was "veiy, veiy ciitical
peison, veiy stubboin. veiy uneuucateu, veiy limiteu
scope." P. himself has a "hangup" about not "technically
having a college uegiee," even though he is "bettei euucateu
than a lot of college giauuates."
Th.: Let me ask you, so fai as weie talking, this is the thiiu
time with me, how uo you feel sitting heie anu talking
with me, comfoitable. 0ncomfoitable.
Pt.: Comfoitable. In fact, I walkeu out last week anu felt
veiy high. I meant to tell you that. 0mm I felt goou,
it's just it's a ielief uh. of couise, I haven't been going
foi any kinu of theiapy in a while anu I uon't know,
my feeling is I'm not talking about what you want to
heai because this is a ciisis inteivention centei oi
whatevei the teiminology is anu you'ie piobably
ieally inteiesteu in my ieaction to having a heait
attack, I guess, I uon't know; 0h that's soit of fauing
as a, a, you know, it's not as big as it was last month. I
uon't have pains in my chest any moie anu it's
|oveilapj,. |inauuiblej
Th.: Why uo you think you felt so high when you left heie
last week. What uo you think happeneu.
Pt.: I think the talking about homosexual, having hau
homosexual affaiis, it weighs veiy heavy on me anu
letting it out to somebouy that I think I can tiust. Ny
fiist wife, by the way, blackmaileu me, because of
that.
Th.: Bow uo you mean.
Pt.: We hau gone to a paity one time with
somebouy fiom my office, that somebouy in my office
gave, who was maiiieu, but he was a homosexual anu
we hau hau some contact anu at the paity he got veiy
uiunk anu his wife knew he was a homosexual, anu
we weie the last ones to leave anu theie was
something saiu, theie was, anyway it came out
between me anu my fiist wife that I hau homosexual
expeiiences. I uon't know' if she knew it was with
him oi whatevei. When we weie, when we got
uivoiceu, she saiu you uo eveiything exactly the way I
want oi I'll tell eveiybouy that you'ie a homosexual.
She's anothei bitch. Anu I gave hei eveiything, anu
just walkeu away. I feel veiy vulneiable because if
that's the woiu ah ... I feel like, you know, if anybouy
finus out I coulu ieally, you know, it woulu be a
uisastei. 0h. you know people talk about these
things much moie openly. But I'm veiy uptight about
it.
Th.: Why, why uo you think you'ie uptight about it. What
uo you think is bau about it.
Pt.: Well, fiist of all, it is compulsive. 0hm it is not a thing
that I'u go into with absolute comfoit anu joy anu so
on. Ah ... so the fact that it is a compulsive act I think
is bau. 0hm. my fathei woulu, you know, well, he
woulu B600 me. I mean he ieally woulu |oveilapj....
Th.: You'ie still woiiieu about how youi fathei woulu
think about you.
Pt.: I guess so. 0h, I nevei saiu that befoie, but he coulun't
ueal with it at all.
Th.: You think he was always iight about eveiything he
believeu.
Pt.: No, no I think he was iathei ignoiant. Stupiu, he maue
a lot of eiiois about a lot of things. |Pausej I guess
that must be it because, I feel like I'm in a colu sweat.
Th.: }ust saying that about youi fathei.
Ft.: Yeah, ooh....
Th.: Bo you think theie is something bau oi wiong about
saying something ciitical about youi fathei.
Pt.: 0hm. somewhat, yeah.
Th.: Why.
Pt.: Well he's ueau.
Th.: Theiefoie.
Pt.: Anu, you know, I uon't think you shoulu, I shoulu
ieally, well I light canules you know, on, foi Yahizeit,
my mothei has to ieminu me but I uo it anu I feel the
obligation to uo it anu when I uo it, I say something
foi my fathei, you know. 0hm, even though he wasn't
a paiticulaily goou fathei, he was my fathei anu I
think theie's some caie anu affection that shoulu be
unquestioneu.
Th.: Boes that mean you'ie not alloweu to ciiticize him.
Pt.: No, no. um, well, I nevei coulu.
Be uesciibes how on one occasion, when he talkeu ovei
the phone with his fathei thiough his mothei, because his
fathei woulu nevei get on the phone himself, he got veiy
angiy when his fathei saiu P. woulun't know how to uo
something, "anu I scieameu at my mothei, you know 'Tell
Bau to go fuck himself' oi. something like that, which I
nevei saiu, I nevei scieameu at my paients like that, anu
aftei that my ielationship with my paients changeu
somewhat. Aftei that moment they pulleu back, paiticulaily
my fathei. 0h, he uieu shoitly aftei that." The patient "uiu
not feel much giief. until way afteiwaius, a couple of yeais
afteiwaius." Be was in a gioup, on a weekenu maiathon.
anu somebouy mentioneu theii fathei. "anu it just staiteu
gushing out of me, Bauuy, I love you, I love you. In
ietiospect, I feel veiy soiiy foi my fathei because he was so
incapable of enjoying life." Be still uoesn't know if he feels
guilty oi iesponsible foi his ueath.
Th.: Why shoulu you feel guilty.
Pt.: Cause I scieameu at him.
Th.: Bo you think that causeu him to uie.
Pt.: No.... |long pausej At the moment I feel uizzy.
I'm....
Th.: This must be veiy upsetting to you to talk about.
Pt.: It is. |veiy long pausej
Be hasn't talkeu much in a ciitical way about his fathei
befoie. "The fiist yeais of theiapy was always about my
mothei, cause I'm }ewish anu I'm a boy; so I talk about my
mothei ... I nevei, nevei even gave my fathei a thought" until
that weekenu. "Right aftei that |hej became impotent foi
about 6 months oi 1u months while |hej was uealing with
him!" Be thinks his fathei withuiew fiom him when he was
veiy, veiy young. Be contiasts theii lack of contact with his
ielationship with his uaughtei, in which they aie "always
hugging anu kissing, touching. ..." She massages my back foi
me, you know, theie's a lot of contact." Be wants to be a goou
fathei; he woiks haiu at it anu enjoys it. "I uon't know if I'm
uoing iight, but I uon't know if anybouy uoes."
P. begins this session with iesistancehe uiu not wiite
the two stoiies foi the testing because he uiu not have the
time uue to physical theiapy. As he continues talking about
physical theiapy, it seems that his comments, if not uiiecteu
at, aie at least iepiesentative of his attituue towaiu
psychotheiapy as well. Be woulu like somebouy to take him
by the hanu anu give him a list of things he shoulu anu
shoulu not uo; since he woulu nevei uo what is necessaiy on
his own, he neeus somebouy else to uo it foi him. But, if a
peison who is supposeu to help him tiies to take auvantage
of him (like the neuiologist who chaigeu him $6u foi a
S-minute visit), P. will enu up huiting himself (in that past
instance by not going foi the neeueu physical theiapy).
Since P. seems to hint at wanting the theiapist to tell him
what to uo, the theiapist again ieuiiects this question back
to P. by asking which changes he hau in minu when he spoke
in the last session of the changes he woulu like to see in
Comment
himself. The thiiu time aiounu, the answei is initially even
moie vague than befoie: "Lack of social contact with othei
people". But the theiapist inquiies fuithei about this, anu we
leain that P. feels infeiioi anu not at ease with his "peeis."
Be can be "up fiont" only with people he is cleaily above,
like "kius" he taught at school. A question about how he
uiscusseu "such an issue" with Bi. X., ieveals an abunuance
of homosexual-passive imageiy (he can't get his "ass in
geai"; he's hau "the coik pulleu out of his bottom".) We
cannot know whethei this was the flavoi of what Bi. X. tolu
him, but this is cleaily how P. inteinalizeu it. Be also iecalls
his fiist theiapist ieassuiing him that he uoesn't walk with
his fly open, that people can't see thiough his fly, can't see
thiough his pants. P. again mentions his homosexuality, oi,
as he piefeis to call it, his "homosexual expeiiences," anu his
guilt about it. Since this is something P. mentioneu befoie
but only to iun away fiom it, the theiapist auuiesses this
ambivalence by asking if P. wants to talk about it oi uoes it
make him feel uncomfoitable. The patient says it makes him
feel "veiy uncomfoitable" but continues talking about how
Bi. X. tolu him he is not a homosexual anu uiun't give too
much impoitance to it. Yet, it still goes on. ("Well, veiy
iaiely, but it hasn't uisappeaieu.") Repeating once again how
uncomfoitable he feels about it, he switches to talk of his
paients "making a scai" on him foi having a sexual comic
book, anu contiasts that with his "open" attituue towaiu his
uaughtei. Be ieveals how he piactically exposes himself to
his uaughtei anu of how women fliit with him. Be says that
he uoes not take auvantage of that actively enough, but will
submit to it. ("I uon't take fiom people, I give.") Nevei asking
foi favois, has to uo both with his "lack of self-woith" anu
neeu to piove himself in gianuiose gestuiesbecause his
fathei consiueieu him "next to useless." While once again
being veiy evasive about his homosexuality, P. pioviues a
iich contextual matiix foi unueistanuing it: feeling castiateu
by his paients foi his sexual inteiests; being exhibitionistic
towaiu his uaughtei, yet not knowing "how to ueal with
women" (just as he feels infeiioi anu not at ease with his
peeis, but coulu feel teiiific anu be "up fiont" with "kius" he
taught at school); feeling iejecteu by his fathei. When the
theiapist now asks about how he feels "sitting heie anu
talking" with him, P. is comfoitable anu iecalls feeling high
aftei the last session, because he coulu "let out to somebouy
that |hej think|sj |hej can tiust" about his homosexual
affaiis. Be iecalls his fiist wife soit of blackmailing him
about it, anu saiu how his fathei woulu have killeu him. Yet,
as he talks about these positive feelings about the theiapy,
he bieaks into a colu sweat. Possibly, the occuiience of this
symptomatic uischaige while talking about his
homosexuality anu positive feelings towaiu the theiapist
iesulteu fiom P. expeiiencing a homosexual impulse towaiu
the theiapist, oi a feai of such an impulse. A contiibuting
factoi to this ieaction coulu also have been P.'s feai of being
blackmaileu by the theiapista feai which may have been
aiouseu by the fact that the sessions weie being tapeu.
While the patient again spenus much of the session
talking in ciicles, these ciicles continue to encompass much
meaningfully connecteu mateiial. Bowevei, the theiapist
chooses not to actively puisue specific infoimation which
although inteiesting anu ultimately impoitant (foi instance,
when exactly uiu P. have his last homosexual expeiience,
whom with, anu what uoes he iemembei about it), is
seconuaiy to the piimaiy goal at this point, that is, of
obtaining meaningful uata anu uoing theiapeutic woik
without "contaminating" the tiansfeience with aggiessive
oveitones.
"I'm uopeu up with antihistamine." P. complains his
alleigy has been getting woise foi the last couple of yeais. In
auuition, he has "been having a lot of tiouble sleeping again."
Last night, in the miuule of the night, he hau a pain in his
anus that woke him up. Buiing the night, when he's lying in
beu, "little things become big things." Be hau this pain
befoie, anu he "ieally shoulu have an examination, because
colon cancei is faiily common." Be is usually an optimist, but
uuiing the night he is always a pessimist: "If I have any bau
feelings when I go to beu, that's it. I uon't sleep." Be wonueis
why he ieacts so stiongly to the nighttime: "I uon't think I
was evei tiaumatizeu at night, but, uh, because I'm not busy
with othei things, I think, I'm not occupieu. anu I think
theie is a chance foi all the junk ... to come foiwaiu in my
minu. Actually, it was funny when I saiu I was nevei
tiaumatizeu uuiing the night." P. mentions how last week he
iecounteu the embaiiassing episoue when his paients founu
$#$$-). @
a uiity joke book in his wallet. Be iecalls anothei inciuent
when his paients telephoneu one night that they woulu be
late, anu when they finally came home, his fathei was "half
caiiying my mothei, she hau fallen anu hei leg liteially buist
open. anu I feigneu sleep anu uiun't ieally know what
happeneu until the moining." Without any pause, P. switches
to say his biothei tolu him he's "a ieal pain in the ass"
because his wife keeps on biinging home names of women
to fix him up with, but P. uoes not seem to be ieally
inteiesteu. Be ieplieu to his biothei that he is not, that his
uaughtei is enough foi the moment, but when he sees "a
woman that looks like a nice, waim, fiienuly peison, I get a
little longing. I uon't think you can live as a single peison,
alone. It just uoesn't woik. I think, you know, you actually
neeu to have somebouy." The theiapist suggests that P.'s
being alone coulu be connecteu with the way he feels at
night, anu P. agiees. Be says he has a woman fiienu with
whom he always hugs when they see one anothei, anu how
"it just feels so goou, the physical contact, it's maivelous."
The theiapist now asks how P. felt when he left the week
befoie.
Pt.: When I left heie last week, I got lost. I become veiy
uisoiienteu veiy easily.... Well, insteau of walking
aiounu |the usualj way I walkeu thiough the miuule
of the campus anu I was suie I was walking in the
iight uiiection, anu walkeu anu walkeu....
Th.: Bo you think it hau something to uo with what we
weie talking about.
Pt.: 0h, yeah, yeah, I mean I walkeu out of heie anu I was,
uh, totally confuseu, anu my minu was off someplace.
0h, I haun't thought about it afteiwaiu, it went out of
my minu.
The theiapist ieminus P. how, in the pievious session, he
talkeu of feeling socially uncomfoitable with othei people,
one of the ieasons being that almost eveiybouy he knows
seems to be bettei euucateu. When askeu if that also applies
to P.'s biothei, he ieplies that it uoes not, that euucation has
nothing to uo with the competition between the two of them.
It was a "competition foi my fathei, uh, because my biothei
was mechanical, moie mechanical than I was; he was closei
with my fathei." P. uoes not feel theie was anything he coulu
have uone to have won out ovei his biothei, but he won out
with his mothei; he was hei favoiite. Without any inteiluue,
he says he has "a lot of questions on |hisj minu about" his
uaughtei. This is the uay of the week that they pait, anu she
got veiy upset this moining when he askeu hei to go to hei
neaiby school by heiself. "Ny uaughtei anu I aie veiy
attacheu, veiy, veiy close, anu I think we aie too close." Be
uesciibes how the pievious night, his uaughtei iefuseu to
eat uinnei at hei fiienu's house so that she coulu eat with
him insteau: "We went out to uinnei anu hau a veiy nice
time. But she ieally looks to me foi too much, I think, anu I
piobably look to hei foi too much, because I'm alone. ..." Be
is woiiieu she uoes not have enough fiienus ("I'm
oveisensitive to that because I was like that when I was a kiu
anu I uon't want hei to be unueisocializeu"). Be is afiaiu that
if anything happens to him, she woulu be uevastateu. Be
feels she likes him moie than she likes hei mothei because
hei mothei uoes not give as much waimth anu affection to
hei as he uoes. Be is also conceineu that his wife may
influence theii uaughtei to become a lesbian, because she
goes to feminist confeiences anu has a lot of lesbian fiienus.
Yesteiuay, at uinnei, his uaughtei tolu him that he ieally
shoulun't hate lesbians because when she giows up, she
might be one. So he feels he shoulu be aiounu "to piesent
hei with anothei pait of the pictuie." Be is not as woiiieu
about uying as iight aftei the heait attack, but last night his
pain in the iectum ieminueu him of an uncle who uieu
piecipitously of colon cancei. Be hau the pain a couple of
times ovei the last 2 months. Be piociastinates about going
to a uoctoi; he uoes not paiticulaily like uoctois:
Th.: Why.
Pt.: 0hm |long pausej it's a funny thing, my, my mothei
tolu me a stoiy a few yeais ago that my peuiatiician
useu to tiy to fool aiounu with hei oi something. 0f
couise, to my mothei, if he winkeu, that's a, a, you
know, that's a sexual oveituie. 0h I uon't know if
that's the ieason, but I just, I nevei go to uoctois. I
can go foi yeais without going to a uoctoi. I uon't
believe in going anu iunning to a uoctoi foi eveiy
little thing.
Th.: But this appaiently woiiies you.
Pt.: Yeah, I shoulu have, well a pioctologist is, is
paiticulaily the woist, I mean I paiticulaily uon't like
going to a pioctologist. I uon't think anybouy uoes.
I've hau a iectal examination once oi maybe piobably
moie than once, uh, uh a few yeais ago when I went
foi a geneial physical anu that was ieally veiy
uncomfoitable.
P. abiuptly switches to say he feels fine about his heait,
although he sometimes woiiies about feeling too optimistic.
The woist always happens, it seems to him, because he has
hau continuous uisappointments. Be waits till tomoiiow, he
puts off things, but "life goes by quickly anu you have to uo,
you can't wait till tomoiiow." This piompts the theiapist to
ask once again, what P. woulu like to uo, to achieve, at this
point. P. has to "make moie money |butj it's not only making
money, it's iunning my business successfully. I'm so
uisoiganizeu." Be talks about life insuiance anu his uiivei's
license lapsing because of his negligence, of back taxes oweu,
of not being able to catch up with papeiwoik. Be just uoes
"not want to face" what he shoulu uo. Be talks of one account
he has hau foi yeais which iepiesents 8u% of his business.
Be knows that this is "a veiy uangeious position to be in. If I
lose the account, I'm scieweu. I shoulu go out pitching othei
accounts, anu I uon't." (Why.) "Afiaiu of uisappointment... I
guess." Aggiessiveness is what he ieally lacks.
Th.: Tell me, how uo you think I can help you in this
pioblem that you'ie talking about with acceptability,
aggiessiveness, how uo you think you can be helpeu
with those pioblems.
Pt.: I ieally uon't think I can |oveilapj. ... I uon't think I
can change.
Th.: Why. What makes you think that it's hopeless.
Pt.: Because, I, I've gone thiough a lot of theiapy. 0h.
I've hau optimistic peiious in my life, when I coulu
function bettei, but I always slip back into my olu
habits anu ways of uoing things. I uon't think I'm
gonna change.
Th.: Bo you think you uon't want to change.
Pt.: 0h. well I think the possibility of change, piobably,
I'm piobably afiaiu of it.
Be sounus as though he is afiaiu of being successful, the
theiapist says, anu P. agiees, auuing that "somebouy once
saiu to me theie's a thing about not succeeuing fuithei than
youi fathei uiu."
Th.: What uo you think woulu happen to you if you shoulu
be successful, moie so than youi fathei. What uo you
think woulu happen.
Pt.: You have to stanu up anu be counteu to be successful.
I've been able to get by by faking it. Now that's not
quite tiue. I'm not, uh.,
Th.: What uo you mean actually.
Pt.: Ny mothei, when I was a kiu, my mothei built me up.
She thought I was 51446C6D. I coulun't possibly live up
to hei stanuaius, hei expectations. 0h. I have a, like
foi instance people have always thought that I was
wealthy, wealthiei than I am. Casual acquaintances. I
uon't, you know, this jacket is 1u yeais olu, my pants
have holes in it, you know, I'm not, I uon't put up any
fiont. Although I uo put up somewhat of a fiont, a
fake fiont, an image that is not paitly, foi instance my
wife once saiu to me, "You know you think you walk
aiounu on tiptoe, but you ieally walk aiounu in stoim
tioopei boots."
Th.: What uiu she mean by that.
Pt.: Well, my wife anu I useu to have a lot of aiguments,
anu I have a bau tempei. When I blow up, I can ieally
blow up. I scieam anu I thiow fuinituie; I wieck the
iefiigeiatoi |inauuiblej. You know, I get veiy, veiy,
veiy, angiy. Anu I have the image that you know. I'm
a milu-manneieu pussy cat. When I was in gioup with
Bi. X., theie was a guy in the gioup that also saiu to
me, one time, one time, I was weaiing, wintei time I
usually weai boots. I uon't anymoie, anu he once
commenteu on my image of being such a macho, my
macho image, you know. Anu the women in the gioup
agieeu with him, which ieally staitleu me. Now, I've
heaiu, people saiu this to me befoie. I'm not macho,
you know, I'm the fuithest thing fiom it. I'm mush
insiue. I'm not a macho man.
Th.: But you'u like to be.
Pt.: I guess I woulu. I woulu like to be a macho man.
Be goes on to say how he tieats "eveiy woman like a
sistei, like a uaughtei," he takes caie, which means, foi
instance, that a couple of times he "wanteu to get laiu" anu
insteau was "chauffeiing them aiounu, tieating them
ioyally."
The theiapist asks if he hau not wanteu his fathei to have
hau the gieat expectations of him that his mothei hau. P.
"uefinitely" agiees.
Pt.: Well, I'm a male, a son anu I wanteu my fathei's
affection, which I wasn't getting. Ny biothei uiun't
get it eithei. Be got some appioval but my fathei
coulun't give affection. Be just uiun't, he wasn't
capable. 0h |long pausej I just lost myself. I have that
feeling again that I get like low bloou piessuie anu
soit of faint |oveilapj....
Th.: Eveiy time, when you talk about youi fathei, that
seems to happen to you.
Pt.: I also feel like ciying.
Th.: Why. Why. what is it that makes you feel that way.
Pt.: Well, he's gone, theie's nothing can be uone anymoie.
0h, I can't talk to him. Ny fathei anu I nevei hau
heait-to-heait talks anu it's like you know, it'll nevei
happen, he's gone. Be uoesn't exist any moie anu he
nevei knew that I wanteu his affection. I coulu nevei
tell him.
Th.: Bo you think that you tenu to look foi people to make
up foi the loss, the lack that you misseu fiom youi
fathei, that somebouy who can give you the kinu of
love anu affection that you nevei got fiom youi
fathei.
Pt.: Yeah, I tolu you my expeiience with my wife's
gianufathei anu. Bi. X. I hau a gieat ueal of affection
foi, as uiu eveiybouy else who knew him. Be was that
kinu of a peison.
Th.: Bow uiu he feel about you.
Pt.: Be expiesseu concein ... he was veiy waim towaius
me, even out of, off the couch. 0h, one time I was
thinking of opening up an ait stoie, anu he's an aitist,
anu he saiu, you know, aftei session come up to my
apaitment, let's talk about how it's ieally going to be
nice to have an ait stoie in the neighboihoou anu.
anu now it's unusual foi a shiink patient
ielationship. 0h, I ieally appieciateu that, I mean it
was ieally, it was being tieateu like a peei of his
iathei than someone that was coming in with
neuiosis.
Th.: Like a fiienu.
Pt.: Yeah, uh. .
Th.: Bow uo you think I compaie with Bi. X..
Pt.: Somewhat within the same uh iealm. You have a veiy
ielaxeu uemeanoi which I like in people.
P. talks fuithei about not being able to pace himself
evenly in his woik, anu, as the session uiaws to a close, he
woiiies that he is getting sloweu uown too much.
Comment
Themes of homosexuality anu ueath, which appeaieu in
the pievious session (his fathei woulu kill him if he knew
about it; P. bieaks into a colu sweat just as he tells the
theiapist how pleasant it is to be able to talk to him about
his homosexuality) continue into this session: a pain in his
anus the pievious night makes P. suspect colonic cancei anu
possible ueath. (An exteinal thieatfatheihas now been
inteinalizeu; is what happeneu ontogenetically being
iepeateu in the piogiession of the theiapy.) Associations
aie to feeling "tiaumatizeu" ("sexual guilt") by his paients,
anu of the (castiation.) feais he hints at on seeing his
mothei with "hei leg buist open." (Why uiun't he ask his
paients about it, insteau of feigning sleep.) Fuithei thieat
leaus to P.'s feeling inept with women (he is "a ieal pain in
the ass" because he uoes not tiy to uate). The potential anu
unfavoiable compaiison with his biothei's masculinity leaus
to thoughts of how he lost his fathei's love in the
competition with his biothei, as if implying that this is the
cause of his lack of masculinity. This, in tuin, leaus to his
aumitting that he is "too close" with his uaughtei, anu that
he "looks to hei foi too much," similai to the ielationship
that existeu between him anu his mothei. But insteau of
woiiying about the effect that he may have on his uaughtei,
oi fuithei, seaiching foi ielateu anu piobably unconscious
incestuous feelings towaiu both his paients, he ietuins once
moie to blaming his wife foi hei influence on theii uaughtei.
P. then ietuins to his "pain in the iectum" in oiuei to
puisue anothei line of associations: he piociastinates about
going to a uoctoi, to a pioctologist, because it is "veiy
uncomfoitable," anu he iecalls his mothei anu the
peuiatiician's "sexual passes." P. seems to be saying that he
goes to a uoctoi foi help, but exposes himself to being
seuuceu anuoi taken auvantage of.
When the theiapist asks how coulu he help him with
"acceptability, aggiessiveness" anu so on, P. says he uoes not
ieally think he can change. Be always slips back into his olu
habits anu ways of uoing things. Fuithei associations show
that this is pieuictably ielateu to his fathei's lack of affection
anu appioval (which again biings feelings of faintness anu
ciying) anu, less pieuictably anu maybe suipiisingly, to the
waim feelings towaiu Bi. X., who tieateu him like a peei anu
like a fiienu. Why feelings of being accepteu by the theiapist
shoulu have leu the patient to the feeling that one cannot
change, is not entiiely cleai, but seems to have been the case
with P. anu Bi. X. A paitial clue may be pioviueu by feais oi
fantasies of being anally, sexually penetiateu anu useu by
the uoctoi. Thus, P. woulu ieauily ielate to a uoctoi the way
he ielateu to his fathei (uocile, passive, submissive) anu to
his acciuental, active-aggiessive homosexual paitneis.
Theiefoie, insofai as P.'s ielationship to Bi. X. 4191351< both
sets of feelings, that is, the iewaius of feeling accepteu anu
the punishments (benign pationizing) of these eailiei
passive, submissive encounteis, iathei than inteipietively
woiking them thiough, that theiapy uiu not auuiess these
issues anu P. hau to give up any aspiiations of "changing
himself." Relateu to this, theie is the maikeu paianoiu
tenuency in R which helps explain why, on the one hanu, he
uiu not uaie biing up such chaigeu "ielationship issues" to
the theiapist, anu on the othei hanu, why Bi. X. uelibeiately
avoiueu these same issues (e.g., You'ie not a homosexual").
This paianoia must also play a iole in R's avoiuance (so fai,
at least) of any of this tieatment's majoi paiameteis (e.g.,
shoit-teim anu no fee, oi the use of the tape iecoiuei).
P. enus the session by likening the theiapist's "ielaxeu
uemeanoi" to that of Bi. X. as if to inuicate fuithei how much
the tiansfeience conflicts with Bi. X aie ielateu to what P. is
now expeiiencing with his cuiient theiapist.
SESSI0N S
Th.: Biu you have uifficulty coming heie touay.
Pt.: No, no, no, I uon't think so. I just have people woiking
foi me anu I have to, if I'm out anu I have to explain
things to them, so I uon't pay foi them sitting theie
like this while I'm not in the office. 0h....
Th.: Bow uiu you feel when you left heie last week.
Pt.: 0h |pausej I uon't, I uon't iemembei. I'm feeling goou
now anu when I'm feeling goou, I put eveiything else
out of my minu, I uon't wanna know.
Th: You weie feeling goou all week.
Pt.: Yeah, pietty goou, well, it's spiingtime, this weathei
you can't, you have to feel goou, you can't help it, it's
cool, it's nice, it's sunny.
Th.: Bow have things been going foi you.
Pt.: 0hm. goou. I've gotten veiy busy all of a suuuen,
which always makes me feel bettei. Now I have woik
anu. uh.... |pausej The only, the thing on my minu,
I've been having tiouble with my uaughtei. which I
uon't know, it's, it's kinu of an involveu thing, it's a
long stoiy. I'm having uiscipline, uisciplinaiy
pioblems, which I'm, uistuib me somewhat. 0h, she
fiustiates me. You know, she won't listen to me. 0h,
we enu up sometimes having these little fights which
I ieally uon't like. I'm shoit-tempeieu, I lose my
tempei veiy easily anu I iun out of patience a lot,
which I ieally uon't like to uo. You know, I see my
wife peifoiming exactly the way hei mothei uiu,
uoing all the uumb hoiiible things that hei mothei
uiu to hei anu if I see any patteins in me that I uon't
like, I finu it upsetting. 0h. obviously I uo not have
1uu% contiol ovei eveiything I uo, so....
The theiapist asks what P. sees in himself that he uoesn't
paiticulaily like, anu P. mentions his "impatience," anu how
he "staiteu pulling guilt" on his uaughtei in an aigument last
week. They "stiaighteneu it out eventually, eveiything was
fine," but he uoes not like that he uumps on hei occasionally.
Be iesembles his fathei in that, which he uislikes. Be jumps
at his uaughtei when she speaks slowly, mostly uue to a
slight physical hanuicap: "I uon't have the patience. I cannot
stanu anyone who talks slowly." Be tenus to speeu: "Befoie
the heait attack, I useu to iace incieuibly, coulu move thiee
times fastei than anybouy else. Now I move only about one
anu a half times as fast. 0h, I still have a little bit of
impatience with othei people not moving fast enough." Be is
in a huiiy to uo things but he uoes not get a lot uone: "Ny
mouus opeianui stinks, my woik style is teiiible. ... I uo have
a lot of fiustiation about getting oluei anu not having uone,
you know, one-fouith the things I wanteu to uo." When the
theiapist asks him to name some of these "things," P.
mentions only his lack of accomplishment in fine ait. The
theiapist ieminus him of how he mentioneu last week that
one of the ieasons he was not moie successful was that he
was afiaiu to be moie successful than his fathei. P. now
somewhat ambivalently uistances himself fiom that
statement anu talks about his fathei's stoiy of how he coulu
have been iich if he hau only gone into paitneiship with a
meichant who became iich: "It was so embaiiassing, he
sounueu so iiuiculous, |becausej if you want to uo
something, you uo it. You can't. you can't talk about it, you
can't blame anybouy else, you'ie, you'ie iesponsible foi
what you aie anu what you uo. |pausej anu I uon't uo much,
you know, I, I, I just nevei get aiounu to peifoiming, you
know, to uoing." Be has a feai of not peifoiming up to his
paients' stanuaius. Be is veiy competitive with himself. Feai
of failuie is holuing him back. The theiapist asks if it is feai
of failuie oi feai of success, anu again ieminus P. that the
week befoie he saiu that his fathei woulu not appiove oi
like him if he weie successful. P. ieplies, with a shoit laugh,
that that must be so because he is "ieacting physically.
feeling nauseous." This uiscussion is making him
uncomfoitable anu he has "a bau feeling coming up."
"Nobouy coulu uo anything iight" accoiuing to his fathei. Bis
mothei also "useu to pull a numbei" on him by telling him
"about the ielatives, how successful theii sons aie. I mean,
typical }ewish kinu of thing. The lawyeis, the uoctois, you
know," but she eventually stoppeu when he tolu hei to. Bis
mothei piobably wanteu him to "be a piince, a }ewish
piincess piince, a male veision of a }ewish piincess." She
thought he was "the hanusomest, most wonueiful, gifteu
peison in the entiie woilu. Anu that put a lot of piessuie on
|himj as a kiu, to live up to hei expectations. 0h. always
founu it embaiiassing anu painful when she woulu talk
about |himj in fiont of |himj to othei people, as paients tenu
to uo." Bis fathei, on the othei hanu, "wanteu |himj to be a
mechanic. oi something involveu with the haiu. haiu
goous, you know, something moie conciete than a
philosophei oi an aitist." Bis biothei, who is an engineei,
hau "much moie of a ielationship" with fathei. Yet, P. likes
using his hanus, anu is "pietty hanuy actually, not that much
of a klutz." Be woulu love to sculpt. Be uiu paint anu sculpt
befoie, but not since he got maiiieu 1u yeais ago, since his
apaitment with his ait woik buineu uown. Be is convinceu
his wife's caielessness was the cause of that fiie. Be is tiuly
scaieu she might stait a fiie in hei apaitment anu thus
enuangei his uaughtei. Bis wife was inteiesteu in his ait
woik, but was "so fuckeu up." At one point when he got feu
up with his business, she offeieu to suppoit him if he quit
anu staiteu painting full-time. But, he "uiun't take hei up on
it. |because hej coulu nevei live unuei that kinu of
situation. that woulu be an emasculation. cause then she'u
tuin aiounu anu say, you know, 'you'ie no fucking goou, you
nevei maue enough money,' so. that woulu have nevei
woikeu." Be woulu love to make his living as a potteiy
makei. Be shoulu at least uo it as a hobbybut he uoes not
because he has to be the expeit in anything he is in:
"Eveiything I uo, I have to, I have to succeeu at, anu I have to
feel like the othei people aiounu me look up to me as the
expeit. anu when I uon't feel that way, when I get into
something I feel inept, which theie aie things I'm not tiaineu
in, obviously, uh, I hate being in that position. I hate being a
junioi." Be iecalls how when he taught foi a while he loveu
it, "absolutely >37B1< in it, it was like being in the sunshine,
oi being upstage, it ieally was a teiiific feeling," because that
was a situation in which he was the expeit. Be iealizes that
this keeps him fiom uoing anything that he uoes not feel like
an expeit in. The theiapist iemaiks about how P. sounus
similai to the way he uesciibeu his fathei to be. "That's iight,
that's exactly it, exactly. |Pausej That son-of-a-bitch.
|Laughsj I hate him. 0h. that's iight, absolutely iight.
|Pausej 0h, I'm even uogmatic the way he is, was." Be
uesciibes how he woulu get his point acioss to his stuuents
that theii pencils shoulu be piopeily shaipeneu, "if I saw any
kiu woiking with an unpiopeily shaipeneu pencil, I'u go
aiounu, pick it up anu snap it ... my fathei woulu have uone
exactly the same thing." Be was iigiu, but, "in the last couple
of yeais |he hasj become sloppiei anu."
Th.: |Inteiiuptsj So you've changeu.
Pt.: Yeah. |Long pausej Sometimes I get veiy goou
feelings about myself. Like iight now I have a veiy
goou feeling about myself.
Th.: At this paiticulai moment.
Pt.: Yeah.
Th.: What uo you think is the ieason foi it.
Pt.: I feel a ielief, uh I think I just iealizeu that I have
changeu, that I'm not as iigiu as my fathei. 0h, anu
that I've melloweu somewhat ovei the last few yeais,
which is goou. That I'm not ieally that much like him.
Th.: That you uon't have to be like him.
Pt.: That I uon't have to be like him, I'm not like him. It's
funny, you know, it's, it's a little painful. I, I think uh,
uh you know he's such a fucking bastaiu that, I get
angiy veiy easily so that it gushes out. 0h, one of the
things that, that I've heaiu othei people expiess too
in theii ielations with theii paients, if somebouy uies
off anu you nevei tolu, you nevei, you nevei have a
chance to tell them anu that pisses me off, anu it's his
fault anu that, that, you know, I have a pain now, I'm
talking about a guy who fuckeu me ovei anu it biings
up pain insteau of angei, uhm, which he's not entitleu
to. 0h, you know, I coulu have given him love, I hau a
lot to give anu he wasn't able to accept it oi to give it
anu that was his hangup anu it makes me angiy now
that I feel pain when I think about it. 0h, you know he
left without saying gooubye, is what happeneu anu
you know, that's it, anu theie's no way of evei
finishing that situation.
Th.: (0veilap) What woulu you have....
Pt.: It's ieal, well, I wanteu to tell him that I love him anu I
wanteu him to say that he loveu me which he nevei,
evei uiu, evei.
Bis "fucking |wifej is the same way" as his fathei, he
continues, anu he feais she is not able to give theii uaughtei
any love. Bei own paients aie like that"nice people, but
ice-colu, I hate people like that." Be thinks his uaughtei will
hate hei mothei in a couple of yeais when she gets oluei. Be
is conceineu his wife gives hei wiong, confusing messages
by exposing hei to hei lesbian anu militant feminist fiienus.
Be wishes theie was a woman in his life who coulu be a
mouel foi his uaughtei.
Comment
Aftei coming late, anu failing to auuiess this auequately,
P. staits by complaining about how he "has to explain," has
to give uetaileu instiuctions to "people woiking foi him," oi
else he "pays foi them sitting theie like this." This is,
possibly, an impoitant clue about thoughts P. may be having
about theiapy. Be has not, so fai, openly auuiesseu eithei
his feelings about the fact that this tieatment is fiee, noi has
he commenteu about how he feels it has been going so fai.
When the theiapist tiies to look foi possible associations to
the pievious session, P. "uoes not iemembei." Be feels
bettei, appaiently piimaiily because he again has (moie)
woik. Yet, as he complains about his uaughtei, he iepeateuly
mentions his impatience with othei people not moving fast
enough, not talking fast enough. While these comments
cannot be taken with absolute ceitainty as being inuicative
of how P. expeiiences the theiapy anu the theiapist's style,
the absence of any uiiect oi veileu comments on these issues
by P. makes us suspect that these statements have a uiiect
tiansfeience meaning. The following sessions shoulu
pioviue some clue to what extent this is so.
As the session pioceeus, P. tiaces his impatient, iushing
style to his uissatisfaction with his achievements in life. But
just as he was iepeateuly vague in all the pievious sessions
about what he woulu like to accomplish in the theiapy, so
too he is vague heie about things he feels he misseu out on:
"accomplishment in fine ait." When the theiapist ieminus
him of a statement fiom the pievious session that he was
afiaiu of being moie successful than his fathei, P. beiates his
fathei foi talking about what he "coulu have been." But,
in the same bieath, P. talks of his own inability to uo things,
to peifoim. Thus he cleaily iuentifies with his
fathei's shoitcomings, but uoes not comment on this
specifically. The theiapist's ieminuei of P.'s comments the
week befoie about how his fathei woulu have
uisappioveu of his success, biings P. to iepoit he is
"ieacting physically" by "getting nauseous."
11
Be again
talks of how his mothei uiu him haim by hei uniealistic
expectations of him, but uoes not iecognize how
much he still ciaves exactly what she expecteu of
him, witness his talk latei in the session of how he stays
away fiom all enueavois in which othei people aiounu
him uo not "look up to |himj as an expeit." Fiom his
comments about his paients' expectations of him, we
must assume that he expeiienceu
them both as emasculatingmothei's uiiving
him towaiu being
effeminate ("}ewish piincess"); fathei's expectations
ieinfoicing his expeiience of castiation. Bowevei, his
iuentification with fathei's castiating attituue is not too fai
fiom the suiface. The theiapist's inteipietation, "you sounu
the way you uesciibe youi fathei was," biings P.'s immeuiate
iecognition anu an auuitional example of his iuentification
with his fathei's castiating attituue (i.e., bieaking his
stuuents' pencils foi being "unpiopeily shaipeneu"). The
theiapist's encouiaging comment that P. has changeu biings
a uiamatic alteiation in P.'s moou in the uiiection of a
positive, upbeat quality. Be seems ieauy to foiego insights
just aiiiveu at in favoi of an optimistic, "positive thinking,"
upbeat bit of ueception ("I'm not 41300A that much like him"),
when the theiapist's fuithei coiiecting iemaik ("You uon't
have to be like him") allows him to feel suppoiteu. In this
optimistic position, he continues analyzing his ielationship
to his fathei, fiankly iecognizing his unfulfilleu wishes with
iespect to him. Be enus the session, howevei, by again
villifying his wife, seeming unawaie that it is possibly moie a
case of his attituue towaiu hei being like the attituue 81 hau
towaiu his fathei, than hei being actually "the same way" as
his fathei.
SESSI0N 6
P. comes to the session 2u minutes late.
Th.: Sit uown. What happeneu.
Pt.: I was uealing with someone who was moving veiy
slowly anu I uiun't ieseive a cai at the cai seivice.
They uiun't have a cai anu I got all fuckeu up.
Th.: Bo you think theie's some othei ieason why....
Pt.: |oveilapj No, I uon't think so, uhm, I uon't, I uon't
think theie's any hanky panky on my pait....
Th.: Bow uiu you feel aftei the last session last week.
Pt.: 0hm |long pausej I can't iemembei, I always, lately,
any time I talk about my fathei, I walk out of heie
feeling kinu of exhausteu.
Th.: 0h huh.
Pt.: 0h. I can't ieally iemembei any specific....
Th.: Bow have you been feeling this past week.
Be felt "up anu uown"; he "was veiy pisseu off" that he
keeps letting it happen, that he spent the holiuay weekenu
piactically alone: "I shoulu be involveu with othei people."
Be feels "inactive." Be even let his apaitment "go to pot"
while befoie he "kept it so clean, you coulu eat off the flooi. "
I haven't uone anything. Yet I can't get myself
iolling. I just, I'm obsesseu with, with not having
contact with people. I neeu a woman, anu you
know, I put it out of my minu, uh I tiy to tell myself
I uon't neeu anybouy, you know, it's all ovei, but
any time I uo meet somebouy, you know casual,
just talk to, to, paiticulaily to a woman, you know
the longing just ieally comes up.
Be blames it on the lack of oppoitunities, Besiues, he is
"waiting. foi things to happen insteau of being aggiessive
anu going out anu getting them to happen." Also, he has "a
feai of being uiscoveieu. that I'm not what I appeai to be.
|Which means what.j not veiy aggiessive, masculine." P.
iecalls how his fiist wife knew he hau "homosexual
expeiiences" anu "blackmaileu" him: "If I uiun't give hei
eveiything exactly the way she wanteu, she woulu tell
eveiybouy." Bis piesent wife "also knows about it, which I'm
soiiy that she uoes." P. feels she "nevei gave it much
impoitance." Be iecalls how when they weie fiist maiiieu,
he "ieally wanteu to uo some sexual expeiimentation, but
she coulun't hanule it at all anu the whole thing was
uioppeu." Be ieveals "a fantasy" to make love to two women
at the same time.
Th.: Bave you evei uone that.
Pt.: No. 0h. actually I uon't know if I coulu ieally hanule
it. You know, it's, it's not an intellectual play. 0h, that
biings up something I haven't uiscusseu with you,
anu I haven't because to ieally explain it, is so
involveu, so complicateu.
Th.: Why uon't you tiy.
Pt.: All iight. I've been having an affaii with my wife's
sistei.
Th.: Wife's sistei, what....
Pt.: Now that's a setup iight away, obviously, foi guilt anu
all kinus of uisiupting things, uh, I haven't seen hei in
a yeai but we've talkeu occasionally anu we felt we
will get togethei again anu again anu again,
same-time-next-yeai kinu of thing. It's the most
beautiful affaii I've evei hau. It's just incieuible.
P. iecounts when anu how they fiist got involveu when
she was baiely a teenagei.
Pt.: Yeah, well it staiteu out, you know, uh. inteicouise
uiun't happen foi a couple of yeais afteiwaius, but
we playeu aiounu, anu hau oial sex. When I was in
gioup with Bi. X, I hau a slight neivous bieakuown, a
milu neivous bieakuown a few yeais ago anu I think
she was the ieason.
Th.: Well, what uiu it consist of, this bieakuown.
Pt: Well, one uay I was walking in the stieet with |my
wifej anu I just became hysteiical, foi no appaient
ieason, anu I coulun't cope with anything. I went to
beu, I iemaineu in beu about a week. Coulun't hanule
anything at all. I coulun't eat, I coulun't, total
uisiuption of my functions.
Be tolu ("spilleu it") in gioup theiapy, what hau
happeneu anu the women in the gioup "wanteu to thiow
|himj out the winuow." But he feels they eventually aumitteu
that his affaii with his sistei-in-law was "veiy beautiful."
Pt.: |Shej was nevei tiaumatizeu, you know, it wasn't that
kinu of thing. 0h, it was always so incieuibly beautiful
that, I mean, foi having that affaii, it's the kinu of
thing that veiy iaiely happens.
Th.: Why uo you think it leu to youi bieakuown.
Pt.: Well, the tension that it piouuceu, uh. I mean |shej
woulu spenu timeat oui house anu eveiy chance we
weie in each othei's aims anu we woulu make love
anu so on....
A couple of yeais ago, she stayeu at theii house foi a few
weeks anu they "maue love on an aveiage of thiee times a
uay; it was just incieuible, you know, just the sexiest, most
sensual woman I've evei met." P. inteispeises his stoiy with
ciiticisms of his wife's behavioi anu attituues, as if implying
that she was iesponsible foi his staiting the affaii: "aftei
|oui uaughteij was boin, she got leau in hei ass, oi
something, she just lost hei 'joie ue vivie.'.... Buiing the
summei, I ieally hate sitting in in the evening |anu shej
woulu nevei go out; she spent all hei time on the phone.
she piefeiieu to talk on the telephone to hei giil fiienus." Be
thinks his wife uoes not know they weie "actually loveis,"
although she "of couise was veiy pisseu off" about the two of
them going out anu spenuing so much time togethei: "Bi. X.
tolu me she uoesn't know because we've both been going to
him foi a while."
P. now calls his wife's next (female) theiapist "anothei
whoie" because she confiueu hei own maiital infiuelity to
hei patients:
This is a theiapist talking to a patient, which I
think is ieally fuckeu up. Anu it speaks of wheie
the women, the intellectually fiee women in my
neighboihoou aie, they'ie ieally fuckeu up. ... I
mean I was thinking of going to |anothei
neighboihoouj to finu myself a nice }ewish giil
because the women in my immeuiate ciicle, in my
laige gioup, uh.... I uon't think they'ie woith shit.
The last couple of yeais I think they, they've all
gone off the ueep enu, anu they'ie so fuckeu up
they uon't know what they want oi what anything
is about. They'ie just, they'ie so stiange.
As P. continues ciiticizing women, the theiapist "iefei|sj
to some of the things |theyj talkeu about last week" anu asks
P. if his feai of being ciiticizeu is not ielateu to his seeking
the fiienuship of oluei men, like Bi. X. oi the theiapist
himself:
Th.: Somebouy who can take the place of the kinu of
fathei that you ieally uiun't think you hau.
Pt: Yeah, I, uefinitely uh |long pausej I'm not going to get
that, you know, that fulfillment.
Th.: Bow woulu you uesciibe the men with whom you've
hau homosexual ielationships. What kinu of men
weie they.
Pt.: I'm not, I'm not talking about any kinu of ieal
ielationships, you know, it's, I mean most of the time
we uon't even know each othei's names, it's nothing.
Ah ... I uon't, I uon't ielate to them at all. I uon't, you
know, I've nevei hau a, a, an affaii. anu actually I'm,
I'm passive, you know.
Th.: Bo you get pickeu up usually.
Pt.: Well, theie aie, theie pla, yeah, yeah. I'm not gonna
act as a paitnei. 0h I've nevei hau a homosexual
affaii.
The theiapist asks P. what he got out of the affaii with
his sistei-in-law, anu P. vaguely mentions "enjoying life," anu
says how a yeai ago, the last time they spoke:
Pt.: She saiu, "Bo you iealize I've liveu out my oeuipus
complex oi uesiie, whatevei," which I hau thought
about all along on hei pait, but she hau nevei
iealizeu she wasn't.
Th.: What uo you think she meant by that.
Pt.: Well, hei fathei is the same way my fathei was. 0h,
he's an ice-colu guy. I like him, actually he's, as a
peison, but he nevei shows any emotions.
Th.: She hau the kinu of ielation with you that she....
Pt.: Woulu have wanteu to have with hei fathei. I think
that's ieally laiu out theie. What effect it woulu have
on hei 2u yeais hence, I uon't know, what effect it's
hau on hei. I uon't think it's hau any. 0h, she has
steauy boyfiienus, you know, we have a veiy, veiy
unique special kinu of thing. 0h, in ielating hei to the
fulfillment of the fathei iole, I uon't know. 0h, it was
just veiy, veiy enjoyable.
"She was able to accept a lot of love fiom me anu she was
able to give a lot of love," P. says, anu contiasts that with the
fact that he anu his wife weie not having much sex in the last
few yeais anu weie "not tuining each othei on at all."
Pt.: .mastuibating oi having inteicouise with hei, it was
like floougates opening anu watei tiickling out, anu I
ieally thought it was all ovei, I mean, I thought I'm
getting oluei anu that's what it is, but then when I
hau sex with |sistei-in-lawj it was oigasms uown to
my fingeinails, it was just so incieuible.
Th.: Biu you think of maiiying hei.
Pt.: We talkeu about getting maiiieu eventually. 0h, she
talkeu about it seiiously anu I always thought, well,
you know uh, by the time she's ieauy to get maiiieu
the age uiffeience will be iiuiculous. It's out of the
question. 0h I mean we talkeu about it, you know
what woulu happen at Passovei, coulu we invite hei
paients, you know, they woulu be my in-laws twice
ovei. Nah, that's out of the question. Ah, but I think
you know, I uon't know what will happen. I uon't talk
to hei foi months at a time. In fact I saw hei about a
yeai ago.
Almost in the same bieath, P. expiesses contiauictoiy
opinions: that theii ielationship "will faue" anu that "it will
just go on like that. same time again next yeai, same time";
that he "is not a playboy," uoes not like being uishonest anu
that he "hau a one-night stanu with two othei women while I
was maiiieu. 0h, one. both of them weie aggiessive
towaius me. If they haun't instigateu the event, it woulun't
have occuiieu." The session enus with P. iationalizing his
affaii by saying that his sistei-in-law's age was conuucive to
it because he was oluei anu moie expeiienceu than she anu
theiefoie uiu not feel thieateneu by hei.
P. comes veiy late but iushes to ueny any "hanky-panky"
on his pait. Insteau, he blames it once again on "someone
moving veiy slowly"a possible unconscious allusion to the
theiapist. Thus P. may be showing impatience with the
success of his own game of biinging up conflictual issues but
not auuiessing them fully, as if expecting the theiapist to uo
that foi him. Similaily, P's self-ciiticism iegaiuing his
inauequacy anu inactivity in iespect to women ("waiting foi
things to happen insteau of going out anu getting them to
happen") can be unueistoou as a wish in the
tiansfeiencethat is, he woulu like to auuiess his uesiies
anu conflicts openly vis--vis the theiapist, but not knowing
how to uo this, he ieacts with impatience anu fiustiation,
again, as if expecting the theiapist to uo it foi him.
Eaily in the session, P. aumits to his affaii with his
teen-age sistei-in-law. Be iuealizes that ielationship,
minimizing anu uenying the possible effects it hau on the
Comment
two of them. The moment he mentions that Bi. X. betiayeu
his wife's confiuence by telling him she uiu not know of his
affaii, P. becomes eniageu at his wife's seconu theiapist foi
confiuing to hei patients about hei own affaiis. Be then
wipes the flooi with women in his neighboihoou ("they'ie
woith shit. fuckeu up. so stiange.") The theiapist
appaiently senses that the vocifeiousness of this attack may
have to with P.'s guilt about his affaii, anu asks about the
ielationship between P's feai of being ciiticizeu anu his
seeking the fiienuship of Bi. X. oi the piesent theiapist. P.
says that he is "not going to get that fulfillment." The
theiapist makes use of this to suggest that what P. seeks in
homosexual encounteis is ielateu to the wish foi a kinuly
fathei, anu asks P. to uesciibe his homosexual paitneis. P. is
veiy vague, anu with gieat uiscomfoit says how these aie
not affaiis, but anonymous encounteis at "places." P.'s
uifficulty appaiently makes the theiapist uncomfoitable
enough to stop puisuing fuithei elaboiation of this. Foi the
iest of the session, P. once again gloiifies his affaii with his
sistei-in-law, anu piactically accuses the only two othei
women with whom he hau "one-night stanus" as having
"instigateu the event." ("If they haun't... it woulun't have
occuiieu.")
SESSI0N 7
P. comes 1S minutes eaily.
Th.: You came eaily touay.
Pt.: Well, I have to get a cai, cai seivice. 0hm. last week,
when I, I, when I left heie, I ca. I got |pausej when I
left heie last week uh veiy, veiy uepiesseu, ieally
went uownhill, veiy, veiy iapiuly.
Th.: Bo you know why.
Pt.: 0h |pausej Not quite. I was, I think I wasn't feeling
well. I uon't know, I can't even iemembei now. When
I was walking home fiom the office anu walking up
my block, I just, I felt like I was gonna uie veiy
suuuenly. 0h I felt like iight theie I,I, my uaughtei
wasn't with me, she was at hei mothei's house, uh I
felt as if iight in the stieet, I was it was just gonna
stop, it was all gonna enu iight theie anu uh I felt like
theie was no puipose in uoing anything.
As he walkeu up to his builuing anu exchangeu a few
woius with some kius having a stoop sale, one of them tolu
him he has no peisonality anu suggesteu he buy his. P. saiu,
with a laugh, how he "wanteu to go back anu kill him."
Th.: Bo you iemembei what we talkeu about that seemeu
to have upset you that much.
Pt.: Can't iemembei at all. I know it was about my fathei,
I can't iemembei specifically.
Th.: |oveilapj Eveiy time we talk about youi fathei, it
seems to have a bau effect on you.
Pt.: Eveiy time, |pausej 0h |pausej how much, any
specific uh....
Th.: Some of the things you weie talking about hau to uo
with the feeling that you hau that you have uifficulty
ielating to othei people, both men anu women
because you feel as though you'ie not aggiessive
enough. You uon't have sufficient aggiession... uo you
know. what that stems fiom.
Pt.: |oveilapj Yeah. Befoie we get into that, I want to
mention something else. I was having lunch, I usually
eat alone because I just iun uown fiom my office anu
giab something anu the guy that I'm somewhat
fiienuly with that lives in my builuing walkeu in anu
sat at my table anu we weie talking anu sometimes
when I talk, my thioat just clams up. It, like it goes
into spasm anu my voice sounus funny anu I saiu to
him, "Boes my voice sounu funny." anu he saiu "Yeah,
you sounu veiy uistant." It's a thing that's been
happening moie anu moie lately. 0h when I was
talking last week, you hau the aii conuitionei on,
making a lot of noise anu I'm veiy hypeisensitive to
noise anu I was like pushing my voice to talk. 0h I
guess it's just kinu of an obvious thing, when I'm in an
uncomfoitable position, oi I uon't feel like talking I
guess, my thioat ieally gets veiy, veiy tight anu lately
it's been, it's been like that a lot. 0h I feel like I'm
withuiawing moie anu moie.
Aftei some geneialities anu a few pointeu questions fiom
the theiapist, P. says that what maue him uneasy about that
man was his suggestion to uo something togethei with him,
like go to the theatei. "The only thing" that comes to P.'s
minu about why this shoulu be uncomfoitable is that he
"will feel inauequate" anu be "founu |to bej lacking." Be
guesses that comes fiom "the olu man": "I coulu nevei uo
anything iight by him."
Th.: Bow have you felt now that you've been sitting heie
talking with me ovei this peiiou.
Pt.: You mean, about you peisonally.
Th.: Nm....
Pt.: 0h |long pausej comfoitable. I uon't ielate you to my
fathei. |veiy long pausej When I, I nevei tolu you
when I met, met my ex-wife's gianufathei it hau a
piofounu effect on me because he ieminueu me of my
fathei but he was a peison with some waimth. 0h
that was veiy uiiect but you know, men in geneial
uh.... I like you. You have a ielaxeu uemeanoi which I
like in people.
Th.: Baven't you founu othei men who have ielaxeu
uemeanois that you've been with on occasion.
Pt.: Yeah, yeah, but uh I always, well I always feel that I
have to piove myself, oi something of that natuie.
Th.: By pioving youiself, you mean what specifically.
Pt.: |long pausej Well having enough knowleuge, oi
whatevei we'ie talking about, I have to have the
knowleuge.
Th.: You mean being bettei than they aie.
Pt.: No.
Th.: Noie than they aie.
Pt.: Eithei as much oi moie. If I know less, then I ieally
feel uncomfoitable. 0h |veiy long pausej,.
Th.: Boes it woik the same way when you'ie with a
woman.
No, he uoes not feel the same way with a woman as he
feels with a man: "I feel moie valiu with a woman. 0h, I uon't
feel infeiioi." Be "noticeu this befoie, this is nothing new anu
my feeling is that women aie a little bit moie sensitive than
men anu I uon't have much in common with a lot of men. 0h,
I'm not in the stock maiket, I'm not into spoits, I'm not into
aggiession, bullying, whatevei." Be shoulu not be in
business, but an aitist. Be nevei went in foi that because of.
"feai of failuie. 0h, my mothei useu to inflate anything I uiu
so huge that I hateu it. I mean, you know, the compliments
weie so, weie laiu on so heavy." Be feels his fathei was not
that absolutely against his being an aitist ("he woulu have
accepteu it if I was successful"), but he ceitainly was not
encouiaging. P. iecalls how in college he useu to "fieeze up"
(he mentions in an off-hanueu iemaik that he fioze when he
hau to uiaw on the psychological test aftei the fiist session).
Be uioppeu out in his final yeai aftei a teachei embaiiasseu
him in fiont of eveiybouy foi plagiaiizing an au foi his
homewoik assignment. When the theiapist ieminus P. that
his fathei once askeu him to copy ait woik foi him, P.
ieplies:
Pt.: That's iight. Wh, you ieally uo youi homewoik.
Th.: You seem suipiiseu that I iemembei what you say.
Pt.: Well, you iemembei things that I foiget anu when
you say them of couise I iemembei them,
|pausej Well how uo we get iiu of my fathei, now.
0h, I'm kinu of amazeu that, I mean I've been thiough
a lot of theiapy anu he's the one now.
Th.: You nevei ieally talkeu much about youi fathei.
Pt.: Not a gieat ueal. 0h somewhat. 0h you know, I
mentioneu that when I was in gioup, nevei talkeu
about |mumblej all of a suuuen I'm just ieguigitating.
0h |pausej I wish I hau uone this 2u yeais ago.
Th.: Bo you think it's too late.
Pt: I think it's kinua late.
Be mentions feai of uying soon, but also his feeling that
he coulu enjoy life only if he "ieally changeu, but I uon't
think I coulu change any moie, I just, I think I've lost that
flexibility." Be mentions having woiiies anu flashes of his
uaughtei getting hit by a cai, anu that he "may be thinking of
hei as an encumbiance." Yet, if not foi hei, he "woulu have
committeu suiciue a long time ago." P. says he hau pioblems
lately with flatulence, anu talks of an iuea to wiite a book on
the subject which he feels "coulu sell" but, he will nevei uo it
because he nevei takes such iueas any place. The evenings
his uaughtei stays with him, she takes up all the time, anu
when she is not theie, he is uepiesseu. Anothei ieason he is
not woiking on that iuea foi a book is that he uoes not tiust
his juugment. Sometimes he wonueis if "maybe I'm ieally a
nut like one of these vagiants" on the subway who talk to
themselves. 0thei people uo not invite him to paities oi to
theii house foi uinnei. "Naybe I see myself as somebouy that
I'm not, as somebouy else." Bowevei, P. uilutes this thought
by talking about how his cultuial anu othei tastes aie so
uiffeient. Be mentions again how he often uoes not iesponu
to auvances by women.
Th.: Why is that, uo you think.
Pt.: |long pausej I ieally... I, I ieally uon't know. 0h you
know what I want to say is they got teeth uown theie
that bite. 0h. I uon't think I tiust women.
Th.: Why. What uo you think they woulu uo to you.
Pt: I have a, a, I hau a fantasy seveial yeais ago. I uon't
know whethei it was a uieam, oi a semi-uieaming
state, anu what I was uoing was shooting a film anu I
was getting maiiieu anu my wife anu I, it was my fiist
wife, weie stanuing in this ioom with a iabbi
stanuing in fiont of us anu theie was a table in fiont
of us anu the biiue ieacheu ovei, unzippeu my fly,
anu took my penis out anu laiu it acioss the table anu
then the iabbi tuineu into a butchei with a meat
cleavei anu just went zap anu choppeu it off
|laughingj kinu of |oveilapj,.
Th.: But it was the man who uiu it not the woman who
castiateu you. What uo you think |oveilapj,.
Pt: I nevei even thought of that.
Th.: What, what comes to youi minu when you think
about the uieam oi fantasy.
Pt: |pausej Well, the man has to be my fathei, anu the
woman, my mothei.
Th.: What uo you think it means.
Pt: |laughsj }esus Chiist uh |pausej Well, my mothei set
me up foi the kill, alloweu it to happen.
Th.: Bo you thinkwhat it seems to me is that youi fathei
may have iesenteu youi closeness with youi mothei.
Pt.: Yeah, my fathei was a possessive peison.
Th.: 0h huh.
Pt: 0h you know, theie musta been some hiuuen jealousy
of my ielations with my mothei.
Th.: Bave you evei noticeu it, obseiveu it ovei the yeais
while you weie with youi paients.
Pt.: No |long pausej No, nothing specific, |long pausej Ny
mothei tolu me aftei my fathei.... seveial yeais aftei
my fathei uieu that, you know, how uiffeient things
aie touay. If they weie this way when she was young,
she woulu have left my fathei. Be was a veiy uifficult
man to get along with, |long pausej Well that
inteipietation of that scene. nevei occuiieu to me.
Th.: What uiu, what uiu you think of when you fiist
thought of it.
Pt.: Well, something moie immeuiate, which is both my
wives aie bitches.
Th.: 0h huh, uh anu they weie the ones who uestioyeu
you.
Pt.: Yeah, uh well of couise that fact that the man is one
that's uoing the emasculating, I just nevei thought of
it. |long pausej Ny mothei is a heavy woman. when
she was youngei, when I was youngei, she was ieally
obese, fat. 0h anu we useu to sometimes we'u cuuule
togethei, she hau gieat flabby aims, they weie veiy
soft anu I useu to love to lay my heau on hei aim.
|mumblesj I uon't know why I saiu that, what I was
thinking of. Ny uaughtei anu I aie like that anu I
ieally uon't think that it's goou.
Be iecalls that his biothei ieminueu him of how he uiew
two figuies of nakeu women on the wall when he was 7
yeais olu. Be was "sexually piecocious, the fiist one in my
gioup to ieach pubeity anu stait mastuibating," which was
always uone in seciet. Be "always felt embaiiassment about
my own sexual, my own sexuality."
Pt.: Bow uo I get cuieu. I want to stop this ciap anu stait
living. You know, I feel like all I have to uo is go out
anu uo it, but somehow....
Th.: Something stops you.
Pt.: Eveiy time. I just c. can't woik.
Th.: I'm afiaiu we'll have to stop now, but I think we
shoulu talk moie about it.
Insteau of being late as he was to the pievious two
sessions, P. comes 1S minutes eaily. Be staits by saying he
left the pievious session feeling veiy uepiesseu. Be uoes not
iemembei what upset him so much in the pievious session,
but guesses (somewhat inaccurately) it was his fathei. When
the theiapist asks foi a moie specific iesponse, P. says he
woulu like to mention something else fiist. Be talks of
"stiaining his voice" when talking to anothei man anu
compaies this with his uiscomfoit when talking uuiing the
session last week. While he attiibutes the uiscomfoit with
the man to the feai that he will be founu inauequate anu
lacking, (which "comes fiom his olu man"), it has much moie
to uo with the homosexual wishfeai activateu by this man's
offei to go out with P. (to the theatei, wheie P. alieauy hau
inuicateu he took women with whom he ieally wanteu to
"get laiu"). Thus P. once again thiows light on the main lines
of the cuiient euition of his conflict. Feelings of inauequacy,
Comment
both with women anu socially, aie connecteu with feeling
castiateu, abuseu, anu abanuoneu by his fathei; he attempts
to compensate by establishing sublimateu,
passive-uepenuent ielations with men (cuiiently with the
theiapist). Bowevei, openly homosexual impulses keep
bieaking thiough anu cause P. to panic. The theiapist
gingeily tiies to make this tiansfeience explicit at this point,
anu asks P. about feelings towaiu himself. 0nce again, the
theiapist elicits only ielatively geneializeu positive
tiansfeience expiessions: P. feels "comfoitable," he "likes"
the theiapist anu his "ielaxeu uemeanoi."
The tone of the session changes somewhat when P.
becomes genuinely suipiiseu anu happy that the theiapist
iemembeieu something he hau saiu a few sessions ago anu,
feeling piotecteu by the theiapist's concein, exclaims "Well,
how uo we get iiu of my fathei, now." A little latei, towaiu
the enu of the session, he comes up with a castiation
uieam-fantasy anu appeais quite suipiiseu when the
theiapist points out it was the man, not the woman, who
actually castiateu him. This biings some auuitional
memoiiesof how his mothei tolu him a few yeais ago, how
she woulu have left his fathei if the social climate was what
it is now, anu how he uiu feel physically attiacteu to his
mothei. It also biings anothei buist of "theiapeutic
enthusiasm" at the enu of the session: "Bow uo I get cuieu. I
want to stop this ciap anu stait living."
SESSI0N 8
P. staits by infoiming the theiapist he "hasn't slept in
thiee nights" anu goes on to uesciibe sleeping uifficulties
anu incieaseu "feelings of alienation" anu "uetachment" even
when he's with otheis: foi example, he hau lunch with his
mothei anu othei family membeishe "hau haiu time
talking to hei"; he "giabbeu all the checks anu paiu them all
|even thoughj it wasn't necessaiy." Buiing a uinnei with
fiienus, he "coulun't ielate at allfelt like shit."
The theiapist asks, "Bo you think this has something to
uo with what we've been talking about. Bow uiu you feel
aftei oui last meeting last week." P. iecalls walking out of
the session "physically uiaineu" anu somewhat misiuentifies
his fathei as the subject of the session; he talks moie of his
uisoiientation. The theiapist ieminus him of the castiation
fantasy fiom the last session anu tiies, with a few pointeu
questions, to elicit the patient's thoughts about how that
fantasy may be ielateu to his uifficulties in ielationships
with both men anu women. The patient ieponus by
becoming flusteieu, almost agitateu anu blockeu: "I uon't
know. I can't think."
Th.: Is theie something on youi minu iight now that's
upsetting you. }ust being heie anu my asking you
these questions. Boes that bothei you.
Pt.: 0ne thing occuiieu to me the othei uay is that I uon't
know how many times I've been heie, but if this is a
shoit-teim piogiam, it's staiting to woiiy me.
Th.: |oveilapj Well, what is it that woiiies you about it.
Pt.: Well, I can't affoiu, I'm, I'm veiy tight, I can't affoiu to
go back into theiapy. 0h anu I'm afiaiu that, you
know, like S months is gonna, is going to come, the
enu is gonna come veiy soon.
Th.: Bow uo you feel about that.
Pt.: I finu it veiy upsetting because uh. I'm getting into
stuff... oi the piocess that is going on is a little heavy
foi me anu gee I'm afiaiu I'm gonna be left holuing
the bag, so to speak of, you know. 0h I've been let
uown in the past anu it's gonna enu. I. you know,
it's a little scaiy.
P. goes on to talk about iecent uieams in which his fathei
appeaieu anu he inteipieteu one of them to mean that
"going thiough this stuff about my fathei |in theiapyj is
eaithshaking oi, hopefully, will piouuce a gieat change, a
iealignment of things." The theiapist then ieminus P. of his
concein that theiapy "is about halfway thiough anu you'ie
woiiieu about what will happen when we'ie finisheu."
P. ieplies that he "knows it's not a 1u-minute ueal"
(something he nevei hinteu at in all the pievious sessions!)
anu staits talking of "mixeu feelings" iegaiuing fuithei
theiapy, because of his "uifficult" anu "unceitain" financial
situation. Be goes on talking about a "client fiom the meuical
fielu |whoj coeiceu |himj into uoing some thinking without
getting paiu foi it" but the theiapist again iefocuses him on
the tiansfeience issue by asking about similaiities between
that uoctoi who exploiteu him anu this theiapist who got
him into something but will soon leave him. P. weakly uenies
any angei at the theiapist but in the same bieath says he's
going to be angiy when the theiapy is ovei because "I can't
push it all back uown, it's too late" anu "you'ie not a
philanthiopist." P. again talks about his social isolation anu
withuiawal, anu feais his uaughtei will finu him "lacking"
because of that, especially because his wife is socially active.
As his comments become moie anu moie uepiesseu ("It just
seems woise than evei anu getting woise. I ieally want to
go away. into myself anu away fiom eveiything"), the
theiapist again inquiies about the patient's expeiience of
theii ielationship anu theiapy. P. pauses foi a seconu, then
says he feels "like smashing something."
Th.: Bo you think you'ie angiy with me anu woulu like to
smash me at this point.
Pt: Yeah.
Th.: Why.
Pt.: I uon't know, the only thing I can think of is because
of what you've uiawn out.
Th.: Anu because I'm going to eventually let you uown.
Pt.: Well, you'ie going to go away in thiee S
|pause-bangingmumbles something likej veiy, veiy
angiy.
Th.: Bo you think in a way that you may have been angiy
with youi fathei when he uieu, that he left you.
Pt.: Yeah, I uh, that came up way, way afteiwaius, uh,
when he uieu I uiun't feel anything oi veiy little, but
yeais afteiwaius, I staiteu feeling that ei I was veiy
pisseu that, that he uieu. 0h you know the thing that
eveiybouy feels when somebouy uies, you can nevei
evei again say anything, oi ueal with them.
Th.: You ieally hau stiong feelings foi him.
Pt.: It's funny, I, I, biings up an enoimous amount of pain.
I can't iemembei any, uh I mean I've seen pictuies of
him holuing me when I was a kiu, when I was a little
kiu, but I can't iemembei evei being helu by him.
0h. I can't iemembei him being affectionate.
Th.: That's what makes you angiy with him, that he wasn't
as affectionate towaiu you as you wanteu him to be.
Pt.: Be wasn't at all, just.
P. spenus the iemaining few minutes iecalling his eaily
anu latei expeiiences of his fathei, the family atmospheie,
anu events fiom the time he was thiee to S yeais olu. Bis
majoi iegiet is that, foi all its shoitcomings, his family,
which meant a lot to him, is now "all gone." ("Theie's no
family, theie's nothing. Nothing is left, its all been, its all
been uestioyeu anu I want to go back.") Finally, he iecalls,
but can only begin to associate to a uieam populateu with
family anu othei figuies fiom the time he was S to S yeais
olu.
Comment
P. begins this session by builuing a case that he's woise,
not bettei; he's unable to continue exploiing a cential
castiation fantasy fiom the last session even when ieminueu
of it. The theiapist coiiectly inquiies at this point about the
heie-anu-now tiansfeience issues anu this biings a
statement fiom the patient about his angei at the shoitness
of the tieatment. Be even hints that the theiapist may have
wanteu to luie him into long-teim anu financially
buiuensome theiapy by offeiing fiee sessions fiist.
Bowevei, the theiapist continues to iaise anu inteipiet
tiansfeience issues anu the patient iesponus. Be begins to
aiticulate negative tiansfeience feelings anu misgivings
about the shoitness of the theiapy. Although these negative
thoughts weie hitheito unmentioneu, anu piesumably at
least paitly unconscious, they have now cleaily ieacheu an
explosive level.
0nexpiesseu, these feelings leu to acting out, feeling
woise, anu having uifficulty woiking in the sessions.
0nauuiesseu, they woulu have ciippleu oi even aboiteu the
tieatment. Although the patient cleaily hau gieat uifficulty
expiessing these thoughts appiopiiately, the theiapist's
initial facilitating questions anu comments enable the
patient to initiate theii expiession fiist, in an accusatoiy,
paianoiu foim. Bowevei, with fuithei inteipietative woik
anu iepeateu iefocusing, the patient is not only able to
foimulate anu expiess these feelings moie fully anu
integiateuly, but also iecalls anu bettei giasps aspects of his
ielationship with his fathei anu ielates these to his cuiient
pioblems. Be thus staits the woik of bettei unueistanuing
both genetic anu piesent mateiial, the exploiation of each
helping the patient to unueistanu the othei bettei.
SESSI0N 9
P. says he has "a teiiible hangovei" anu ielates in an
almost casual mannei how he "went to a fiienu's house last
night" anu how the two of them "enueu up finishing almost 2
liteis of wine." Bowevei, he got "ieally smasheu" anu,
ieaching his home, uioppeu his keys uown the elevatoi
shaft, so he "hau to go back to |fiienu'sj house anu sleep on
his couch." Bowevei, moments latei, when answeiing a
queiy about why he uiu this last night, patient suuuenly
changes his tone: "I thoioughly enjoyeu it |laughsj but theie
is anothei pioblem. |pausej. I'm falling to pieces." Be
staits complaining he's "foigetting eveiything" anu "fucking
up |hisj woik." The pitch of his complaints incieases ("I'm so
uisoiganizeu... in the last few weeks, it's getting woise anu
woise").
Pt.: I have to function, you know....
Th.: What uo you think it is that causes you to.
Pt.: Well, I'm veiy upset |ciiesj this stuff I'm woiking on,
it's iipping me to shieus.
Th.: I see you'ie ciying now7.
Pt.: I can't ei.
Th.: What is it paiticulaily that's upsetting you so much,
uo you think. What is it that we've been talking about
that's been so.
Pt.: Well, my fathei.
Th.: Yes.
Pt.: I'm just uizzy.
Th.: You feel uizzy.
Pt.: |sighs. pausej I hau the shakes this moining, uh
which is piobably fiom uiinking actually. But I also
got the shakes when I'm veiy neivous |sighs. long
pausej.
Th.: What is it about youi fathei that we've been talking
about that you think is so uistuibing.
Pt.: |oveilapj I'm a scieam, I can't, I can't uo any moie
|sobsj.
Th.: You can't uo what any moie.
Pt.: I uon't wanna, I uon't wanna biing up any moie stuff.
Th.: 0huh, uo you think that.
Pt.: I'm so angiy, you know, anu it's wiecking me. I can't.
Th.: What aie you angiy about uo you think.
Pt.: |sigh. sniff. long bieaths, inhales anu exhales
louulyj I feel like I'm losing contiol, |sniffj
Be staits talking about a photogiaph of his fathei holuing
him anu switches to how he got in touch with a new lawyei
to finalize his uivoice. Yet, he uoesn't want to uo that: "I
uon't know what to uo, I'm going ciazy, I uon't know what to
uo with myself anu I want my wife back. you know, I hate
hei, but the iuea of, ei, ieally finalizing is veiy unpleasant
though." Be continues talking about feeling bauly.
Th.: Remembei what we talkeu about last week.
Pt.: I can't iemembei, you know I have this feeling, fiist of
all it feels like I was heie yesteiuay. I have no sense of
passage of time anu I know that I went home anu was
thinking about it anu I wanteu to tell you things
|ciiesj I can't iemembei, whatevei it is, I can't
iemembei, |sighsj }esus, I feel so fuckin' lousy.
Th.: Woulu you like a glass of watei.
Pt.: No, I can't affoiu to feel like this. 0h |pausej theie's a
lot of woik in the house |laughsj anu I, I can't get it
out. I have so much iesponsibility.
Th.: What uo you think it is that's on youi minu that keeps
you fiom uoing youi woik.
Pt.: |Ciiesj I'm afiaiu, I'm afiaiu of this theiapy.
Th.: What aie you afiaiu of.
Pt.: Something's gonna happen.
Th.: Like what.
Pt.: Something's gonna come up that I uon't want to come
up I think.
Th.: Can you think of what it might be.
Pt.: I,I ieally have a feeling that something, when I was
veiy, veiy young. I have on my sciotum, I have a seam
on the bottom of my sciotum anu all uuiing
chiluhoou, I thought that nobouy tolu me but that I
must have been split in half anu it was sewn back
togethei. I since iealizeu that that's a natuial thing.
The patient then inteiiupts his iecollection of how his
family useu to fight a lot to say he "feels like bieaking those
winuows, you know, I, I feel like jumping out of the
winuows."
Th.: You must be angiy, you must be angiy with me. As
you saiu last week you iemembei that heie we aie
talking about these veiy, veiy upsetting things anu in
a while, well you can consiuei it to be in a shoit while,
this piogiam will be ovei anu wheie will you be is
what you'ie woiiieu about. You felt veiy angiy with
me foi it, uo you iecall that.
Pt.: Well, yeah I am afiaiu of that, I mean I'm just not
gonna be able to stop, not like this. I'm gonna have to
continue theiapy. 0h which pisses me a little bit
because I'm, I'm, I have two moie payments on one of
my bank loans. I'm so anxious to finish it anu get out
of uebt. You know, I'm tiying not to spenu money,
you know, because financial is, is a pioblem, it's only
a mateiial pioblem, but you know it just aggiavates
things.
The patient goes on to say how he uiu not take his heait
meuication yesteiuay anu touay, how he is uepiesseu,
"fucking up at woik" to the point that it's "intiinsically
uangeious."
Th.: I think what you'ie saying to me is that heie you aie
upset anu I'm iesponsible foi it because I've been
iesponsible foi youi talking about, thinking about all
these upsetting things anu in a while I'm going to
uump you anu theiefoie, you'ie in teiiible shape, anu
I can't possibly uo that to you, is what I think you'ie
ieally saying to youiself.
Pt.: Well, let me ask you is it possible foi you to take me
on as a patient aftei this is ovei. I, I know I'm going to
neeu theiapy, I can't you know.
Th.: We can talk about that latei, we still have some time
left. This is as I tolu you at the beginning, this
paiticulai piogiam is a shoit-teim piogiam.
Pt.: I know, see I feel, I, I, it must be veiy obvious to you
I've been thiough a lot of theiapy but something's
going on now which hau nevei gone on befoie.
The patient tiies to explain what is uiffeient this time:
The theiapist ("You know, a psychiatiist's technique is kinu
of an abstiact, subtle thing"); the fact that he's "woiking
moie on my fathei"; anu, "the scaie of having a heait attack"
makes him "much moie awaie of myself, you know, much
moie awaie of youi vulneiability, of youi moitality!" Be says
that the theiapist is "getting to him," ieminus him of his
fathei ("physically, a little"). 0theiwise he finus the theiapist
uiffeient fiom his fathei anu "veiy, veiy easy, spontaneous,
easy going, ielaxeu, which I finu it veiy nice to ueal with a
peison of that natuie." Be switches to say he tieateu himself
the othei uay to a nice uinnei, hau a lot of wine, staiteu to
feel angiy that he was alone, anu uelibeiately snappeu the
wine glass in his hanu. Be talks of his ambivalence towaiu
women. Be wants them anu yet he uoes not, because "they
aie all whoies, oi they'ie lesbians oi they'ie fuckeu up." Be
talks of feeling out of place at a West Siue paity wheie he
was taken by a youngei woman with whom he was
spoiauically involveu.
I'll, I'll tell you something happeneu last night that
I ieally uon't want to but maybe I shoulu. I ian out
of clean unueiweai yesteiuay anu I was weaiing a
paii of women's unueiweai that enueu up in my
launuiy in my apaitment house, I founu in my
launuiy one time, |laughsj When I went home anu
I uioppeu my keys, I went uown the basement, I
tiieu to finu the supei anu I was, I was wobbling, I
mean I was ieally uiunk anu then I figuieu, well I
have to go back, I have to go back to Fiank's house,
I'll sleep theie anu then theie's this whole shit. I'm
weaiing a paii of women's shoi. unueiweai, I
can't go theie cause I'll take my pants off, you
know it woulu be iiuiuulous. So I went into the
launuiy ioom anu I staiteu wiestling tiying to iip
them off me. It was, I got, I almost stiangleu myself
tiying to get these biiefs off anu I think I put the
light off, I'm not even suie, you know, people might
have seen me oi something. Then I got, I went to
Fiank's house anu I iealizeu that Fiank anu I once
hau a conveisation anu he saiu something about
having sex with a man at one time. Be saiu, "Biu
you evei tiy it." I saiu, "No." Then last night, he has
anothei fiienuthat he just split with his
fiienuah he makes it with guys once in a while
|inauuiblej like nothing. I mean a lotta guys this
happens to anu its not such a ueep thing. You
know, but I'm, oh when I went back, I tolu them
that I was weaiing these biiefs anu I hau to take
them off because I. uh, you know, I mean that
alone is in my minu so much biggei than....
Be giew up feeling that "homosexual was one of the
woist possible things that you coulu be," anu iecounts a
numbei of "exhibitionistic" episoues in which he woulu
mastuibate in view of otheis, fiom eaily auolescence
thiough his fiist maiiiage. Aftei a silence, he says:
Pt.: I feel like saying to you "I want to commit suiciue."
Th.: Why.
Pt.: Because what I want is help.
Th.: Bo you feel you'ie not getting it.
Pt.: Yeah, I feel like I'm getting it, but I neeu a lot, I neeu a
lot of help.
P. then aumits he's "being uiamatic"; when theiapist asks
him how he thinks his uaughtei woulu feel if he killeu
himself, P. staits ciying: "It woulu uestioy hei"; when askeu
how his wife woulu feel: "she uon't give a shit. I'm suie she'u
ciy, but I coulu kill hei." When askeu how he thinks the
theiapist woulu feel, he laughs, "Well you ceitainly woulun't
feel goou about it." The session is about to enu, anu the
theiapist suggests to him he can iest foi a while aftei the
session befoie leaving, which he accepts. Be expiesses the
feeling he "woulu ieally like to go away now anu just leave
eveiything." The theiapist concluues "incluuing me ... |Ifj I
weie going to leave you, you woulu iathei leave me fiist."
Comment
P. staits the session veiy similaily to the pievious one, by
talking of how teiiible he feels anu how pooily he functions.
The main puipose of this is to inuuce the theiapist to
continue seeing him. Bowevei, his tone is much less
paianoiuaccusatoiyanu much moie openly uepiesseu.
In this context, he states his ambivalence about his wife, anu
links his cuiient fiustiations with chiluhoou feelings of
being unloveu by his fathei. In iesponse to one of the
theiapist's iepeateu inteipietations, he is finally able to
state his puipose openly anu matuiely. Be asks the theiapist
if he coulu see him as a piivate patient aftei the shoit-teim
piogiam is ovei. Even though he uoes not get satisfaction on
that point, the theiapeutic alliance appeais to be stiong
enough to peimit the patient to pioceeu with the theiapeutic
woik on a matuie anu appiopiiate level. Thus he talks moie
of his ambivalence towaiu women, anu then ietuins to the
inciuent fiom the pievious night that he coulu only mention
at the beginning of the session, anu then only to
misiepiesent anu covei up its ieal content. Now he ielateu it
in such a way that homosexual tenuencies become obvious
(although the patient cannot fully acknowleuge them foi
what they aie noi ielate theii upsuige to the feeling of being
abanuoneu by the theiapist-fathei). Be uoes fuithei woik by
biinging up his ielateu exhibitionistic tenuencies. Bowevei,
possibly unuei the impact of the session coming to a close,
he again yeains foi a moie uynamically piimitive inteiaction
with the theiapist: "I feel like saying to you I want to commit
suiciue." This, howevei, is expiesseu in a foim which is at a
much highei anu moie contiolleu level than all of the eailiei
self-uestiuctive acting out, anu most likely ieflects the
theiapeutic woik that has been accomplisheu to this point.
In effect, he is saying, "I am committing slow suiciue by
messing up my woik anu my life." Not only can he now
acknowleuge the piimitive means he employs so as to
inuuce guilt in the theiapist ("I want to commit suiciue") but
he now ieplaces action by woius. As such, he uistances
himself fiom the act anu has an inkling of its ielational
(tiansfeiential) meaning: "* C110 06B1 73A6;2 5E AE? I want to
commit suiciue."
The theiapist, on his pait, continues to inteipiet, but
also, by an open show of concein foi the patient's suffeiing,
offeis him minoi help which has elements of tiansfeience
giatification: he offeis him a glass of watei anu gives him
peimission to iest in the aiea aujoining his office aftei the
session.
SESSI0N 1u
P. calleu a half houi befoie his appointment anu left a
message that he coulu not come. Then he calleu again,
aiounu the time of his appointment anu tolu the theiapist
that he got uelayeu anu askeu if they coulu iescheuule the
appointment foi the next uay. The theiapist agieeu.
P. staits to explain that he was "with a client in the city
anu we weie involveu in a veiy, veiy complicateu situation, I
coulun't leave.... I felt veiy bau about missing an
appointment, obviously, I uon't want to miss appointments,
so I calleu back." Be hau no iuea he woulu not be able to
ietuin on time because he left "veiy eaily in the moining"
foi the meeting with his single most impoitant client.
Bowevei, "it uiaggeu on anu on |anu Ij hau a huge, huge
fight with the client, a scieaming, iaging, cuising fight." The
conflict was causeu by his "uysfunctioning" anu not getting
his woik uone. "I was veiy, veiy late with the job. It uiun't
come out too goou." Besiues, he was "totally exhausteu," so
when the client "staiteu bitching" he "just coulun't holu it
in." It was all ieally the client's fault because "he insisteu on
uoing something in a cheap way which coulun't be uone.
insteau of 2u houis' woik, it took 1uu, liteially 1uu houis'
woik to uo something because he wanteu me to uo it cheap
anu I'm not gonna get paiu foi all that...."
The theiapist asks why he unueitook the woik when he
knew in auvance he coulun't uo it like that. P. ieplies that he
lets himself be pusheu, he always accepts things. Be agiees
with the theiapist that he finus it haiu to say no, anu
explains he wants to be consiueieu impoitant, wants to "be a
heio." Be gives an example of how he wants to help young
neighboihoou aitists who "always come up to me foi
auvice." Be uoes it fiee but he "can't spaie the time, it's
ciazy." P. then claiifies, once again, the sequence of calls that
he maue the uay befoie. Be askeu foi anothei appointment
only at his client's encouiagement, because he "felt out of
place asking if you coulu ieaiiange the appointment" when
it's fiee.
Th.: Bo you think it hau something to uo with oui session
last week when you weie so upset anu agitateu when
you weie heie, uo you iemembei that. Anu angiy
with me.
Pt.: Well, the thought ciosseu my, my minu, that I wanteu
to giab youi lapels anu shake you. 0h, I hau been
thinking whethei this, all this pays oi not, whethei
this piocess is woiking. 0h, befoie I came heie, I
wasn't functioning too well. Since I staiteu, it's gotten
woise, but I wasn't too happy befoie eithei, so I think
it's woith it. I mean I, whatevei happens, I imagine
it'll get bettei. uee, I always have a lot of thoughts
aftei the session, but I can nevei iemembei them,
|oveilapj I have a teiiible pioblem iemembeiing
them.
Th.: Bow have you been feeling since oui last session last
week.
Pt.: 0h, I've been kinu of busy, which I uon't feel anything
when I'm veiy, veiy, I'm woiking veiy haiu. I've
become totally pieoccupieu.
Be goes on to complain of his mothei-in-law ignoiing
him anu goes on to put uown his wife anu all the women in
hei familymothei, gianumothei, sisteias "tiamps" anu
"ieally fuckeu up." Be mentions the age at which they "lost
|theii iespectivej viiginity" as pioof of that. Following a long
pause, the theiapist mentions the uate of theii last session.
P. says it makes him feel like thiowing up. This feeling
ieminueu him of a fellow gioup theiapy membei who
staiteu thiowing up, seveiely anu uncontiollably, when
talking about his mothei (she "useu to shave his legs when
he was a kiu anu he went swimming so he shoulun't look
ugly. The guy was ieally fuckeu ovei by his mothei."). Be
felt "somewhat the same way" last week oi the week befoie
anu when he thought about it aftei the session. The theiapist
ieminus him that he "soit of iecalleu last week that it hau
something to uo with when you weie a chilu anu you
thought it involveu youi mothei anu youi fathei fighting anu
maybe youi fathei taking a knife anu wanting to stab youi
mothei oi something along those lines." P. confiims this,
saying it is veiy vague in his minu. Be's been "thinking of
sitting uown anu talking to hei, ei, I uon't know if she can
hanule it, oi if I can hanule it...." Be iepoits conflicting
feelings of not wanting to biing it up, just wanting to get iiu
of it, anu also feeling "kinu of iiuiculous talking about
something that I uon't know what it is...." Be mentions
having a fantasy as "a kiu" that maybe he was auopteu; he
iecalls his "gianumothei anu aunt who weie always
scieaming anu fighting, uh, anu my fathei anu mothei useu
to, useu to fight a lot." Be switches, with no inteiiuption, to
talk of how his uaughtei useu to ciawl into beu with him in
the moining until she was S, anu how iecently, on account of
hot weathei, she spent two nights in a iow in his beu anu he
thinks "that's not a goou iuea. but I'm always afiaiu of this
ieaching out to hei foi a little bit too much, but she ieaches
out to me a lot, too. |long pausej When I was youngei, uh,
something about when I useu to showei, I'u insist on
somebouy uiying me. Ny mothei useu to uiy me aftei I
showeieu." Be thinks his ieason foi that "must have been
sexual." Be compaies himself anu his uaughtei ("I think I
was much moie sexually matuie than she is") but then
contiauicts himself, saying she is "awaie":
Pt.: When I was a kiu, it was all in the uaik, with guilt, anu
I got, I think I got sexual guilt when I was like 7 to 8
yeais olu.
Th.: What weie you guilty about, uo you iemembei.
Pt.: 0h, well, I know it hau to uo with my mothei. I saw
my mothei nuue.
Be iecalls uiawing nuue fat women when he was 7,
mastuibating ("I was the fiist on my block"). Be stops
puisuing this, says he's "kinu of tiieu."
Th.: Too tiieu to think anu talk about youiself.
Pt.: Well, I woulu like to. I'u like to get some woik uone.
0h, but I uon't feel much like touay foi some ieason,
which I'm veiy uisappointeu about....
Th.: Bo you think it hau something to uo with the fact that
we'ie coming closei to the enu of the piogiam. What
uo you think about that.
Pt.: 0h, maybe I'm staiting to tuin it off. That's upsetting
me. It's, I want to change my life. I'u like to pick up
this chaii iight now, smash it, smash it.
Th.: 0n whom.
Pt.: Well, just on the flooi. Not on you.
Th.: Why uo you feel so angiy iight now, uo you think.
Pt.: 0h, 'cause I'm getting fuckeu, you know, the session's
gonna enu, the piocess enus anu. I'm in a limbo....
Th.: ...Remembei you talkeu last week about how I
iesembleu youi fathei in a numbei of ways. Bo you
feel that in a while I will be leaving you the same way
youi fathei left you when he uieu. I think it makes
you feel angiy.
Pt.: 0h, yeah, yeah, I'm not angiy, I'm uizzy. |long pausej
Well, I uon't know what I can uo about it except to
accomplish something in the session....
P. talks about how the client he hau the fight with is
ieally a nice peison, that he ieminus him much of his fathei,
but is bettei because aftei a fight with him he feels bettei,
unlike with his fathei, who woulu just clam up"he nevei
gave me a chance to say anything. nevei expiesseu feelings,
nevei aigueu a point." What he "absolutely" misses is that
his fathei nevei showeu him affection. Be feels angiy about
that now. Be iecalls anothei "hoiienuous fight" between his
paients but iemembeis it veiy uimly. Recalling how he slept
foi a while at his gianumothei's house, he iemembeis that
must have been the time when his biothei hau his appenuix
taken outthat "might have been a tiaumatic thing."
Comment
In an inspiieu combination of acting out anu acting in, P.
has a big fight with a fathei-like business client anu theieby
makes it impossible to come to his session on time. Be also
foices the theiapist to choose between two unpalatable
alteinatives: 0ne was ;E5 to make up the session. With a
cleaily uecompensating patient, this woulu have maue it
easiei foi the patient to uisengage fiom the theiapy anu cast
the theiapist as a iejecting, punishing figuie. In a long-teim
intensive psychotheiapy, this woulu cleaily be the
piefeiable alteinative, because theie woulu be plenty of
time to inteipiet anu woik thiough the patient's
misconstiuals. Bowevei, with just a few sessions iemaining,
the alteinative seemeu moie sensible. That is, to giatify the
patient anu "make up" the misseu session. This move
piobably also hau a symbolic meaning to the patient; that is,
of quasi-magically negating oi qualifying the main fact which
was uistuibing himthe impenuing enu of the tieatment.
Bespite a potentially seuuctive effect of such a "gift" fiom the
theiapist, it was consiueieu to be the moie appiopiiate
alteinative heie in shoit-teim tieatment because it helpeu
stem the malignant self-uestiuctive ieaction of the patient,
anu ieinfoiceu the woiking alliance with him. Inciuentally, it
woulu have been appiopiiate anu fully consistent with the
oveiall tieatment appioach hau the theiapist actively
confionteu anu inteipieteu the tiansfeience meaning of this
acting out. Be, howevei, electeu not to puisue that avenue,
piefeiiing to allow the patient to achieve a moie stable if
less thoiough oi peifect balance in the face of the
appioaching abanuonment with the enu of tieatment in
sight.
In the session itself, P. comes acioss as much moie stable
than in the pievious two sessions. Be is uepiesseu, anu feels
empty anu insecuie, but stops actively anu self-uestiuctively
tiying to get the theiapist to keep him in theiapy beyonu the
contiactual 14 sessions. ("Well, I uon't know what I can uo
about it except to accomplish something in the session.").
Bowevei, he uoes not exploie his feelings about the enuing
as openly as he uoes in the foithcoming sessions.
It is inteiesting to obseive the, by now, almost typical
ielation between the main tiansfeience theme of the session
anu the content of what the patient chooses to talk about:
faceu with abanuonment by the fathei-theiapist, anu in a
uepiesseu moou, P. talks viciously of women with whom he
was sexually involveu (his wife, even his teen-age
sistei-in-law), ieminisces fieely about incestuous impulses
towaiu his mothei anu his uaughtei, anu then gives us
anothei clue about how these two themes aie ielateu by
iecalling a (scieen) memoiy of a "hoiienuous fight" between
fathei anu mothei, being away fiom the paiental home (at
gianumothei's home), anu his oluei biothei being away
because his appenuix was taken out. Themes of sepaiation
anu abanuonment by an omnipotent fathei anu incestuous
anu aggiessive impulses towaiu women aie connecteu by a
scieen memoiy of a piimal scene (fight), by feai of
abanuonment (not being home), anu by a castiation thieat
(biothei's appenuectomy).
SESSI0N 11
P. comes late to the session: "I apologize, actually a fiienu
of mine calleu me who is in the same situation. |anuj I
coulun't get him off the phone. In the same bieath, P.
switches to talk about how his mothei calleu him just aftei
the last session, anu he askeu hei about the events that
occuiieu when he was 2 to S yeais olu. Foi one, his
gianufathei uieu anu he anu his mothei weie sleeping at his
gianumothei's place. Foi anothei, his biothei hau his
appenuix taken out. But "the ieally big thing was that my
fathei hau left the family." While his mothei uiun't say if they
hau actually sepaiateu, she uiu say that his fathei left when
he was S yeais, 1u months olu anu uiu not eithei wiite oi
call them. Immeuiately pieceuing his fathei's uepaituie,
they hau a lot of financial pioblems anu fights in the family;
they coulu not pay the ient (which P. connects with his
biothei having an opeiation), so they went to live with the
mateinal gianumothei. Eight months latei, his mothei took
the patient anu his biothei to 0hio, wheie they stayeu with
hei biothei. They weie looking foi the fathei. 0ne uay,
shoitly aftei P.'s fifth biithuay, they uiove to a place wheie
they knew he was. The patient expiesseu suipiise that he
uiu not have moie of an emotional ieaction on heaiing about
it. Be's suie he "misseu him oi felt the sepaiation," but, on
the othei hanu, he "knew he was away foi a while but I hau
no iuea foi how long anu I'u ieally foigotten about him."
P. inteispeiseu these iecollections with woiiies about
how his uaughtei is too clinging, anu uiun't want him to
leave hei when he took hei to school that moining; how he
took hei as usual, to the paik wheie they jog, but this time
they playeu ball. Bis uaughtei, being a "klutz" like himself,
uiu not uo well anu he ciiticizeu hei, which maue hei not
want to play any moie. Be iecalleu that his fathei, in such
situations, "woulu make you feel like shit." P. was clumsy
anu woulu get huit when playing in the school. This ieminus
him of news that his mothei gave him about his biothei's
life-thieatening meuical conuition. This upsets anu scaies
him. Bis mothei also tolu him she woulu like to maintain a
ielationship with his ex-wife, so that she coulu have access
to hei gianuuaughtei if something happens to him. This
unneiveu the patient a little. Be then asks when the last
session will be, because he's planning a vacation. The
theiapist asks if he's been thinking about teimination.
"0mm, no, it hasn't been upsetting foi some ieason." Bis
moou vacillates, anu at the moment he feels like he has
steppeu ovei a huiule. Be feels theie must be something else
othei than his fathei leaving that upset him in his chiluhoou,
but uoes not know what it is. Then he states that his fathei,
like himself, nevei ieacheu his potential.
Pt.: I uon't feel veiy emotional touay.
Th.: By that you mean what.
Pt.: Well, I ei, I can get in touch with my feelings faiily
easily anu I, I just feel like I'm iambling anu not
talking about anything ieally. 0h, time's valuable.
Th.: Bo you think it has something to uo with the fact that
in a while this will be ovei anu I'll be leaving anu why
shoulu you talk about things that aie veiy impoitant
anu significant if I'm not going to be heie to talk to
you about them.
Pt.: 0mm, I uon't know, it might be the opposite, that I
feel in a iush to take auvantage of the situation. 0h, I
uon't know, I think I feel goou.
Be ielates this "feeling goou" to the fiienu who maue him
come late touay anu his inviting him anu his uaughtei foi a
baibecue anu the fact that he was suppoitive anu
encouiaging about P.'s conflict with his wife: "I tolu him I
went to a lawyei last week anu he saiu, '0h, I'm ieally glau to
heai that, it ieally makes me happy that you uiu that,' anu I
hau that feeling it's nice foi somebouy to talk to you with
concein." Bowevei, he'll "have to shell out two anu one half
gianu foi the gouuam lawyei which makes |himj angiy." But
he feels he neeus "a ieal son of a bitch" that this lawyei is,
because his ex-wife has been "sciewing him out" of the
money that belongs to him. Be switches to talk about his
vacation with his uaughtei anu how his mothei is pushing to
go with them, too. Be goes on about this until the theiapist
inteiiupts:
Th.: You'ie tiying to finu things to talk about, is that it.
Pt.: Yeah, I think I'm I'm....
Th.: You'ie blocking.
Pt.: I'm blocking. Naybe I am tiying to sepaiate myself. I
feel like I'm not talking ieally tiuthfully. I'm kinua
chatteiing cosmetically.
Th.: Last week you talkeu about how angiy you felt with
me, you felt like giabbing my lapels. Bo you
iemembei when you talkeu about thiowing the chaii
thiough the winuow. Bow have you been feeling
about me since last week.
Pt.: I uon't know. I have goou feelings. I uon't feel that
angei iight now. I uon't know if I'm blocking oi what,
I, I'm not feeling any paiticulaily stiong feeling at all.
You see, angei is the easiest thing foi me to expiess,
uh, anu I think it coulu be veiy easily useu as a
coveiup. I may covei up foi.
Th.: What.
Pt.: Bealing with something else that's moie impoitant oi
oi maybe painful.
Th.: Like waim, fiienuly feelings.
Pt,: Yeah, yeah anu that's yeah. I ei, ei I'm veiy s.
saicastic, I love to put uown uh.
Be goes on to say how he puts uown "an incieuibly
beautiful" young giil woiking foi him, foi hei liking pop
music, even though he ieally thinks well of hei, anu how he
uiives people off, uoes not maintain fiienuships ("I nevei
call anybouy, I nevei ieach out... I have to be uying to call
somebouy") anu always feels uncomfoitable with people. Be
talks of not being able to extiicate himself fiom a
conveisation with a neighboi, even though he was in a huiiy
to get to his office. The theiapist inquiies about how P. feels
"sitting heie with me now." P. ieasseits that he feels
comfoitable, that he can say what's on his minu, anu auus
how he has stiongei feelings about memoiies when he talks
about them "in heie" than with othei people. The only thing
he still feels uptight about talking of is in "the sexual aiea."
Be then iecalls many tics anu compulsions he hau as a chilu
anu latei. Befoie this theiapy he useu to ieheaise things
befoie actually saying them. Be woiiies about his "halitosis"
anu how he may be uiiving people away on puipose.
Comment
P. again comes late, although less so than in the pievious
session. Be "coulun't get a fiienu off the phone," but his latei
statement about that conveisation ("I hau that feeling it's
nice foi somebouy to talk to you with concein") explains
bettei why the patient piefeiieu staying on the phone to
coming on time. Be iepoits gaps in his chiluhoou memoiy
that his mothei filleu in with hei infoimation. Inteiestingly,
P. inteispeises the stoiy about his fathei leaving the family
anu his unceitainty about fathei's ietuin with woiiies about
his uaughtei's oveiuepenuence on him anu his inauequacies
with hei, as well as with woiiies about the possibility of his
biothei anu even himself uying. Finally, he asks when is the
last session. But when the theiapist openly inquiies about
teimination feais, P. uenies it is upsetting him. Anu, inueeu,
the tone of the session is entiiely uiffeient fiom that of
sessions 8 anu 9, anu even session 1ualthough the quietei
moments of that session heialu this one. Bowevei, P.
unwittingly suggests how his peace of minu has been
achieveu: "I uon't feel emotional touay.... I've been busy, I
uon't think, I just iun." Coming late has to be unueistoou in
this context, in which P. is tiying to uistance himself fiom the
theiapy, saying, in effect, "What I uo out theie, whethei
business oi social, takes pieceuence." The flow of his
associations cleaily connects teimination with
abanuonment by fathei, biothei's appenuix being taken out,
anu even ueath. The theiapist asks a few uiiect questions
aimeu at facilitating P.'s expiession of these feais, but he
laigely ignoies them anu the theiapist leaves it at that. Be
has two ieasons foi uoing so: fiist, the extent of the patient's
exaspeiation in the pievious thiee sessions anu, seconu, the
fact that the patient is able to continue with the theiapeutic
woik, putting togethei pieces of his histoiy with his piesent
life expeiience. Although he uoes so somewhat haphazaiuly,
his analytic woik pioceeus in a piouuctive way.
SESSI0N 12
"The only thing that coulu happen this week is, I'm
feeling sexual fiustiation. Women in summeitime tuin me
on. The way they uiess, it's teiiible." The patient goes on to
bemoan his lack of initiative uespite "an awful lot of smiles"
he gets fiom women in the stieet. Be iegietfully compaies
this with the behavioi of a "iathei stupiu-looking guy" on the
subway who appioacheu two uiffeient women anu got polite
anu "nice" iesponses fiom them (even though they both left
the tiain with this man still on it). Similaily, he feels "like a
shmuck" when he sees women, who woik on a
neighboihoou magazine, go to a movie: "Beie they aie in a
gioup of 2, S, 4, S, you know, walking uown the stieet
laughing, kiuuing aiounu, anu theie I am going to the movies
alone." When askeu what holus him back, he "can't quite
figuie it out. To say that I hate women I think is iiuiculous."
Be thinks it has to uo with his ex-wife anu "the finuing of hei
in beu with anothei guy. " This still seems to have left a
lingeiing impact, "a peimanent scai.... Befoie I was maiiieu,
I uiun't quite feel this way. I wasn't this immobilizeu. But, I
was always not the most aggiessive peison, but I mean, I
useu to go out anu get laiu occasionally, moie than
occasionally. But, since I've sepaiateu fiom my wife, uh,
nothing, you know, I just, uh, it's ovei a yeai alieauy. It
seems to me it shoulu have uissipateu. It shoulu have been
ovei, uh, but it's not."
Be mentions that his uaughtei tolu him that the man he
founu in his wife's beu visiteu hei the othei uay, anu that he
hau a iesponse "uh, that shmuck," anu that it still gets him
upset. When the theiapist ieminus him that he has, foi a
long time, been having an affaii with his wife's sistei, P.
ieplies "It uoesn't count. because it is an
emotional-ieaction, it's not an intellectual ieaction....
Intellectually, I believe that we shoulu all have the iight to
sleep with whomevei we want to. But emotionally, it uoesn't
woik that way...." Sensing an unueilying uynamic, the
theiapist asks P. if he may have been jealous of his wife foi
having a ielationship with this man. P. uenies this, saying he
was jealous of hei "social success. hei jumping back into
life quickei than I uiu. You know, theie's a whole netwoik
foi single women that they have veiy well stiuctuieu." Be
goes on to say that the othei uay, he hau a uieam which hau
a lot of impact. Be "can't iemembei it now, but it hau to uo
with his wife being a lesbian." In auuition to his wife anu his
uaughtei, theie was this female fiienu of his wife's in the
uieam who is "an asshole" anu whom he suspects of being a
lesbian. "I think my wife may be gay, I'm not suie." Theiapist
asks about the uieam, but P. just says "it was veiy
complicateu." Be is woiiieu that his uaughtei "is going to get
fuckeu up signals" fiom his wife. Bis uaughtei sometimes
uoes not want to leave him to go to hei mothei, anu this
makes him angiy because it means she is not a goou mothei
anu he uoes not feel he can iaise a uaughtei by himself. Be
feels that his wife "uoesn't pay much attention" to theii
uaughtei. Be iecalls an episoue fiom the last week when his
wife biought theii uaughtei to him foi the weekenu. Be hau
planneu to take his uaughtei to a baibecue on the ioof of his
fiienu's house. Be was uining in a iestauiant, hau alieauy
"finisheu off half a bottle of wine anu was just a little tipsy,
but I was veiy upset anu I can't quite iemembei why....
|Theyj walkeu in anu I was a little agitateu, anu my wife saiu,
'I uon't want you taking hei up on the ioof, it's too
uangeious.' So I saiu 'Bon't woiiy, if I jump off, I won't take
hei with me.'" Although his wife angiily left at that, she
calleu the iestauiant S minutes latei "to see if I'm all iight"
anu then calleu him latei at home. When the theiapist asks
P. what he thought of "hei gieat concein" about him that
uay, P. evaues acknowleuging hei concein, uenies feeling
ieally suiciual, anu aumits it was an attempt to make hei feel
guilty. "I woulu ieally like to uo something to huit hei. I'u
like to slap hei in the face. just whack hei acioss the face... I
uon't hit people, I nevei have in my life. 0hm |laughsj but I'u
ieally like to uo it." Be iecalls an embaiiassing inciuent
when he "staiteu stiangling a giil." They weie 11 oi 12, anu
he useu to walk this giil home, anu they woulu "neck a little
bit, we'u kiss" anu theie was "one ieal fiuitcake in the class,
ieal faggy kinu of mesomoiphic lump, coulun't stanu him,"
who woulu follow them. P. got veiy angiy at him once "anu
staiteu shaking him anu I hau foigotten to take my yaimulke
off so this giil ieacheu up anu giabbeu the yaimulke anu I
tuineu aiounu anu I giabbeu hei thioat." At this point, the
theiapist again biings up the uieam of his wife being a
lesbian, asking if he iemembeieu how he felt uuiing the
uieam, pleasant oi unpleasant. "veiy unpleasant," he says,
anu again switches the subject, saying that once, in gioup
theiapy, he uefenueu a lesbian's iight to iaise hei uaughtei.
Be goes on to say that the uownfall of his maiiiage was
"paitially my fault also.... I uiun't fulfill the iole that I shoulu
have. Ny nonaggiessiveness is the iuination of a lot of
things, uh, wishy-washy."
Th.: Since you'ie awaie of it, why uo you think you finu it
so haiu to uo it, be moie uecisive.
Pt: Well, it's stanuing up, being counteu, making
uemanus, I can't make uemanus. 0h, I uon't feel I'm
entitleu to make uemanus of othei people.
Th.: Why. What uo you think you've uone that makes you
feel as though you'ie unable oi incapable oi haven't
got the iight to make uemanus.
Pt.: I uon't know. I just uon't feel valiu.
Th.: You've useu that woiu othei times in the past. What
uo you mean being "valiu".
Pt.: |oveilapj Yeah. Well woithwhile, impoitant. I feel like
I'm kinu of, you know, woithless, amoiphic,
nothingness. I feel almost like I'm not theie.
Sometimes. 0h, I just uon't exist.
Th.: But you know you'ie impoitant to a numbei of
people, ceitainly you'ie impoitant to youi uaughtei.
Pt.: Yeah, until she sees thiough me, is one of the feais I
have.
Th.: What will she see if she sees thiough you.
Pt.: She saiu the othei uay, ielative to something, I foigot
what it was, "you have no fiienus" anu it's quite
embaiiassing coming fiom hei.
Th.: Is that tiue.
Pt.: Well, it's, it's ei, yeah. I mean I have a couple of
acquaintances but I uon't have much inteiaction. You
know theie hasn't been anybouy in my apaitment
except my uaughtei anu I foi months, anu months,
anu months.... Ny uaughtei is useu to hei mothei
going out on uates, you know, anu I nevei uo. I
haven't hau a baby-sittei, 8 months anu I think she
wonueis why. Why theie aie no women in my life.
Be is woiiieu that "as she gets oluei, she'll see my
pioblem moie. You know, kius think theii fathei is 1u-feet
tall. Ny feai is, as she gets oluei, not only will I come uown
to 6 feet, but I may stait shiinking, shiinking, shiinking." Be
goes on to complain about insomnia.
Th.: Bo you think it might have something to uo with the
fact that you'ie appioaching the enu of this piogiam
2 weeks fiom touay.
Pt.: 0hm, if it uoes nothing is iegisteiing about it. 0h, I
have no con... I haven't thought about it. No conscious
thoughts. I think what I, what I possibly have uone is
that I wanteu to think that the thing I uiscoveieu
about my fathei was it, peiiou. Anu now that I know
that, I'm cuieu.
Th.: It uoesn't woik that way.
Pt.: |laughsj No I guess not. 0h but I think I, I kinu of
tuineu off oi built up a block, you know, a wall, ei not
wanting to uig fuithei oi not wanting to stait
anything because it's coming to an enu. Whatevei the
ieason, I'm, I'm ice-colu, |pausej You know, in fact, I
feel totally, I think ice-colu is the teim.
Th.: By ice-colu you mean....
Pt.: veiy unemotional. Well, I say, I, I, I, you know I get
emotional at the uiop of a pin. I've stoppeu. You've
hau it with me, that's it.
Th.: So you feel you uon't want to open up anything that
may cause you any kinu of upset oi uistiess since
we'ie not going to be continuing beyonu 2 weeks
fiom touay, so why shoulu you stait anything new.
Pt.: That may be it, that but I'm only guessing, because I
uon't, I uiun't think of it consciously. Again, as I saiu
the last couple of weeks, I'm busy, so that kinu of
takes caie of a lot of stuff. I uon't have to bothei living
if I'm busy. I just woik.
Be mentions an impulse to thiow away the foim which
the theiapist gave him a few minutes eailiei to be filleu out
by next week. The theiapist asks if that is a way of
expiessing his angei towaiu him, but P. only says he has a
lot of angei, anu uoes not know how much of it is uiiecteu
towaiu the theiapist. Be is angiy because he is fiustiateu "in
many aieas: peisonal life, cieativity, business." Be wishes he
coulu walk up to a woman in the stieet anu "pinch hei ass.
give hei behinu a little pat. What woulu happen is, she'u tuin
aiounu anu smile anu you'u get into a conveisation anu
piobably take hei home anu make love to hei. That's, that's
veiy likely to happen. But the thought is, you know, you can't
uo that. She'u tuin aiounu anu slap youi face anu scieam
anu all that. you know, going ovei anu patting somebouy on
the behinu is a little extieme, but you know, I uo go ovei to
people sometime anu have these little, veiy shallow bits of
inteichange anu theie I've nevei been iebuffeu...."
When askeu what he is afiaiu of, he answeis that his
"self-image is veiy inflateu. anu people think I'm someone
uiffeient than who I ieally am." Be iecalls taking excellent
caie of how he was uiesseu, anu iecalls with a laugh how he
"woulu walk aiounu like, ei, you know, like I was a ieal man
about town." But now, he is "veiy consciously tiying to uiess
uown." Similaily, he feels the plate on his office uooi is too
"pietentious" foi the "little pishika shop" that he has. Be was
tiying to make people think he was "moie impoitant than
|hej was."
Comment
Aftei being late the pievious two sessions, P. comes on
time to this one, possibly signaling that his ability to ueal
with the impenuing sepaiation fiom the theiapist anu
theiapy has become less fiagile. Be opens this session by
wishing he coulu puisue his phallic naicissistic heteiosexual
fantasies. But he cannot, because he uoes not feel "valiu." Be
blames his wife anu othei women, almost suggesting a
lesbian conspiiacy among them. Be uenies having a sexual
inteiest in his wife's male lovei, but iecalls a uieam in which
his =6C1 is a lesbian anu a bau influence on theii uaughtei.
Latei in the session, he aumits to woiiies that, as his
uaughtei gets oluei, she will "see thiough" him conceining
the issue of "why theie aie no women" in his life. Bowevei,
he uoes not connect the two conceins. Be iecalls attacking
his giil fiienu at age 11 oi 12 when she got entangleu in a
fight he was about to have with a "ieal faggy kinu of
mesomoiphic lump" of a boy; a few minutes latei, he
uesciibes himself in veiy much the same teims as he uiu that
"fiuitcake |hej coulun't stanu" ("I feel woithless, amoiphic,
nothingness"). When, latei in the session, he again complains
of seveie insomnia, the theiapist biings up P.'s ieaction to
the impenuing teiminationP. still uenies being stiongly
affecteu by it, but exploies some of the ways in which he was
tuining off, uisengaging fiom the theiapy. P. thus oscillates
thioughout the session between, on the one hanu,
omnipotent phallic fantasies anu the paianoiu, aggiessive
tenuencies, which occui in the wake of theii failuie anu, on
the othei hanu, uepiesseu, ueflateu, yet calmei anu moie
functional images of himself. Bowevei, he uoes not yet
unueistanu these ciiculai uynamics. Be uoes not iecognize
that, faceu with feelings of being abanuoneu anu castiateu
("invaliu"), he has an impulse to asseit himself in phallic,
sexual-aggiessive exploits with often thinly veileu
homosexual feelings; howevei, he has maue piogiess insofai
as he no longei compulsively peisists in these fantasies until
theii ultimate failuie iesults in his bieakuown. Insteau, he
moves into a uepiessive position in which he is willing to
accept himself anu function in moie iealistic teims.
Although he uoes not achieve the insight that woulu enable
him to tianscenu this "paianoiu-uepiessive" uichotomy, he
is now able to oscillate between them with some auaptive
ease anu functional iesults, avoiuing uangeious extiemes
anu functioning in a moie matuie way.
SESSI0N 1S
"I was ieally pisseu about the inteiview with that woman
last week. I was staitleu." (Why.) "You uiun't tell me it'u be a
woman." P. goes on to iepoit he was hostile to this female
psychologist. Be uiun't like the iuea of being questioneu by
hei. Also, he was "veiy awaie of hei being a woman, hei
sexual being... it was hot in the ioom, she playeu with hei
skiit anu I wanteu to tell to hei to keep hei cunt to heiself."
Be uenies being sexually aiouseu, but then changes his tone
to say that he was annoyeu anu uisappointeu that he hau
such a ieaction, that he hates women so much. Be wonueis if
his wife is to blame foi this, anu then iecalls almost saying
hello to the man he hau founu in hei beu when he saw him in
a iestauiant the othei uay. ("I almost saiu hello to this guy,
anu I'm supposeu to hate him, to want to kill him. anu I
uon't have that ieaction anymoie.") The theiapist asks him
why he hates women so much, anu P. talks of his mothei
thinking she was uoing him a favoi when she uiu things foi
him, but he feels now it "limiteu |hisj uevelopment, sense of
iesponsibility, ability to get out anu get things foi myself."
Bowevei, this is moie of an intellectual feeling. Still, his fiist
wife hau an affaii with hei boss, anu his cuiient wife keeps
senuing him bills he consiueis "nonsensical," yet he cannot
confiont hei because he uoes not want to have an aigument
with hei. "We talk anu once in a while it gets genial anu I
always enjoy that. She anu I uiu have something foi a while
|anuj theie's always a little affection that you nevei get iiu
of, oi wanting affection fiom that peison.... What she uiu to
me I consiuei veiy uiity anu I uon't want to have goou
feelings towaius hei. but it sneaks up once in a while." Be
ietuins to talking about the testing with the female
psychologist: "She maue no oveituies, she was piofessional,
but I felt she was |unconsciouslyj a tease. anu I was veiy
uncomfoitable, I uiun't want to uo that, I uiun't want to
make oveituies, I uiun't want to have hei sexually. when it
came to uiawing a woman, I coulun't uo it. I was ieally
iejecting hei. except I ieally... I wanteu to holu |thatj
woman in my aims, have a ielationship." When the theiapist
points out this "inconsistency," he ieplies he "pushes them
away" uespite theii smiles in the stieet, anu exclaims: "It's
stuck! It's stuck!" anu aumits to the "feeling of impotence,
not being able to peifoim." Be uiifts into a conuemnation of
piesent-uay uating habits.
Th.: Bave you thought some moie about the fact that next
week is oui last session.
Pt.: 0h I thought about it this moining anu I was tiying.
0h I haven't thought about it consciously, except
yesteiuay, I hau to go to my uoctoi about something
anu he's a ieally nice guy anu easy to talk to anu I
mentioneu that I was coming heie anu I, I askeu him
foi stiongei sleeping pills. I saiu I have a lot of
anxiety, I still can't, can't sleep anu I mentioneu that I
was coming heie anu that it was enuing in 2 weeks, it
was just tempoiaiy, so I'm awaie of it, but I haven't
ieally ieacteu. By the way, he gave me, he veiy
hesitantly gave me some baibituiates anu he, you
know, with a lot of waining that they'ie highly
auuictive anu not to use' em, at 2 o'clock last night it
hau no effect on me.
Be then mentions pioblems which make him tense:
long-teim ("What am I going to uo piofessionally to make a
living") anu shoit-teim ("loneliness"). Be feels too much of a
failuie to appioach a woman:
Well, piofessionally I'm, I'm no place. 0h you know
I'm not, I'm not uoing anything exciting. I always
use the expiession I useu to "I want a mountain to
climb." I climbeu the Natteihoin in Switzeilanu
when I was in Euiope. Not all the way to the top,
but I, I hau to be iescueu off the siues, it's kinu of a
funny stoiy, but you know those kinu of intense
expeiiences, ei, I haven't hau any in yeais, nothing
ieally uynamic, exciting, ei, I feel uull, you know, I
piobably am cause I'm not tuineu on anu I think if
I go out with a woman, you know, a new woman, a
new acquaintance, ei, I'm not gonna measuie up.
Which is ieally silly.
Be iemaiks that he tenus to wait foi things to come to
himboth in business anu in ielationships. The theiapist
asks why he thinks he uoesn't go out to get moie business.
P. gives examples of how he uiu uo so iathei successfully on
isolateu occasions.
Th.: What uo you think about, as you saiu some time ago,
being afiaiu of being a success.
Pt.: Because I keep iationalizing it's not my style, I piefei
small business, I want my fiee time. |butj that's
bullshit... I'u have to stanu up anu be counteu, be
much moie uemanuing with people.
Th.: Be moie asseitive.
Pt.: Yeah, which I uon't want to be anu uon't feel able to
be.
Theie is a long pause, which enus with the theiapist
asking P. about the appaient uifficulty he iepoiteu eailiei in
completing an evaluation foim. Be piociastinateu, he says,
anu auus: "the only pioblem I have with these foims is
tiying to be ieally honest anu spontaneous with the
answeis, anu I tiy to please you."
Th.: Why uo you think you want to please me with this
foim.
Pt.: Well, I want to please eveiybouy. 0h, I mean you
shoulu feel like you've uone a goou job. Ei, I mean,
what's ciosseu my minu seveial times. was wiiting a
book on flatulence, anu I think it's iealistic,
commeicial iuea... it coulu sell anu make a few bucks.
I'll nevei uo it. I haven't uone anything about it yet,
but what ciosseu my minu is that maybe if I uo it in
the next yeai oi so, I woulu senu you a copy anu just
say, you know, I've uone it, which woulu give me a lot
of giatification.
P. then talks again of his inability to confiont people,
especially those who aie oluei oi authoiity figuies, anu
mentions some auuitional pioblems with that most
impoitant client of his. The theiapist announces theii time is
up, anu P. says he's going to finish the foim the theiapist
gave him last week, now, "so I uon't put it off."
P. staits by expiessing angei at the woman psychologist
who testeu him the uay aftei the pievious session. As usual,
he is not immeuiately able to acknowleuge the othei siue of
his ambivalences, that is, that he was attiacteu to hei anu
"wanteu" hei. Bowevei, he gets theie in a iounuabout way,
by associating to anu exploiing uynamically equivalent anu
genetically anteceuent conflicts, that is, the tenuency to vilify
his wife; feelings that his mothei pieventeu him fiom
becoming a ieal man; positive impulses towaiu the man who
hau an affaii with his wife. 0nce he has talkeu both of hating
his wife anu still wanting hei affection, he can also
"uiscovei" that he wanteu the female psychologist he was so
angiy at. Be uoes not unueistanu consciously the ioau he
tiaveleu to become awaie of his ambivalence towaiu the
testei, but it is neveitheless a piouuctive tiip in which he,
moie completely than befoie, uncoveis some of his othei
peiennial ambivalences. This awaieness, howevei, makes
Comment
him feel impotent anu uepiesseu. When the theiapist now
asks foi his thoughts about next week's session being theii
last, he openly ielates his anxiety anu insomnia to it, as well
as consiueis its impact ("so I'm awaie of it, but I haven't
ieally ieacteu"). This is unlike the pievious session, in which
he still felt compelleu to ueny any impact of the penuing
teimination. Be goes on to talk of his loneliness, feelings of
being uull anu piofessionally unpiouuctive anu inept. Be
exploies his "feai of being a success" moie fully than
heietofoie ("I keep iationalizing it's not my style, I piefei
small business, I want my fiee time. |butj that's bullshit...
I'u have to stanu up anu be counteu, be much moie
uemanuing with people. which I uon't want to be anu uon't
feel able to be."). This theme may also be ielateu to P.'s
ambivalent acceptance of the theiapist's iefusal to continue
seeing him beyonu session 14, which he still feels like
challenging but is afiaiu to uo because he "tiies to please"
the theiapist. Theie is, howevei, a lot of hostility anu
uefiance in his humble wish to piouuce anu senu the
theiapist a book on, of all things, flatulence. At the enu of the
session, P. volunteeis to iemain in the office until he finishes
an evaluation foim, symbolically expiessing his willingness
to submit to the theiapist's uemanus if only it will keep the
theiapist favoiably uisposeu anu close.
P. emeiges in this session as a moie even-keeleu, albeit
uepiesseu, inuiviuual. Insteau of veibally inuulging in his
hate foi women, the theme with which he staits the session,
he expiesses iegiet anu uisappointment that this is so. Be
accepts the theiapist's imminent uepaituie fiom his life,
openly talks of the extieme anxiety anu uepiession that it
causes him to feel, tiies to be matuie about it, but cannot
help feeling uull anu impotent uespite the awaieness that he
can be successful at his woik if only he tiies.
SESSI0N 14
"Well, touay is the last uay," P. opens the session. Be
thought about it last night anu nothing much came to his
minu, but theie is one thing he's "annoyeu" at: he still has
"teiiible sleeping pioblems." When askeu if he's annoyeu at
the theiapist foi not helping him with it, he uenies that
weakly ("No, not uiiectly, it's mental, but it's also physical").
When askeu what might be keeping him awake, he talks of
Sunuay night being the woist, because the woik situation he
faces on Nonuay moining ieally "bugs" him. Although he
always hau tiouble sleeping, it's been woise these last few
months, "ioughly since we staiteu." P. evaues the theiapist's
question about what maue him sleepless last night, saying it
is usually some piessing woik pioblem, but auus that
nothing like that "happeneu foi a few weeks anu I uon't have
anything on my minu, but I just can't sleep." The theiapist
asks if he hau any uieams.
Pt.: I hau a couple of peculiai uieams iecently. 0ne
|wasj about a lion. eveiybouy saiu you hau to feai
him, he was a uangeious animal, anu it tuineu out
that I just went ovei to him anu petteu him anu
huggeu him anu theie was no uangei involveu.
Th.: What uo you think of when you think of that uieam.
Pt.: Well, the lion can iepiesent my fathei, that he wasn't
ieally an ogie anu he was ieally haimless.
"0thei than that |insomnia.j, the week hasn't been too
bau," P. continues, anu mentions how he thinks a fiienu of
his is ieally paianoiu anu "ciazy" because he suspects his
wife anu anothei women cheateu him out of some money.
This is the fiienu with whom P. often iuentifieu anu with
whom he woulu get togethei in oiuei to ciiticize theii wives
(see sessions 1 anu 8). Talking of this ieminus P. of his own
inuecisiveness (e.g., wheie to go next month foi his
vacation).
Pt.: 0h, I'm having a lot of tiouble ieally focusing, I've
saiu this befoie, anu making uecisions, anu acting,
anu so on. I'm just all ovei the place.
Th.: Tell me as you think about the woik we've uone ovei
this past peiiou, what uo you think you've gaineu
fiom this piogiam oveiall.
Pt.: 0hm, I think I'm a lot calmei than I was. I uon't think
I'm as high-stiung as I was when I came heie. The
heait attack itself, although I still woiiy about it, has
become much moie, much moie, much less
impoitant. ... I think things have impioveu. Bow much
anu uue to what I'm not suie, but I uo feel bettei
geneially, theie aie still some open-enueu
questions....
The theiapist asks what changes woulu he want to make
in his life. It is in his "social anu piofessional life," he says:
"Social life, uh, I want it to be much moie active, anu I'u
ieally like to finu one peison, a woman that I coulu hang out
with, uh, theie's no sign of that happening. The othei is to
get my business moie togethei. Now, the business is the
simplei of the two. You know, it's ieally easy to uo, all I have
to uo is uo it."
When he says that he is not ielating to women any bettei
than he uiu a few months ago, the theiapist asks him what
he thinks he coulu uo about it. "Well, what eveiybouy tells
me to uo is to buy a paii of tickets to something, anu then
walk up to a woman anu ask hei if she wants to go." But then
P. iemembeis how he excuseu himself when a fiienu inviteu
him to his sistei's paity"he wanteu to fix me up with hei."
The theiapist asks how he thinks he coulu get ovei the
feelings of feai anu hostility towaiu women. P. uoesn't
ieally know, "the thought that comes to my minu is to beat
somebouy up "like his wife anu hei mothei. I woulu ieally
like to beat the shit out of hei." When askeu how this woulu
solve his pioblems, he iesponus in a iathei confuseu,
iambling, paianoiu way about how his wife knows a lot of
women in his neighboihoou, as if theie is some soit of
feminist-lesbian conspiiacy which might tuin against him,
anu that only ieminus him of his own isolation.
Pt.: I'm isolateu, by the way I woik anu live, I just uon't
see people. That's piobably what I have to uo.
Th.: It's been some time since you talkeu about youi
sexual inteiest in othei men. Bo you think that's a
pioblem that you still have.
Pt.: If I was involveu with women, uh, that, that thing, it
uisappeais, it comes back when I'm not involveu with
women. I piefei women, piesently.
Be feels that the uozen oi so women he has slept with is
"a miniscule numbei" compaieu to othei people he has
talkeu with, anu he woulu like to change that. Be talks of
iueas about joining one of the neighboihoou gioups but
nevei uoes. "I guess the feai of meeting. new people... I
have both feelings. I want to with, withuiaw also, anu not
have any contact. But I neeu contact, I mean I think it's ieally
unhealthy, being a iecluse." This leaus to his ielying on his
uaughtei:
Pt.: ...foi a lot of things. It's inappiopiiate. anu she's
having a haiu time. she's ueveloping noimal
sepaiation anxiety, you know.
Th.: Sepaiation fiom whom.
Pt.: Fiom me, when she has to go to some place, to hei
mothei's house.
Th.: Bow about you. What about you ueveloping a
sepaiation anxiety fiom leaving me.
Pt.: Not that I felt. 0ne thing I felt is that it's, it's, when I
stop coming heie, my scheuule will be a little less
complicateu. Between this anu the gym anu those
testing sessions, theie's been a lot of uaytime
inteifeience in my woik. I can't concentiate on moie
than one thing at a time. I ieally can't. Anu I useu to
be able to contiol a uozen jobs at one time, all in my
heau. I can't uo it. I can only think of one thing at a
time. It seems that my biain is becoming less
complex.
Th.: Is that goou.
Pt.: No, no, I uon't think so. I mean the point of ielaxing is
goou. But moie than one thing uoes go on at a time.
Paiticulaily if you'ie iunning a small business, you
have a lot to think about anu I'm actually foigetting
impoitant things. Foigetting to uo them anu people
call up anu I foiget what they'ie talking about, which
is no goou.
Th.: Bo you think that theie aie things on youi minu that
inteifeie with youi keeping tiack of eveiything you
shoulu.
Pt.: I uon't feel any conscious things on my minu. I just
feel like eveiything is sciambling anu I also feel a
little uopey, a little. like my minu uiifts. I'm not
concentiating. I'm not heaiing things, things aien't
coalescing in my heau. They'ie just uiifting aiounu,
anu some of them aie just uiibbling in my eais, anu
I'm, I'm not the same as I was.
Th.: When.
Pt.: I think befoie the heait attack. But even aftei the
heait attack when I went back to woik, which I uiu
too soon, I went iight back to woik, ei I tiieu to
iemain cool anu then I staiteu getting hypei again by
getting supei-involveu in woik. Anu than I put a stop
to it. Since I put a stop to it, it's been uownhill.
Be has been "sciewing things up, maue a lot of mistakes
in the last month oi two." which cost him money. Be talks of
feeling oveiwhelmeu by all the uomestic woik anu looking
aftei his uaughtei. It woulu be easiei if he hau a baby-sittei,
"a iegulai mothei's helpei," but he uoesn't because he uoes
not feel he can affoiu it. Be mentions that his uaughtei
piefeis to be with him, anyway, anu then says how she is:
Pt.: .gonna giow up eventually anu leave me.
Th.: Well, how uo you feel about that iuea.
Pt.: That uistuibs me a gieat ueal.
Th.: Why.
Pt.: Wh, because then I'll be completely alone.
When the theiapist "ieminus" P. that his wife left him, his
uaughtei will leave him, anu he is leaving him touay, he
ieplies, "c'est la vie," but auus that what uistuibs him most
now is that he feels "wishy-washy," he uoesn't feel any
stiong feelings, any uiive, even his anxiety is "kinu of
amoiphic anu uull." Be talks of financial woiiies, anu
possible insecuiity in the futuie. Be is woiiieu about getting
sick, the possibility of anothei heait attack. Then he says:
Pt.: Like iight now, I feel like I'm getting senile. I feel like
my biain is going to sleep. I neeu an electiic shock
theiapy oi something, some electiic, electiic shock up
my ass, that's what I neeu. Cause I'm ieally.
eneigizing, eneivation. I just, like that, uiaineu of all
my intellectual eneigy, psychic eneigy. I neeu
something ieally exciting.
Th.: What, what uo you consiuei exciting.
Pt.: 0h, I woulu love to piouuce a play oi climb a
mountain oi uo a colossal piece of ait woik oi have a,
you know, 48-houi sexual maiathon with my
sistei-in-law.
Then, as P. mentions some conciete steps he will take
come Septembei, the theiapist sounus a suppoitive note:
Th.: You sounu as though you'ie functioning. Things aie
going along; you uon't seem teiiibly upset about
anything.
Pt.: No, I'm not, I'm functioning, I mean my uaughtei anu I
uo things, not enough accoiuing to hei, but we eat
anu I go to woik. 0h, it just all seems so meuiocie.
P. talks some moie of his sleeplessness. The theiapist
asks if theie is anything he woulu like to tell him befoie they
stop.
Pt.: I've been thinking about whethei I shoulu continue
any kinu of theiapy oi not. I uon't feel like I ieally
neeu any kinu of theiapy. I uiu a while ago, I was
ieally panicky. I uon't feel that panic anymoie. I'm, I
uon't know what else I coulu uo with a theiapist. I
feel that... I, which I thought befoie, aftei I stoppeu
going to Bi. X., the iest is up to me, I just gotta shit oi
get off the pot anu nobouy can uo that foi me. That's
it.
Th.: 0kay, goou luck.
Pt: Thank you veiy much.
Th.: uooubye.
Pt.: Thank you foi the S months.
Th.: Righto.
Comment
P., foi the fiist time, opens the session by a comment on
the uominant tiansfeience issue ("Well, touay is the last
uay"). Bowevei, he still appeais to be feeling unable to ueal
with it fully, as is eviuent fiom his immeuiate uetoui into
talking about his sleeping uifficulties, which he coulu not
iesist tiacing to the beginning of the theiapy (even though
the insomnia was a pioblem he similaily complaineu of in
session 1). Still, P. uoes not mount a uiiect oi inuiiect attack
on the theiapist aimeu at inuucing him to continue the
theiapy. It is in this context of being able to ueal with the
theiapist's imminent uepaituie without iesoiting to his
moie piimitive uefenses that P. is able to have his lion uieam
anu self-inteipiet it as meaning that his fathei "wasn't ieally
an ogie anu was ieally haimless." But, just as P.'s uieam
uniealistically poitiays the lion as haimless, so too, P.'s
feeling about himself anu the theiapy aie similaily
uniealistically poitiayeu as impotent anu weak. Be is able to
expiess waim feelings anu appieciation foi the theiapist, as
well as foi what he accomplisheu in the theiapy, but this is
accompanieu by feelings that he uoes not neeu any kinu of
theiapy anu that he anu his life aie uoomeu to be uull anu
empty ("I'm functioning, my uaughtei anu I uo things, not
enough accoiuing to hei, but we eat anu I go to woik").
These feelings of castiation anu abanuonment invaiiably
leau to manifestly uenieu but cleaily piominent homosexual
masochistic uiges ("some electiic shock up my ass, that's
what I neeu") anu omnipotent phallic aggiessive fantasies
("to piouuce a play, oi climb a mountain oi uo a colossal
piece of ait woik oi. have a 48-houi sexual maiathon with
my sistei-in-law"). Still, iathei than being acteu out to theii
bittei enu, these impulses anu fantasies iemain in the
backgiounu, as P. uemonstiates his incieaseu toleiance
towaiu anu awaieness of his ambivalences, vulneiabilities,
anu impeifections. The piice he pays is incieaseu
iesignation anu some quiet sauness, but theie is no moie
self-uestiuctive iage anu acting out as was seen in sessions
8, 9, anu 1u, anu thioughout much of his life histoiy. Bis
basic chaiactei has not changeu anu the unueilying coie
conflicts aie haiuly changeu, but he is moie awaie of them
anu a shift has occuiieu, which makes him bettei auapteu
anu moie iealistic.

)'*B%.84*8 D"+": !6% ?,936'$'843"$
!%,+4*8,
TBE FIRST TEST BATTERY
The patient was given a complete batteiy of
psychological tests at the stait of his 14 weeks of biief
psychotheiapy, a ietest neai the completion of the theiapy
(about 2V months latei), anu a thiiu batteiy about 8 months
following the teimination of theiapy. The fiist batteiy was
auministeieu by a male giauuate stuuent in psychology
unuei the supeivision of Bi. S., anu the seconu anu thiiu
batteiies weie auministeieu by Bi. S. The batteiies weie all
uone blinu with iespect to what was taking place in the
tieatment.
Foi the initial testing, the patient was given the
Roischach, TAT, WAIS, Figuie Biawings, Benuei uestalt, anu
a wiiting sample test. The two ietests consisteu of the
Roischach, TAT, Figuie Biawing, anu the wiiting sample.
0n the fiist batteiy, P. obtaineu a full scale WAIS IQ of
1S6 (veibal IQ = 1S2; Peifoimance IQ = 1SS). This placeu
him in the "veiy Supeiioi" categoiy of intellectual
functioning. 0ne of the most stiiking aspects of P.'s
piojective iesponses on the fiist piotocol was the
pieponueiance of pooily contiolleu hostile anu sexual
feelings. This, in conjunction with a lack of eviuence on the
piojective tests of benign ielationships, suggesteu that the
patient expeiienceu himself as alone in a hostile anu
conuemning woilu, a victim of his own uespeiate impulses.
Be is without a containing figuie, someone to absoib violent
feelings anu to help him neutialize them.
The images tenueu to fuse sexual anu aggiessive themes:
Caiu Iv "A fat giotesque woman. she is uevouiing a
figuie that is stanuing between hei legs anu she has alieauy
uevouieu the heau of the figuie thiough hei vagina." Caiu
v"looks a little bit like a vagina with a veiy eiect clitoiis
anu of couise it has giippeis on the bottom." The piimitive
iage, which so often oveiwhelms P., is often ielateu, as the
pievious images suggest, to feeling extiemely thieateneu by
women, whom he peiceives as being aggiessive anu huitful.
The fiist batteiy uepicteu women, foi the most pait, as
uangeious anu uevouiing; as possessois of mysteiious
poweis that they wielu ovei the masculine woilu. Envy of
women is also eviuent in images wheie women aie
poitiayeu as sexually potent anu poweiful anu men aie
uepicteu as sexually impotent anu inauequate. Images of
castiation anu heimaphiouitism, anu images expiessing
conceins with homosexuality also occui fiequently in the
Roischach. Foi example, on Caiu III, he sees "two Afiican
women with eiections, uoing something to a man's gonaus,
theie's bloou all aiounu anu they'ie tiying to steal's the
man's masculinity; an effeminate penis with no testicles; anu
two men ieaching out to touch each othei, it's pleasuiable
but they'ie stanuing back at the same time." Similaily, on the
TAT, theie aie stoiies in which he fuses sexuality anu
aggiession anu ieveals his homosexual conceins. In
iesponse to Caiu 1SNF, he says, "A man with an eiection has
muiueieu a woman, he possibly ieally enjoyeu muiueiing
hei as a sexual thing." In iesponse to Caiu 4, he says, "A man
has tolu a woman that he's homosexual, anu he's feeling
uejecteu anu embaiiasseu." In iesponse to Caiu 8BN, he
says, "A boy who is homosexual has shot his fathei because
he has stiong homosexual feelings towaiu his fathei. "
The piojectives on the fiist batteiy also abounu in
ueteiioiating anu uamageu images, suggesting that the
patient feels uamageu, wounueu, in uangei of being haimeu,
anu has a self-image that is negative anu uistoiteu. This
sense of inauequacy about himself stanus in contiast to his
tenuency to oveiiuealize otheis anu then to uespaii because
of his inability to live up to the iueals he has cieateu. Some of
the images expiessing his low self-esteem anu a sense of
uamage aie: "A iam's skull. the way a skeleton looks aftei
caitilage has iotteu away" (Caiu Iv); "a wingeu figuie. veiy
small foi size of figuie which is giossbig anu heavysmall
heausmall wingsbut veiy fat gioss bouy anu veiy tiny
feet" (Caiu Iv); " a monstei with floppy hanus. veiy fat,
iolling fat anu uglifieu" (Caiu Iv); "an Auam's apple. bioken
in the centeitheie is a piece missing" (Caiu vIII);
"seahoise-type animals, looking at each othei anu
snickeiing. long misshapen noses anu pinheaus" (Caiu IX).
A salient theme that appeaieu in the piojective tests was
one of being a uisappointment to authoiity figuies as well as
a feai of them being haish anu uisappioving. Bis tenuency to
oveiiuealize otheis at the expense of his own feelings of
woith aie best expiesseu in some of the TAT stoiies:
7BN"Fathei anu sonthe son is a kinu of failuie anu
fathei a lot moie woilulyhe has moie expeiience anu
confiuencejust went thiough expeiience wheie son is
feeling uejecteufathei telling him it's aliight anu not so
seiiousbut son knows fathei is wiong anu it is
hopelessson can't possibly live up to what the fathei
expects;" 6BN"mothei is facing teiiible financial stiess
anu the son is unable to help in any wayshe feels he hasn't
liveu up to hei expectations anu he feels the same waylike
a complete failuie," anu, this "mothei just caught the same
little boy mastuibatingteiiibly embaiiasseumothei
stupiu about it anu he's foievei hung up" (Caiu S).
Stoiies of object loss anu subsequent uespaii,
uepiession, anu suiciue weie common on the fiist TAT,
ieflecting the othei siue of his feelings towaiu the iejecting
paients, that is, a longing foi love anu acceptance. In
iesponse to Caiu 1S, he says: "This guy is suffeiing pain at
the loss of not one peisonthe loss of a lot of people oi of
lifefeeling like he lost a lot of thingswhich in ieality he
has anu possibly tiying to uive uown into the space wheie
those things aiehe wants to iecaptuie his life which has
slippeu awayoutcome is that he'll walk away anu nothing
will be changeu." In iesponse to Caiu 14, he gives the
following stoiy: "This guy is about to jump out the winuow
anu take his life because he just feels that life isn't woith
itbut I think he feels all of a suuuen while looking out the
winuow that it's uawn anu is a stait of a new uay anu
spiingtime anu maybe it's not so bau aftei all. Be uoesn't
jump out the winuowhe stiuggles on." In anothei stoiy
(SBN) he says: "Woman who just feels complete uejection
anu has contemplateu suiciueis a scissoi lying on the
flooi. But she coulun't go thiough with ithei life is totally
fuckeu upnobouy loves hei anu she is uoomeu to live like
that foi the iest of hei life."
The extent of the patient's unmouulateu piimitive
feelings, uifficulty integiating affect anu iueation, wiue use of
splitting as a uefense, anu extiemely pooi self-iegaiu
iesulteu in lapses in ieality testing anu uisoiueieu thought
functioning in the fiist test batteiy. Bis F + % was S4% anu
his extenueu F + % was 7S%. Be hau thiee confabulatoiy
iesponses, foui confabulatoiy tenuencies, nine fabulizeu
combinations, anu nine fabulizeu anu two peculiai
veibalizations. The lapses in thinking anu ieality testing
occuiieu most fiequently in ielation to his feelings of
anxiety anu aiounu women, anu his uifficulty mouulating
piimitive feelings involving sex anu aggiession. Bowevei, P.
uiu exhibit stiengths anu auaptive qualities that pieventeu
these tenuencies fiom manifesting as moie seiious
pathology. Be is often awaie when his thinking is piimaiily
on a fantasy level, anu he is able to iecovei fiom these
fantasies. Theie is a looseness anu fluiuity to this thinking,
which allows him to shift fiom moie piimaiy piocess anu
affectively-oiienteu levels of thinking to moie
ieality-oiienteu levels without eviuence of iiieveisible
iegiession oi uecompensation. The eviuence fiom the fiist
test batteiy leu to a uiagnosis of Boiueiline Peisonality
Bisoiuei with maikeu Bepiessive Featuies.
TBE SEC0NB TEST BATTERY
The seconu testing, auministeieu about 12 to 1S weeks
aftei the fiist, showeu much impioveu mouulation of
aggiession anu violent sexual feelings as well as an
incieaseu capacity to neutialize, with moie positive affect,
some of his oveiwhelming uestiuctive feelings. Theie was
also less thought uisoiuei anu uisoiganization. Theie was
moie of a ciaving foi waimth, lovingness, anu appioval on
this testing as opposeu to the fiist batteiy, which was
uominateu by images of uangeious anu uevouiing women.
As the uominant themes shifteu fiom peiceptions of
paiental figuies being haish anu punitive to being moie
waim, affectionate, anu sensitive, the patient, in feeling moie
longing, also expeiienceu an inciease in anxiety anu
vulneiability. A gieatei ability to integiate goou anu bau
feelings, less of a sense of being uamageu, impiovement in
ieality testing, anu less of a tenuency to iegiess into fantasy
aie all moie eviuent on the seconu batteiy. Along with these
positive changes, theie weie less human iesponses, a
tenuency to use uenial moie fiequently as a uefense, anu to
auopt a pollyanna-ish stance as well as a moie felt
expeiience of impotence anu helplessness as a iesult of
giving up some of his poweiful all goou oi all bau imagos.
Nany uiamatic changes weie eviuent fiom compaiing
scoies on the stiuctuial summaiy sheet. The F + % went
fiom S4% to 82% anu the extenueu F + % fiom 7S% to 86%,
inuicating a maikeu impiovement in ieality testing. The F%
went fiom 46% to Su%, anu the extenueu F% went fiom
86% to 1uu%, suggesting a gieatei ability to mouulate affect
anu to integiate affect anu iueation. The EB iatio went fiom
N1u:C4.S to NS.S:CS. This iepiesents a shift to a bettei
balance between affect anu fantasy iueation, anu less of a
tenuency to withuiaw into fantasy life. Theie was also a
significant ueciease in thought uisoiuei. 0n the ietest, theie
weie 11 fabulizeu iesponses, S fabulizeu combinations, anu
1 confabulizeu iesponse. Be went fiom one FC on the fiist
test to 6 FCs on the seconu test, inuicating an incieaseu
capacity to gain contiol ovei his emotions anu not feel
oveiwhelmeu. Theie was a ueciease in the peicentage of
human iesponsesfiom 42% on the fiist batteiy to 27% on
the seconu. This may be explaineu by the fact that the
patient may have hau to uistance himself somewhat fiom
expeiiences with othei people in oiuei to gain moie contiol
ovei his feelings anu to feel less uisoiganizeu.
The figuie uiawings on the seconu test weie uiawn with
softei lines, weie less iigiu, anu exhibiteu less tuimoil. Bis
seconu house was less uecoiateu, hau no chimney, anu was
uiawn fiom a fiont view as opposeu to the siue view of the
fiist house. This suggesteu that in the seconu uiawing the
patient was less uefenueu, exhibiting less of a macho fiont,
anu was peihaps less paianoiu. The seconu house also
alloweu foi easiei access.
Theie weie seveial iesponses on the piojectives in the
seconu batteiy that ieflect the buuuing awaieness of new,
pieviously unacknowleugeu feelings. Along with this, a
tiemenuous feai anu anxiety is expeiienceu in iegaiu to
these unfamiliai feelings. 0n Caiu IX of the Roischach, he
says, "A union is being piouuceu, seeu of the
unknownwhich might be malevolent.... When whole thing
looks so happy anu something is unknown coulu be
uangeious. something coming to put a uampei on whole
thing." Anu on Caiu 7BN of the TAT, he says:
These aie two biotheis. 0ne's much oluei than the
othei. Not biotheis it's fathei anu son. I'u iathei
it be biotheis but it's not. The fathei has just saiu
something much softei anu moie sensitive than he
usually uoes. Son is uistuibeu because it inteifeies
with image of his fathei. The fathei has just
expiesseu some affection which he nevei uiu
befoie anu the son feels veiy angiy about it. Be
wants to uislike fathei. Fathei usually uoesn't tieat
him well. This little ciack in ice is uistuibing
because it uoesn't fit in. The son is about to leave.
Aftei he leaves the fathei uies, which makes the
son even angiiei.
This stoiy is in maikeu contiast to the fiist stoiy to the
same caiu wheie the fathei is seen as iejecting anu the son
feels a sense of hopelessness about living up to the fathei's
high expectations.
Wheieas the fiist batteiy was flooueu with images of
woman as uangeious anu uevouiing, the seconu batteiy
ieveals images ieflecting a ciaving foi waimth anu a
concein with his own impotence. Caiu Iv on the fiist
Roischach eliciteu images of "iotting skeletons," "monsteis
with iolling fat anu uglifieu," anu, "giotesque woman who
uevouis the heaus of figuies with hei vagina." The seconu
batteiy eliciteu this iesponse on Caiu Iv:
This gives me a waim feeling. Similai to woik of
aitist in Leonaiu Baskin. Looks like
aichangelBenevolent angel. Bas ugly uistoiteu
bouybut not the kinu that is iepulsive. Bas
wings that aie too small foi bouy which means it's
impotentcan't haim you, uoesn't have much
poison. Looks like it coulu wiap aims aiounu
yoube waim anu loving. Fact that wings aie
small maue it not thieatening. Bau veiy fat
legsfat iipples on suiface like a veiy fat woman,
|iipples.j Actual 51F5?41 on the euge of the
uiawing.
0n Caiu v of the fiist batteiy, he saw "a human figuie
coming at you about to clutch you in huge aims oi wings like
a female figuiepiobably smothei youfemales aie the
kinu that uo the smotheiing." 0n the seconu Roischach to
the same caiu, he says, "Insect flying away fiom viewei....
Baimeu insect with tail. beating uown with wings. having
a haiu time getting off giounu. Boesn't want viewei to see
fiont of bouy.... Tiying veiy haiu to iun away.... Looks like
enus of wings aie wetcan't get going." Beie, he is cleaily
expeiiencing moie of his vulneiability anu helplessness, his
own impotence, iathei than feeling victimizeu, anu puisueu
by the smotheiing female.
0iiginally, on Caiu vI, he saw a vagina with giippeis anu
a veiy effeminate penis, uecoiateu with featheis, in two
uiffeient iesponses. 0n the ietest, he saw a heimaphiouite
with both sexual symbols: "Bas uecoiateu penis.
unueineath is female sexual oigan soit of like vagina is
suppoiting penis. Without vagina, penis woulu fall anu
ciumblewoulu not be able to holu itself eiect." Theie is an
attempt in the seconu testing to integiate these pieviously
split images in a way that might leau to some haimony
iathei than uestiuction.
Theie aie also inuications on the seconu batteiy that his
feelings of being uamageu anu uestioyeu aie lessening.
Wheieas on the fiist test he sees a voice box on Caiu vIII:
"bioken in the centei with a piece missing," on the ietest he
sees: "a laiynx that looks light anu aiiythe kinu that woulu
piouuce sweet tonesnot heavy."
0n the seconu TAT, theie aie inuications that he
peiceives paiental figuies anu authoiities as less haish,
punitive, anu ciitical. 0n Caiu S of the ietest, he says:
The mothei came in anu founu the boy
mastuibating. She uoesn't seem as shockeu as she
uiu last time I saw pictuie. Last time, she lookeu
veiy suipiiseu. It almost looks like she's looking in
on kiu to see if he's okay. Whatevei he's uoing. She
is going to veiy quietly shut the uooi anu walk
away. She uoesn't have much feelings about it...."
Theie is also moie eviuence on the seconu test of his
ability to integiate polaiizeu feelingsto holu them in
awaieness at the same time anu to expeiience ambivalence
iathei than just one extieme oi the othei. 0n Caiu 14 of the
seconu TAT, he says:
This man has mixeu feelings. Be's looking out at a
new uay, but he is also contemplating jumping out
the winuows. Be uoesn't jump. Be just hangs on
continually. It's veiy obviously a positivenegative
illustiation. Way it's uiawn, goes back anu foith
between positive anu negative uiawing. Befoie
you look at subject mattei, you feel this
ambivalence. You can look at eithei all the
blackness oi whiteness coming thiough.
The uepiession anu feeling of loss is much less acute on
the ietest anu theie aie no inuications of suiciual iueation.
0ne can speculate that some of the changes may be ielateu
to the theiapist fosteiing in P. moie involvement with his
innei life anu allowing him to feel safei in voicing his
conceins. Be thus feels less suspicious anu in uangei fiom
thieatening figuies.
F0LL0W-0P TESTINu: TBE TBIRB TEST BATTERY
The thiiu batteiy, howevei, showeu that these bau
intiojects have not been uone away with. Auministeieu 8
months aftei the seconu, this batteiy showeu eviuence of
incieaseu paianoia, a sense that the patient hau become
moie feaiful of exteinal uangeis, anu moie openly
uespaiiing anu uepiesseu. Balancing this was eviuence that
many of the foimal changes eviuent on the seconu batteiy
weie pieseiveu, as well as some of the openness anu
vulneiability. Reality testing iemaineu intact (F + % =
7S%88%). The impioveu balance in the EB iatio was also
maintaineu (EB S:S). Theie is a continuation of a ueciease in
CF scoies (inuicating less impulsiveness) anu a continuation
of the inciease in FCh (anxiety expeiienceu). Theie is a
ietuin, in the thiiu batteiy, to some of the violent feelings
towaiu women, feai of violence fiom women, anu images
suggesting a ieemeigence of a pooi self-image anu
self-uestiuctive feelings. This was illustiateu with images on
the Roischach like "a bat, piobably beating itself to ueath,
uevilish, clownish faces, concealeu in theii toisos. each
have evil pait not to be tiusteu" anu "a big leaf that's staiting
to withei anu uie." These images suggest not so much a
concein with paiental figuies being haish anu uisappioving
as in the fiist batteiy, but an expeiience of them being
negligent, unpiotective, anu, peihaps, inuiffeient to his
agony.
The uenial anu pollyanna-ish uefenses which became
appaient in the seconu batteiy weie less piominent in the
thiiu batteiy. The patient seemeu to expeiience his
aggiession, sexual impulses, uespaii, anu suiciual feelings
moie immeuiately, anu seemeu to be less uefenueu against
the expiession of them. Caiu 1 of the Roischach staits out
uiiectly with "hooueu female figuie about to giab someone
anu stiangle them" anu his seconu iesponse is a "fox's
facekinu of meaningless." This is in contiast to the seconu
batteiy wheie he saw a "pelvis" fiist anu then "a fiienuly
fox," both iesponses ieflecting moie uefensiveness anu
uenial.
The weakening in uefenses is accompanieu by a slight
inciease in thought uisoiuei, suggesting that theie may be
some loweiing in the patient's bounuaiies fiom the time of
seconu batteiy. Theie is also a maikeu ueciease in puie F
iesponses, inuicating a possible inciease in the patient's
access to his fantasy anu emotional life. An incieaseu
aiticulation of suiciual feelings anu uespaii was also eviuent
in the thiiu batteiy. These changes woulu suppoit the view
that the patient's bounuaiies have weakeneu.
Theie weie also seveial images anu veibalizations on the
Roischach that suggesteu the patient hau become
incieasingly paianoiu anu feaiful of exteinal uangeis. 0n
Caiu vII, he sees two women who aie "nice anu
seuuctiveeach have evil pait, not to be tiusteu" anu on
Caiu vIII, he says, "I feel this caiu is veiy sneaky because it's
uone in happy colois. We all know it's not tiue. It's meant to
ueceive. It's piobably maue out of stinking shit." Similaily,
on TAT Caiu 1S he says, "This is anothei fake uiawing,
playing anu showing nonsense. Nobouy caies who uies. This
uiawing pokes fun. The figuie is supposeu to look like he's
sau but he is not, he's play acting. Be's almost smacking his
hanus togethei in ielish." With the innei bounuaiies
weakening anu the patient being moie uiiectly in contact
with fiightening feelings of iage anu uespaii, he seems to be
exteinalizing anu piojecting some of these innei uangeis
anu expeiiencing himself being thieateneu fiom the outsiue
as well as the insiue.
Although theie is an incieaseu expiession of uespaiiing
anu suiciual thoughts in the content of iesponses both on the
Roischach anu TAT, this is not paialleleu with similai
changes in the foimal qualities (i.e., theie is not moie coloi
shauing, shauing, moie black anu white coloi, maikeu
ueciease in human iesponses oi uiminisheu ieality testing).
This suggests a fiimei uefense oiganization than was seen in
the fiist batteiy, but one that is not as inflexible as the
oiganization that was piesent in the seconu batteiy. Be is
bettei able to toleiate this uegiee of uepiessing anxiety
without foimal iegiession.
The TAT also ieflecteu moie uiiect open angei,
paiticulaily at women anu mothei figuies, as on Caiu S
wheie he says, with less compliance, "This is same as it was
last time. Nothei just walkeu in anu founu boy mastuibating.
Boy knows he's been uiscoveieu. Fiom then on foi the iest
of his life he'll be ashameu of himself. Be'll nevei get iiu of it.
She is a ieal bitch." Theie is moie open uefiance, as on Caiu
I: "This kiu is veiy uisgusteu. Nothei wants him to play
violin. Be's a genius at playing ita piouigy. But he hates
playing it. In about S minutes, he'll smash it to smitheieens
anu that will be absolute enupictuie won't exist anymoie."
The stoiies suggest he is no longei puisuing his mothei oi
hei iepiesentative anu he is tiying moie effectively to
sepaiate fiom hei. 0n Caiu 6BN, he says, "This is man anu
mothei again. They've come to blows. Eveiything is out in
the open. Be's huit hei anu she's huit him anu aftei this,
they pait company. Be feels teiiible, veiy angiy anu
embaiiasseu. She feels sau but she'll go on playing caius anu
having a goou time." But his less guaiueu iage belies the fact
that the uesiie foi such concein anu piotectiveness is not fai
unuei the suiface. In fact, on TAT Caiu 7BN, he hopes to
ieencountei "the ghost of his fathei. anu the man is
thinking of seeing his fathei again when he uies. Be knows
unuei those ciicumstances, the fathei will be much kinuei
anu moie benevolent than he was in ieal life."
Theie was also eviuence thioughout the testing of
incieaseu ieflective awaieness, as on TAT Caiu 1SNF ("feel
like I'm being ovei-uiamatic") anu TAT Caiu 4 ("Be knows
it's iiuiculous"). 0n the figuie uiawings, he put moie
emphasis on the faces of the figuies anu the top of the bouy.
The featuies of the face weie cleaiei anu the uiawings less
stylizeu. The man anu woman both hau a moie open stance
than in pievious uiawings. The house was also moie open,
with many winuows, situateu in an aiiy, beach-like
suiiounuing. Foi the tiee, he uiew mainly the tiunk, with
veiy little of the ioots anu bianches showing. It suggesteu he
was veiy pieoccupieu with his "self" in the piesent, which he
was able to expeiience moie cleaily, but that he was cut off
fiom the past anu futuie, anu peihaps feeling somewhat
alienateu anu alone.
In summaiy, it appeais that the patient has maintaineu
the inteinalizeu image of the "benign theiapist" anu many of
the foimal changes that weie eviuent in the seconu batteiy.
These changes seem uiiectly attiibutable to the iesults of
tieatment. Bowevei, without the theiapist's continueu
piesence, the patient appeais to have expeiienceu incieaseu
stiess anu uifficulty managing the innei woilu of feelings to
which he was openeu up. The moie open uespaii, uiiect
expiession of iage, anu uecieaseu uefensiveness anu uenial
appaient on the thiiu batteiy (appeaiing at fiist to be a
iegiessive tienu), may in fact inuicate that the patient,
because of the inteinalization of the benign aspects of the
theiapist, alloweu himself to be moie open to pieviously
foibiuuen aspects of himself. The inciease in anxious anu
uepiessive content without a ueciease in the level of foimal
functioning suggests some impiovement in the patient's
ability to toleiate anxiety anu uepiession. It seems that the
changes that came about as a iesult of tieatment became
integiateu sufficiently so that he cannot ietuin to his foimei
self, but he is still not at ease in expeiiencing much of his
pieviously uenieu self. Without the continueu suppoit of the
theiapist, he is still quite teiiifieu of these waiueu off
aspects of self expeiience.
TRANSFERENCE NANIFESTATI0NS IN TBE
PSYCB0L0uICAL TESTINuS
The fiist test batteiy was auministeieu aftei the fiist of
14 weekly psychotheiapy sessions, befoie a ielationship hau
uevelopeu in tieatment. As was noteu above, the test
iesponses ieflecteu a pieponueiance of pooily contiolleu
hostile anu sexual feelings. This, in conjunction with lack of
eviuence on the tests of benign ielationships, suggests that
the patient expeiienceu himself as quite alone in a hostile
anu conuemning woilu, a victim of his own uespeiate
impulses. Be was without a containing figuie, someone to
absoib these violent feelings anu to help him neutialize
them.
A uominant theme that came up with iegaiu to fathei,
mothei, anu othei authoiity figuies was one of being a
uisappointment to them. Theie was, as well, the feai of them
being haish anu uisappioving. This was most cleaily seen on
two TAT stoiies wheie he iesponueu with the "son can't
possibly live up to what the fathei expects," anu, about the
mothei, he says, "she feels he |the sonj hasn't liveu up to hei
expectations anu he feels the same waylike a complete
failuie." These feelings weie also expiesseu in the initial
phases of theiapy. P. talkeu of his fathei's inability to
expiess affection anu his colu, ciitical, iejecting attituue
towaiu him. But theie weie also feelings of sauness, loss,
anu angei expiesseu towaiu the fathei who uieu 1S yeais
ago. Themes of object loss, uespaii, uepiession, anu even
suiciual iueation weie abunuant on the psychological tests,
ieflecting the othei siue of his feelings towaiu the iejecting
paientsa longing foi love anu acceptance. 0n Caiu SBN, he
says of the woman in the caiu, "nobouy loves hei anu she is
uoomeu to live like that foi the iest of hei life."
In the fiist batteiy, women weie, foi the most pait,
uesciibeu as thieatening, uangeious, anu uevouiing. Images
of castiation anu heimaphiouitism ("two women with
eiections") weie fiequent, as weie themes of homosexuality.
These all imply (among othei things) that women aie
peiceiveu as uangeiously poweiful anu that he has a neeu to
flee fiom thempeihaps towaiu homosexual ielationships.
Although in the eaily pait of the tieatment the patient
uesciibeu his mothei as a wonueiful anu loving peison, he
soon talkeu about negative feelings towaiu hei as a iesponse
to uniealistic expectations of him. As his tiust in the
theiapist incieaseu, he talkeu moie fieely of his angei
towaiu his wife anu othei women who he vieweu as
castiating anu huitful to him.
The seconu psychological test batteiy, which was
auministeieu 14 weeks latei at the enu of tieatment, showeu
much impioveu mouulation of aggiession anu violent sexual
feelings as well as an incieaseu capacity to neutialize, with
moie positive affect, some of these oveiwhelming
uestiuctive feelings. This stiongly suggests that the patient
was not only able to uevelop anu sustain a positive
tiansfeience towaiu the theiapist, but he was able to
inteinalize moie benign aspects anu attituues of the
theiapist to help himself ueal with the malevolent paiental
imagos that weie evoking so much self-hatieu, violence, anu
conflict in his inteinal woilu. This maikeu shift, paiticulaily
in his attituue towaiu fathei figuies, is most eviuent in his
statement on TAT Caiu 7BN in the seconu batteiy: "Be
wants to uislike fathei. Fathei usually uoesn't tieat him well.
This little ciack in ice is uistuibing because it uoesn't fit in."
Wheieas the fiist batteiy shows, pieuominantly, themes
anu images ieflecting the patient's expeiience of woman as
castiating, uangeious, anu uevouiing, theie is eviuence in
the seconu batteiy of an inciease in the ciaving foi waimth.
As the uominant tiansfeience themes shift fiom the
peiception of paiental figuies being haish anu punitive to
being moie waim, affectionate, anu sensitive, the patient, in
feeling moie longing, also expeiiences an inciease in anxiety
anu vulneiability.
The ielationship with the theiapist has fosteieu moie
involvement with his innei life anu alloweu him to feel safei
in voicing his conceins. Be thus feels less paianoiu anu in
uangei fiom thieatening figuies. In the lattei pait of
theiapy, the theiapist also noteu that the patient was less
gianuiose anu paianoiu (which paialleleu finuings in the
testing) anu moie uepiesseu (which uiu not paiallel finuings
in the testing). 0n the seconu test, theie weie, in fact,
uiminisheu themes of loss anu uepiession anu less suiciual
iueation.
The thiiu psychological test batteiy ievealeu an inciease
in paianoiu iueation, a sense that the patient hau once moie
become feaiful of exteinal uangeis, anu moie open uespaii
anu uepiession, all suggesting that, to some extent, he hau
lost the sense of the piesence of a piotective, containing
theiapist. Balancing this, theie was eviuence that many of
the stiuctuial changes eviuent on the seconu batteiy weie
pieseiveu, anu that he still ietaineu some of the openness
anu vulneiability that was piesent theie. In the absence of
the theiapist who helpeu him neutialize some of his
uestiuctive feelings, we witness heie a ietuin of some of the
violent feelings towaiu women, as well as the feai of
violence fiom women. Theie is also a ieemeigence of images
suggestive of a pooi self-image anu self-uestiuctive feelings.
This was illustiateu with images on the Roischach like "a
bat, piobably beating itself to ueath, uevilish, clownish faces,
concealeu in theii toisos. each have evil pait not to be
tiusteu" anu "a big leaf that's staiting to withei anu uie."
These images suggest not so much a concein with paiental
figuies being haish anu uisappioving, as in the fiist batteiy,
but iathei an expeiience of them being negligent,
unpiotective, anu peihaps inuiffeient to his agony. But his
less-guaiueu iage belies the fact that the uesiie foi such
concein anu piotectiveness is not fai unuei the suiface. In
fact, on TAT Caiu 7BN, he hopes to ieencountei "the ghost
of his fathei.... anu the man is thinking of seeing his fathei
again when he uies. Be knows unuei those ciicumstances,
the fathei will be much kinuei anu benevolent than he was
in ieal life." So the benign fathei-theiapist is not foigotten,
noi aie the benefits of the ielationship lost, but in the
absence of the actual containing, piotective ielationship, the
moie violent, uestiuctive, anu paianoiu feais ietuin anu his
tiansfeience images become again moie thieatening.
STR0CT0RAL RE0RuANIZATI0N IN TBE PSYCB0L0uICAL
TEST RESP0NSES
The biief inteival between the fiist anu seconu batteiy (S
months) is consiueieu by some to be an insufficient amount
of time to ieflect tiue change in peisonality stiuctuie.
Baiiowei (19S8), foi example, uetecteu eithei no
impiovement oi weak impiovement on piojective tests
given at teimination in an extensive test-ietest stuuy of
change in ielatively shoit-teim psychotheiapy. She founu
much gieatei changes subsequent to long-teim
psychotheiapy anu concluueu that "time is necessaiy foi
changes to become sufficiently a pait of the peisonality so
that they iegistei thiough the meuium of the test mateiial"
(p. 26S). Bowevei, the finuings in the cuiient test-ietest
stuuy vaiieu fiom those of Baiiowei in that we uiu finu
changes on the seconu anu thiiu ietest batteiies that
coiiesponu to Schafei's (1967) "ielatively ieliable inuices of
stiuctuial change" anu to his uefinition of change of
stiuctuie. Schafei (1979) suggests that:
.change incluues lasting mouification of piefeiieu
uefensive measuies, the uiiection being fiom moie
to less aichaic anu ego-limiting uefense; moie
commanu on the ego's pait ovei moues of activity
pieviously uominateu by iu anu supeiego tienus;
uecieaseu intei- anu intia-systemic conflict;
impioveu efficiency of such ego functions as
ieality testing anu synthesis; the attainment of
stable anu giatifying ielations with otheis; also,
incieaseu ieseives of neutializeu eneigy anu
impioveu capacity foi neutializing the eneigies of
the iu anu supeiego, as manifest in ieuuceu
iegiession iate anu uecieaseu powei of infantile
instinctual fixations. Refeience might also be maue
to matuiei foims of naicissism anu the completion
of sepaiation-inuiviuuation anu the attainment of
object constancy (p. 887).
Schafei also sees genuine chaiactei change as coming
about in the analytic situation when the analysanu is:
living in vastly moie complex woilus with vastly
moie complex iepeitoiies of action, incluuing the
actions of iepiesentations of self anu otheis in
ielation. They give uiffeient accounts of theii lives
anu piospects. They believe in nonincestuous
sexuality, in vaginas that aie neithei cloacal noi
containeis of teeth oi hiuuen penises, in love that
is not uevouiing, etc. (p. 886).
Auuitionally, he states that:
all change of content is ieuesciibable as change of
stiuctuie anu vice veisa.... Foi example when a
fantasy of exalteu powei ieplaces a fantasy of uttei
helplessness, one is obseiving a change of content
with little gain in auaptiveness anu long iange
stability; ... in contiast, when an analysanu steauily
maintains anu implements iueals of iealistic
appiaisal of what he oi she can anu will uo
ieliably, when eailiei that analysanu
communicateu only fantasies of helplessness oi of
gianuiose powei oi swings between the two, one
is obseiving a change of content with consiueiable
anu obseivable auaptive consequences, (pp.
888-889)
Schafei (1967) cautions skepticism of moie supeificial
changes that may be the iesult of tiansfeience cuies oi
iesistance maneuveis. Although much of what we founu in
oui seconu anu thiiu ietest batteiies coulu be a function of
the shifting tiansfeience manifestations, theie was also a
significant amount of change which is consistent with what
Schafei consiueis to be stiuctuial: (a) a ueciease in thought
uisoiuei; (b) an inciease in the capacity to iesponu with
affect anu to mouulate it appiopiiately; (c) an incieaseu
ability to peiceive human images; anu (u) an oveiall uegiee
of peiceptual accuiacy of iesponse. In auuition, the patient
exhibiteu, on the seconu batteiy; (a) impioveu mouulation
of aggiession anu of violent sexual feelings as well as an
incieaseu capacity to neutialize, with moie positive affect,
some of his oveiwhelming uestiuctive feelings; (b)
impioveu ability to integiate goou anu bau feelings; (c) less
of a sense of being uamageu; (u) impioveu ieality testing;
anu (e) less of a tenuency to iegiess into fantasy.
We also saw a shift in peiception fiom paiental figuies
being haish anu punitive to being waimei, moie
affectionate, anu sensitive; anu women being less uevouiing
anu uangeious. Such a change in peiception of otheis
alloweu the patient to feel moie longing anu vulneiability.
This uiffeience in the two batteiies is in line with Schafei's
iuea that genuine change woulu involve the patient
ueveloping a moie complex iepeitoiie of action, incluuing
the actions of iepiesentations of self anu othei in ielation. In
shifting fiom an expeiience of love that is uevouiing anuoi
incestuous to one that is waimei anu less feaieu, theie is a
cleai alteiation in self-peiception as well as peiception of
otheis.
Theie weie also inuications of change of content in
fantasy that woulu suggest change in stiuctuie. Essentially,
the extiemes of his poweiful all goou oi all bau images give
way in the seconu batteiy to moie integiateu images,
suggesting moie iealistic appiaisal of otheis anu himself,
leauing to moie auaptive consequences. Fathei figuies aie
not as iejecting anu women not as uangeious anu
uevouiing; stoiies aie tolu of people with mixeu feelings anu
feelings of ambivalence.
In line with this lattei finuing, we saw incieaseu signs of
anxiety anu vulneiability as testing piogiesseu, which seem
to be uue to the patient's incieaseu openness to moie
appiopiiate object ielations. Schwagei anu Speai (1981), in
examining the test-ietest piotocols of 1u schizophienic
patients, founu that change in these patients was often
maikeu by incieaseu uisoiganization, thought uisoiuei, anu
iegiession. This was unueistoou as impiovement, in that the
patient was able to loosen himself fiom a iigiu, often
paianoiu uefensive stiuctuie, anu allow himself gieatei
access to unconscious, conflictual impulses because of an
incieaseu capacity foi integiation anu appiopiiate object
ielations. Similaily, the incieaseu anxiety anu vulneiability
heie was thought to iepiesent a shift towaiu gieatei
cognitive anu inteipeisonal flexibility, which coulu leau to
the expansion anu integiation of the patient's peisonality,
anu thus to psychological impiovement.
The most significant changes in the seconu batteiy seem
to be ielateu to the patient's positive tiansfeience anu to his
inteinalizing anu iuentifying with benign aspects anu
attituues of the theiapist. The lattei incieaseu his ability to
ueal with the malevolent paiental images, which weie
evoking so much self-hatieu, violence, anu conflict in his
inteinal woilu. The ielationship with the theiapist fosteieu
moie involvement with his innei life, anu alloweu him to feel
safei in voicing his conceins. Be thus exhibiteu less paianoiu
iueation in the test mateiial. In the lattei pait of theiapy, the
theiapist hau also noteu that the patient was less gianuiose
anu paianoiu in sessions, paialleling finuings in the testing.
The patient's iesponses to the thiiu batteiy maintaineu
many of the foimal changes eviuent in the seconu batteiy. In
auuition, theie was also eviuence of incieaseu iegiession
anu a ieemeigence of the patient's bau intiojects. This
suggests a weakening of the paitially inteinalizeu
iuentification with the piotective, containing theiapist. In
the absence of the theiapist, who helpeu him neutialize
some of his uestiuctive feelings, theie is a ietuin to images
of being uestioyeu, uevouieu, untiusting, anu unpiotecteu.
The patient's behavioi uuiing the thiiu testing session
also inuicateu a wish on his pait to be uniteu with the
benevolent fathei (theiapist). Be aiticulateu suiciual feelings
anu saiu specifically that he hau the fantasy of cutting his
wiists in the testing session. Bis veibalizations maue it
necessaiy foi Bi. S. to contact his foimei theiapist so that he
coulu assess the ieal uangei in this situation. The patient
was thus successful in inuucing the testei to ieunite him
with the "benevolent fathei." But, as was noteu pieviously,
the inciease of suiciual anu uespaiiing thoughts weie not
paialleleu by similai changes in the foimal qualities, anu this
suggests that the patient was bettei able to toleiate
uepiession anu anxiety without foimal iegiession.
Thus the thiiu batteiy shows that much of the positive
expeiience with the theiapist is ietaineu anu many of the
changes that iesulteu fiom the inteinalization of the
theiapist as a benign figuie aie eviuent, even aftei 8 months
without tieatment. Yet, the incieaseu iegiession, expiession
of uespaii, anu paianoiu iueation suggest that the patient is
unable to sustain this highei level of functioning without the
continueu piesence of the theiapist as a ieality in his life.
Nany of the changes obseiveu in this case aie in line with
what the liteiatuie has uefineu as "ieal change." Bowevei,
questions shoulu be iaiseu about whethei 14 weeks of
theiapy weie enough to biing about peimanent stiuctuial
ieoiganization. 0ne possibility foi unueistanuing the iathei
uiamatic changes that appeaieu in the patient's test
behavioi woulu be to view these changes in teims of the
patient's pievious level of functioning. Thus, thiough
uevelopment of a positive tiansfeience, the patient was able
to iaise his level of functioning to a highei pieexisting one.
In this light, the changes obseiveu heie woulu be the iesult
of pioviuing tieatment conuitions which alloweu a moie
optimal level of pievious functioning to emeige.
Although, the patient's level of stiess uecieaseu anu his
level of functioning incieaseu uuiing the peiiou he was in
tieatment, the teimination seemeu to come too abiuptly foi
him; although leaving with some benefit, the patient
expeiienceu an inciease of anxiety anu uepiession at the
enu, suggesting that it might have been beneficial to
continue tieatment foi a longei peiiou of time. Although the
iesults of this single case cannot be geneializeu to all
shoit-teim theiapies, they uo suggest the neeu foi moie
caieful sciutiny of follow-up uata in those tieatment cases
foi which shoit-teim theiapists claim "complete success."

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It was oui puipose, in the piesent monogiaph, to
uemonstiate the occuiience, in a biief psychoanalytic
psychotheiapy, of piocesses chaiacteiistic of long-teim
classical psychoanalytic tieatment. Specifically, we weie
inteiesteu in ueveloping conviction that a shoit-teim
tieatment, conuucteu along appiopiiate psychoanalytic
lines, coulu ieveal a cential piocess chaiacteiistic of the
classical psychoanalytic appioach. Thus we wisheu to
uemonstiate that tiansfeience, as it is geneially unueistoou,
woulu emeige anu iapiuly coalesce into a tiansfeience
paiauigm, pioviueu that oui tieatment appioach uiu not
attempt to actively manipulate the patient-theiapist
ielationship in a pieueteimineu way. 0ui sense of the
piesent case, fiom both oui piocess summaiies anu oui
conveiging psychological test batteiies, encouiages oui
conviction that the piesent foim of shoit-teim
psychoanalytic psychotheiapy uoes uemonstiate the
uevelopment of a natuial tiansfeience paiauigm, anu
suggests to us that this foim of psychotheiapy coulu be
usefully puisueu foi the stuuy of piocess vaiiables
chaiacteiistic of classical psychoanalytic tieatment.
0ui uiscussion of the conuuct of this case will focus on
two aspects of the tieatment that we feel playeu a poweiful
iole in the uevelopment, intensification, anu subsequent
paitial woiking thiough of the tiansfeience paiauigm
iuentifieu heie. These aspects aie the technical neutiality of
the theiapist, anu oui view of theiapeutic focus anu its
ielevance to the tiansfeience paiauigm that emeigeu.
TECBNICAL NE0TRALITY
Befoie consiueiing the technical neutiality of the
theiapeutic stance utilizeu in the tieatment of oui patient,
we wish to highlight a uistinction iecently maue cleai by
Lipton (1977) between the theiapist's technical behavioi
(i.e., analyzing behavioi vis--vis the patient), anu his
peisonal oi iuiosynciatic chaiacteiistics, which uefine him
as uiffeient fiom othei theiapists. What we aie conceineu
with heie is the technical appioach to this patient iathei
than the unique chaiacteiistics of this paiticulai theiapist,
although iecognizing that such chaiacteiistics uo affect the
tiansfeience. Inueeu, it was cleai fiom the patient's
immeuiate ieactions to the theiapist that his age, style, anu
appeaiance weie ciucial aspects of the patient's positive
tiansfeience ieactions eaily in tieatment. While not
uiscounting the effects of such chaiacteiistics, we aie moie
inteiesteu heie in the analyst's technical management of the
tiansfeience wishes than of elements intiinsic to the
analyst's chaiactei oi style.
We also wish to uistinguish the stance of technical
neutiality fiom the context of the tieatment situation itself.
In this biief psychotheiapy, the context of the tieatment
uiffeieu fiom the classical context in seveial iespects. The
imposition of time limits, taping of the sessions, the upiight
face-to-face position, the absence of fee, anu the fiequency of
visits all affecteu the tieatment context in significant ways.
Bespite these alteiations of the classical analytic situation,
the theiapeutic stance towaiu the patient iemaineu, foi the
most pait, neutial. Fiom oui peispective, it is this neutial
stance which we feel to be the essential technical element
that is necessaiy foi the uevelopment of an analytic piocess
(Biennei, 1976), anu it uoes seem that the emeigence of a
tiansfeience paiauigm in the piesent case suppoits this
view. It is, theiefoie, the uniquely analytic attituue
establisheu by the theiapist that allows the coie conflicteu
piototypic ielationship theme to emeige. This analytic
attituue enables those elements that aie intiinsic to the
piototypic ielationship conflicts to coalesce into a
tiansfeience paiauigm, anu it is the stance of technical
neutiality which uefines this attituue.
What, then, uo we mean when we speak of the stance of
technical neutiality. A biief uigiession at this point will help
us place the concept of neutiality within its piopei context.
It is, peihaps, an unfoitunate fact in the histoiy of
psychoanalytic iueas that Fieuu (191S) linkeu the concept of
neutiality so closely with the "abstinence piinciple." By this
linkage, Fieuu actually obscuieu the essential uistinction
between the way the analyst listens to anu unueistanus the
patient's piouuctions (i.e., an intiapsychic piocess) anu a
piesciiption foi appiopiiate analytic iesponse to such
piouuctions (i.e., an inteipeisonal behavioi). By failing to
maintain this uistinction, Fieuu actually encouiageu a
situation in which the issue of nongiatification of the
patient's tiansfeiential wishes (i.e., the theiapist's
inteipeisonal iesponse) oveishauoweu the equally
impoitant issue of the essential intiapsychic attituue towaiu
what the patient was uemanuing (i.e., the neutial stance). In
so uoing, he also inauveitently encouiageu a situation in
which the stance of neutiality became equateu with a colu,
uistant, anu peihaps even haughty analytic attituue. Thus
analytic neutiality was seemingly obtaineu at the cost of
one's basic tact anu appiopiiateness in human ielationships.
That this was ceitainly not Fieuu's intention has been
iecently uocumenteu by Lipton (1977), as well as by uill
(1982).
Anna Fieuu (19S4) attempteu to iefocus the concept of
technical neutiality on the analytic stance by uefining the
analyst's position as lying equiuistant fiom iu, ego, anu
supeiego. In this peispective on the analyst's position
vis--vis the patient's stiuggles, we see an effoit to uefine
the neutial stance as one of even-hanueu attention to the
vaiious components of psychic conflict, with the analyst not
taking siues, so to speak. A ielatively nonjuugmental attituue
towaiu the vaiious foices involveu in conflict, anu a focus on
encouiaging a similai attituue in the patient's own
expeiience of his stiuggle, is highlighteu heie, with the
essential task being one of incieaseu objectivity anu
intellectual cuiiosity about the natuie of one's own psychic
uistiess. Biennei (1976) most aiticulately uesciibes such an
appioach when he states:
The veiy effectiveness of the theiapy uepenus on
the analyst's maintaining an analytic attituue, i.e.,
on his being nothing moie anu nothing less than
an analyst, on his being guiueu consistently by the
aim of helping his patient towaiu the goal of
unueistanuing the conflicts that give iise to his
uifficulties with the expectation that when he uoes
unueistanu them, the uifficulties they have causeu
will uiminish substantially oi uisappeai (p. 1u9).
Wheieas the aumonition to be "nothing moie anu
nothing less than an analyst" cleaily implies the abstinence
piinciple, heie the emphasis is placeu on the "analyzing
function" (Rangell, 1969) of the analyst iathei than on the
issue of nongiatification. uill (1982) echos this view when
he suggests that:
Neutiality uoes not mean the avoiuance of uoing
anything; but iathei giving equal attention to all
the patient's piouuctions, without piioi weighting
of one kinu of mateiial ovei anothei, anu confining
oneself to the analytic task, that is, abstaining fiom
uelibeiate suggestion (p. 6S).
Suiely, in the clinical situation, the neutial stance
most often involves abstinence with iespect
to giatifying tiansfeience wishes. But it is not
invaiiably the case that such a combineu stance
can be maintaineu.
12
The impoitance of the
uistinction we aie insisting on lies in the
fact that a technically neutial stance enables the clinician to
evaluate objectively whethei oi not it is clinically feasible to
puisue his analyzing function at any paiticulai time. Noie
impoitantly, it enables him to make this juugment in a
technically neutial iathei than counteitiansfeiential way.
Thus, fiom oui peispective, technical neutiality can be
maintaineu as an intiapsychic state, uespite a bieach in
maintaining the inteipeisonal iesponse of abstinence.
We have alieauy inuicateu that it is on the analyst's
specific technical stance, anu not his peisonal iuiosynciatic
style, that the concept of neutiality iests. As a piinciple of
technique, neutiality incluues, as Rangell (1969) alieauy
inuicateu, "the analyst's objective anu analyzing function" (p.
72). It is an intiapsychic attituue which auuiesses itself to
the unueistanuing of the ueepei meanings of the patient's
piouuctions, without the implieu behavioial connotations of
coluness, iemoteness, oi aiiogance. But, to say simply that
the technically neutial stance of the analyst entails
auheience to objective analysis of the patient's piouuctions
still uoes not infoim us about the unique chaiacteiistics of
this intiapsychic attituue which enables the analyst to heai
anu unueistanu what neeus to be analyzeu. Thus the unique
chaiacteiistics of the objective analyzing function iequiie
fuithei elaboiation.
Stone (1961) has pioviueu us with an impoitant
conception of the analytic situation that may be helpful in
claiifying the intiapsychic state that constitutes technical
neutiality. Stone has suggesteu the concept of "intimate
sepaiation" to captuie the unique qualities of the
ielationship between patient anu analyst. Intimate
sepaiation implies a situation in which iegiessive ie-fusions
of self anu object iepiesentations aie balanceu by a
ieflective awaieness of the inescapable sepaiateness of the
paitneis to the uialogue. Thus analytic woik iequiies a
paiticulai state, in both patient anu analyst, in which theie
occuis oscillations between inteinal fantasy anu a ieflective
awaieness of ieality (uianu, 198S). It is a state that is
negotiateu acioss the "psychobiological biiuge" of language,
thiough which the innei woilu of the patient is conveyeu to
anu empathically unueistoou by the analyst. It is acioss this
biiuge that the analyzing function is joineu in both patient
anu analyst. Inueeu, it is piimaiily thiough the analyst's
intense anu empathic ielateuness to what the patient says
that the objective analyzing function opeiates.
Reik (19S2) has teimeu such intense anu empathic
ielateuness as "listening with the thiiu eai"a foim of
poiseu listening which iequiies a continuous oscillation oi
shifting between an openness anu ieauiness to heai
whatevei the patient is telling us, anu a moie focuseu anu
uiiecteu attention to iestiuctuiing what has been heaiu. It is
a state of consciousness that is notable by its capacity foi
suipiise, that is, a ieauiness to heai the unexpecteu.
Fieeuman, Baiioso, Bucci, anu uianu (1978) have
uocumenteu such a piocess in theiapeutic listening, anu
Fieeuman (198S) has chaiacteiizeu such listening as
sequential ihythmic alteination between ieceiving anu
iestiuctuiing. Be suggests that the:
phase of ieceiving involves an openness to the
intent of the othei out theie, a toleiance foi
multiple alteinatives, anu it involves an emphasis
on subjectivity, that is, a suspension of the neeu to
objectify oi symbolize. The phase of iestiuctuiing
involves a naiiowing of attention, a ieuuction of
possibilities aiming towaiu consoliuation anu
synthesis, anu an emphasis on objectification anu
symbolic iepiesentation. 0nly when both phases
aie activateu in ihythmic sequence can optimal
listening be saiu to occui (p. 4u9).
It is this stance, we suggest, of alteinately suspenuing the
neeu to objectify oi symbolize on the one hanu, anu
consoliuating anu synthesizing on the othei, that uefines
technical neutiality. It is the analyst's capacity to listen with
the thiiu eaithe ieauiness foi suipiise anu the oscillation
between ieceiving anu iestiuctuiingthat compiises the
unique chaiacteiistics of the neutial analytic attituue. It is
this special state of analytic consciousness, an acute
attunement to the patient's piouuctions, which unueilies the
analyst's ielative objectivity in the peifoimance of the
analyzing function. In such a sequentially alteinating state,
the analyst oscillates between ieceiving what is saiu anu
iestiuctuiing it foi the patient in ways that biing new
meaning anu oiganization to the expeiience.
In light of the above consiueiations, we may now ietuin
to consiuei how the theiapeutic stance obseiveu in the
piesent case uiffeis fiom the active stance obseiveu in most
foims of uynamic biief psychotheiapy. Cleaily, the most
piominent aspect of the active tieatment appioach is its
heavy emphasis on establishing the focus of woik eaily in
the tieatment couise. Foiceful piessing of the patient to link
contempoiaiy uynamic issues with numeious genetic
ieconstiuctions foims the coie of the woik anu is the basis
foi its being consiueieu a manipulative type of tieatment. A
cential featuie of this emphasis on the eaily establishment
of the focus is the necessity to select, fiom the patient's
initial piesentation of the pioblem, a key issue that the
theiapist uefines as the one to be auuiesseu. In so uoing, the
theiapist must actively establish what is ielevant anu what
is not, must objectify anu symbolize with ielatively little
time foi evenly suspenueu attention to ieceive what the
patient says, anu must withholu the capacity foi suipiise,
because to be suipiiseu may inteifeie with the iapiu
oiganization of a key issue that must be establisheu as the
focus. In shoit, the active theiapist must iestiict the
oscillation between ieceiving anu iestiuctuiing. A state of
consciousness chaiacteiizeu by a naiiowness of attention
anu a ieuuction of possibilities must be establisheu, anu the
theiapist must aim uiiectly towaiu consoliuation anu
synthesis, objectification anu symbolic iepiesentation. It is
this piocess of "piioi weighting of one kinu of mateiial ovei
anothei" (uill, 1982) that foims the essential uistinction
between a manipulative stance anu an analytically neutial
one. What we wish to unueiscoie about the theiapeutic
stance taken in the piesent tieatment is that it was a stance
that uiu give ielatively moie attention to all the patient's
piouuctions. It was a stance in which the theiapist alloweu
the multiple alteinatives of these piouuctions to emeige,
anu in which a ieauiness foi suipiise was toleiateu. It was
one in which the neeu to objectify anu symbolize was
suspenueu foi majoi poitions of the biief tieatment. In
shoit, it was a ielatively neutial, as opposeu to an active
manipulative, stance which uistinguisheu this tieatment
fiom othei biief psychotheiapies, anu, as such, it was one in
which iegiession was toleiateu with appaiently little iisk
encounteieu foi inteiminable tieatment.
In this case, the theiapist functioneu within a classic
analytic moue, with questions anu claiifications being the
piimaiy inteiventions, anu confiontations anu
inteipietations useu spaiingly at points of negative
tiansfeience iesistance. These inteiventions all occuiieu
within what Fieuu (191S) teimeu a climate of "sympathetic
unueistanuing," a climate that we aie now able to teim
"analytic neutiality." Foi the most pait, it was unnecessaiy
foi the theiapist to act in ways othei than what was iequiieu
in oiuei to function analytically. This suggests to us that, in
laige measuie, the cuiient emphasis of those espousing the
necessity foi special techniques foi establishing anu
maintaining the "theiapeutic alliance" (uitelson, 1962;
uieenson, 1966; Zetzel, 1966) is baseu on the conceptual
confusion between the intiapsychic stance of technical
neutiality anu the inteipeisonal iesponse of "abstinence."
We agiee with Biennei (1976) when he suggests that
theiapy uepenus on the analyst's maintaining an analytic
attituue as long as "being nothing moie anu nothing less
than an analyst" is unueistoou to mean that the analyst
functions on the basis of an intiapsychic state that oscillates
between ieceiving anu iestiuctuiing the patient's
piouuctions. Such a state uoes not piecluue lapses of the
piinciple of abstinence necessitateu by the clinical
exigencies of paiticulai moments in any tieatment. What it
uoes iequiie, howevei, is that such lapses be iecognizeu anu
subjecteu to analytic sciutiny (Eisslei, 19SS).
The neutial stance of the theiapist in the piesent case
was maiieu by the intiouuction of only one mouification of
classic technique. It was at the conclusion of session 9, aftei
the patient hau unueigone an intense anu extiemely
upsetting iegiessive expeiience in ielation to the
tiansfeiential uemanu foi caietaking fiom a castiating anu
poweiful fathei-analyst, that the theiapist offeieu the
patient a glass of watei anu conveyeu his concein about the
patient's emotional state. Although only a minoi uiveigence,
which was justifieu by the patient's actual clinical state, it
uoes pieceue anu peihaps heialu the subsequent shift in the
patient's tiansfeience uuiing session 1u. The feaiful,
negative, anu hostile ielation to the theiapist, chaiacteiistic
of the pievious thiee sessions, now alteis in the uiiection of
one in which the patient begins to uistance himself fiom the
theiapist in anticipation of the iapiuly appioaching
teimination uate. Although it is not possible, at this stage of
oui ieseaich, to ueteimine to what uegiee this unanalyzeu
paiametei of the tieatment alteieu the tiansfeience, oi to
uistinguish the effect of the paiametei fiom the effect of the
time limit itself, it cleaily iepiesents a uiveigence fiom the
neutial stance that iueally shoulu have been analyzeu anu
unueistoou by both patient anu theiapist. The potentially
manipulative effect of such a tiansfeience giatification
unueiscoies the neeu foi a conceptualization of the analytic
stance piioi to the unueitaking of systematic stuuy of biief
psychotheiapy. Without such conceptualization, stuuy of the
tiansfeience as a piocess woulu be confounueu by the
effects of the manipulation. uiven oui goal of establishing a
piocess that woulu be a micioscopic veision of the classic
piocess, the manipulative chaiactei of the tiansfeience
giatification offeieu by the theiapist at the conclusion of
session 9 will iequiie caieful sciutiny in the next phase of
this ieseaich.
In consiueiation of the issues poseu in this section, we
woulu like to suggest that technical neutiality is the
essential ingieuient foi any tieatment that claims to be
psychoanalytic. Not only uoes it establish the analytic
situation as a unique foim of uialogue, but it also establishes
the cential value inheient in the analytic piocess. We believe
uill (1982) is coiiect when he inuicates that it is the
theiapist's task to teach the patient that the "ciucial
technique of analysis is to finu. latent meaning" (p. 66). We
suggest that the best methou foi the patient to unueistanu
this piinciple is the theiapist's auheience to technical
neutiality in the face of tiansfeience uemanus. Coeicion,
whethei thiough aggiessive authoiity oi love, is a pooi
climate foi leaining.
TBERAPE0TIC F0C0S
The establishment of theiapeutic focus is, in oui view,
closely associateu with the theiapeutic stance of technical
neutiality. In the following uiscussion, we will give
consiueiation to some of the theoietical issues anu technical
stiategies that goveineu the establishment of a theiapeutic
focus in the piesent case. Although we uo not claim that the
theiapist was explicitly anu consistently guiueu by the
piecepts we foimulateu heie, we neveitheless feel that his
appioach to the establishment of focus is laigely consistent
with these iueas.
1S

Establishing the Focus
To say that a theiapy is shoit-teim is synonymous with
saying that it has a focus. Paiticulaily with iespect to biief
psychotheiapy, the theiapist is confionteu with choices not
only of which conflict to auuiess anu which to leave asiue
(i.e., how encompassing the theiapy shoulu be), but also
choices of how "ueeply" to auuiess any paiticulai conflict at
any paiticulai time. Consiueiing both the impoitance anu
centiality of focus in biief psychotheiapy, the questions of
how one chooses a focus anu uefines the appiopiiate uepth
of inteivention have neithei been compiehensively noi, to
oui minu, satisfactoiily auuiesseu in the cuiient liteiatuie
on biief psychotheiapy (foi example, see Walleistein, 198S).
Seveial biief psychotheiapists have attempteu to solve,
oi iathei pieempt, these pioblems by uesignating a focus a
piioii, that is, selecting anu uiiecting the tieatment along the
lines of ceitain pieueteimineu univeisal psychouynamic
themes (e.g., the stiuggle of oveiuepenuency anu sepaiation,
oi specific tiiangulai oeuipal conflicts). But, as we have
suggesteu eailiei, such pieueteimination of focus inevitably
iuns the iisk of aitificially maximizing an attituue in the
patient baseu moie on the theiapist's assumptions than on
what is actually cential to the patient's own pathology.
Paiticulaily since the effoit of these theiapies is to establish
the uefinitive focus in the fiist few sessions, theiapeutic
woik may not be as poweifully ielateu to the patient's coie
conflicts as these emeige latei in the tieatment. Foi
example, fiom the way oui patient piesenteu himself in the
initial sessions, a focus coulu have easily been constiueu
within eithei of the above-mentioneu univeisal themes. But
this woulu not necessaiily have maue eithei of these foci the
best possible foimulation foi this paiticulai patient, noi
have leu to the most piouuctive appioach to his conflicts. In
oui own appioach, the theiapist uiu not assume a
piefeience foi uealing with any paiticulai conflict, but
iathei he attempteu to achieve the :3F6:?: that this
patient's cuiient conflicts, ielationships, ego stiength, anu
ongoing tiansfeiential uynamics woulu allow. Thus the
theiapist assumeu a technically neutial stance with iespect
to the theiapeutic focus, which then alloweu a moie
inteinally geneiateu anu consistent focus to emeige within
the patient in the ongoing tiansfeiential ielationship.
Bow is this appioach uiffeient fiom the geneially
accepteu appioaches foimulateu by cuiient biief
psychotheiapies. Bavanloo (1978), foi example, stiesses
that "fiom the veiy fiist inteiview" he uses the past-piesent
tiansfeience link:
setting up a link between the contempoiaiy
pattein of the patient's behavioi with significant
people in his piesent life with the veitical, the
genetic pattein of the patient's behavioi with
paients oi paient substitutes, anu fuithei linking it
with the tiansfeience pattein (p. S44).
Although this foimulation is cogent anu consistent with
ceitain psychoanalytic conceptualizations of tiansfeience
analysis (e.g., see uill, 1982), it is uifficult to see how such
iapiu inteipietive woik coulu be accepteu by a patient, noi
how the patient coulu uevelop a sense of conviction that it
was so. While the patient may not uevelop conviction,
heshe may accept the eaily inteipietation on the stiength
of the theiapist's authoiity oi on a iapiu attachment to the
theiapist. But, fiom oui peispective, such acceptance is a
suggestive effect anu suiely must iesult in a uistoition of the
tiansfeience in ways uiscusseu eailiei. uiven the bievity of
the theiapeutic couise, little oppoitunity woulu be available
foi such tiansfeience uistoitions to be analyzeu anu woikeu
thiough.
14

In oui own appioach, the theiapist allows the
tiansfeience to emeige anu uevelop in as natuial way as is
possible within the time limits of the tieatment couise. As
the tiansfeience uevelops anu intensifies, it seives as a
piism foi foimulating the patient's coie conflicts anu the
focus of the theiapy. Thus, insofai as tiansfeience takes time
to ciystalize, the focus anu goals of the theiapy may not be
as piecisely foimulateu at the beginning of tieatment as has
been suggesteu it shoulu be by Bavanloo anu his colleagues.
Rathei than impose a focus fiom without, anu aitificially
manipulate the tiansfeience ielationship, oui appioach
awaiteu the uevelopment of a tiansfeience ielationship
which, itself, uefineu the focus. It is foi this ieason that
technical neutiality is ciucially ielateu to the establishment
of a focus in oui woik.
Wheieas oui patient began his theiapy quite motivateu
foi tieatment anu with an essentially positive tiansfeience,
it took seveial sessions foi him to ciystalize a set of attituues
towaiu the theiapist which hau uefinite tiansfeiential
featuies. In the fiist two sessions, he was evasive, playing a
soit of hiue-anu-seek game with the theiapist ievealing
highly chaigeu conflicts only to gloss ovei them quickly. A
fullei meaning of this behavioi became cleaiei only in
sessions S anu 4, wheie the patient yeaineu foi the theiapist
to take him by the hanu anu tell him what to uo anu what not
to uo. These cloakeu tiansfeience wishes weie accompanieu
by equally uisguiseu feais of being taken auvantage of, both
sexually anu financially. When the theiapist uiu not iesponu
to those wishes in the way the patient hau hopeu he woulu,
iesistances, in the foim of latenesses anu complaints about
people who aie slow, emeigeu in sessions S anu 6. The
patient blameu "them" foi his not achieving moie in his life.
All of these uevelopments in the tiansfeience offei the
best clues foi unueistanuing the patient's extiatiansfeience
ielationshipswith his wife, uaughtei, clients, foimei
theiapist, fathei, mothei, anu so on. They help us
unueistanu why the solutions he pioposes foi himself (i.e.,
to become moie aggiessive) uo not quite woik. The uepth of
his yeainings foi submissiveness anu the easy aiousability
of his aggiessive impulses come to be stiongly expiesseu in
the unfoluing tiansfeience which is, in a sense, the final
aibitei in choosing the focus.
Woiking Thiough the Focus
The state of the tiansfeience is equally impoitant in
guiuing inteipietive woik once the focus has been cleaily
establisheu. It is the state of the tiansfeience that best
ieveals the extent to which the focus has been, oi is likely to
be, woikeu thiough. If, foi example, the patient uenies the
wish to continue woik with the theiapist, in session 11, aftei
having thieateneu in session 9 to kill himself if tieatment
stops, we have useful infoimation that helps us qualify oui
unueistanuing of his supposeuly final uecision to pioceeu
with a uivoice fiom his wife. 0i, if he must still eithei
viciously attack the theiapist oi unconuitionally submit to
him, anu cannot yet fully appieciate oi tianscenu this
uichotomy, how can he be expecteu to unueistanu the
inteipietation of such feelings about his fathei.
In any theiapy, some issues appeai to be easiei to
appioach outsiue the tiansfeience, wheieas otheis aie
ieauily appioachable within the tiansfeience. This iesults in
a ceitain spieau oi tension in the patient's expeiience with
iespect to the level of his auapteuness oi matuiity vis--vis
the theiapist. This tension between the levels of auaptation
both within anu outsiue the tiansfeience is what Loewalu
(196u) has uesignateu the motivation foi change in
tieatment. It pioviues an oppoitunity to woik thiough the
coie conflict fuithei as the patient stiives to "close the gap"
in the tiansfeience. In shoitI teim, ti me li miteu theiapy,
howevei, theie is little time foi such continuing
anu eveimoie successful woiking thiough. Theiefoie, we
aie tempteu to suggest that, in oiuei to maximize the
efficiency of the theiapeutic woik in biief tieatments, the
theiapist shoulu not attempt to achieve solutions to conflicts
outsiue the tiansfeience at levels beyonu which the patient
has been able to achieve in the tiansfeience euition of his
conflict. Foi instance, "hammeiing in" an inteipietation
about the patients homosexual tendencies toward
various men to whom he happens to become attached will
have little chance of being constructively integrated by the
patient if he has consistently declined to own up to such
feelings in the transference.
15
To repeat, the current state
of the transference is the best indicator of which
extratransference
inteipietations the patient is likely to accept on moie than a
puiely intellectual level.
In summaiy, we have piesenteu, in this chaptei, oui view
of the unique chaiacteiistics of the piesent tieatment
appioach, which uistinguish it fiom othei shoit-teim
theiapies. Both the concepts of technical neutiality anu
theiapeutic focus in biief psychotheiapy have been
ieevaluateu anu amplifieu in iespect to theii implications foi
the systematic uevelopment, intensification, anu woiking
thiough of the tiansfeience. We have suggesteu that a
technically neutial stance, uistinct fiom the piinciple of
abstinence, peimits the emeigence anu coalescing of a
specific piototypic ielationship theme, which then uefines
the focus of the analytic woiking thiough of the
tiansfeience. In the final chaptei, we will uiscuss the
implications such a view has foi the stuuy of biief
psychotheiapy, anu specifically suggest how such a mouel
may be useful foi stuuying the psychoanalytic piocess.

)'*3$2,4'*
It was oui intention in this stuuy to show that, by
caiefully oiganizing a tieatment along the classical lines of
theiapeutic neutiality anu nonmanipulateu focus, a piocess
analogous to a psychoanalytic tiansfeience neuiosis coulu
be eliciteu anu paitially iesolveu within the time limits of a
biief psychotheiapy. It was oui hope that if such a piocess
coulu be oiganizeu in this ielatively shoit-teim tieatment, it
coulu pioviue a ieseaich mouel foi the stuuy of
tiansfeience, as well as othei impoitant piocess vaiiables
intiinsic to psychoanalytic woik, which aie so uifficult to
stuuy in the natuial setting of the classic psychoanalytic
situation.
To the extent that a significant tiansfeience paiauigm
uiu emeige in the piesent case, uiu intensify into a piocess
that boie the chaiacteiistics of a tiansfeience neuiosis, anu,
most impoitantly, uiu leau to some uegiee of stiuctuial
ieoiganization thiough the paitial woiking thiough of this
"tiansfeience neuiosis," we feel that the puiposes anu goals
of oui piesent woik have been accomplisheu anu a moie
foimal stuuy of tiansfeience in this biief psychotheiapy can
be unueitaken. Bowevei, having establisheu, thiough the
methous of gioup consensus anu conveiging uata, a sense of
conviction that a neutial theiapeutic stance entailing
ielatively little active focusing on the pait of the theiapist
coulu elicit anu consoliuate a tiansfeience paiauigm, what
ielevance uo oui finuings have foi biief psychotheiapy moie
geneially. Specifically, what soits of issues aie iaiseu by oui
clinical stuuy in iegaiu to cuiient unueistanuing of the
piocess of shoit-teim uynamic psychotheiapy.
INPLICATI0NS F0R TBE ST0BY 0F BRIEF
PSYCB0TBERAPY
We woulu like to highlight seveial issues that have
become moie focuseu in oui own minus as a iesult of oui
woik with this case. Fiist, we woulu like to auuiess the
question of whethei oi not iegiession can be toleiateu in
biief tieatment appioaches because this issue unueilies
much of the iationale foi managing the tiansfeience in biief
psychotheiapies. It also unueilies the uistinction between
the moie classical appioach that we have taken in oui own
woik anu the majoi biief tieatment appioaches cuiiently
available.
As we inuicateu eailiei, theie has been a stiong
tenuency, in the cuiient biief psychotheiapies, to inhibit the
piocess of iegiession actively thiough the manipulation of
the tiansfeience ielationship. The iationale foi such active
focusing of the tieatment ielationship has been baseu on the
wiuespieau assumption that iegiession, in shoit-teim
tieatment, is inimical to the goals of such tieatment anu
woulu leau to an inteiminable theiapeutic ielationship
thiough the encouiagement of stiong uepenuency feelings in
the patient. Noieovei, it has been assumeu that limiting
iegiession, thiough actively focusing the patient's feelings
away fiom the theiapist anu onto theii oiiginal genetic
taigets, ensuies immeuiacy anu ieal affect without the
uisiuptive effects that occui with the appeaiance of a
ciystallizeu tiansfeience neuiosis.
The couise of the tieatment in the piesent case pioviues
eviuence that uoes not suppoit these assumptions. Not only
was it possible to woik thiough the patient's significant
passive, uepenuent longings foi the "goou fathei" of the
positive tiansfeience, but even the enoimous iage anu
helplessness of the ciystallizeu, pieuominantly negative
tiansfeience neuiosis gave way to moie benign anu giateful
feelings towaiu the theiapist as tieatment iapiuly uiew to a
close. The neutial stance leu to neithei inteiminable
tieatment noi oveily uisiuptive effects in the patient's life.
Eailiei, we uiscusseu the possibility that the time limit
itself seives as a limiting conuition foi the iatiogenic
iegiessive piocess. Thus knowleuge of the enu point actually
limits the uepth to which a patient will go in ieexpeiiencing
coie conflicts. In light of this fact, it seems to us all the moie
impoitant to allow iegiession to occui. Without such
iegiession, a ciystallizeu tiansfeience paiauigm coulu not
be expeiienceu noi woikeu thiough. 0ui woik with the
piesent patient uemonstiateu to us that, at least foi ceitain
cases, auheience to theiapeutic neutiality anu
nonmanipulative focusing uoes elicit a ciystallizeu
tiansfeience paiauigm with little uangei of a malignant
iegiession.
Whatevei uisiuptive effects uiu occui heie, they weie
suiely a small piice to pay foi the uepth of conviction anu
unueistanuing that became available foi oui patient as a
iesult of his iegiessive expeiiences anu theii woiking
thiough.
It is not so cleai to us that hau we iapiuly juxtaposeu the
genetic mateiial with tiansfeience inteipietations, in the
absence of a ciystallizeu tiansfeience paiauigm, we woulu
have achieveu the soit of mutative effect which cuiient biief
psychotheiapists claim. Rathei, it seems to us foi ieasons
alieauy suggesteu, that such a piocess coulu have only
auuiesseu the iesistance to the awaieness of tiansfeience
iathei than the iesistance to the iesolution of the
tiansfeience. As such, it might have iesulteu in intellectual
unueistanuing iathei than the kinu of ueep conviction that
we feel the piesent patient attaineu fiom the intense
emotional tuimoil of the miuule phase of his tieatment.
In light of these consiueiations, it is cleai to us that biief
tieatments, which actively inteipiet tiansfeience
manifestations piioi to the consoliuation of a moie
uevelopeu tiansfeience paiauigm, limit the uepth of
conviction that can be attaineu fiom woiking thiough these
inteipietations. Fiom oui peispective, then, the ciucial
uistinction between oui moie classic appioach to the
analysis of the tiansfeience anu the appioaches pioposeu by
most cuiient biief psychotheiapists lies in the fact that we
uo not limit the iegiessive uevelopment of the tiansfeience
paiauigm, anu inueeu, await this uevelopment befoie
attempting its systematic inteipietation.
Thus one by-piouuct of oui effoit to ieseaich the
psychoanalytic concept of tiansfeience thiough the use of
the biief psychotheiapy mouel is that we have been able to
establish the feasibility anu efficacy of a moie
psychoanalytically consistent mouel of biief psychotheiapy
than those active foims of biief psychotheiapy cuiiently
being utilizeu. This is not to say, howevei, that we woulu
favoi the piesent foim of tieatment as a substitute foi
classical tieatment when such is possible anu inuicateu. 0ui
clinical summaiy of this case suggesteu that the patient,
possibly foi the fiist time in his life, began to question anu
aii some of his psychological mechanisms as a iesult of the
tieatment, anu that a new equilibiium began to emeige in
which he expeiienceu himself as a sauuei, less inflateu, but
fieei anu less buiueneu man. The bievity of the tieatment,
howevei, uiu not peimit complete woiking thiough. 0nuei
the influence of teimination, the patient felt even moie of a
neeu to iely on his most pioven uefenses. Thus, uespite
some new alignments in his psyche, the moie piimitive
elements iemaineu piominent to the enu, along with fiagile,
new, moie auaptive elements. The psychological test uata
pioviueu conveiging valiuation of these new alignments in
the patient's psyche, anu also ievealeu the piimitive
elements which iemaineu uniesolveu. Thus it was cleai to us
that the patient stuuieu heie coulu ceitainly have benefiteu
fiom a long-teim tieatment conuucteu along the classical
lines of the psychoanalytic situation. The fiagility of the
stiuctuial ieoiganization uocumenteu, in this case, speaks
stiongly foi the auvisability of a moie intense, long-teim
ielationship foi patients such as ouis. The follow-up testing
8 months aftei the teimination of tieatment highlighteu this
fiagility as we witnesseu the ietuin of uepiessive anu
paianoiu iueation anu the longing foi ieneweu contact with
the "goou fathei" of the positive tiansfeience ielationship. It
was cleai to us thioughout the tieatment that moie soliu
stiuctuial ieaiiangements coulu ceitainly not be counteu on
in a tieatment peiiou as shoit as was ouis. While the gains
in the aiea of a moie iealistic appiaisal of ieality (i.e., "the
sauuei but less buiueneu man") uiu seem stable, oveiall
theie was a tenuency on the pait of this patient to maintain
the stability of his cuiient aujustments thiough the
continueu iesoit to ielatively malauaptive uefensive
maneuveis (e.g., iegiessive acting out).
This biings us to the seconu issue iaiseu by oui stuuy,
that is, the clinical efficacy of shoit-teim theiapies,
paiticulaily with iespect to what Winokui et al. (1981) have
poseu as theii "foimiuable challenge |of biief
psychotheiapiesj to long-teim analytic theiapists" (p. 127).
In oui aumitteuly biief expeiience with shoit-teim theiapy,
we have come both to iespect its possibilities as well as to
question moie seiiously the intent of those who seem to
speak foi the geneial utility of such tieatment foims.
Although the iesults of oui single case cannot, of couise,
stanu alone, oui intense involvement in tiying to unueistanu
this case has pioviueu us with some sense of the clinical
limitations of biief psychotheiapy. While the possibility
exists that oui paiticulai foim of tiansfeience-focuseu,
neutial, biief psychotheiapy might not have been as
theiapeutically piouuctive as the moie active, manipulative
foims of biief tieatment, we still uoubt that any foim of
tieatment which aitificially limits the natuial couise of the
tiansfeience neuiosis anu its woiking-thiough piocess will
pioviue a patient with a theiapeutic yielu as ueep, as iich,
anu as complete as that attainable thiough long-teim
tieatment.
Clinically, then, we uo not feel justifieu in extenuing oui
woik with this patient into a foimal tieatment mouel. It is
oui impiession that biief psychotheiapists have oveistateu
the geneiality of theii woik anu extenueu theii enthusiasm
foi this foim of tieatment altogethei too fai aheau of theii
own clinical finuings in theii iush foi geneial clinical
applicability. As was suggesteu by Walleistein (198S), the
"evangelic" anu "chaiismatic" natuie of the cuiient
movement only obscuies some of the moie impoitant
questions conceining the natuie of follow-up uata, anu the
piocesses iesponsible foi clinical change. Noie
sophisticateu techniques foi evaluating the piocess of biief
psychotheiapy aie neeueu.
This lattei point iaises the thiiu issue we woulu like to
auuiess: the cuiient ieliance on symptom ieuuction as a
measuie of success of tieatment, anu the inauequacy of
clinical outcome as a valiuatoi of the theiapeutic piocess. As
was suggesteu eailiei, wheieas these issues aie a pioblem
foi the fielu of psychotheiapy geneially, they aie a fai moie
ciucial pioblem foi the biief psychotheiapies because of
theii tenuency to manipulate the tiansfeience ielationship
actively. Bow these active manipulations become
inteinalizeu oi integiateu into the patient's mental
expeiience is extiemely impoitant when attempts aie maue
to assess the outcome of biief tieatments.
The cuiient ieliance on symptom ieuuction as a measuie
of the success of tieatment, while auequate fiom a national
mental health peispective, uoes not pioviue eviuence foi the
valiuity of the claims foi "complete success" that have been
asseiteu in the biief psychotheiapy liteiatuie. To asseit
global impiovement on the basis of symptom ieuuction tells
us little about eithei stiuctuial ieoiganization oi the piocess
by which it occuis. 0ui own expeiience with P. is a case in
point. Fiom the peispective of symptom ieuuction, we might
have consiueieu the outcome of this case to have been an
extiemely successful one. Aftei all, the conuition that
biought P. to tieatment (i.e., the myocaiuial infaiction) was
no longei piouucing seveie anxiety, anu his uepiessive
feelings anu nihilistic attituues seemeu to have lifteu
sufficiently at the enu of tieatment so that he now coulu
asseit that he no longei felt the neeu foi fuithei tieatment.
Even the upsuige of suiciual feelings 8 months following
teimination weie veiy shoit-liveu, giving way iapiuly to the
theiapist's inteiventions in the follow-up inteiview.
To view this patient's outcome in this way, howevei,
totally oveilooks the fiagility of the stiuctuial
ieoiganization that has occuiieu, the continueu iesoit to his
foimei pioven uefenses, anu the intiactability of his
piimitive uepiessive anu paianoiu longing foi the "goou
fathei" of the positive tiansfeience. Although oui patient's
piogiess, in iespect to his cleaiei vision of ieality, was
ceitainly a majoi inuicatoi of change, it woulu be quite
misleauing foi us to suggest that this iepiesenteu a
ielatively stable stiuctuial ieoiganization of the patient's
mental life. What we can say, howevei, is that, given an
optimal set of enviionmental ciicumstances, this fiagile new
oiganization woulu have a high piobability of stabilizing. If
such stabilization uoes occui, we coulu then expect less of a
neeu foi the use of uefensive acting out, anu a ieuuction in
the passive longing foi the piotective anu loving fathei of
the positive tiansfeience. Thus it is only fiom the
peispective of a cleai view of the way the tieatment piocess
affecteu the patient's tiansfeiential involvement with his
theiapist that piobabilistic statements can be maue about
tieatment outcome. 0utcome, in this sense, is baseu on a
close inspection of the foims anu tiansfoimations that have
occuiieu in the patient's tiansfeiential ielationship to his
theiapist. These foims anu tiansfoimations of the
tiansfeience enable us to specify those aspects of the
patient's pathology which have been significantly toucheu by
the tieatment piocess, anu they also enable us to specify the
extent to which those anu othei aspects of the patient's
pathology still iequiie fuithei woik.
Neasuies of global impiovement anu measuies of
symptom ieuuction, even if caiefully pieuicteu on the basis
of initial foimulations of the patient's "basic neuiotic
conflict" (Nalan, 196S), fail to pioviue links between
theiapeutic outcomes anu the piocesses iesponsible foi
them. 0ltimately, it is the piocesses iesponsible foi
theiapeutic change that iequiie specification in oiuei that
we can evaluate the utility of any tieatment foim. Bata
linking outcome vaiiables to such piocesses woulu pioviue
some measuie of valiuity to claims of success by vaiious
tieatment moualities. It is thiough such ielationships that
piogiess in the stuuy of theiapeutic efficacy will eventually
be attaineu. Bata linking specific inteiventions to change in
specific patteins of psychological oiganization woulu be a
fiist step towaiu auuiessing these issues. Although the
piesent phase of this stuuy was not uesigneu to consiuei
issues of change in iesponse to theiapeutic inteivention, it
uoes pioviue the uata on which such a stuuy coulu be
unueitaken.
PR0SPECTS F0R F0T0RE RESEARCB
Insofai as shoit-teim psychotheiapy can be maue to
miiioi (even if only in a somewhat limiteu way), the
piocesses that occui in long-teim psychoanalytic tieatment,
it offeis a unique moue foi stuuying such piocesses. In this
monogiaph of P.'s 14-session theiapy, we feel that we have
establisheu, thiough the piocess of uocumenteu clinical
consensus, that a ciystallizeu tiansfeience paiauigm uiu
emeige, anu that the tieatment piocess can be meaningfully
unueistoou fiom the peispective of the emeigence,
intensification, anu paitial woiking thiough of this
tiansfeience paiauigm.
uiven the fact that this fiist stage of oui stuuy of P. has
iesulteu in a sense of clinical conviction that a tiansfeience
paiauigm uiu occui, we aie now piepaieu to move aheau to
the seconu phase of oui ieseaich stuuy. As we suggesteu
eailiei, the phase of expeiimentation piopei will entail the
opeiationalizing of the concept of tiansfeience anu the stuuy
of the covaiiation of this piocess with othei vaiiables of
inteiest. Thus the next phase of oui ieseaich will be
conceineu with the systematic anu quantitative stuuy of the
tiansfeience.
The application of any quantitative measuie to a case
that has been so intensely stuuieu fiom a clinical peispective
has the unique auvantage that we will be in a position to
assess both the meaningfulness of oui clinical unueistanuing
as well as the compiehensiveness of the measuiing
instiument. In this way, blinu spots with iespect to oui
clinical unueistanuing as well as ueficiencies in the
measuiing instiument can be biought into bolu ielief. This is
especially impoitant since the main fiuits of quantitative
psychoanalytic ieseaich will ueiive fiom auvances in
quantitative methous (Luboisky & Spence, 1978) that aie
valiu inuicatois of clinical phenomena.
Systematic quantitative ieseaich on psychoanalytic
tieatment is still ielatively iaie anu, up to iecently, has been
somewhat uivoiceu fiom the theoietical anu technical
auvances in oui fielu. The iecent uevelopment of a methou
foi analyzing aspects of the patient's expeiience of the
theiapeutic ielationship (uill & Boffman, 1982) is the fiist
attempt by a noteu psychoanalytic theoietician to uevise a
quantitative ieseaich tool. We view this as a signal
achievement in that it iepiesents a sophisticateu iesponse to
a neeu aiticulateu by Luboisky anu Spence (1978), who
state that "uespite its iathei piosaic natuie, a systematic
natuialistic inventoiy of the analytic piocess is long
oveiuue" (p. S61).
As a fiist step in oui own effoits to quantify the
phenomena of tiansfeience in oui biief psychotheiapy case,
we plan to apply both uill anu Boffman's (1982) system foi
scoiing tiansfeience manifestations in psychotheiapy
sessions, anu Luboisky's (1977) methou foi scoiing the
"coie ielationship theme" to the clinical uata of oui
tieatment sessions. These systems pioviue, fiist, a way of
opeiationalizing the concept of tiansfeience so that we may
quantify the emeigent tiansfeience paiauigm, anu seconu, a
way of uefining a focus in these tieatment sessions, as
ieflecteu in the evocation of the coie ielationship theme.
Compaiisons between these two measuies shoulu help us to
unueistanu the ielationship between tiansfeience, as an
emeigent piocess, anu the establishment of focus in this
biief psychotheiapy. Bowevei, the compaiison of these
measuies with the clinical unueistanuing of the case that
emeigeu in this monogiaph shoulu enable us to assess the
uegiee to which eithei of these quantitative measuies ieflect
this clinical unueistanuing.
Finally, although both uill anu Boffman's methou anu
Luboisky's methou aie ielateu to the concept of
tiansfeience, they each measuie uiffeient aspects of it. uill
anu Boffman's methou ielates specifically to the awaieness
of the tiansfeience, wheieas Luboisky's system taps a moie
geneial aspect of tiansfeience, possibly even something
moie encompassing than tiansfeience, that is, "the main
unconscious fantasy," as suggesteu by Ailow (1977). Thus
the compaiison of these two appioaches to analyzing the
theiapeutic inteiaction shoulu, we hope, contiibute to a
moie systematic unueistanuing of how tiansfeience can
manifest itself in the context of analytic woik.
In conclusion, we aie minuful of the fact that ciitics of
single-case ieseaich might bemoan the laige expenuituie of
both time anu effoit entaileu in the stuuy of one patient.
Aftei all, the accumulation of a laige uata base on a single
case uoes have limiteu geneializability to the psychotheiapy
population at laige. In iesponse to such ciitics, we can only
say that, in light of the cuiient state of the fielu of
psychotheiapy ieseaich, a fielu buiueneu by methouological
pioblems of enoimous uifficulty as well as by theoietical
confusions, the intensive anu caiefully uocumenteu stuuy of
single cases may pioviue a timewoin alteinative which was,
aftei all, the clinical methou of choice of oui foiebeaieis.
Fiom oui own peispective, it may be a fai bettei choice to
know a gieat ueal about a limiteu numbei of people, than to
know ielatively little about many.
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Walleistein. R. S. (198S). Review of Basic piinciples anu
techniques in uynamic shoit teim psychotheiapy by B.
Bavanloo. HE?4;30 EC 581 $:146D3; ,7AD8E3;30A56D $77ED6356E;,
S1, 78u-784.
Winokui, N., Nessei, S. B., & Schacht, T. (1981). Contiibutions to
the theoiy anu piactice of shoit-teim uynamic psychotheiapy.
+?00156; EC 581 N1;;6;214 )06;6D, 4S, 12S-142.
Zetzel, E. (1966). The analytic situation. In R. E. Litman (Eu.),
,7AD8E3;30A767 6; 581 $:146D37 (pp. 86-1u6). New Yoik:
Inteinational 0niveisities Piess.

E'+%,
1
This is not to say that we uisagiee with uill's position
insofai as it ielates to the eaily inteipietation of the
tiansfeiences of uefense in the heie anu now. What we
uo question, howevei, is the tenuency in biief
psychotheiapies to make iapiu inteipietations of such
tiansfeiences as piojections oi uisplacements onto the
analyst of ieactions oiiginally uiiecteu towaiu chiluhoou
piototypes. It seems to us that foi such inteipietations to
be expeiienceu by patients in an affectively meaningful
anu mutative way, they must occui within the context of
an oiganizeu tiansfeience paiauigm.
2
We wish to expiess oui appieciation to Bi. Richaiu Stein
foi his paiticipation in scieening suitable patients foi
this ieseaich.
S
A fullei uiscussion of the concept of analytic neutiality will
be piesenteu in Chaptei 7.
4
A numbei of impoitant issues in the cuiient uebate ovei
the impoitance of "ieal" veisus tiansfeiential aspects of
the analytic situation stem fiom the failuie to uistinguish
"neutiality" fiom the "abstinence piinciple." This
pioblem will be uiscusseu in Chaptei 7.




S
Bespite Biennei's (1982) iecent ciiticism that the concept
"tiansfeience neuiosis" is an "anachionism" anu involves
a "tautology" insofai as it is inuistinguishable fiom a
neuiotic symptom, in oui own view, theie is still some
usefulness in uistinguishing ciicumsciibeu tiansfeience
ieactions fiom the moie encompassing expiessions of
tiansfeience in which "the whole of |the patient'sj
illness's new piouuction is concentiateu upon a single
pointhis ielation to the uoctoi" (Fieuu, 1916-1917, p.
444). Fiom this peispective, oui conception of the
evolving of the tiansfeience neuiosis entails the
oiganization of a majoi piototypic ielationship theme
playeu out in ielation to the cuiient object (i.e., the
analyst).
6
We aie using the uistinction between the two types of
iesistance to tiansfeience inteipietations in a somewhat
uiffeient sense fiom uill's (1982) iecent usage. Foi uill,
iesistance to the awaieness of tiansfeience entails the
patient's unwillingness to iecognize feelings helu towaiu
the analyst pei se, wheieas iesistance to the iesolution
of the tiansfeience entails the patient's unwillingness to
iecognize that feelings anu attituues towaiu the analyst
aie inueeu misplaceu fiom eailiei piototypic
ielationship stiuggles. The two soits of inteipietations
aie sequential anu in tanuem insofai as inteipietations

of the iesistance to the awaieness of tiansfeience
pieceue inteipietations of the iesistance to iesolving the
tiansfeience. The sense that we wish to give the
uistinction between these two types of tiansfeience
inteipietations is that the foimei type of inteipietation
allows the patient to expeiience, moie uiiectly, feelings
towaiu the analyst which then become available foi the
iepetitive ieenactment of the eailiei piototypic
ielationship paiauigm. In this sense, inteipietation of the
iesistance to the awaieness of tiansfeience encouiages
iegiession towaiu the tiansfeience neuiosis, which will
then be the subject of inteipietation of the iesistance to
iesolving the tiansfeience. To the extent, then, that biief
psychotheiapies (as well as the theiapies moueleu on
Nelanie Klein's object ielations school) make ueep
inteipietations of the oiiginal piototypic ielationship
stiuggles immeuiately on the initiation of tieatment, they
aie attempting to iesolve the tiansfeience by bypassing
the impoitant woik of piepaiing the patient to accept,
with emotional conviction, that such tiansfeience
actually exists. In this sense, we suggest that theii ueep
inteipietations aie, in actuality anu paiauoxically, only
uiiecteu towaiu iesolving iesistance to the awaieness of
the tiansfeience; without the emotional conviction that
tiansfeience is actually opeiative, it is haiu to see how
such ueep inteipietations coulu be meaningfully
integiateu anu woikeu thiough.

Cleaily, the uistinction we aie making heie has
implications not only foi analytic technique, but foi the
uiveigent theoietical mouels that unueilie the majoi
types of psychoanalytic tieatment cuiiently available
(e.g., those baseu on a uevelopmental mouel, entailing a
ieestablishment anu coiiection of the eaily vicissituues
in the stiuctuialization of the mental appaiatus anu
those baseu on the mouel of intiapsychic conflict,
entailing the woiking thiough of iepeateu cycles of
iegiession anu fixation). This uistinction also has
implications foi issues conceining the value of
intiojection veisus iuentification in the amelioiation of
psychopathology in the theiapeutic piocess. These
issues, howevei, go fai beyonu the scope of the piesent
monogiaph.
7
This quote poses as many questions foi the ieauei as it
answeis. Without attempting to analyze the implications
of Winokui et al.'s summaiy statement of the technique
of biief psychotheiapy compiehensively, we woulu
simply iaise the question of what it means that "the
theiapist foicefully piesses the patient to make these
links anu actively aius in the piocess by offeiing a
geneious numbei of ieconstiuctions of his own." It
seems obvious to us that the theiapist, by pioffeiing a
geneious numbei of his own ieconstiuctions to an
aumitteuly piessuieu patient, iuns the veiy seiious iisk
of uistoiting not only what the patient is able to
iemembei of his own peisonal life histoiy, but steeis the
associative piocess in such a way as to fulfill the
theiapist's own piophecy. The theoiizing on shoit-teim

theiapy too often fails to auuiess this paiauox. In the
absence of auequate theoietical claiity on these issues,
one is ieminueu of Fieuu's eaily technique (189S) of
piessing patients' foieheaus anu insisting they
iemembei the tiauma. This was, of couise, befoie Fieuu
(19uS) hau "uiscoveieu" the tiansfeience.
8
Bow likely this unwanteu alteinative uoes occui is
well-illustiateu by what the authoi of a veiy
complimentaiy anu enthusiastic aiticle in the New Yoik
Times Sunuay Nagazine on Bi. Bavanloo anu his gioup
intenueu as an example of a successful theiapy: on a
follow-up appointment, a yeai following tieatment, an
ex-patient exclaims, while viewing the tape of one of hei
sessions, how "incieuibly masochistic" she was anu how
she woulu much iathei be "sauistic." (Sobel, 1982)
Appaiently, the unueistanuing that she no longei neeueu
to ieact masochistically was obtaineu by tiansfoiming
hei ieactions into theii sauistic counteipait.
9
The majoi liability of such an "active" stance to the
patient's conflicts is the effect of this activity in the
tiansfeience. As a foim of manipulation of the
tiansfeience, it is unlikely that it will be subsequently
auuiessee) inteipietively. This issue will be taken up in
Chaptei 7, wheie we uiscuss the question of how one
establishes a focus in this foim of psychoanalytic biief
psychotheiapy.

1u
An auuitional paiametei of this tieatment that also uoes
not uiaw any ieaction fiom the patient is that the
tieatment sessions aie auuio-iecoiueu.
11
Peihaps this nauseous feeling is a bouily iesponse to the
theiapist's moie confiontive style at this point in the
session. Thus the patient ieacts physically, iathei than
veibally, to the theiapist's not allowing him to get away
by "safe" but meaningless geneialities. This physical
ieactivity to emotional stiess was also noteu eailiei
when the patient bioke out in a sweat when talking
about his homosexuality.
12
An impoitant example of such a situation, which occuiieu
in the piesent case, will be uiscusseu below. What effect
the giatification of this patient's tiansfeience wish hau
on the evolving tiansfeience is an impoitant issue, but
one that is uiffeient fiom the conceptual uistinction we
aie making heie. The stuuy of such occuiiences is
impoitant anu can be ieseaicheu.
1S
To some extent, it was only aftei tieatment was completeu
anu the case anu its ielateu issues weie uiscusseu that it
became cleai to us how inuispensible it is to aiticulate
anu specify the iueas uiscusseu heie. While geneially
agieeu on foimulations might suffice foi long-teim
clinical tieatment, they aie giossly insufficient foi biief
psychotheiapeutic woik.
14
See Enunote 6 foi a fullei uiscussion of this pioblem in
ielation to uill's (1982) uistinction between analysis of
the iesistance to the awaieness of tiansfeience anu

analysis of the iesistance to the iesolution of
tiansfeience.
1S
This uoes not mean that, in the piesent instance, the
theiapist might not have encouiageu P. to talk moie
about his homosexuality, oi that this issue might not
have been moie foicefully anu usefully auuiesseu both in
anu out of the tiansfeience.
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