COMPR EHENSI VE HA NDBOOKOF

PSYCHOTHER APY

COMPR EHENSI VE HA NDBOOK

OF

PSYCHOTHER APYV O L U M E 1

PSYCHODYNAMIC/OBJECT RELATIONS

Editor-In-Chief FLORENCE W. KASLOW

Volume Editor JEFFREY J. MAGNAVITA

JOHN WILEY & SONS, INC.

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v

Contributors

Jacques P. Barber, PhD, is associate professor and associate director at the Center for PsychotherapyResearch, Department of Psychiatry and Psychology, University of Pennsylvania School of Medi-cine in Philadelphia, Pennsylvania. Dr. Barber has published more than 100 articles, chapters, andbooks in the area of psychotherapy research.

Helen E. Benedict, PhD, is professor of psychology at Baylor University and a registered play ther-apist supervisor for Association for Play Therapy. She is a frequent leader of national and interna-tional workshops on play therapy, especially object-relations play therapy and play therapy forchildren with attachment disorders and children who have experienced interpersonal trauma. Shealso leads an active research program on play therapy process using children’s play themes.

M. Sue Chenoweth, MS, PsyD, is in private practice in Hartford, Connecticut. She is affiliated with the Institute of Living–Hartford Hospital Mental Health Network in Hartford. She is a consultant for the Women’s Sexual Health Program–Connecticut Surgical Group, P.C., UrologyDivision in Hartford.

John F. Clarkin, PhD, is a professor of clinical psychology in psychiatry at the Joan and Sanford I.Weill Medical College of Cornell University, the codirector of the Personality Disorders Institute,and the director of psychology at the Cornell Medical Center. Dr. Clarkin is on the research facultyand is a lecturer at Columbia University’s Psychoanalytic Center.

Gerhard W. Dammann, MD, Dipl.-Psych., is attending psychiatrist, clinical psychologist, and psy-choanalyst (IPA) at the Psychiatric University Hospital in Basel, Switzerland, and Department of Psy-chosomatic Medicine and Psychotherapy, Technical University Medical School in Munich, Germany.

Ellen A. Dornelas, PhD, is director of Behavioral Health Programs, Preventive Cardiology, at Hartford Hospital and assistant professor of medicine at the University of Connecticut School ofMedicine. Her research interests are focused on health psychology with special emphasis on psycho-logical factors related to heart disease.

Scott C. Duncan, PhD, is clinical lecturer, Department of Psychiatry, at the University of Alberta,Edmonton, Canada. He is a therapist in the Psychiatric Treatment Clinic of the Department and alsomaintains a private psychotherapy practice.

vi CONTRIBUTORS

Peter Fonagy, PhD, FBA, is Freud Memorial Professor of Psychoanalysis and director of the Sub-Department of Clinical Health Psychology at University College in London. He is director of theClinical Outcomes Research and Effectiveness Centre and the Child and Family Centre, both at theMenninger Foundation in Kansas. He is also director of research at the Anna Freud Centre, Lon-don, a clinical psychologist, and a training and supervising analyst in the British Psycho-AnalyticalSociety in child and adult analysis.

Diana Fosha, PhD, is associate clinical professor of psychology at Adelphi University’s Derner Insti-tute of Advanced Psychological Studies. She is the author of The Transforming Power of Affect: A Modelof Accelerated Change (Basic Books, 2000) and of recent articles that integrate emotion theory, affectiveneuroscience, and attachment research into the theory and technique of accelerated experiential-dynamic psychotherapy. She maintains a private practice in New York City.

Cheryl Glickauf-Hughes, PhD, is a licensed psychologist, an adjunct professor at Emory UniversityDepartment of Psychiatry, and a private practitioner in Atlanta, Georgia. She has co-authored twobooks and numerous book chapters and articles.

Paul A. Grayson, PhD, is director of New York University Counseling Service and clinical assistantprofessor of psychiatry at New York University Medical School. Dr. Grayson is coauthor of Beatingthe College Blues, a self-help guide for students, and coeditor of College Psychotherapy, a volume forcollege psychotherapists.

Stanley I. Greenspan, MD, is clinical professor of psychiatry and pediatrics at George WashingtonUniversity Medical School, supervising child psychoanalyst at Washington Psychoanalytic Insti-tute, and chairman of the Interdisciplinary Council for Developmental and Learning Disorders.

José Guimón, MD, PhD, is professor of psychiatry at Geneva University Medical School in Switzer-land, director of the World Health Organization Collaborative Center for Research and Training inMental Health, and author of more than 150 papers and 30 books.

Mary F. Hall, PhD, LICSW, is currently an associate professor at the Smith College School for Social Work where she teaches the Human Behavior in the Social Environment and Clinical Practicesequences. Major administrative assignments have included service as director of Continuing Edu-cation, clinical coordinator of the school’s doctoral program, and area coordinator in the Field WorkDepartment for MSW interns. She has also held prior faculty appointments at the ShirleyEhrenkrantz New York University School of Social Work and the Boston University School of SocialWork. Her current research interest is the interface between race and gender in pregnant substanceabusers.

Lara Hastings was trained at Baylor University and is currently completing a postdoctoral at theChild and Family Guidance Center in Dallas, Texas.

Cecile Rausch Herscovici, Lic, is a full professor of psychology at the Universidad del Salvador andcodirector of the Institute of Systems Therapy in Buenos Aires, Argentina. She is an approved su-pervisor of the American Association for Marriage and Family Therapy, member of the American

Contributors vii

Family Therapy Academy, of the Academy for Eating Disorders, and of the European Council forEating Disorders. She is also editor of the Ediciones Granica Series in Eating Disorders.

Michael D. Kahn, PhD, ABPP, is professor emeritus of clinical psychology at the University ofHartford in West Hartford, Connecticut, where he recently retired as director of academic affairsfor the Graduate Institute of Psychology. He is a fellow in the American Psychological Associa-tion, the American Orthopsychiatric Association, and an approved supervisor of the AmericanAssociation of Marital and Family Therapy. He is a charter member of the American Family Ther-apy Academy, member of several editorial boards, and author of more than 40 publications on sib-ling relations and integrative therapies. Dr. Kahn maintains an active private practice in Hartford,Connecticut, and is also a professional jazz musician in New England.

Rosemarie LaFleur Bach, PsyD, is a psychologist with The Institute of Living, Hartford Hospital’sMental Health Network, and school clinician at the Chesire School System, contracted through Hart-ford Hospital and the Grace Webb School, The Institute of Living. She is also in private practice.

Kenneth N. Levy, PhD, is assistant professor of the Clinical Psychology Doctoral Program, Gradu-ate School and University Center, and Department of Psychology at Hunter College, City Univer-sity of New York. He is also adjunct assistant professor, Psychology Section, Department ofPsychiatry, Joan and Sanford I. Weill Medical College of Cornell University. Dr. Levy also has a pri-vate practice in New York, New York.

Leslie M. Lothstein, PhD, ABPP, is director of psychology at The Institute of Living, Hartford Hos-pital’s Mental Health Network, and has academic appointments at Case Western Reserve University,University of Hartford, and UCONN Farmington Health Center. Dr. Lothstein serves as consultanton risk assessment for sex offenders for the Department of Mental Health and Addiction Services,Connecticut, and as vice chair of the Advisory Board, Whiting Forensic Division, Connecticut ValleyHospital.

Rita E. Lynn, PsyD, has been a senior member of the Institute of Group Analysis (London) for morethan 30 years. She worked with Dr. Robin Skynner as his cotherapist. She was a teaching fellow atSt. Bartholomew’s Hospital (London) and held a post at the Medical College of the London Hospi-tal, where she taught and consulted for 10 years. Until moving to the United States, she supervisedand trained the Institute’s trainee analysts. She now lives in Los Angeles, where she is a professor atthe American Behavioral Studies Institute. She has authored numerous articles on the British Ob-ject Relations approach to treatment.

Jeffrey J. Magnavita, PhD, ABPP, is a fellow of the American Psychological Association and is both a licensed psychologist and marriage and family therapist. He is the founder of the ConnecticutCenter for Short-Term Dynamic Psychotherapy and an adjunct professor of clinical psychology at theUniversity of Hartford’s Graduate Institute of Professional Psychology. He is the author of threebooks: Restructuring Personality Disorders, Relational Therapy for Personality Disorders, and Theories ofPersonality: Contemporary Approaches to the Science of Personality, as well as numerous professionalpublications.

viii CONTRIBUTORS

J. Christopher Muran, PhD, is chief psychologist and director of the Brief Psychotherapy ResearchProgram at Beth Israel Medical Center, associate professor of psychiatry at Albert Einstein Collegeof Medicine, and associate editor for psychotherapy research. He has coedited The Therapeutic Al-liance in Brief Psychotherapy, coauthored Negotiating the Therapeutic Alliance: A Relational TreatmentGuide, and edited Self-Relations in the Psychotherapy Process.

John S. Ogrodniczuk, PhD, is a clinical assistant professor in the Department of Psychiatry at theUniversity of British Columbia. His research interests include identifying matches between patientcharacteristics and types of short-term, time-limited psychotherapies (group, individual, partial hos-pitalization). Other interests include the use of psychotherapy for medically ill patients.

Ferruccio Osimo, MD, is a psychiatrist in Milan, Italy. He is adjunct professor of Dynamic Psy-chotherapy, Università Statale di Milano; president of IESA (International Experiential STDP Asso-ciation), New York; a fellow of the American Academy of Psychoanalysis; and treasurer of OPIFER(Organization of Italian Psychoanalysts-Federation and Roster).

Jeree H. Pawl, PhD, was the director of the Infant-Parent Program at the University of California, SanFrancisco, for twenty years following her work with Selma Fraiberg at the Child Development Projectat the University of Michigan. She is also a current member of the board of directors of Zero to Three,The National Center for Infants, Toddlers and Families, and a past president of that organization.

William E. Piper, PhD, is a professor in the Department of Psychiatry at the University of BritishColumbia, Vancouver, Canada. He was president of the Society for Psychotherapy Research and ofthe Canadian Group Psychotherapy Association, and is currently editor of the International Journalof Group Psychotherapy.

Jeremy D. Safran, PhD, is professor of psychology at the New School for Social Research and SeniorResearch Scientist at Beth Israel Medical Center. He has authored Widening the Scope of CognitiveTherapy, coauthored Emotion in Psychotherapy, Interpersonal Process in Cognitive Therapy, and Negotiat-ing the Therapeutic Alliance: A Relational Treatment Guide. He has also coedited Emotion, Psychotherapy,and Change and The Therapeutic Alliance in Brief Psychotherapy.

Lynne R. Siqueland, PhD, is currently an adjunct assistant professor at the University of Pennsylva-nia Medical School in the Center for Psychotherapy Research, where she has been involved in trainingand supervision of supportive expressive dynamic therapy. She is also in private practice at the Chil-dren’s Center for OCD and Anxiety specializing in the treatment of anxiety disorders.

Marion F. Solomon, PhD, is on the Senior Extension Faculty at UCLA, Department of Humanities,Sciences and Social Sciences, and a professor at the American Behavioral Studies Institute in LosAngeles. She is author of two books, Narcissism and Intimacy, and Lean on Me: The Power of PositiveDependency in Intimate Relationships. She is coauthor of Short Term Therapy for Long Term Change, andhas coedited two books, Countertransference in Couples Therapy, and The Borderline Patient.

Maria St. John, MA, MFT, has been a senior therapist and clinical supervisor at the Infant-ParentProgram at the University of California, San Francisco, for nine years. She is currently a doctoral

candidate in the Department of Rhetoric at the University of California, Berkeley, studying therhetorics of psychoanalysis.

Mary Target, PhD, is a senior lecturer in psychoanalysis at University College London and an asso-ciate member of the British Psychoanalytic Society. She is deputy director of research at the AnnaFreud Centre, member of the Curriculum and Scientific Committees, chairman of the ResearchCommittee of the British Psychoanalytic Society, and chairman of the Working Party on Psychoan-alytic Education of the European Psychoanalytic Federation.

Paul D. Thompson, MD, is director of Preventive Cardiology and director of Cardiovascular Re-search at Hartford Hospital and professor of medicine at the University of Connecticut School ofMedicine. His research interests include the effects of exercise training in preventing and treatingheart disease and risk of sudden death during exercise.

Manuel Trujillo, MD, is director of psychiatry at Bellevue Hospital and professor of clinical psy-chiatry and vice chair, Department of Psychiatry, at New York University School of Medicine. Dr. Trujillo is a distinguished academic clinician, psychiatric administrator, innovator, and re-searcher. He has been involved extensively in the fields of urban, cross-cultural, and communitypsychiatry.

Marolyn Wells, PhD, is director, professor, and licensed psychologist at Georgia State UniversityCounseling Center; joint appointment with the Department of Counseling and Psychological Ser-vices; and private practitioner in Atlanta, Georgia. Dr. Wells has coauthored two books and nu-merous book chapters and articles, and is a fellow of the Georgia Psychological Association.

Contributors ix

xi

Foreword

Dr. Magnavita has collected a broad-ranging group of contributions, providing an open-minded but critical, enthusiastic yet realistic educational experience. We are in good hands.As the book illustrates, psychodynamic approaches to psychotherapy have proliferated,stimulated by the limitations of traditional psychoanalysis and by infusions of existential thought,with its emphasis on selfhood and being with the other, as in Kohut’s self psychology, and of inter-personal or social concepts, centering on relationship patterns and their reoccurrence in therapy, as inobject relations and intersubjective analysis. There is also the now widely accepted body of evidencelinking change in psychotherapy to the quality of the relationship between patient and therapist.

What is the conscientious reader to do with the many ideas celebrated here? They are a wonderful challengeto efforts of selection and digestion.

For example, central to much clinical thinking are concepts of development. But what are we to dowith the problem of individual uniqueness, the unpredictable outcome of the myriad factors shap-ing development? We need concepts of growth, but they must not constrain us. So often, the most re-markable people emerge from the most difficult circumstances.

How do we select the unit to work with? Is it the traditional one-to-one, couples, or group work,or even the home-bound therapy eloquently described here?

Bodies and urges have long been central concerns. There is also the brain as the organ of mentalrepresentation, and affects that now rival ideas as the medium of change.

And how much pathological emphasis should we give, perhaps particularly, to the most frighteningpresentations? The redemption of a pedophile is described in one of these chapters as partly the resultof his therapist’s inspired remark, “Anyone who loves kids that much can’t be all bad.” By the pa-tient’s own testimony, this changed his life.

Critical in these chapters is a contest between the usual subjects of therapeutic attention—id,ego, and superego (plus the ego ideal that self psychology has made central)—and the intersubjec-tive field, in which the goal is to create a space where both parties can freely exchange what occursto each and where the two can arrive at understanding and change.

Patterns of sexuality are an age-old topic. Today, the ground has partly shifted to concerns withpower, respect, and equality.

And the problems of marriage, without which many of us might well be unemployed, seem in-creasingly to have become an educational tool for the long-term study of one self in relation toanother.

Here is perhaps as close to a practical answer as we are likely to get: Keep as much as we can putinto the back of our minds for those occasions that may prompt retrieval. Let our intuitive responses

xii FOREWORD

guide us. Or the deeper, perhaps wiser, reflection offered here: Ours is an effort to plumb a depth ofthought untouched by words and a gulf of formless feelings untouched by thought! We work in thedark. Our doubts should be cherished.

Meanwhile, neuroscience is teaching that the human brain is significantly a creation of each in-dividual’s experience, the individual self being formed by interaction with the world and others,including our therapeutic selves. Rather than replacing these chapters, neuroscience is confirm-ing and may someday be extending them.

The challenge of the work is immense, needing the lifetime that, often, we can give it. Let us cel-ebrate the diversity of our efforts and the opportunities they provide. We have the chance, seldommatched, to make lives better.

LESTON HAVENS, MDProfessor of PsychiatryHarvard Medical School

and The Cambridge Hospital

xiii

Preface

The world of psychotherapy theory and practice has changed markedly in the past 30 years.During this time, many forces have converged, leading to major alterations in the therapeuticlandscape. Therefore, it seemed essential to produce this four-volume Comprehensive Handbookof Psychotherapy to illuminate the state of the art of the field, and to encompass history, theory, prac-tice, trends, and research at the beginning of the twenty-first century.

These volumes are envisioned as both comprehensive in terms of the most current extant knowl-edge and as thought provoking, stimulating in our readers new ways of thinking that should provegenerative of further refinements, elaborations, and the next iteration of new ideas. The volumes areintended for several audiences, including graduate students and their professors, clinicians, and re-searchers.

In these four volumes, we have sought to bring together contributing authors who have achievedrecognition and acclaim in their respective areas of theory construction, research, practice, and/orteaching. To reflect the globalization of the psychotherapy field and its similarities and differencesbetween and among countries and cultures, authors are included from such countries as Ar-gentina, Australia, Belgium, Canada, Italy, Japan, and the United States.

Regardless of the theoretical orientation being elucidated, almost all of the chapters are writtenfrom a biopsychosocial perspective. The vast majority present their theory’s perspective on dealingwith patient affects, behaviors or actions, and cognitions. I believe these volumes provide ample evi-dence that any reasonably complete theory must encompass these three aspects of living.

Many of the chapters also deal with assessment and diagnosis as well as treatment strategiesand interventions. There are frequent discussions of disorders classified under the rubric of AxisI and Axis II in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders withfrequent concurrence across chapters as to how treatment of these disorders should be ap-proached. There are other chapters, particularly those that cluster in the narrative, postmodern,and social constructivist wing of the field, that eschew diagnosis, based on the belief that the onlyreality of concern is the one being created in the moment-to-moment current interaction: in this in-stance, the therapeutic dialogue or conversation. In these therapies, goals and treatment plans arecoconstructed and coevolved and generally are not predicated on any formal assessment throughpsychological testing. Whereas most of the other philosophical/theoretical schools have incorpo-rated the evolving knowledge of the brain-behavior connection and the many exciting and illumi-nating findings emanating from the field of neuroscience, this is much less true in the postmodernwing of the field, which places little value on facts objectively verified by consensual validation andreplication.

xiv PREFACE

One of the most extraordinary developments in the past few decades has been that barriers be-tween the theoretical schools have diminished, and leading theoreticians, academicians, re-searchers, and clinicians have listened to and learned from each other. As a result of thiscross-fertilization, the move toward integration among and between theoretical approaches has beendefinitive. Many of the chapters in Volumes 1, 2, and 3 also could fit in Volume 4. Some of the dis-tance between psychodynamic/object-relations therapies and cognitive-behavioral therapies has de-creased as practitioners of each have gained more respect for the other and incorporated ideas thatexpand their theory base and make it more holistic. This is one of the strongest trends that emergesfrom reading these volumes.

A second trend that comes to the fore is the recognition that, at times, it is necessary to combine ju-dicious psychopharmacological treatment with psychotherapy, and that not doing so makes the heal-ing process more difficult and slower.

Other important trends evident in these volumes include greater sensitivity to issues surround-ing gender, ethnicity, race, religion, and socioeconomic status; the controversy over empirically val-idated treatments versus viewing and treating each patient or patient unit as unique; theimportance of the brain-behavior connection mentioned earlier; the critical role assigned to devel-opmental history; the foci on outcome and efficacy; and the importance of process and outcome re-search and the use of research findings to enhance clinical practice. There is a great deal of excitingferment going on as our psychotherapeutic horizons continue to expand.

These volumes would not have come to fruition without the outstanding collaboration and team-work of the fine volume editors, Drs. Jeffrey Magnavita, Terrence Patterson, Robert and SharonMassey, and Jay Lebow, and my gratitude to them is boundless. To each of the contributing authors,our combined thank you is expressed.

We extend huge plaudits and great appreciation to Jennifer Simon, Associate Publisher at JohnWiley & Sons, for her guidance, encouragement, and wisdom. Thanks also to Isabel Pratt, EditorialAssistant, for all her efforts. It has been a multifaceted and intense enterprise.

We hope the readers, for whom the work is intended, will deem our efforts extremely worth-while.

FLORENCE W. KASLOW, PHD, ABPPEditor-in-Chief

Palm Beach Gardens, Florida

xv

Contents

FOREWORD xiLeston Havens, MD

PREFACE xiiiFlorence W. Kaslow, PhD, ABPP

CHAPTER 1PSYCHODYNAMIC APPROACHES TO PSYCHOTHERAPY: A CENTURY OF INNOVATIONS 1

Jeffrey J. Magnavita

S E C T I O N O N E

PSYCHOTHERAPY WITH CHILDREN

CHAPTER 2THE DEVELOPMENTAL BASIS OF PSYCHOTHERAPEUTIC PROCESSES 15

Stanley I. Greenspan

CHAPTER 3OBJECT-RELATIONS PLAY THERAPY 47

Helen E. Benedict and Lara Hastings

CHAPTER 4INFANT MENTAL HEALTH 81

Jeree H. Pawl and Maria St. John

CHAPTER 5PSYCHODYNAMIC APPROACHES TO CHILD THERAPY 105

Peter Fonagy and Mary Target

S E C T I O N T W O

PSYCHOTHERAPY WITH ADOLESCENTS AND YOUNG ADULTS

CHAPTER 6EATING DISORDERS IN ADOLESCENCE 133

Cecile Rausch Herscovici

xvi CONTENTS

CHAPTER 7PSYCHODYNAMIC PSYCHOTHERAPY WITH UNDERGRADUATE AND GRADUATE STUDENTS 161

Paul A. Grayson

S E C T I O N T H R E E

PSYCHOTHERAPY WITH ADULTS

CHAPTER 8SUPPORTIVE-EXPRESSIVE PSYCHOTHERAPY 183

Lynne R. Siqueland and Jacques P. Barber

CHAPTER 9BRIEF PSYCHODYNAMIC THERAPY 207

Ferruccio Osimo

CHAPTER 10AN OBJECT-RELATIONS APPROACH TO THE TREATMENT OF BORDERLINE PATIENTS 239

John F. Clarkin, Kenneth N. Levy, and Gerhard W. Dammann

CHAPTER 11A RELATIONAL APPROACH TO PSYCHOTHERAPY 253

J. Christopher Muran and Jeremy D. Safran

CHAPTER 12MASTERING DEVELOPMENTAL ISSUES THROUGH INTERACTIONALOBJECT-RELATIONS THERAPY 283

Cheryl Glickauf-Hughes and Marolyn Wells

CHAPTER 13THE ACTIVATION OF AFFECTIVE CHANGE PROCESSES IN ACCELERATEDEXPERIENTIAL-DYNAMIC PSYCHOTHERAPY (AEDP) 309

Diana Fosha

CHAPTER 14SHORT-TERM DYNAMIC PSYCHOTHERAPY OF NARCISSISTIC DISORDERS 345

Manuel Trujillo

CHAPTER 15A RELATIONAL-FEMINIST PSYCHODYNAMIC APPROACH TO SEXUAL DESIRE 365

M. Sue Chenoweth

S E C T I O N F O U R

PSYCHOTHERAPY WITH FAMILIES AND COUPLES

CHAPTER 16OBJECT-RELATIONS COUPLES THERAPY 387

Marion F. Solomon and Rita E. Lynn

Contents xvii

CHAPTER 17SELF-OBJECT RELATIONSHIP THERAPY WITH COUPLES 407

Michael D. Kahn

CHAPTER 18RELATIONAL PSYCHODYNAMICS FOR COMPLEX CLINICAL SYNDROMES 435

Jeffrey J. Magnavita

S E C T I O N F I V E

GROUP PSYCHOTHERAPY

CHAPTER 19PSYCHODYNAMICALLY ORIENTED GROUP THERAPY 457

William E. Piper, John S. Ogrodniczuk, and Scott C. Duncan

CHAPTER 20PSYCHODYNAMIC/OBJECT-RELATIONS GROUP THERAPY WITH SCHIZOPHRENIC PATIENTS 481

José Guimón

CHAPTER 21GROUP THERAPY TREATMENT OF SEX OFFENDERS 501

Leslie M. Lothstein and Rosemarie LaFleur Bach

S E C T I O N S I X

SPECIAL TOPICS

CHAPTER 22GROUPS IN THERAPEUTIC COMMUNITIES 529

José Guimón

CHAPTER 23PSYCHODYNAMIC TREATMENT FOR CARDIAC PATIENTS 549

Ellen A. Dornelas and Paul D. Thompson

CHAPTER 24RACE, GENDER, AND TRANSFERENCE IN PSYCHOTHERAPY 565

Mary F. Hall

CHAPTER 25CONTEMPORARY PSYCHODYNAMICS: MAJOR ISSUES, CHALLENGES, AND FUTURE TRENDS 587

Jeffrey J. Magnavita

AUTHOR INDEX 605

SUBJECT INDEX 614

1

C H A P T E R 1

Psychodynamic Approaches to Psychotherapy: A Century of Innovations

JEFFREY J. MAGNAVITA

The first century of modern psychotherapybegan with Freud’s “discovery” of the un-conscious and use of free association. Weare at an auspicious time at the turn of the cen-tury in the field of psychotherapy; much hasbeen achieved over the past century and manynew developments are occurring. Althoughsome believe that psychoanalysis has outlived itsusefulness (Dumont, 1993), the discoveries ofFreud and his followers have continued to spawnremarkable developments that have created anever stronger amalgam of psychodynamic psy-chotherapy. It is true that some aspects of psy-choanalytic theory have not been empiricallysupported or clinically validated, most notable,the psychosexual theory of development and the view that wishes rather than trauma accountfor some forms of psychopathology. However,many constructs remain vital and central topresent-day clinical practice (Magnavita, 1993b).Many of these constructs have evolved and con-tinue to evolve as other clinicians/theorists haveexpanded, altered, and blended them, and asnew breakthroughs in other disciplines havebeen made and incorporated. For example, the

incorporation of von Bertalanffy’s (1948) gen-eral systems theory has greatly expanded therange of psychodynamic conceptualization andtreatment. The twentieth century saw variousgroundbreaking theoretical innovations.

Many of the cutting-edge theoretical and tech-nical developments in the field today are pre-sented in this volume. Schafer (1999), himself an analytic pioneer, comments: “In the secondhalf of the 20th century, we have been witness toremarkable changes in psychoanalytic theoryand practice” (p. 339). Prior to Freud’s discoveryof free association, the use of hypnosis was themajor technique for exploring and mapping theunconscious. With the advent of the technique of free association, a remarkable window intothe unconscious process was opened. In thischapter, I review some of the essential develop-ments and advances that have occurred in psy-choanalysis and psychodynamic psychotherapyduring the past century. Now, the beginning of the twenty-first century, the field of psycho-analysis can be seen to be enormous and its influence on popular culture and lexiconwidespread. This chapter refers to only a small

2 PSYCHODYNAMIC APPROACHES TO PSYCHOTHERAPY: A CENTURY OF INNOVATIONS

fraction of the diversity of work that has evolvedfrom Freud’s original conceptualization and ap-proach to treatment.

T H E O R I G I N S O F T H E T E R M P S Y C H O T H E R A P Y

In the first chapter of this four-volume work, amention of the origins of the word psychother-apy is in order. “Long before terms such as psy-chotherapeutics and psychotherapy were coined,methods were employed for treating or minis-tering to various forms of suffering—whetherthose were thought of as diseases, illnesses,ailments, disorders, syndromes, or other formsof sickness—through the use of psychologicalrather than physical measures” ( Jackson, 1999,p. 10). The origins of the term psychotherapysuggest that it appeared “toward the end of the 1880’s, and had its roots in the Liebeault-Bernheim school of suggestive therapeutics atNancy” (pp. 7–8). According to Jackson, it firstappeared in a work by Hippolyte Bernheim en-titled Hypnotisme, suggestion, psychotherapie in1891. Essential to early “healer-sufferer” rela-tionships were factors such as hope, sympa-thy/compassion, and the influence of the mindon the body.

THE FIRST COMPREHENSIVE THEORETICALMODEL OF HUMAN PSYCHIC FUNCTIONING

The discovery of the unconscious and the devel-opment of psychoanalytic methods ushered in a new form of scientific inquiry that may beconsidered to be the birth of modern scientificpsychology. This is not to minimize the otherparadigmatic shifts that occurred in other areasof psychology, such as the application of em-pirical methods to the study of various psycho-logical topics, for example, Pavlov’s (1927) workwith classical conditioning, which set the stage

for the development of behaviorism. Freud’swork stands as one of the intellectual milestonesof the twentieth century (Schwartz, 1999). Histheory of psychoanalysis is considered by manyto be equivalent to the genius of Einstein’s the-ory of relativity and Darwin’s theory of evolu-tion (Bischof, 1970). Freud offered remarkablenew ways of understanding the mind, psycho-pathology, and methods of ameliorating humanemotional suffering. It is important to remem-ber from a historical perspective that “there wasa profound awareness of an unconscious realm”prior to Freud’s work and that “there is an im-pressive 19th century literature that deals withunconscious psychic structures” (Dumont, 1993,p. 195). Freud and his followers were “large sys-tem builders” and “beneficiaries of a vast litera-ture that provided them with virtually all theinsights bearing on the unconscious” (p. 196).

Psychoanalysis was born when Freud aban-doned hypnosis in favor of the technique of freeassociation (Magnavita, 2002). Freud originallywas very taken with hypnosis and was influ-enced by Charcot, who pioneered the technique.Breuer also stoked his interest in hypnosis, butS. Freud (1966) became frustrated with it:

Originally Breuer and I myself carried out psy-chotherapy by means of hypnosis; Breuer’s firstpatient was treated throughout under hypnoticinfluence, and to begin with I followed him inthis. I admit that at that period the work pro-ceeded more easily and pleasantly, and in a muchshorter period of time. Results were capriciousand not lasting; and for that reason I finallydropped hypnosis. And I then understood thatan insight into the dynamics of these illnesseshad not been possible so long as hypnosis wasemployed. (p. 292)

According to Havens (1973): “Breuer’s method,however, remained very close to Charcot’s. Itwas symptom-centered, hypnotic, and objective”(p. 90). Freud’s method was a radical departurefrom Breuer’s and Charcot’s approaches.

Psychodynamic Approaches to Psychotherapy: A Century of Innovations 3

“Fundamental to Freud’s thinking about themind was a simple assumption: If there is adiscontinuity in consciousness—something theperson is doing but cannot report or explain—then the relevant mental processes necessary to‘fill in the gaps’ must be unconscious” (Westen& Gabbard, 1999, p. 59). Freud’s technique of freeassociation allowed him and others who fol-lowed to explore the dark recesses of the humanpsyche and to provide a map of the unconscious.He outlined the topographical contours with hisdelineation of the regions of unconscious, pre-conscious, and conscious zones. He proposed atripartite model of human psychic functioningwith three structural components, now taught inevery introductory psychology course: the id, theego, and the superego. He offered an explana-tion of how the instinctual sexual and aggressiveforces were modulated and channeled eitherneurotically into symptom formations or charac-terologically into personality disturbance. Hisemphasis on psychosexual development, much of which has not been validated, represented oneof the first credible stage theories of human development. Key concepts of repression and re-sistance offered psychoanalysts a way to under-stand how unacceptable impulses and painfulaffects are lost to the conscious mind but are ex-pressed in a variety of symbolic ways. Current-day psychotherapists of just about every ilk haveincorporated the concept of repression into theirtheoretical systems.

D E R I VA T I V E T H E O R E T I C A LS Y S T E M S

Psychoanalysis and psychodynamic conceptsare in constant evolution; they are reinter-preted, transformed, and revitalized. A staticsystem never could have provided the field withsuch a wealth of raw material that could bemined for over a century and still continue tobe vital for each new generation. The following

four models all have an important place in psy-chodynamic theory and are reviewed in moredetail throughout this volume.

EGO PSYCHOLOGY: THE EMPHASISON ADAPTATION

The ego psychologists were especially inter-ested in the functioning of the ego and empha-sized the importance of adaptation (Hartmann,1958, 1964). Ego psychology set out to elaboratethe various aspects of healthy functioning orego-adaptive capacity. This aspect of psychody-namic theory was expanded by Horner (1994,1995) and is an extremely valuable componentof psychodynamic assessment, especially whenconducting brief dynamic therapy.

OBJECT-RELATIONS THEORY: THE EMPHASISON ATTACHMENT

Winnicott viewed aggression as emerging fromthe disruption of attachment rather than ema-nating from an instinctual drive, as Freud sug-gested (Winnicott, Shepherd, & Davis, 1989).This was the beginning of the object-relationsmodel, advanced by Melaine Klein (1975), W. R.D. Fairbairn (1954), Margaret Mahler (Mahler,Pine, & Bergman, 1975), Annie Reich (1960),and others (Buckley, 1986). Object relationsrecognized the primacy of attachment. Winni-cott did not believe the infant could be studiedoutside the maternal-child dyad; he went so farto say “There is no such thing as a baby,” sug-gesting that when you describe the baby, youdescribe the dyad (Rayner, 1991, p. 60). Thistheoretical development heralded the moveaway from the emphasis on the intrapsychic to adyadic model. One of Winnicott’s best-knownconcepts is the “good-enough mother,” whichimplies that although one doesn’t need perfectparenting, there must be at least a critical level

4 PSYCHODYNAMIC APPROACHES TO PSYCHOTHERAPY: A CENTURY OF INNOVATIONS

of parental function for uncomplicated develop-mental progression (Winnicott, Shepherd, &Davis, 1989, p. 44).

SELF PSYCHOLOGY: THE STUDY OF NARCISSISM

Kohut’s (1971, 1977) groundbreaking work ex-panding Freud’s concept of narcissism enabledclinicians to begin to understand and treat an-other form of pathological adaptation that wasnot effectively treated with standard psycho-analysis. Stolorow, Atwood, and Orange (1999)describe some of the inherent difficulties:

As useful and pathbreaking as his contextual-ization of narcissism may have been, Kohut’s(1977) subsequent elevation of his psychology ofnarcissism to a metatheory of the total personal-ity—a psychoanalytic psychology of the self—has created some knotty problems. For onething, self psychology’s unidimensionality, theexclusive focus on the narcissistic or selfobjectdimension of experience and of transference—its establishment, disruption, and repair—hastended to become reductive, neglecting andfailing to contextualize other important dimen-sions. Even more problematic has been theinsidious movement from phenomenology toontology, from experience to entities—a move-ment reminiscent of Freud’s (1923/1961) shiftfrom the centrality of unconscious emotionalconflict to the trinity of mental institutions pre-sumed to explain it. (p. 384)

Kohut’s major contribution was in his em-phasis on the development of the self from thefragile infant state to the cohesive adult person-ality. He added much to our understanding ofpatients who have disorders in their basic senseof self-esteem. This branch of psychoanalytictheory then began to provide a clearer differen-tiation between those with emotional distur-bances based on intrapsychic conflict who hadsufficient attachment experience and those pa-tients with deficits in their self-structure. The

patients with deficit have not had the necessaryexperiences that lead to a solid intrapsychicstructure, as reflected by adaptive defenses anda stable sense of oneself. Traditionally, these pre-oedipal or, in many cases, prelanguage traumapatients have disturbances in primary attach-ments. This may be the result of injuries thatoccurred from insufficient mirroring of the pri-mary attachment figure or severe attachment in-sufficiency or disruption (Frank, 1999).

INTERPERSONAL PSYCHIATRY:THE DYADIC RELATIONSHIP

Harry Stack Sullivan (1953) developed an inter-personal theory of psychoanalysis from his ob-ject-relational perspective. Havens (1973) writes:“Harry Stack Sullivan is the most original figurein American psychiatry, the only American tohelp found a major school” (p. 183). Sullivan wasnot so concerned with what transpired insidepeople but rather focused on what occurred inthe relational field. This represented the mostradical departure to that time from Freud’sstructural drive theory of repressed emotionsand intrapsychic forces. Sullivan believed thatneeds were interpersonal and that the therapeu-tic process was based not on detached observa-tion but on being a participant-observer. In otherwords, the therapeutic matrix included two peo-ple who mutually contributed to the interp-ersonal experience. He coined the term “self-sys-tem” to account for the process of gaining satis-faction and avoiding anxiety in interpersonalrelations.

IntersubjectivenessMany theorists and clinicians challengedFreud’s position that the therapist should be adetached observer of the patient’s unconsciousprocess. In their book Faces in a Cloud: Subjectiv-ity in Personality Theory, Stolorow and Atwood(1979) began to explore the issue of subjectiv-ity and laid the groundwork for the study of

Psychodynamic Approaches to Psychotherapy: A Century of Innovations 5

intersubjectivity (Stolorow et al., 1999). Theystate: “To be an experiencing subject is to be po-sitioned in the intersubjective contexts of past,present, and future” (p. 382). This theory of in-tersubjectivity emphasizes what many currentworkers believe is vital: affect. “The shift fromdrive to affect, one of the hallmarks of our in-tersubjective perspective, is of great theoreticalimportance, because unlike drives, which origi-nate deep within the interior of an isolatedmental apparatus, affectivity is something thatfrom birth onwards is regulated, or misregu-lated, within an ongoing intersubjective sys-tem” (Stolorow et al., 1999, p. 382). Affectivetheory (Ekman & Davidson, 1994) has onlyfairly recently been considered a topic worthyof scientific focus.

THE CATALOGUING AND EMPIRICALSUPPORT OF DEFENSES

In Freud’s structural drive model, defensivefunctioning was accorded a prominent role inprotecting a person against anxiety and contin-ues to represent a major conceptual leap in un-derstanding intrapsychic and interpersonalfunctioning. Freud considered defenses to beused both adaptively and in pathological form,and his original conceptualization continues tospawn new developments (Holi, Sammallahti,& Aalberg, 1999). Key concepts in understand-ing the function of defenses include repressionand resistance. Defenses allow for repression ofpainful conflict in many patients and lead topatterns of reenactment in others. Defensesalso turn into resistance to the therapist’s effortto relieve the suffering. Higher-level defensesserve to enrich and strengthen the ego organi-zation (Schafer, 1968).

Anna Freud (1936; Sandler, 1985) continuedthe process her father began of enumeratingand cataloguing defenses. Although for a time,academic psychologists eschewed the constructof defense as being irrelevant, it has proven to

be quite robust and has continued to demon-strate tremendous clinical utility and promi-nence in most current psychodynamicconceptual systems. Researchers such asGeorge Vaillant (1992) and Phebe Cramer (1987,1991, 1998, 1999) have empirically documentedthe validity of many of these defenses and theirdevelopmental progression from lower to higherlevels. This “stage-related fashion” has been val-idated by Cramer’s (1991, p. 39) research. For ex-ample, projection, a higher-level defense thandenial, seems to increasingly predominate dur-ing adolescence. Also, the research shows thatanxiety does increase defensive functioning(Cramer & Gaul, 1988).

P E R S O N A L I T Y T H E O R Y ,P E R S O N A L I T Y D I S O R D E R ,

A N D C O N T E M P O R A R YP S Y C H O PA T H O L O G Y

Freud’s metapsychology was a theory both ofpersonality and of psychopathology, as well as amethod of treatment for emotional disorders.Many conceptual elements of Freud’s modeland subsequent developments continue to beuseful to current personality theorists and theircontemporary models of personality (Mag-navita, 2002).

Psychoanalytic theorists/clinicians were veryinterested in and contributed vast amounts ofclinical case material and insight into an under-standing of character development, which serveas the basis for current diagnostic systems. Cur-rent psychopathologists and personality theo-rists draw from over a century of conceptualdevelopments, many of which are presented in this volume. Psychodynamic constructs haveshown remarkable explanatory power, “includ-ing characteristic ways of coping with and de-fending against impulses and affects; perceivingthe self and others; obtaining satisfaction ofone’s wishes and desires; responding to envi-ronmental demands, and finding meaning

6 PSYCHODYNAMIC APPROACHES TO PSYCHOTHERAPY: A CENTURY OF INNOVATIONS

in one’s activities, values, and relationships”(Westen & Gabbard, 1999, p. 82). Contemporarytheorists such as Millon (1999) and Kernberg(1996) recognize what the early character ana-lysts such as W. Reich (1949), Horney (1937),and Fenichel (Fenichel & Rapaport, 1954) cameto see as crucial: that personality configurationshould guide treatment.

Personality disorders are endemic in contem-porary society, most likely the result of the In-dustrial Revolution and the fragmentation ofsocial structure and extended family units dueto the mobility of members of modern society(Magnavita, 2002). Clinicians are faced with thefact that approximately half of those receivingmental health treatment are diagnosed eitherwith a primary or comorbid personality disor-der (Merikangas & Weissman, 1986; Weissman,1993). Furthermore, 1 in 10 Americans qualifyfor this diagnosis. “Personality Disorders (PDs)are a topic of considerable interest to both clini-cians and researchers alike, in part because ofthe high prevalence in the general population,and because of the difficulty in treating theseconditions with standard forms of therapy”(Magnavita, 1999b, p. 1). New applications ofpsychodynamic treatment as well as cognitive,cognitive-behavioral, interpersonal, and inte-grative approaches have been developed ex-pressly for treating personality disorders andcomplex clinical syndromes, a combination of anumber of clinical syndromes and personalitydisturbance (Magnavita, 2000a). Most models ofpsychotherapy have integrated or expanded toinclude the construct of unconscious process-ing. The effective treatment of these personalitydisorders and complex clinical syndromesrequires comprehensive treatment integrationand, often, multiple models and combinationsof treatment (Magnavita, 1999a; Millon, 1999).

It is interesting to note that neuroscientifictheory provides some support for the clinicalmethods of Ferenczi’s and Reich’s approaches totreating personality pathology (Grigsby &Stevens, 2000). “Here is where Sandor Ferenczi’s

‘active’ therapy may be useful. If one wants tochange one’s character, it is not simply enoughto become aware of an unconscious schema—one also must make an effort not to engage it”(p. 322). Based on their neurodynamic model ofpersonality, Grigsby and Stevens conclude:

If the therapist repeatedly points out charactertraits of which the patient is ordinarily unaware,their automatic performance is disrupted andlearning (in other words, a change in the neuralnetworks subserving the schema) may occur. Thehabitual behavior in a sense is “unlearned” asone tends to become increasingly aware of thebehavior during its performance. . . . The processis not easy, however, and the individual may bereluctant to go against the grain of character,since it is uncomfortable and may require greateffort. (p. 322)

T H E F O U N D A T I O N A N DA S C E N D A N C E O F

A F F E C T I V E S C I E N C E

Darwin (1998) demonstrated the importanceand function of affect, and Freud offered a the-ory about the place of affect in human psycho-pathology. The emphasis on repressed affect as a source of anxiety and symptom formationlaid the foundation for today’s affective science.The importance of affective functioning was em-phasized by Silvan Tomkins (1962, 1963, 1991)who advanced our understanding of the central-ity of emotional experience (Ekman & Davidson,1994). For the most part, however, “The topic ofemotion was downplayed until the 1960’s, adecade characterized by the advent of neobehav-iorism and social learning theory, a movementtoward cognitivism, and greater interest in sys-tems theory” (Lazarus, 1991, p. 40). Neuroscien-tists have also recognized the importance ofemotion in understanding consciousness andbrain structuralization and organization. Emo-tion primes the neuronal networks and assists inlearning. We have come to understand why the

Psychodynamic Approaches to Psychotherapy: A Century of Innovations 7

intense emotional activation that occurs fromtrauma, particularly when the trauma occursearly in development, has a significant impacton personality formation. The universality ofemotion seems to be a cross-cultural phenome-non, although there is still some debate be-tween the cultural relativists and Darwinians.Nevertheless, it is fairly well established thatthere are six primary emotions—anger, fear,sadness, disgust, happiness/joy, and surprise—and secondary emotions, which include guilt,shame, and pride. Emotion is considered bymany contemporary theorists and clinicians tobe the lifeblood of the therapeutic process. Forexample, rage and its mobilization can be apowerful transformative experience. Cum-mings and Sayama (1995) write about a require-ment they believe is important:

Just as one would not trust a surgeon who fearsthe sight of blood, why trust a therapist who can-not stand the sight of “psychic blood” when anintervention that might be termed psychologicalsurgery is in the best interest of the patient. Mo-bilization of rage in the interest of health is apowerful technique in the hands of a compas-sionate therapist. It is deadly in the hands of anoncompassionate therapist. Similarly, the sur-geon’s scalpel in the wrong hands would be inap-propriate, sadistic, or fatal. (p. 54)

Affective science, like cognitive science, is be-coming a component part of understanding per-sonality, psychopathology, and psychotherapy(Magnavita, 2002).

T H E D E V E L O P M E N T O FS U P P R E S S I O N A N D

R E D I S C O V E R Y O F T R A U M A T H E O R Y

Freud believed that hysteria derived from childsexual abuse. In fact, he believed that he haddiscovered the “causative agent in all the majorneuroses” (Schwartz, 1999, p. 73). This finding

about the prevalence of child sexual abuse by fa-thers and others, which has held up in currenttime as a factor for Dissociative Identity Disor-der and Borderline Personality Disorder, mayhave been too much for Freud to accept. Somebelieve that he experienced a personal crisisand worried about the impact that publishingthese findings might have on his career. He hasbeen harshly criticized and condemned bysome modern-day writers (Masson, 1984, 1990).According to Masson, the field of psychoanaly-sis suppressed the truth and did not take seri-ously patient reports of incest and abuse.Rachman (1997) writes:

Psychoanalysis has had a love/hate relationshipwith the seduction theory and the treatment ofthe incest trauma. In point of fact, the origins ofpsychoanalysis are based upon Freud’s discoverythat neurosis (hysteria) was caused by the sexualseduction of mostly female patients by theirfathers (and secondarily by surrogated father fig-ures). This was a remarkable discovery and es-tablished psychoanalysis on a phenomenologicalbasis—that is to say, the data for the analysiswere generated from the subjective report of thepatient. (p. 317)

Freud’s abandonment of this seduction/trauma theory was a major setback for him andthe field of psychoanalysis. His replacement,wish fulfillment, had the aura of blaming thevictim. Even though Freud abandoned traumatheory as the cause of many forms of psycho-pathology when he replaced the seduction the-ory with an Oedipal one, others, most notablyFerenczi (1933), continued to work along theoriginal line. Rachman (1997) suggests thatFerenczi’s early findings and model of traumaare remarkably consistent with contemporarytrauma models (Herman, 1992): “On the basis ofhis work with difficult cases, Ferenczi verifiedFreud’s original seduction theory and empha-sized a return to the original findings” (p. 317).The suppression of Ferenczi’s findings is a darkspot in the history of psychoanalysis.

8 PSYCHODYNAMIC APPROACHES TO PSYCHOTHERAPY: A CENTURY OF INNOVATIONS

L O N G - T E R MP S Y C H O A N A L Y T I C

P S Y C H O T H E R A P Y A N DP S Y C H O A N A L Y S I S

As Freud’s psychoanalytic technique began tocrystallize, his original experimentation andinterest in brief treatment waned. The develop-ment of his technique of free association andthe emphasis on the development of the trans-ference neurosis lengthened the course of psy-choanalysis. Psychoanalytic treatment providedFreud with the method he needed to probe fur-ther the unconscious and begin the process oforganizing his observations and mapping theintrapsychic terrain. This led to the develop-ment of metapsychology.

Traditional psychoanalysis, consisting ofthree to five psychotherapy sessions per weekover the course of many years, has greatly re-ceded as a form of treatment due to the cost andtime required. However, for those who are in-terested in becoming psychoanalysts, a traininganalysis is still required by some psychoana-lytic institutes (Havens, 2001). This can be ex-tremely beneficial for those who want to pursuea career as a “depth” therapist or to conductpsychoanalysis. At the turn of this century, mostpractitioners who conduct long-term therapy arehighly influenced by the psychodynamic model,with its emphasis on unconscious processes,transference/countertransference, and establish-ing conditions where the patient can freelyspeak what comes to mind. This model of treat-ment offered a compendium of technical ad-vances that have been well articulated in majorworks, such as The Technique of PsychoanalyticPsychotherapy (Langs, 1989).

EFFORTS TO ACCELERATEPSYCHODYNAMIC TREATMENT

From the very beginning, efforts were made to accelerate the course of psychoanalysis. The

major innovator and father of short-term dy-namic psychotherapy, Ferenczi, was rejected forhis challenge to orthodox psychoanalysis (seeOsimo, this volume). Ferenczi (Ferenczi & Rank, 1925) and generations of clinician-theo-rists after him developed innovative technicalinterventions. The analytic community tendedto discredit them and reject their pioneeringefforts, though others, such as Alexander andFrench (1946), rediscovered them later (Mag-navita, 1993a). The field of short-term dynamicpsychotherapy is one example of how psychody-namic metapsychology continues to revitalizeand shape the field of psychotherapy. In the past20 years there has been a major resurgence ofinterest in this evolutionary branch of psychody-namic therapy. Many of the cutting-edge theo-rists/clinicians are included in this volume. Ascost-effectiveness has become a major concern inthe delivery of mental health treatment, contem-porary clinicians increasingly revisit the worksof the pioneering figures in short-term therapy(Cummings & Sayama, 1995).

A P P L I C A T I O N O FP S Y C H O A N A L Y S I S A N D

P S Y C H O D Y N A M I C T H E R A P YT O C H I L D R E N

The twentieth century witnessed another majorphenomenon when psychotherapeutic tech-niques were modified for the treatment of child-hood disorders. Although Freud treated a fewchildren, it was not until his daughter Anna’s pi-oneering work at the Hamptead Child-TherapyClinic was disseminated that the field of childtherapy emerged. Melanie Klein (1975), anotherpioneering figure in theories and techniques ofchild therapy, also contributed much to the fieldand modified analytic techniques in the treat-ment of psychotic disorders (Sayers, 1991). Manytechniques of current-day play therapy havetheir origins in the works of these two pioneer-ing women of psychoanalysis.

Psychodynamic Approaches to Psychotherapy: A Century of Innovations 9

A T R E N D T O W A R DI N T E G R A T I V E T H E O R Y A N D

A M U L T I P E R S P E C T I V EA P P R O A C H T O

P S Y C H O T H E R A P Y

Many theorists have recognized the need forintegration in the field of personality theoryand psychotherapy (Magnavita, 2002). In fact,William James (1890), the father of modern psy-chology, was one of the original proponents ofintegrating seemingly disparate systems. Hebelieved that human nature was far too complexto be reduced to a theoretical, consistent sys-tem. His clarion call did herald a movement,which gained credibility in the last quarter ofthe twentieth century. However, before integra-tion could occur, a variety of models had to bedeveloped and tested over time.

Gordon Allport (1968) also called for system-atic eclecticism. He realized that eclectic was aword of “ill-repute” (p. 3), but he believed thattheoretical assimilation offered promise. Theo-rists and clinicians had to wait until there weresufficiently developed discrete theories or mod-els that could be integrated. The topic of psy-chotherapy integration is covered extensively involume 4 of the Comprehensive Handbook of Psy-chotherapy and will not be recapitulated here. Itis important to note, however, that modern psy-chodynamic theory and practice have beenshaped by integration within psychodynamicschools.

Pine (1985) and Mann and Goldman (1982)have suggested a multiperspective approachusing the main theoretical perspectives aslenses, each offering a different view of a clinicalphenomenon. Theoretical blending occurs aswell when other theoretical constructs outsidepsychoanalysis, such as systems theory, havebeen assimilated (Messer, 1992). Dollard andMiller (1950) presented a major effort in the clas-sic volume Personality and Psychotherapy: AnAnalysis in Terms of Learning, Thinking, and Cul-ture. This groundbreaking volume represented a

new integrative theory of personality andpsychotherapy (Magnavita, 2002). The domainand scope of psychodynamic psychotherapy hasbeen broadened even further with the incorpora-tion of triadic theory (Bowen, 1978) and a rela-tional-systemic component (Magnavita, 2000b).

C R I T I C I S M A N DC O N T R O V E R S Y

Numerous criticisms have been leveled againstthe field of psychoanalysis, some justified andothers less so. One of the major problems of thepast century has been the isolation of psycho-analysis from other disciplines although therehave been exceptions such as the interdiscipli-nary work of Erik Erikson (Coles, 2000). This isbeginning to shift, although much potentialwas lost for interdisciplinary cross-fertilization,which would have strengthened and furtherevolved the field. Another problem for whichthe field has been justly criticized is the relativelack of interest in providing empirical supportfor treatment effectiveness. Admittedly, this is an onerous task, but nevertheless a vital one.Popular notions about psychodynamic treat-ment have been difficult to dislodge. One im-portant assumption made by many regards the sanctity of the therapeutic relationship.This has been reified to the point of not allow-ing the process to be studied, except third-hand. With the advent of low-cost audiovisualequipment, the process of psychotherapy is nowcapable of being readily studied by clinicians.Inspired by the trendsetting and courageouswork of pioneering practitioners who video-taped their treatment sessions, a new genera-tion of clinicians is using this technology toadvance the field and provide more intensivetraining for psychotherapists. Clearly, there arepotential pitfalls and a possible downside tousing videotape for research and training, butthe advances in knowledge seem to outweighpotential difficulties.

10 PSYCHODYNAMIC APPROACHES TO PSYCHOTHERAPY: A CENTURY OF INNOVATIONS

S U M M A R Y

Psychoanalytic concepts, theories, and tech-niques continue to have a strong influence oncurrent psychodynamic psychotherapy, as wellas many other schools presented throughout this Comprehensive Handbook of Psychotherapy.Psychoanalysis offered the first comprehensivemetapsychology of personality function, psycho-pathology, and methods of psychological heal-ing. Many of the main evolutionary theoreticalmodels of psychoanalysis continue to offer mul-tiple perspectives for understanding the vastvariations in human suffering confronted inclinical practice by mental health clinicians. Use-ful methods and techniques of treatment havederived from these theoretical systems and offerthe clinician at the start of the second century ofmodern psychotherapy an array of approacheswith which to assist those who come with thehope of being healed.

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SECTION ONE

PSYCHOTHERAPY WITH CHILDREN

Chapter 2 The Developmental Basis of Psychotherapeutic Processes

Chapter 3 Object-Relations Play Therapy

Chapter 4 Infant Mental Health

Chapter 5 Psychodynamic Approaches to Child Therapy

15

C H A P T E R 2

The Developmental Basis ofPsychotherapeutic Processes

STANLEY I. GREENSPAN

Through clinical work and observationswith infants and young children, we havebeen able to more fully identify and de-scribe the early stages of ego development. Wehave also been able to describe stage-specificaffective interactions and relationship patternsand individual motor and sensory processingdifferences that influence these early ca-pacities. Taken together, these elements consti-tute the Developmental, Individual-Difference,Relationship-Based (DIR) model (Greenspan,1997a, 1997b). This model provides a develop-mental framework for conceptualizing the psy-chotherapeutic process. The DIR framework,which can be applied to both children andadults, includes an individualized developmen-tal approach to assessment and diagnosis andthe practice of psychotherapy and psychoanaly-sis. It also includes developmental insights intoa range of disorders (e.g., anxiety, depression,character, and personality disorders, autism,mental retardation, learning disorders) and in-forms a comprehensive intervention programfor children with autistic spectrum disordersand other special needs.

The DIR model is based on relatively recentinsights about three interrelated processes thatcontribute to a child’s development. The firstprocess involves early stages in a child’s presym-bolic functional emotional development (the build-ing blocks of ego functioning and intelligence).These capacities include regulation and sharedattention; relating with intimacy; gestural, affec-tive reciprocal and social interactions; and creat-ing and connecting symbols. The second processinvolves each child’s individually different underly-ing processing capacities, such as sensory modula-tion, auditory and visual-spatial processing, andmotor planning. Infants and young children dif-fer significantly in their sensory reactivity, au-ditory and visual-spatial processing, and motorplanning and sequencing, and these differencesare important contributors to ego structure, char-acter, and symptom formation. The third processinvolves the role of relationships and affective inter-actions in facilitating a child’s intellectual andemotional growth. For example, the earliest cog-nitive structures and sense of causality do not, asPiaget believed, first arise from early sensorimo-tor (cognitive) explorations. They arise from even

16 PSYCHOTHERAPY WITH CHILDREN

earlier affective interactions between a baby andhis or her caregiver (e.g., a smile begetting asmile). At each stage of early cognitive develop-ment, emotional interactions lead the way. Themeaning of words, early quantity concepts (“alot” to a 21⁄2-year-old is more than he expects; “alittle” is less than he wants), logical and abstractthinking, and even important components ofgrammar depend on specific types of emotionalinteractions (Greenspan, 1997b; Greenspan &Wieder, 1999). Similarly, early ego developmentcan now be traced to specific types of earlyemotional interactions. For example, complexreciprocal affective interactions in the secondyear of life enable children to begin integratingaffective polarities and form a more integratedsense of self.

T H E D I R M O D E L A N DC O N S T R U C T I N G T H E

D E V E L O P M E N T A L P R O F I L E

In the DIR model of development, there are threedynamically related influences on development.Biological, including genetic, influences affectwhat the child brings into his or her interactivepatterns. They do not act directly on behavior,but on part of the child-caregiver interactive pro-cess. Cultural, environmental, and family factorsinfluence what the caregiver or interactive part-ner brings into the interactions. The resultantchild-caregiver interactions then determine therelative mastery of six core developmentalprocesses (e.g., regulation, relating, preverbalaffective reciprocity). Symptoms or adaptive be-haviors are the result of these stage-specific af-fective interactions.

The DIR model enables the clinician to con-struct a detailed developmental profile based onthese dynamic processes. A special feature ofthe profile is its focus on early presymboliclevels of ego functioning. Higher levels of egofunctioning are explored through an elabora-tion of the content of the patient’s mental life;

presymbolic levels often involve basic structure-building, affective interactions. In consideringdifferent types of problems and personalities,one is often tempted to go where the action is,getting caught up in the conflict of the moment(the family drama or, understandably, the pa-tient’s anguish). However, a full developmentalprofile includes early presymbolic structures aswell as dynamic contents (i.e., a full profile in-cludes the “drama” and the “stage” on whichthe drama takes place).

The profile begins with a description of indi-viduals’ regulatory capacities: the ability to re-main calm, attentive, and process and respondin an organized way to the variety of sensationsaround them. Next is a rich description of theirstyle and capacity for engaging, followed bytheir capacity to enter into reciprocal affectivegesturing in a full range of emotional and the-matic realms. Then comes their ability to orga-nize their behavior and affects into purposefulpatterns that constitute a presymbolic sense ofself and take into account the expectations oftheir environment. These presymbolic capaci-ties are followed by the ability to representwishes, affects, and ideas, use them imagina-tively, and then create bridges between differ-ent represented experiences as a basis for arepresentational sense of self and other, a dif-ferentiated sense of time and space, and affectproclivities, the capacity to construct a sense ofreality and to move toward abstract and reflec-tive thinking.

In each area of the profile, one looks for com-petencies as well as deficits (where the ability isnot attained at all). One also looks for constric-tions (where the ability is there but not at its full,robust, and stable form). Constrictions may in-volve a narrowing of the thematic or affectiverange (only pleasure, no anger), a lack of stability(the child can engage, but loses this capacity andbecomes self-absorbed whenever anxious), or alack of motor, sensory, cognitive, or languagesupport for that capacity (e.g., the child can be as-sertive with words, but not with motor patterns).

The Developmental Basis of Psychotherapeutic Processes 17

After an individual’s profile is constructed,two contributions to the challenges or strengthsof that profile are explored. These are the biolog-ically based regulatory contributions (i.e., motorand sensory processing differences) and thefamily, cultural, and interactive contributions.

C A S E E X A M P L E O F T H E D I RD E V E L O P M E N T A L P R O F I L E

To illustrate the importance of constructingsuch a profile, consider the following example.A 6-year-old girl presented with an inability to talk in school and an ability to talk only toher mother. She had always been a dependent,clingy, quiet, and passive little girl, had a lot ofseparation anxiety in going to school, and al-ways had difficulty interacting with other chil-dren. However, her difficulties were gettingworse over the prior two years. It will be in-structive now to look at the profile that was con-structed for this little girl from numerous playsessions. She took a long time to connect withthe therapist doing the evaluation. She wouldinitially fiddle with toys or other objects in aseemingly self-absorbed way and only withmany vocal overtures would she enter into astate of shared attention, where she was pay-ing attention to the therapist. The therapisthad to maintain a fairly high level of activity tokeep this state of shared attention. Similarly,although she had some warmth and the thera-pist found herself looking forward to seeingthe child, the therapist kept feeling she had towork hard to maintain the sense of engage-ment. There was some emotional expressive-ness and some back-and-forth smiling andsmirking, suggesting some capacity for emo-tional reciprocity, but often, the emotional re-sponses were either very inhibited (lacking) orglobal, with seemingly inappropriate gigglingor repetitive, tense, discharge-oriented play(such as banging a doll). Often, the content ofthe play, such as banging the doll, was not

connected to the affect (which might be a smileas she banged the doll aggressively). She waspurposeful and organized in her interactionsand play, but during times of transitions, goingfrom one activity to another, she would seem toget lost in her own world again, and the thera-pist would have to work to regain a sense of or-ganized interaction. She used lots of ideas andwas able to build bridges between her ideas (an-swering “what” and “why” questions), but herimaginative play was focused on only a fewthemes in a very intense, repetitive manner. Shehad dolls undressing and had one doll doing ag-gressive things to the genital areas of the otherdolls. In one scene, she had monsters blockingsome of the dolls from getting their clothesback, with sadistic fights ensuing. In this profile,then, we see a child who has marked constric-tions at the presymbolic areas of developmentaround attention, engagement, and reciprocalaffective gesturing and cuing, as well as a preoc-cupation and constriction at the symbolic or rep-resentational level.

In cases like this, with a little child who canelaborate themes, I found that many therapistswould focus predominantly on the content ofthe child’s themes (in this case, her preoccupa-tion with sexual and aggressive themes) andobviously want to explore the family dynamicsthat were contributing, including questions ofsexual abuse, sexual play with other children orbabysitters, or overstimulation due to exposureto sexual materials or witnessing sexual scenes.But our profile, in addition to alerting us tothese factors, also alerts us to the fact that thereis a lack of mastery of critical early phases of de-velopment, including an ability for consistentattention, engagement, and the earliest types ofaffective reciprocity. When, for example, chil-dren cannot match the content of their intereststo their affects, it often suggests that early inlife, a caregiver was unable to enter into recip-rocal gesturing around certain affective incli-nations. For example, the way children learn tomatch content with affect is by demonstrating

18 PSYCHOTHERAPY WITH CHILDREN

different affects as an infant in association withdifferent kinds of behavior, perhaps knockingthe food off the table with a look of defiance orsurprise. In return, they get a reciprocal affector gesture back from Mommy or Daddy. If theparent freezes or withdraws at that moment,however, there is no return affective gestureand the child’s content (i.e., throwing the foodon the floor) now has no reciprocal affects as-sociated with it. As a consequence, the childdoesn’t develop the rich connections betweeninteractive affects and content. Obviously, var-ious types of processing problems can alsocontribute.

In terms of regulatory patterns in this case,the child did have some overreactivity to touchand sound and some mild motor planning problems, but was quite competent in her au-ditory and visual-spatial processing abilities.There were both physical and interactive differ-ences contributing to her profile.

As we looked at her developmental profile, wewere therefore alerted to the fact that there werea number of prerepresentational issues that needto be worked on in therapy as well as issues in-volved in her emerging symbolic world. As wewere speculating from her profile, we wonderedwhether there were some profound difficultiesongoing in the early relationship between thischild and her caregivers as well as some currentexperiences that were leading to her preoccupa-tion with sex and aggression. We also wonderedabout current trauma severe enough to disruptbasic presymbolic abilities (if, for example, theywere formerly attained).

As a result of this profile, the therapist whohad started with twice-a-week sessions to workon the content of the child’s play and once-a-month sessions with the parents shifted her ap-proach. It was decided that it was important todevelop a deeper alliance with this family toexplore the nature of this little girl’s preoccu-pation with sexual and aggressive content and,therefore, they needed to be seen at least once aweek. It was also determined that becausethere were a number of constrictions of the

prerepresentational capacities, the therapistneeded to work with the parents’ interactionswith their daughter to foster mastery of thesebasic interactive capacities around attention,engagement, and reciprocal affective inter-change. She also began working on the issuesdirectly in therapy, paying more attention to af-fects and gestures, the tone of the relationshipitself, and the understanding of verbal content.

A developmental profile systematically donewill help the therapist look in a balanced way atthe whole individual and, most important, willhelp the therapist raise hypotheses about wherethe challenges may lie and even some potentialreasons for the challenges. The profile enablesthe therapist to develop a therapeutic strategyto further explore the initial hypothesis. With-out such a systematic profile, it’s easy for thetherapist to get lost in the content or symptomsof the moment without a full appreciation of allthe areas of challenge and the likely experi-ences that might be associated with them.

In some respects, by focusing on the patient’sfundamental capacities, the developmental pro-file may reveal aspects of the patient’s develop-mental history that the patient’s “memories”are unable to reveal. The processes that the de-velopmental perspective helps us observe revealwhere the patient has been and, even more im-portant, where he or she needs to go.

T H E D E V E L O P M E N T A L L YB A S E D P S Y C H O T H E R A P E U T I C

P R O C E S S W I T H C H I L D R E NA N D A D U L T S

The individualized profile and the DIR modelcan inform the practice of psychotherapy andpsychoanalysis. Most therapists use a develop-mental framework in their clinical work. Manyrecent developmental discoveries, however, havenot yet found their way into this evolving frameof reference. See Developmentally Based Psycho-therapy (Greenspan, 1997a) for a detailed de-scription of this approach.

The Developmental Basis of Psychotherapeutic Processes 19

OBSERVING AND WORKING WITH FUNDAMENTALDEVELOPMENTAL PROCESSES

The overarching principle of a developmen-tally based approach to psychotherapy is mo-bilization of the developmental processesassociated with an adaptive progression of thepersonality throughout childhood and adult-hood. The therapeutic relationship is the vehi-cle for mobilizing developmental processes inthe therapy sessions and for helping the pa-tient create developmentally facilitating ex-periences outside the therapy situation. Thecritical difference between the developmen-tally based approach to the psychotherapeuticprocess and other approaches is the degree towhich early stages in development are ob-served and worked with. Typically, most ther-apists work with verbal material with adultsand verbal and play themes with children. Ifearlier levels are worked with (e.g., separation-individuation), they are worked with