Journal of Consulting and Clinical Psychology Copyright 1989 by the American Psychological Association, Inc.

1989, Vol. 57. No. 2, 195-205 0022-006X/89/S00.73

The Psychotherapy Research Project of the

Menninger Foundation: An Overview

Robert S. Wallerstein
Department of Psychiatry
University of California, San Francisco

Studied processes and outcomes of psychoanalysis and psychoanalytic psychotherapy, both expres-
sive and supportive. 42 Ss were followed via initial, termination, and follow-up studies over the
entire natural course of treatment, with 100% follow-up 2-3 years posttermination. Some follow-ups
extended over the 30-year life span of the study. Detailed case histories and life histories were ob-
tained from all 42 Ss. Psychoanalyses achieved more limited outcomes than predicted; psychothera-
pies often achieved more than predicted. Supportive mechanisms infiltrated all therapies, psycho-
analyses included, and accounted for more of the achieved outcomes (including structural changes)
than anticipated. An expanded new categorization of supportive therapeutic mechanisms is pro-
posed, along with an elaboration of expressive therapeutic mechanisms.

The Psychotherapy Research Project (PRP) of the Menninger
Foundation was constructed during the years from 1952 to
1954. It was established within an informed and skilled clinical
community, a full-time, salaried, professional staff (essentially
a large-group private practice) dedicated to the intensive psy-
choanalytic psychotherapy of the seriously emotionally ill who
came or were sent to Topeka, Kansas (often as a last resort),
from all over the United States and abroad. A group of clini-
cians and clinical researchers within this professional commu-
nity decided to try to learn more about its central professional
activity and to seek more precise answers to two simple ques-
tions: First, What changes take place in psychotherapy? Second,
How do those changes come about through the interaction of
which constellation of factors in the patient, in the treatment
and therapist, and in the patient's ongoing life situation? These
questions were chosen to explore outcome and process, respec-
tively.
cumbered and uninfluenced by the fact of the research or even
by any knowledge on the part of the participants that the ther-
apy was the subject of research study. In accordance with the
prevailing treatment programs of the institution, half of the pa-
tients studied were in psychoanalysis and half were in other
modes of expressive and supportive psychoanalytic psychother-
apy. A population of 42 (21 in each group) was identified. The
criteria for our naturalistic study required (a) that each patient
be treated by the most clinically appropriate modality (i.e., no
random assignments); (b) that there be no traditional control
conditions or other nonclinical research impositions and, that
therefore, principles of control be implemented in ways other
than the standard; and (c) that the therapy under study be con-
ducted through its natural course with neither therapist nor pa-
tient being influenced by or aware of the research study. The
challenge, then, was to build the research study as comprehen-
sively as possible around this natural psychotherapy.'

Naturalistic Study Method

Within that strategic framework, it was decided that this re- Selection of the Sample
search would be a naturalistic study of psychotherapy, unen- The sample was drawn from the usual patient population in intensive
therapy at the Menninger Clinic. Patients came to the clinic for treat-

This article was based on and prepared from two earlier articles from
the Psychotherapy Research Project (PRP) of the Menninger Founda-
tion. The first article (Wallerstein, 1977) dealt with the conception,
structure, method, design, and data analysis of the project, and the sec-
ond article (Wallerstein, 1988) dealt with the overall results of the proj-
ect. Full citations for both articles can be found in the Reference section.
Other major summaries of the PRP are cited elsewhere in this article.
The project was supported by grants from the Foundations' Fund for
Research in Psychiatry, the Ford Foundation, and the National Institute
of Mental Health (Grant MH8308) as well as by additional generous
support from the Menninger Foundation.
Correspondence concerning this article should be addressed to Rob-
ert S. Wallerstein, Department of Psychiatry, University of California,
San Francisco, Langley-Porter Psychiatric Institute, 401 Parnassus Ave-
nue, San Francisco, California 94143.
' A research study conducted in this way, within the constraints of a
clinical setting to which patients come for the best current help that is
clinically available, clearly does not allow the use of design and control
parameters that are often imposed in pure research settings (random
assignment, traditional no-treatment control groups, wait-list controls,
etc.). These control procedures can pose ethical dilemmas regarding the
withholding or deferring of treatments that the treating clinicians feel to
be most appropriate. We chose to provide the best and most appropriate
treatment that our professional expertise could offer patients and, there-
fore, to look for methods of control and design that would not compro-
mise the nature or conditions of the clinically indicated treatment Go-
ing even further by creating a thoroughly naturalistic design, we were
assured that the therapies being studied were the therapies as they natu-
rally occurred, unaltered by the research or by the patient's and thera-
pist's knowledge that the therapy would be subject to later research scru-

195
196 ROBERT S. WALLERSTEIN
ment because their illness was so severe that it was not readily amenable
to standard outpatient therapy in their home setting. Excluded from the
research sample were patients so ill that intensive concomitant hospital
treatment was a major component of their total therapeutic manage-
ment. Patient disorders included severe psychoneuroses, character neu-
roses, and impulse neuroses; addictions and sexual disorders; and nar-
cissistic and borderline disorders. Individuals with open psychoses or
organic brain disorders or those who were innately retarded were ex-
cluded. Also excluded were those whose treatment was expected to be
brief. Half of the patients were men and half were women, and their ages
ranged from 17 to 47 years for men (M = 33) and from 19 to 50 for
women (M = 30). (Such a range excluded those whose age might have
confounded the study: the young, by growth and developmental pro-
cesses; the old by somatic illness and aging processes.) The socioeco-
nomic and demographic characteristics were those of patients who
could afford such treatment: Subjects were White and upper to upper-
middle class, with IQs ranging from 111 to 141 (M = 124). This was
a reasonably homogeneous but far from representative population
sample.
Initial Study (Diagnostic Process and Predictions)
The study was built around the usual diagnostic process carried out
on all patients at the Menninger Clinic. This 2-week process included
intensive psychiatric case study, a comprehensive projective psychologi-
cal test battery, a social history obtained from a responsible relative, and
the overall case formulation and treatment recommendations (planning
and prognostication) derived from the clinical case conference that
completed each diagnostic work-up. These data, available in the clinical
records, were the basis for the research team's Initial Study of each case.
This evaluative, diagnostic, and prognostic assessment was designed to
make explicit those variable factors within the Patient, within the Ther-
apist and Treatment, and within the interacting life Situation of the pa-
tient that, together, were felt to determine the probable treatment course
and outcome.
Twenty-eight Patient Variables were conceptualized and grouped into
eight areas of psychic functioning. These variables were thought to be
operative in formulations of an understanding of the patient; of his or
her life history, character structure, and emotional illness; and of the
treatment plan and prospects. Except for sex, these were neither demo-
graphic variables (because the population was fairly homogeneous) nor
diagnostic categories (because the patients had roughly comparable de-
grees of illness severity). Rather, they were personality variables, or com-
plex clinical judgments about intrapsychic organizations. Examples in-
cluded the nature of the core neurotic conflicts, the severity and nature
of the symptoms, the patterning of the defenses, the anxiety and affect
tolerance, the resiliency and strength of the ego, the nature of the moti-
vation for change, and the transference dispositions that would expect-
ably unfold. Each was defined in terms of general psychodynamic the-
ory and, more specifically, in terms of the idiosyncratic usage within
our clinical community. Based on study of the case records from the
diagnostic process, two researchers (the Initial Study team) made con-
sensus assessments in writing on each of the 28 Patient Variables for
each patient chosen for study.
Similar consensus assessments were made in writing on each of seven
Situational Variables. These were not related to the life situation, job,
marital status, family and friendship constellations, and so forth, but
rather were related to the impact (psychologic meaning) of the life situa-
tion in its degree of stressfulness, its conflict-triggering components spe-
cific to the core neurotic conflicts of the individual, its supports, its
growth opportunities, and its mutability. Although Treatment and Ther-
tiny. This procedure is an advantage because it negates the need to deter-
mine the impact of research on the process and outcome of therapy.
apist Variables could not be assessed prior to therapy, the Initial Study
team made predictions about the expected course and outcome of the
planned therapy based on research assessments of each patient's pros-
pects, given his or her life situation, in embarking on the appropriate
clinical treatment. These predictions explicitly described the therapeu-
tic course and detailed the expectable unfolding of themes, issues, and
transference positions; the consequences of various contingencies, likely
life events or interactions, to the therapeutic course; and so forth. Ex-
plicit predictions were also made for the therapeutic outcome, detailing
changes in symptoms, manifest behavior patterns, and impulse-defense
configurations; structural alterations in the ego; acquisition of insights;
and similar components.
The overall Initial Study in each case was then completed with a logi-
cal analysis of the discursive clinical predictions, embedded as they were
in clinical context and qualification, in the form of one-sentence predic-
tive statements. These followed a tripartite logical model: If (under these
conditions, given these events or contingencies), then (these conse-
quences, events, changes will occur), because (of these factors in the
patient and in his or her life situation and these theoretical assumptions
about how therapy induces change). There were approximately SO such
predictive statements per case, or about 2,000 specific predictions to be
tested in the 42 cases. However, because the same assumptions often
underlay many predictions within a single case or underlay predictions
across many of the cases, the theoretical assumptions under test finally
totalled about 300, with an even smaller number seen as critical to our
theory of therapeutic change.
Given that the clinical assessments were performed with competence
and skill, the tests of the predictions would ultimately be tests of our
functional theory of therapy. With so many reasons why predictions
could be supported or negated, apart from the adequacy of the theoreti-
cal assumptions, no single test or combination of tests could decisively
confirm or refute any particular assumption under scrutiny. However,
if the majority of the predictions embodying a particular theoretical
assumption were sustained, its plausibility would be strengthened,
whereas if the majority of the predictions embodying an assumption
were not sustained, its plausibility would be diminished. Thus, en-
hanced knowledge of an array of assumptions underlying therapeutic
change could accrue as a result of the project and could help to form a
more precisely denned theory of therapy.
To make this testing of predictions more precise and freer of retro-
spective bias or circular reasoning, we decided in advance on the evi-
dence necessary at the end of the treatment to sustain or refute each
prediction. This evidence statement was then set into an Evidence
Form, a statement of expected outcome for each prediction, embedded
among two or three plausible alternatives, with the expected correct
outcome marked in advance by the Initial Study team. The Initial Study
in each case, then, comprised the assessments of relevant Patient and
Situational Variables, the clinical predictions of expected treatment
course and outcome, the Prediction Form for the predictive statements
in accord with the if-then-because model, and the Evidence Form for
the keyed predicted outcomes. Finally, at the start of therapy, the pa-
tient's placement was determined on a 100-point, clinically anchored,
global rating scale that unified the judgments of seven subscales, the
Health Sickness Rating Scale (HSRS; Luborsky, 1962), and a statement
of the HSRS change predicted for the termination of therapy.
Termination Study (Treatment of the Patient)
At this point, the research study of the case was suspended while the
patient followed the prescribed treatment to its natural conclusion.
Through a monitoring system in the clinic record room, where monthly
progress notes are routinely filed on each Menninger Clinic patient and
where therapists are required to indicate expected terminations, the re-
search team was notified when each of its study cases was planning to
terminate. The team then reactivated the research inquiry and notified
the therapist that the patient was a member of the PRP population. At
 PSYCHOTHERAPY RESEARCH PROJECT
that point, the therapist and, through the therapist, the patient found
out for the first time that they had been chosen for research inquiry.
They were then asked to cooperate in the study of the terminating ther-
apy. For this study, the Termination Study team (different from the Ini-
tial Study team to assure noncontamination of the research) sought ac-
cess to all routine clinical records on the case: These records ranged
from daily process notes for more than 1,000 hr of analysis to the mini-
mum monthly progress notes required by clinic regulations. The team
also sought a series of interviews with the patient, the therapist, the su-
pervisor of the therapy if there had been one, and others significant in
the patient's life (e.g., close family members, clinic staff, employers).2
Finally, the psychological test battery that had been administered ini-
tially was repeated. In a very few instances, the patient's cooperation
could not be secured or the nature of the treatment or of the termination
made direct patient involvement in the research inquiry seem contrain-
dicated. For these cases, a truncated termination study was conducted
using only the clinical records and the interviews with therapist and
supervisor (but not involving the patient directly).
The clinical data thus gathered at treatment termination were sys-
tematically ordered in the Termination Study. The study comprised (a)
a reassessment of the 28 Patient Variables and 7 Situational Variables
in their now changed cross-sectional status after treatment; (b) an assess-
ment of approximately 30 Treatment and Therapist Variables, includ-
ing content areas of the treatment (e.g., themes, transference paradigms,
course, changes in specified attributes or dimensions), formal aspects of
the treatment (e.g., basic techniques and types of subject matter includ-
ing past vs. present, reconstruction and memory, dream and fantasy,
style and form), personal attributes and professional qualities of the
therapist, and the climate of the therapist-patient interaction; (c) the
completed Evidence Form, including the actual results of the evidence
for and against the specific predictions; (d) a new HSRS rating at termi-
nation, plus a new set of predictions (about 10 per case) for the expected
events of the follow-up period with predicted status at follow-up time;
and (e) a new HSRS predicted for follow-up (assessing the status of treat-
ment changes and gains). In each case, the Termination Study was com-
pleted upon treatment termination but before the patient's return to his
or her home community. (Patients who would not be available for fol-
low-up study were excluded from the research sample at the initial
point.)
Follow-Up Study
Between 2 and 3 years posttreatment, the PRP patients were con-
tacted for a prearranged Follow-Up Study.3 Follow-up was conducted
not by mail or telephone but by each patient's return with a significant
family member to the Menninger Foundation (at the project's expense)
for a week-long visit. A new cross-sectional assessment was completed
that included psychiatric interviewing, the third administration of the
psychological test battery, and a social history collected from the accom-
panying relative. The follow-up assessments were designed to duplicate
the original workup while reflecting the patient's posttreatment status
as a research subject, no longer someone coming for help.
The clinical data thus gathered included (a) a reassessment of the 28
Patient Variables and 7 Situational Variables (as seen cross-sectionally
at follow-up); (b) a reassessment of the 30 Treatment and Therapist
Variables as reviewed in the light of posttreatment events in the patient's
life; (c) another Evidence Form, in the light of posttreatment events, as
well as a second Evidence Form for the predictions about follow-up
made at Termination Study and (d) a last HSRS rating for the follow-
up time. Although a few patients would not cooperate fully in the follow-
up (i.e., they spoke on the phone but would not return to Topeka) and a
few were unavailable (i.e., they had died in the interim, in each instance
from illness-related causes), the remaining patients and collateral
sources (treating physician, family members, friends) provided enough
data for an adequate Follow-Up Study in every instance. In that sense,
the PRP had a 100% follow-up study rate.*
197
Thus, some 42 documented case studies were recorded over approxi-
mately 12 years. Four years were needed to accomplish the Initial Stud-
ies at the rate of about 10 per year, each representing about 40 hr of
work for each of the two members of the Initial Study team. Therapeutic
courses were followed for up to 8 years, and each of these was followed
by Termination Study.5 From 2 to 3 years of further follow-up time were
then required for each case. These records included all of the imposed
research forms and the assessments of the relevant variables (Patient,
Therapist and Treatment, and Situational) across the three points in
time (Initial, Termination, and Follow-Up assessments), along with the
logical if-then-because analysis of the individual Prediction Studies, the
Evidence Forms, and the HSRS for each time point, both actual and
predicted.
Data Analysis and Control Methods
Three avenues of data analysis were then followed. The first was a
case-by-case clinical study. All of the material on each case (several hun-
dred pages in each instance) was read and abstracted into a four-part
case study. The parts described (a) the Initial Study, including the sum-
mary of the patient as he or she first presented, with presenting history,
cross-sectional initial assessment, and predictions for therapeutic
course and outcome; (b) the Termination Study, including the summary
of treatment, the cross-sectional termination assessment, and the pre-
diction for follow-up; (c) the Follow-Up Study, including treatment and
its consequences as seen retrospectively through the follow-up course
and the cross-sectional follow-up assessment; and (d) the Synthesis of
Treatment Course and Outcome, including an overall statement about
what had been learned clinically in that case about the determinants
of the course and outcome of therapy. These individual case studies,
averaging 50 pages each, provide a comprehensive description of treat-
ment course and of the patient changes that eventuated.
These detailed case descriptions are presented in Wallerstein (1986),
which provides a final clinical account of the patients' treatments and
subsequent lives. The book was written in 1981-1982, almost 30 years
after the original project planning, which began in 1952. At the time of
its writing, a systematic effort was made to ascertain each patient's sta-
tus at the 30-year mark. Eight patients were now known dead, and of
the remaining 34, 17 had by now become lost to follow-up information.
However, 30-year information was obtained indirectly (through former
2
To ensure minimally adequate levels of therapist competence so that
failures of predictions or of expectable events could not be ascribed to
lack of skill and experience, all therapists whose cases were studied by
the project were at least 5 years beyond their basic clinical training pe-
riod. However, some were candidates in the psychoanalytic institute,
and their psychoanalytic cases were therefore supervised. Of the cases
in psychotherapy, even some treated by senior therapists were in contin-
uing supervision within the clinical structure of the institution.
3
In keeping with the protocols in cancer treatment, project staff had
originally planned 5-year follow-ups, but the exigencies of extramural
funding dictated that, given the length of the treatments under study,
optimal follow-up time intervals had to be partially compromised.
4
In fact, much more serious than patient attrition was the problem
of researcher attrition, the problem of keeping intact a large (15-20
member) multidreciplinary research group comprising individuals with
various research and career commitments over the long life of the proj-
ect (two decades) while interests and lives necessarily changed. We suc-
ceeded well enough in this.
5
Even after 8 years, not all therapies had naturally terminated. How-
ever, the assumption was made that, at that point, the therapy had
reached a stable plateau and could be assessed as a "cut-off termina-
tion," with the continuing therapeutic relationship itself part of the ad-
judged outcome status. There were 5 such patients; 3 of those did come
to formal termination in the interval before the follow-up study.
 198 ROBERT S. WALLERSTEIN
therapists, clinical records, and a network of expatients) for the remain-
ing 17 patients, including their current life status and their current treat-
ment status.
The second avenue of data analysis was the Prediction Study itself.
The predictions, as already indicated, started as clinical predictions of
the kind that usually mark clinical discourse, that is, as implicit aspects
of the clinical dialogue, implicit in every statement of diagnosis, prog-
nosis, treatment planning, and therapeutic expectation, embedded in
clinical context, qualification, and ambiguity. By the analysis of the tri-
partite if-then-because formal model, the predictions were transformed
into discrete explicit predictive statements (average = 50 per case); were
then tested by predetermined evidence or outcome criteria, which had
been keyed in advance to the predicted outcomes; and were presented
for subsequent judgment to determine actual outcomes within an array
of plausible alternative predictions. It is important to remember that
both specific predictions and the evidence necessary to confirm or re-
fute them at the end were specified in advance. In addition, at the end
of treatment, outcome judges who had no knowledge of which of the
plausible alternative outcomes presented in the Evidence Form had
been predicted had to judge which outcomes had actually taken place.
Such keying of the predicted answers on the multiple-choice Evidence
Form would thus provide an easy entry to the adequacy of the reasoning
that was used to form each prediction, reasoning explicit in the assump-
tions expressed in the because clauses of the tripartite logical state-
ments. As already indicated, the assumptions (about 300 in all),
grouped into a hierarchically organized network of increasing generality
and accountability, constituted our then current theory of psychoana-
lytic therapy.
From the systematic confirmation or disconfirmation of groups of
predictions linked to particular assumptions would come a strengthen-
ing or diminution of the plausibility of those assumptions and, hence,
an altered hierarchical tree and a more rigorous theory of therapy, now
linked to empirical data based on actual outcomes of actual predictions.
In this sense, the creation of this prediction study and the advance hier-
archical elaboration of the assumptions that underlay the original pre-
dictions, together with the alteration of that hierarchical organization
in the light of the actual outcomes of those predictions, can be seen as a
major advance in the theory of psychoanalytic therapy. Rapaport (1960)
just a decade earlier described the theory of psychoanalytic therapy as
consisting of only "rules of thumb" in contrast to what he felt was the
comprehensiveness of psychoanalysis as a theory of personality and of
psychopathology.
This Prediction Study, from conception to completion, was described
in two monographs, one prospective discussion on method (Sargent et
al., 1968) and one retrospective discussion cm results (Horwitz, 1974).
Another aspect of the prediction study now requires mention: the estab-
lishment and incorporation of new control principles because the usual
control methods of the experimental paradigm could not be followed
in this naturalistic study. Actually, four methods of control were chosen,
based more on the appropriate selection of material for study than on
its manipulation. The first method, intrapatient control (i.e., using the
patient as his or her own control), is based on individual prediction
study. By setting out the predictions, the necessary evidence, and the
assumptive base all in advance, the element of control is introduced into
observation, and post hoc reconstruction and rationalization is avoided.
The other control methods will be described in the next avenue of data
analysis, the quantifying techniques built on the Fechnerian method of
paired comparisons.
The third avenue of analysis, semiquantitative data study, was chosen
because, in addition to their qualitative clinical complexity and subtlety,
most of the Patient, Treatment and Therapist, and life-Situational Vari-
ables also have a quantitative "more or less" dimension. In addition, it
is clinically common to compare two patients, two treatments, or two
life situations and to say that this is greater than that, that this patient
has more tolerance for anxiety than that patient, and so forth. We there-
fore set up the task of comparing every patient with every other patient
for each of the Patient, Treatment and Therapist, and life-Situational
Variables that lent themselves to such quantitative analysis at each point
in time that the variable was assessed.
Patients were compared in batches of 12 because that number seemed
to reflect the highest number of variables that could be kept in mind at
one time for comparative judgment. For each variable at each time
point, paired comparisons of patients in a batch of 12 meant 66 compar-
ative judgments(12 X 11/2) per batch. After judgment on the first batch
of 12 for a variable, the next batch comprised 6 patients from the prior
batch along with 6 new patients until the last batch was analyzed, which
comprised the last 6 patients from the last batch and the first 6 patients
(circled back) from the first batch. Thus, each variable of each patient
was judged in 2 batches of 12; the overlapping allowed merging so that
all of the patients could be ordered on each variable at each point in
time from the most-often to the least-often chosen.
These resultant ordinal rankings of Patient, Treatment and Therapist,
and Situational Variables (each at several points in time) lent themselves
to interpatient comparison and contrast by permitting the selection of
patients alike in certain variables white dissimilar in other variables.
The rankings also allowed both the quantifying of statistics via factor
analytic techniques and the nonmetrical mathematics of the facet the-
ory and multidimensional scalogram analysis (MSA) techniques of
Guttman and Lingoes.6
To return to control methods, the paired comparisons were used for
interpatient control: If groups of patients are selected who are alike in
certain variables while dissimilar in others, then some variables can be
controlled while the variability of others is investigated. This was done
by the creation of distribution profiles for each patient on each of the
Patient, Treatment and Therapist, and Situational Variables at each of
the three time points. This was the second control method utilized.
The third control method was a parallel, independent prediction
study made on the basis of blind study of the initial psychological test
protocols alone. This prediction study was then compared with the pre-
dictions derived from the total clinical case study. The fourth control
method was the so-called inadvertent control. This control occurred
when patients who, because of finances, geography, or differing judg-
ment on the part of the treating clinicians, were treated by therapeutic
approaches not deemed the therapy of choice by the research team. In
such instances, it was considered possible to ascertain whether changes
that the researchers felt could only come about in the therapy of choice
had nonetheless eventuated when other approaches were used. This
control method again tested the necessary conditions for change (i.e.,
the underlying assumptions about the theory of therapy or about how
change takes place).
Overall Presentation of the Project
The preceding pages may seem to describe an inordinately complex
pyramid of design and execution. To accomplish all its aspects, an inter-
disciplinary research team of about 15 members worked over a period
of two decades to make some systematic, simultaneous inroads into
both the process and the outcome issues of change in psychotherapy. It
is notable that the work was initiated by two seemingly simple ques-
tions: What changes take place in psychotherapy? and How do those
changes come about? Dearly, a number of other research paradigms
have been developed for study in this arena. However, each group of
6
A full description of these data analyses built on the semiquantita-
tive paired comparisons can be found in two monographs, a prospective
discussion of method (Sargent et al., 1967) and a retrospective discus-
sion of results (Kernberg et al., 1972). Sargent et al. found that the ordi-
nal rankings that emerged from the paired comparisons contained
enough cardinal properties to be meaningfully handled by correlational
methods (intercorrelations of the final scaled scores) and factorial stud-
ies (factor analyses of the intercorrelation matrix).
 PSYCHOTHERAPY RESEARCH PROJECT
clinicians and researchers has its own conceptions of its field, its own
commitments to the issues and questions that both warrant and are
amenable to systematic research inquiry, and its own proper sense for
the construction of a research design that is both true to the require-
ments of objectivity in science and true to the nature of the field and its
phenomena.
How well has the PRP succeeded in its research task of answering the
initiating questions concerning the outcomes and processes of psycho-
analytic therapy? What results and conclusions have derived from this
research program? This project has been described in 67 published
writings over its 30-year life span, starting with a statement of rationale,
method, and sample use in 1956 (Wallerstein, Robbins, Sargent, & Lu-
borsky). These writings have sequentially recounted the initial concep-
tion and design; the delineation of sets of variables and of methods for
the data analyses, including the clinical case studies, the individual pa-
tient prediction studies, and the interpatient group statistical and math-
ematical studies; the operational problems encountered in implement-
ing the study according to the chosen design; the alterations in clinical
and theoretical thinking enforced by the emerging data; and, finally, the
expositions of results in the various project areas.
Two of these discussions of results have already been mentioned. The
Prediction Study (one of the three avenues of data analysis) was pre-
sented in two monographs (Horwitz, 1974; Sargent, Horwitz, Wal-
lerstein, & Appelbaum, 1968) that discussed the fate of the 2,000 or so
individual predictive statements and, more important, their implica-
tions for the 300 or so theoretical assumptions that underpinned them.
These assumptions, hierarchically and logically arranged, articulate
into the fabric of the psychoanalytic theory of therapy. Similarly, the
semiquantitative study (another of the three avenues of data analysis)
was presented in two monographs (Kernberg et al., 1972; Sargent,
Coyne, Wallerstein, & Holtzman, 1967) that detailed the fate of the
hypotheses on the relations among the 70 or so patient, treatment and
therapist, and situational variables as they were tested both by statistical
factor-analytic techniques and by nonmetrical mathematical facet the-
ory and multidimensional scalogram analysis techniques. In addition,
two other monographs explored the overall results of other aspects of
the project. Voth and Orth (1973) studied only the situational variables
themselves at the three time points in order to highlight the interaction
between the external and the internal in effecting change. Appelbaum
(1977) studied only the comprehensive projective psychological test bat-
tery protocols at the three time points in order to elucidate their com-
parative changes over time as well as their value as predictors of psycho-
therapy processes and outcomes.
Conception of the Clinical Study
But what broad empirical and clinical knowledge has been gained
from the case-by-case clinical study that was conducted by the PRP?
Within the prevailing theory of psychoanalytic therapy, three overall
treatment groupings were designated: psychoanalysis, expressive psy-
chotherapy, and supportive psychotherapy.' Each treatment was con-
ceptualized and defined according to the prevailing consensus in the
psychoanalytic therapy literature on the characteristics of these discrete
therapeutic modes. Treatments were matched to patients according to
the dynamic formulations of the nature of the patients' lives, their devel-
opmental histories, their character structures, and their presenting ill-
ness pictures. Thus, the overall conceptual frame comprised three
clearly differentiated therapeutic modalities with distinctive technical
characteristics that were differentially indicated for different categories
of patients, that worked toward different goals, and that would expect-
edly lead to different kinds of results. These expected results were
different in scope and depth and different in their promise of stability
and duration because they were based on differing presumed mecha-
nisms of change. However, it was believed that in some cases, a mix of
modalities and, therefore, of subsequent treatment course and outcome
might be appropriate.
199
Within this framework, we had two expectations. First, we expected
to provide a firmer empirical base for the received conceptual wisdom.
Second, beyond that, we expected to learn more about the therapeutic
outcome for each kind of patient who was appropriately treated with
the proffered therapeutic approaches and also about the psychological
change mechanisms operative within each of these approaches as well
as to elaborate empirically on the postulated mechanisms of change in
both the uncovering (expressive) and the ego strengthening (supportive)
therapeutic modes.
Results
A First Result: Blurring of the Interfaces of
Psychoanalysis and Psychotherapy
A first major finding was that psychoanalysis was not carried
out in fully classical form for any of the 22 PRP patients recom-
mended for and started in analysis, if by "classical" form we
mean that the therapeutic activity within the treatment hours
was steadfastly and constantly focused on the interpretive un-
covering of intrapsychic meanings with a constant internally di-
rected scrutiny of the manifest therapeutic content. Certainly,
this may partially have resulted because the patient population
at the Menninger Foundation is a sicker population than the
usual psychoanalytic population that is treated in the custom-
ary outpatient setting. The fact that 10 of the 22 patients in
psychoanalysis required some hospitalization (for time periods
ranging up to 18 months) attests both to the difference from the
usual psychoanalytic patient population and to the substantial
modification of the usual understanding of the analytic process
as something focused exclusively on the private transference-
countertransference interplay between two people.
In addition to the modifications brought about by hospital-
ization, proper analytic procedure was modified in other ways.
These included unusually prolonged terminations that took the
form of a weaning process, extra contacts by phone, or addi-
tional therapy hours in response to the emergencies that often
arose. In the end, we declared that 10 of the 22 patients desig-
nated for psychoanalysis had had treatments that adhered "well
enough" to the model of classical analysis. Although there were
clear departures in every instance, we believe that these were
minimal given the sickness of the individuals treated within the
traditions and expectations of that setting. (In other settings
with more "usual" psychoanalytic patients, even these so-called
minimal deviations might have been regarded as consequential
enough to designate the therapy as modified psychoanalyses.)
For another 6 of these psychoanalytic patients, the analyses
were more significantly modified along a variety of parameters.
These we called "modified" analyses. And an examination of
the analysis for the remaining 6 revealed a modification of ana-
lytic procedures that was quantitatively even greater than that
of the 16 patients mentioned previously. This modification was
7
The terms expressive psychotherapy and supportive psychotherapy
are discussed within the framework of psychoanalytic theory and, thus,
these terms are condensations of the more cumbersome phrases, expres-
sive psychoanalytic psychotherapy and supportive psychoanalytic psy-
chotherapy. It is certainly true that there are expressive psychotherapies
and supportive psychotherapies that are not psychoanalytic and that
are based on different understandings of mental processes, and those
therapies are not being here described.
200 ROBERT S. WALLERSTEIN
substantial enough to be judged by independent research judges
a "conversion" to psychotherapy, or was an explicit conversion
to psychotherapy, clearly presented and acknowledged in the
treatment. Clearly, for the majority of the 22 psychoanalytic pa-
tients, there occurred a marked blurring of the conceptual in-
terface between proper psychoanalysis and intensive psychoan-
alytic psychotherapy.8
A Second Result: Comparable Blurring for Expressive
and Supportive Psychotherapy
A second major finding was that comparable blurring oc-
curred among the 20 patients recommended for either expres-
sive or supportive psychoanalytic psychotherapy. Even to begin
with, the distinction between these therapies was difficult. Very
few patients were recommended initially for purely expressive
psychotherapy, and perhaps even fewer were recommended for
purely supportive psychotherapy. The concern for the majority
of these 20 patients plus the 6 patients who had been converted
from psychoanalysis to psychotherapy was finding the mixture
of supportive and expressive techniques that would fit properly
to the clinical needs of the specific patient. It became clear that
efforts to categorically distinguish the purely expressive from
the truly mixed from the purely supportive treatments at any
point in the therapy process would have been neither possible
nor really useful.
Because the distinction between these techniques initially
seemed quite fundamental, we were surprised at this finding.
After all, the expressive (uncovering, interpretive, insight-aim-
ing) techniques were those directed toward analyzing the de-
fenses (resistances, transferences) as the essential intervening
step toward an eventual reintegration, with expressive psycho-
therapy and psychoanalysis varying in the breadth of the effort
across the personality structure and in the depth of the probe
into the developmental history. By contrast, the supportive (ego
maintaining or ego building) techniques were those presumed
to be polar opposites, directed toward strengthening the de-
fenses in order to make the repression of conflict more effective.
We assumed that a very fundamental demarcation line existed
between the supportive psychotherapies and the expressive psy-
chotherapies, a line perhaps even more pronounced than that
between expressive psychoanalytic psychotherapy and proper
psychoanalysis. Instead, we found that blurring occurred in
both areas.
Mechanisms of Supportive Therapy
Where do these findings leave us? Just as we decided in our
initial conceptualization of patient characteristics to use dis-
crete psychic structures, functions, and attributes rather than
overall diagnostic formulations as a basis for treatment plan-
ning and prediction, so we decided that a detailing of the kinds
of interventions and technical maneuvers that characterized
each individual treatment over time would be more fruitful for
illuminating the relation between the psychological organiza-
tion and psychological problems of the patients and their treat-
ment courses and outcomes. We believe this approach to be
more fine-tuned than focusing on the widely spaced categories
of psychoanalysis, expressive psychotherapy, and supportive
psychotherapy.
There is, of course, a voluminous literature on what makes
individual therapies expressive and on what makes them ana-
lytic. These distinctions are based on issues of interpretation, of
insight, of working through, of uncovering unconscious intra-
psychic conflict, and so forth. What has always been much less
clearly specified in both the theoretical literature and in clinical
case illustration is what makes therapies supportive. We began
our project by designating six different operating mechanisms
characteristic of supportive approaches. However, in the actual
consideration of both expressive and supportive treatment
courses, it became clear that a major common operative sup-
portive mechanism was the evocation and the firm establish-
ment of a positive dependent transference attachment (wholly
or at least significantly uninterpreted and "unanalyzed"),
within which conflicted transference needs and wishes achieved
varying degrees of conscious or unconscious gratification.
This evolved most clearly in those supportive therapies that
went well and were intendedly supportive, and it seemed to be
an essential precondition to the operation of the other support-
ive mechanisms with which it was mixed. This is the basis of
the so-called "transference cure": the willingness and the capac-
ity of the patient to reach therapeutic goals and to change be-
haviors, symptoms, and modes of living "for the therapist" as
the quid pro quo for the transference gratification received
within the positive dependent transference attachment. It is, in
effect, a "transference trade": "I make the agreed upon and de-
sired changes for you, the therapist, in order to earn and main-
tain your support, your esteem, and your love." That this mech-
anism operated as clearly and as pervasively as it did in so many
of our cases (both supportive and expressive) was in itself no
great surprise. What was surprising was how stable and endur-
ing the changes achieved in this way revealed themselves to be.
In addition to the positive transference attachment, other
supporting maneuvers were used and were designed in each in-
stance to insure that the changes achieved on the basis of "trans-
ference cure" would indeed become stable and durable over
time. When the need for continuing transference gratification
within the established positive dependent transference attach-
ment cannot otherwise be transferred, attenuated, or internal-
ized into new intrapsychic alignments, this benevolent depen-
dent transference within the therapy is sometimes maintained
with the nonending therapy of what we call the "therapeutic
lifer." This risk of the "insoluble transference neurosis" that Al-
exander and French (1946) saw as a major therapeutic dilemma
in so many analyses (especially with severely dependent and
masochistic individuals) became here rather the vehicle of con-
8
A question of generalizability arises from the blurring between psy-
choanalysis and psychotherapy in this population. The patient popula-
tion at the Menninger Foundation is indeed sicker than the usual popu-
lation treated in analysis in an outpatient office setting. And in every
case we did see some deviations, albeit minimal in some instances, from
classical analysis. From an overall study of our project results, I con-
clude that such deviations (from an unswerving interpretive uncovering
of intrapsychic meanings and an unswerving avoidance of other kinds
of interventions) occur inevitably, whether they are deliberate, auto-
matic, or inadvertent, in all psychoanalyses. However, that is an empiric
proposition that must be tested in an intensive study of processes and
outcomes in analyses conducted in outpatient office settings with the
better integrated psychoanalytic patients usually treated there.
 PSYCHOTHERAPY RESEARCH PROJECT
tinued maintenance of therapeutically improved psychological
functioning. Given the degree of illness and ego deformation in
our PRP population, it was no surprise that 5 of the 42 patients
more or less became such "therapeutic lifers"; it was more of a
surprise that 3 of those 5 were among those initially recom-
mended for and started in psychoanalysis.
Those patients with comparable dependent tendencies but
with stronger inner psychological resources and with a greater
capacity to relate helpfully to a consolidated introject of the
idealized therapist were often able to terminate treatments
through the kind of pressured tapering and "weaning" process
advocated by Alexander in such circumstances. These patients
who were successfully weaned and who continued to maintain
the achieved level of psychological functioning showed clear evi-
dence of a reasonably consolidated identification with the thera-
pist and the therapist's approach toward and mastery of con-
flict.
Intermediate between those capable of being helped to psy-
chological autonomy via mechanisms of introjection and iden-
tification and those for whom continued therapeutic contact
(possibly lifelong) is necessary for adequate levels of psychologi-
cal functioning are those patients for whom the transference
attachments and gratifications can be transferred (in a "transfer
of the transference") within the now improved life situation to
another individual, often the spouse. The success of this maneu-
ver depends not only on the effectiveness and self-consciousness
of the therapeutic work within the ongoing treatment but also
on the capacity and willingness of the chosen individual to carry
this transferred burden indefinitely. Within our PRP popula-
tion, we observed the full range of results, from an enduring
success to a total failure because of the ultimate refusal of the
spouse to continue to play the assigned transference role. In-
deed, the weakness of this resolution is its reliance on a benign
and fully supportive life context, which is not the reality for
some patients.
Another change mechanism within the supportive mode is
that of fostering the displacement (or transfer) of the neurosis
into the treatment situation (into the transference) to thus alle-
viate the external manifestations of the impaired functioning
and symptoms. An example is the conversion of an unduly de-
pendent and submissive individual into one whose behavior is
more satisfying and assertive outside the treatment on the basis
of a (covert) new submissiveness to the therapist, experienced
as requiring the altered external behaviors as the price of the
dependent gratifications within the treatment. That is, the new
assertiveness in outer behaviors is achieved not on the basis of
having analyzed the roots of the submissiveness so that it is no
longer needed as a neurotic compromise formation but rather
is achieved on the basis of transferring it into the safer arena of
therapy, and paying the price in return of chancing the risk of
an (obedient) assertiveness in the outer world. The ultimate suc-
cess of this supportive mode depends, again, on life circum-
stance and on the reinforcing positive feedback and enhanced
self-esteem that result when the new behaviors bring not neu-
rotically feared disaster but real reward and gratification.
Opposite to the transference cure and to the transferred
transferences is the "antitransference cure." This is the cure
that results from negative transference struggles in which the
patient changes by defiance and acting out against the therapist,
contrary to the perceived expectations of the therapist, usually
201
as an act of triumph over the therapist in the overt or covert
transference struggle. By their nature, such cures are far less
frequent than the so-called transference cures and must be but-
tressed in some way against their potential instability, either
through reinforcement from a stabilizing life situation or from
positive environmental feedback from enhanced life func-
tioning.
Alexander and French (1946) invoked the "corrective emo-
tional experience" as an all-purpose explanatory construct for
the mechanisms of the supportive psychotherapeutic ap-
proaches. This construct serves the counterpart role to interpre-
tation leading to insight as the central mechanism in the expres-
sive psychotherapeutic approaches. Although everything that
goes on in a psychotherapeutic context is indeed intended in
one sense or another to be a corrective emotional experience, I
have used the concept in a more restricted way, in relation to
treatments that provide a kindly, understanding, reality-ori-
ented therapist who is able "to meet the patient's transference
behavior with neutrality. . .and therefore to give him a correc-
tive emotional experience without the risks attendant on taking
a role opposite to that which he expects" (Gill, 1954, p. 782).
The trick here is to refrain from falling victim to the transfer-
ence-countertransference interactions by which the patient has
managed to maintain his or her neurotic suffering in the pre-
treatment life experience.
Actually, the operative mechanism I have called reality testing
and reeducation is only subtly different from such corrective
emotional experience. Here again, reality testing and reeduca-
tion are a part of therapeutic activity in every psychotherapy.
However, again, I use the narrower meaning of educational ac-
tivities that are provided as part of the content focus in support-
ive treatment in which the therapist plays a direct educational
role in the transmission of advice, information, and education
to society's normative behavioral standards and expectations.
Again, at issue is the therapist's capacity to play this role in a
way that the patient perceives as nonjudgmental and, if at all
coercive, as guided solely by the patient's well-being and best
interests. Clearly, the distinction between such activities and the
steady provision of a corrective emotional experience cannot
be a clear one. Both of these technical strategies lead the patient
toward reality-oriented problem solving and reality-corrected
emotional responses on the basis of the "borrowed ego
strength" that comes from identification with the therapist in
the role of helper and healer. And again, the continued mainte-
nance of changes thus achieved in posttreatment is dependent
on appropriate feedback reinforcement from a fulfilling envi-
ronment in addition to some transfer of the transference to sig-
nificant life others.
We must now consider another supportive mechanism,
planned disengagement from unfavorable and noxious life situ-
ations. This mechanism is part of the rationale of sanatorium
care and was a pervasive supporting aspect of many of the treat-
ments of our patients, supportive and expressive. It is conversely
true that treatment success for other patients demands that their
therapy be conducted within their usual life situation and that
if this cannot be properly maintained, for whatever reason, their
chances for an optimal result diminish. In a more usual psycho-
therapy population than that at the Menninger Foundation,
treated maximally expressively within an outpatient setting, the
effort is to maintain maximal involvement in and commitment
202 ROBERT S. WALLERSTEIN
to their usual life situations. However, many of our PRP patients
had to be supported by therapeutically guided disengagement.
Another helping mechanism that I call the "collusive bar-
gain," quite common perhaps in tacit and in minor ways,
though at times quite explicit, plays a very major treatment role.
The collusive bargain is an agreement between therapist and
patient, whether tacit or explicit, to exclude particular areas of
personality functioning, problems, or symptoms from thera-
peutic scrutiny (leaving more or less consequential islands of
maintained psychopathology) in return for the patient's willing-
ness to make agreed upon and substantial enough changes in
other areas. This is actually akin dynamically to the transfer-
ence cure: The patient makes changes for the therapist in return
for a specific reward within the transference, the shielding from
therapeutic probing of a particularly tenacious or rewarding
symptom or behavior. The success of such a maneuver depends
on the value of such a symptom or behavior to the patient as
well as on the capacity of the patient to detach the symptom or
behavior from the other aspects of life functioning that are still
subject to change. Because the symptom or behavior that is al-
lowed the patient in this compromise solution is experienced as
rewarding or gratifying, these particular therapeutic outcomes
have a built-in stability.
A final supportive therapeutic mechanism, a kind of transfer
of the transference, must also be mentioned. For some patients
this took the form of a transfer to an existing advantage (finan-
cial, social, or cultural) in life circumstances; other patients
chose alternative psychological supports (e.g., Alcoholics Anon-
ymous and Christian Science), often in opposition to their ther-
apists. By turning to external material or alternative psychologi-
cal supports for the essential transference dependencies and
gratifications, some of these patients rescued therapies that oth-
erwise seemed nonprogressive or ailing and either stabilized or
enhanced their levels of psychological functioning.
It is clear that psychotherapy can be supportive of improved
psychological functioning in a variety of ways and that these
ways can be structured to maintain such improvement over de-
cades of follow-up, which is far beyond the time allowed for by
the conventional wisdom in psychodynamic psychotherapy. For
each patient, these mechanisms interact in distinctive configu-
rations to meet transference demands and expectations, to up-
hold agreed-upon transference trades, to expedite transfers of
the transference, to arrange engagements with and disengage-
ments from the ongoing life context, and to manage the positive
feedback reinforcements that result in enhanced self-esteem
from behaviors and relationships altered in desired directions.
Mechanisms of Expressive Therapy
In contrast to the diverse change mechanisms of the support-
ive psychotherapeutic approaches is the single, central concep-
tion of change in expressive psychotherapy and in psychoanaly-
sis. In the expressive psychotherapeutic approach, change oc-
curs through properly mutative interpretations that lead to
insight into hitherto repressed unconscious conflicts. This in-
sight provides the basis for a structural change in the personality
and, thus, for the stable and enduring amelioration of symp-
toms and for the alteration of attitudes and behaviors in desired
directions. However, every component of this formulation has
been more or less admittedly problematic, both conceptually
and empirically, and the controversies surrounding these issues
have not yet been satisfactorily resolved.
There is, indeed, a whole theoretical literature examining (a)
the nature and the role of the so-called mutative interpretation
and the controversy over the special character of the transfer-
ence interpretation; (b) the role of insight in relation to change,
whether it be a precondition, a result, or just the ideational rep-
resentation of change; and (c) the meanings and applications of
the concept of psychic structure and of what makes true struc-
tural change distinct from adaptive or behavioral change that
occurs without insight However, a review of those theoretical
controversies is beyond the scope of this article. The literature
hypothesizes that only the major personality unraveling and re-
construction that psychoanalysis provides is truly able to lead
to the kinds of changes (via mutative interpretations, effective
insights, and structural alterations in the ego) that are stable
and enduring. However, this hypothesis has been brought into
question by our finding that treatment changes resulting from
supportive techniques (without full intrapsychic conflict resolu-
tion and concomitant achieved insight) have been quite stable
and enduring over prolonged time spans.
Relation of Insight to Change
Nineteen (45%) of the 42 patients achieved changes through
their treatments that substantially surpassed the insights devel-
oped via the interpretive (psychotherapeutic or psychoanalytic)
process. This result will be no surprise because I have already
described the various supportive mechanisms and techniques
through which change was reached by many of our patients in
the absence (and even in the avoidance) of an interpretive-ex-
pressive working through of intrapsychic conflict. Seven of
these 19 patients were among the 22 started in psychoanalysis,
and the remaining 12 were among the 20 started in psychother-
apy. The finding of change far exceeding achieved interpre-
tations and insights had generally been expected for the 12 pa-
tients started in psychotherapy. However, for the 7 patients
started in psychoanalysis whose change exceeded interpreta-
tion-achieved insights, this finding was far less expected.
Along with these 19 patients whose achieved changes system-
atically exceeded their acquired insights were 10 (25%) of the
42 patients whose insights achieved via interpretation seemed
coordinate with and completely proportional to the changes
reached. As expected, 9 of these 10 patients were in psychoanal-
yses that were maintained as analyses throughout. Not so ex-
pected was the finding that most in this group achieved psycho-
analytic outcomes that fell varyingly short of the ambitious
goals originally posited for them. For example, 6 of these pa-
tients formed a group with a hysterical character structure with
various combinations of depression, anxiety, and phobic symp-
toms, and they had originally received an excellent prognosis
for thoroughgoing neurotic conflict resolution with psychoana-
lytic treatment. Although 4 of these 6 patients had very good
treatment results and 2 sustained moderate improvements, all
6 fell short of a full psychoanalytic resolution through their in-
adequate working through of the pre-oedipal negative mother
transference and their unconscious, hostile identification with
the malevolent, feared and hateful mother imago. Each patient
was able to work around this major area of unresolved conflict,
to realize very good therapeutic gains, to draw the analytic work
 PSYCHOTHERAPY RESEARCH PROJECT
to a close "while she was still ahead," and to maintain to the
end an incompletely resolved positive attachment and sustained
good feeling toward the analyst. Each patient successfully
avoided deeper analytic exploration of the earliest ties to the
mother that had been so fraught with painful and hateful affect.
Thus, although these patients had therapeutically good out-
comes, they also had psychoanalytically incomplete outcomes
with deficiencies in insightful mastery.
Only 3 patients (7% of the sample) attained insights that con-
siderably surpassed their discerned changes. These patients rep-
resented a mixed bag; they included, for example, a long-term
psychoanalytic patient who ended with a large residue of psy-
chologically undigested intellectual insights and with an essen-
tially unaltered, deeply entrenched obsessive-compulsive and
compliant character structure. A balance of 10 patients (almost
25% of the total) achieved little meaningful insight and little
effective change and, thus, essentially failed in treatment.
This accounting of patients reveals that, in one large sense,
our data conformed to our expectations. Most of the 19 patients
whose degree of change exceeded the achieved insights and re-
sulted from processes that were not insight-aiming were psy-
chotherapy patients receiving the kinds of important supportive
mechanisms I have described. The 10 patients whose change
and insight were more directly proportional were almost all in
analyses in which the supportive modifications were minimal.
However, did the changes arrived at by the two kinds of thera-
peutic mechanisms, supportive and expressive, differ in the de-
gree to which they represented true structural changes? This
question was examined in the comparative study of the projec-
tive psychological test battery data obtained from our patients
before therapy, after therapy, and at follow-up. Structural
change was denned as changes in specific intrapsychic configu-
rations, in the patterning of defenses, in thought and affect orga-
nization, in anxiety tolerance, and in ego strength. All of these
variables can be assessed with special clarity in protective test
data.
The data analysis revealed a clear positive relation between
conflict resolution and structural change: The more conflict res-
olution, the more structural change. And yet, there were sig-
nificant exceptions; 7 of the 16 patients with no evidence of real
conflict resolutions nonetheless did show significant structural
ego changes. Thus, both points of view, that structural change
is associated with the resolution of conflict and that it can come
about in the absence of conflict resolution, received support
from our comparative projective test study. Stated another way,
of the 27 patients for whom full projective test data were avail-
able for comparative assessment across the three time points,
significant conflict resolution was seen in 11, with concomitant
significant structural change in 10. For the other 16 patients
whose changes in functioning, behaviors, and symptoms were
judged to have come about by means other than substantial con-
flict resolution, structural change in the ego was still discerned
in 7.
Discussion
How do findings from the Psychotherapy Research Project
throw empirical light on the conceptual issues concerning the
similarities and differences between psychoanalysis and the psy-
choanalytically derived psychotherapies? I will present our over-
203
all conclusions as a series of sequential propositions regarding
the appropriateness, the efficacy, the reach, and the limitations
of psychoanalysis (classical and modified) and of psychoana-
lytic psychotherapy (expressive and supportive). This is of
course with the caveat, as this was discerned within this segment
of the overall patient population, those (usually sicker) individu-
als who have been brought to or sought their intensive analyti-
cally guided treatment within a psychoanalytic sanatorium set-
ting.
The first proposition has to do with the distinction regularly
made in the psychodynamic literature between structural
change, which is based on the interpretive resolution of uncon-
scious intrapsychic conflicts, and behavioral change, or change
in manifest behavior patterns that represents nothing more
than altered techniques of adjustment. It is presumed that only
behavioral change can result from supportive psychotherapeu-
tic techniques and implementations. Intrinsic to this dichoto-
mizing between kinds of change has been the assumption that
only structural change, as brought about through conflict reso-
lution and appropriately achieved insight, has a guarantee of
stability and durability. Thus, it is believed that change brought
about by expressive-analytic means is invariably better. This
belief forms the basis for the clinical operating maxim, "Be as
expressive as you can be and as supportive as you have to be."
Based on the experiences documented in our PRP study, I
strongly question the continued usefulness of this effort to link
the kind of change achieved with the intervention modes, ex-
pressive or supportive, by which it is brought about. If we accept
the observation that the changes achieved through supportive
therapies and supportive modes in our PRP patients provided
often enough just as much structural change and proved just as
stable and enduring as the changes achieved through our ex-
pressive-analytic therapies, then we must accept that the ex-
pressive-analytic approach is not exclusively capable of induc-
ing true structural change.
The second proposition has to do with the argument that
therapeutic change will be at least proportional to the degree of
achieved conflict resolution. This proposition is almost unex-
ceptionable because it is clear that there can be significantly
more change than there is true intrapsychic conflict resolution.
This change can occur through the supportive bases that pro-
voke change as well as through the expressive-analytic bases.
But it is hard to imagine real conflict resolution (and accompa-
nying insight) without at least proportional change in behaviors,
dispositions, attitudes, and symptoms. However, closely related
to this proposition is the proportionality of therapeutic change
to the degree of attained insight (as distinct from conflict resolu-
tion). As I mentioned previously, 3 of our PRP patients revealed
achieved insight in excess of induced change. This is a common
problem and a frequent complaint about psychoanalytic treat-
ment, and it has been the subject of considerable discussion in
the psychoanalytic literature. Our three cases were explained
by undigested intellectual insights or insights within an ego-
weakened or psychotic transference state. What is meant here
of course is insights that for varying reasons are not consequent
to true conflict resolution and do not reflect it.
The third proposition, often linked to the proportionality ar-
gument, has to do with the argument that effective conflict reso-
lution is a necessary condition for certain kinds of change. Our
findings have repeatedly demonstrated that substantial changes
204 ROBERT S. WALLERSTEIN
in symptoms, in character traits, in personality functioning,
and in lifestyles rooted in lifelong and repressed intrapsychic
conflicts were brought about by supportive psychotherapeutic
modes and techniques. An examination of the usual change cri-
teria of stability, durability, and the capacity to withstand exter-
nal or internal disruptive pressures also revealed that these
changes were often quite indistinguishable from the changes
brought about by expressive-analytic means.
Counterpart to the proposition based on the tendency to over-
estimate the efficacy of the expressive-analytic treatment mode
and its operation via conflict resolution for effecting therapeuti-
cally desired change is another proposition. This proposition
is based on the finding that the supportive psychotherapeutic
approaches, mechanisms, and techniques that so often
achieved far more than were expected of them often did so in
ways that represented true structural changes, as denned by the
usual indicators of that state. In fact, the designated psychother-
apy cases did as well proportionately as the designated psycho-
analytic cases. More to the point, the good results in the one
modality were not overall less stable or less enduring or did not
provide less proof against subsequent environmental vicissitude
than those in the other. And more important still, the changes
that occurred within the psychotherapy group, though often
predicated on expressive mechanisms and techniques, in fact
were often achieved through supportive mechanisms and tech-
niques.
Even more important, within the psychoanalysis group, there
were often modifications made in the direction of the more sup-
portive modes. Even by our liberal PRP criteria, only 10 (not
quite half) of the psychoanalytic cases were retrospectively
viewed as having been in essentially unaltered analyses, whereas
6 were considered to be in substantially modified (in the sup-
portive direction) analyses and 6 were considered to be con-
verted to supportive-expressive psychotherapies. By the stricter
criteria of outpatient psychoanalytic and psychotherapy prac-
tice, almost all of our PRP psychoanalytic cases would be con-
sidered substantially altered in the supportive direction. Thus,
more of the patients (psychotherapeutic and psychoanalytic)
changed on the basis of supportive interventions and mecha-
nisms than had been expected or predicted beforehand, either
on the basis of our clinical experience or our theoretical posi-
tions.
The fifth proposition reveals that, just as psychotherapy ac-
complished more stable and enduring results than expected, so
psychoanalysis, as the quintessentially expressive therapeutic
mode, was more limited—at least with these patients—than
had been anticipated or predicted. This was a function of a vari-
ety of factors. In part, this reflects the ethos of the psychoana-
lytic sanatorium and the psychoanalytic treatment opportuni-
ties that it is intended to make possible. The dominant theme
has been the concept that the psychoanalytically guided sanato-
rium, with its ability to provide protection, care, and life man-
agement of the (temporarily) behaviorally disorganized and in-
competent individual, could make possible the intensive psy-
choanalytic treatment of patients who could not be helped to
resolve their deep-seated personality difficulties satisfactorily
with any lesser treatment approach than psychoanalysis but
who also could not tolerate the rigors of the regressive psycho-
analytic treatment process in the usual outpatient private prac-
tice setting.
This, of course, has led to the concept of psychoanalysis on
the basis of so-called "heroic indications," and these kinds of
patients necessarily comprised a substantial segment of our
PRP psychoanalytic population. In our experience, however, the
central tenets of this proposition were found wanting; these pa-
tients characteristically did very poorly in psychoanalytic treat-
ment, however it was modified by parameters and however it
was buttressed with concomitant hospitalization. In fact, they
comprised the great bulk of the failed psychoanalytic cases. On
the other hand, because there were instances of very good out-
comes among the very ill and disordered in the supportive-ex-
pressive psychotherapies, we feel that the sicker patients who
are being talked about can indeed do much better in an appro-
priately arranged and modulated supportive-expressive psy-
chotherapy if the ingredients are put together skillfully and
imaginatively and if truly sufficient concomitant life manage-
ment is ensured. The stipulation concerning the need for ade-
quate life management is one of the central keys to the success
of the treatment recommendations being proposed here and, by
that token, supports the role of the psychoanalytic sanatorium
or of less-controlled life regimen made more possible by mod-
ern-day psychoactive drug management. The big difference is
in our departure from recommending psychoanalysis (even
modified psychoanalysis) as the treatment of choice for these
sicker patients in that setting. On this basis, I have spoken of the
failing of the so-called "heroic indications" for psychoanalysis
and instead believe the pendulum should be repositioned in the
direction of narrowing indications for proper psychoanalysis
along the lines marked out by Anna Freud.
The sixth and final proposition in this sequence has to do with
the fact that the predictions made for prospective therapeutic
courses and outcomes tended to be for more substantial and
permanent change (i.e., more structural change) when the treat-
ment plan and implementation was to be more expressive-ana-
lytic and when changes were expected to be based on thorough-
going intrapsychic conflict resolution through processes of in-
terpretation, insight, and working through. And again in terms
of the conventional psychodynamic wisdom, the other part of
this proposition has to do with the belief that the more support-
ive the treatment was intended to be, the more limited and in-
herently unstable the anticipated changes were predicted to be.
What our research study revealed in great detail is that all of
this was consistently tempered and altered in the actual imple-
mentation of treatment courses. Both psychoanalyses and ex-
pressive psychotherapies as a whole were systematically modi-
fied in the direction of introducing more supportive compo-
nents in widely varying ways, and they often resulted in more
limited outcomes than promised, with a substantial amount of
change accomplished by noninterpretive, supportive means. On
the other hand, the psychotherapies often accomplished a fair
amount more and, in several cases, a great deal more than ini-
tially expected and promised, with more change achieved on
the basis of supportive modes than originally specified.
What does the labor in our Psychotherapy Research Project
add up to? It can be broadly generalized as follows: (a) The
treatment results for patients selected as suitable for psycho-
analysis or as suitable for varying mixes of expressive-support-
ive psychotherapy tended—with this population sample—to
converge, rather than diverge, in outcome; (b) across the spec-
trum of treatment courses, which ranged from analytic-expres-
 PSYCHOTHERAPY RESEARCH PROJECT
sive to inextricably blended to single-mindedly supportive, the
treatment carried more supportive elements than originally in-
tended, and these supportive elements accounted for substan-
tially more of the changes achieved than had been originally
anticipated; (c) the supportive aspects of all psychotherapy, as
conceptualized within a psychoanalytic theoretical framework
and as deployed by psychoanalytically knowledgeable thera-
pists, must be specified more respectfully in all its forms than
it has been in the psychodynamic literature; and (d) when the
kinds of changes reached by this cohort of patients were exam-
ined, divorced from how they were brought about, they often
seemed quite indistinguishable from each other and equally
represented structural change in personality functioning.
In the light of the conceptual and predictive framework
within which the Psychotherapy Research Project was planned
and implemented three decades earlier, there was considerable
surprise from the overall project findings: that the therapeutic
modalities of psychoanalysis, expressive psychotherapy, and
supportive psychotherapy hardly exist in ideal or pure form in
the real world of actual practice; that real treatments in actual
practice are intermingled blends of expressive-interpretive and
supportive-stabilizing elements; that almost all treatments (in-
cluding even pure psychoanalyses) carry many more supportive
components than they are usually credited with; that the overall
outcomes achieved by more analytic and more supportive treat-
ments converge more than our usual expectations for those
differing modalities would portend; and that the kinds of
changes achieved in treatment from the two ends of this spec-
trum are less different in nature and in permanence than is usu-
ally expected. Three decades ago, we did not expect to find these
results. However, when we consider the comments made by
practitioners in informal interchanges about what they regu-
larly do in actual practice as against how it is conceptualized for
formal presentation in professional meetings, our PRP research
conclusions are far less surprising.
Which brings me to the conclusion of this article: Where does
this leaves our field, and how do our results apply to our concern
with both psychoanalysis and psychotherapy? Clearly, because
of its established position as the theory of human development
and personality organization that informs all of our therapeutic
work, psychoanalysis will retain a vital position as a specific
therapy. We will use psychoanalysis first as a research instru-
ment because it provides access to the dynamic and temporal
depths of human mental functioning. In addition, psychoanaly-
sis will continue to be a part of the educational and training
process by which individuals become proficient theoretically
and clinically in the deployment of psychoanalytically concep-
tualized therapeutic approaches, from psychoanalysis proper
through the spectrum of psychoanalytic expressive and sup-
portive therapies, in relation to the patients differentially suited
to these modalities. For our results clearly show that, to be max-
imally effective, each psychotherapeutic approach must be
matched with that patient for whom it is most appropriate. And
it will work best only if employed with the utmost of psychoana-
lytic understanding and skill.
205
Beyond that, our results indicate a more circumscribed role
for psychoanalysis, with a greater awareness of its infiltration by
nonanalytic, supportive intervention techniques and with more
modest expectations in terms of its therapeutic goals than ex-
isted just a few decades back. The counterpart position is of
course that of both the "expanded scope" of psychoanalytic psy-
chotherapy, expressive and supportive, and the enhanced thera-
peutic, heuristic, and conceptual dignity to be accorded (psy-
choanalytically formulated) supportive psychotherapeutic ac-
tivity, with greater awareness of its presence across the
psychotherapeutic range and greater precision devoted to the
delineation and understanding of its mechanisms. Our research
project has turned out to be a substantial effort in that direction.
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Received April 25, 1988
Revision received September 13, 1988
Accepted October 3,1988 •