Psychoanalysis and

Psychoanalytic Therapies
Second Edition
 Theories of Psychotherapy Series
Acceptance and Commitment Therapy
Steven C. Hayes and Jason Lillis
Adlerian Psychotherapy
Jon Carlson and Matt Englar-Carlson
The Basics of Psychotherapy: An Introduction to Theory and Practice,
Second Edition
Bruce E. Wampold
Behavior Therapy
Martin M. Antony and Lizabeth Roemer
Brief Dynamic Therapy, Second Edition
Hanna Levenson
Career Counseling, Second Edition
Mark L. Savickas
Cognitive–Behavioral Therapy, Second Edition
Michelle G. Craske
Cognitive Therapy
Keith S. Dobson
Dialectical Behavior Therapy
Alexander L. Chapman and Katherine L. Dixon-Gordon
Emotion-Focused Therapy, Revised Edition
Leslie S. Greenberg
Existential–Humanistic Therapy, Second Edition
Kirk J. Schneider and Orah T. Krug
Family Therapy
William J. Doherty and Susan H. McDaniel
Feminist Therapy, Second Edition
Laura S. Brown
Gestalt Therapy
Gordon Wheeler and Lena Axelsson
Interpersonal Psychotherapy
Ellen Frank and Jessica C. Levenson
Narrative Therapy
Stephen Madigan
Person-Centered Psychotherapies
David J. Cain
Psychoanalysis and Psychoanalytic Therapies, Second Edition
Jeremy D. Safran and Jennifer Hunter
Psychotherapy Case Formulation
Tracy D. Eells
Psychotherapy Integration
George Stricker
Rational Emotive Behavior Therapy
Albert Ellis and Debbie Joffe Ellis
Reality Therapy
Robert E. Wubbolding
Relational–Cultural Therapy, Second Edition
Judith V. Jordan
 Theories of Psychotherapy Series
Matt Englar-Carlson, Series Editor

Psychoanalysis and
Psychoanalytic Therapies
Second Edition

Jeremy D. Safran and

Jennifer Hunter
Copyright © 2020 by the American Psychological Association. All rights reserved.
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Psychological Association.

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Library of Congress Cataloging-in-Publication Data

Names: Safran, Jeremy D., author. | Hunter, Jennifer (Psychologist), author.
Title: Psychoanalysis and psychoanalytic therapies / Jeremy D. Safran and
Jennifer Hunter.
Description: Second Edition. | Washington : American Psychological
Association, 2020. | Series: Theories of psychotherapy series | Revised edition
of Psychoanalysis and psychoanalytic therapies, c2012. | Includes bibliographical
references and index.
Identifiers: LCCN 2020001139 (print) | LCCN 2020001140 (ebook) |
ISBN 9781433832321 (paperback) | ISBN 9781433832345 (ebook)
Subjects: LCSH: Psychoanalysis. | Psychotherapy.
Classification: LCC BF173 .S257 2020 (print) | LCC BF173 (ebook) |
DDC 150.19/5—dc23
LC record available at https://lccn.loc.gov/2020001139
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http://dx.doi.org/10.1037/0000190-000

Printed in the United States of America

10 9 8 7 6 5 4 3 2 1
 For my daughters, Ayla and Ellie, who liked to tease me
about having “all those Freud books” lying around the house.
—Jeremy D. Safran

For Marvin Hunter, whose adventurous spirit, lively intellect,

and unconditional support formed and sustained me.
—Jennifer Hunter
 Contents

Series Preface xi
How to Use This Book With APA Psychotherapy Videos xvii
Acknowledgements xix
1. Introduction 3
2. History 17
3. Theory 37
4. The Therapy Process 65
5. Evaluation 141
6. Future Developments 151
7. Summary 167
Glossary of Key Terms 173
References 177
Index 195
About the Authors 209
About the Series Editor 211

ix
 Series Preface
Matt Englar-Carlson

S ome might argue that in the contemporary clinical practice of psycho-

therapy, the focus on evidence-based intervention and effective
outcome has overshadowed theory in importance. Maybe. But at the same
time, it is clear that psychotherapists adopt and practice according to
one theory or another because their experience, and decades of empirical
evidence, suggests that having a sound theory of psychotherapy leads to
greater therapeutic success. Theory is fundamental in guiding psycho-
therapists in understanding why people behave, think, and feel in certain
ways, and it provides the guidance to then contemplate what a client can
do to instigate meaningful change. Still, the role of theory in the helping
process itself can be hard to explain. This narrative about solving prob-
lems may help convey theory’s importance:

Aesop tells the fable of the sun and wind having a contest to decide
who was the most powerful. From above the earth, they spotted a
person walking down the street, and the wind said that he bet he could
get his coat off. The sun agreed to the contest. The wind blew, and the
person held on tightly to his coat. The more the wind blew, the tighter
the person held on to his coat. The sun said it was his turn. He put all
of his energy into creating warm sunshine, and soon the person took
off his coat.

What does a competition between the sun and the wind to get the
person to remove a coat have to do with theories of psychotherapy?

xi
 Series Preface

This deceptively simple story highlights the importance of theory as

the precursor to any effective intervention—and hence to a favorable
outcome. Without a guiding theory, a psychotherapist might treat the
symptom without understanding the role of the individual. Or we might
create power conflicts with our clients and not understand that, at times,
indirect means of helping (sunshine) are often as effective as—if not more
so than—direct ones (wind). In the absence of theory, a psychotherapist
might lose track of the treatment rationale and instead get caught up in,
for example, social correctness and not wanting to do something that
looks too simple.
What exactly is theory? The APA Dictionary of Psychology, Second
Edition defines theory as “a principle or body of interrelated principles that
purports to explain or predict a number of interrelated phenomena”
(VandenBos, 2015, p. 1081). In psychotherapy, a theory is a set of princi-
ples used to explain human thought and behavior, including what causes
people to change. In practice, a theory frames the goals of therapy and
specifies how to pursue them. Haley (1997) noted that a theory of psycho­
therapy ought to be simple enough for the average psychotherapist to
understand but comprehensive enough to account for a wide range of
eventualities. Furthermore, a theory guides action toward successful
outcomes while generating hope in both the psychotherapist and client
that recovery is possible.
Theory is the compass that allows psychotherapists to navigate the
vast territory of clinical practice. In the same ways that navigational tools
have been modified to adapt to advances in thinking and ever-expanding
territories to explore, theories of psychotherapy have evolved over time
to account for advances in science and technology. The different schools
of theories are commonly referred to as waves—the first wave of psycho­
dynamic theories (i.e., Adlerian, psychoanalytic), the second wave of
learning theories (i.e., behavioral, cognitive-behavioral), the third wave
of humanistic theories (i.e., person centered, gestalt, existential), the
fourth wave of feminist and multicultural theories, and the fifth wave of
postmodern and constructivist theories (i.e., narrative, constructivist).
In many ways, these waves represent how psychotherapy has adapted
and responded to changes in psychology, society, and epistemology, as

xii
 Series Preface

well as to changes in the nature of psychotherapy itself. The wide variety

of theories is also a testament to the different ways in which the same
human behavior can be conceptualized depending on the view one espouses
(Frew & Spiegler, 2012). Our theories of psychotherapy are also challenged
to expand beyond the primarily Western worldview endemic in most
psychotherapy theories and the practice of psychotherapy itself. That
revision and correction requires theories and psychotherapists to become
more inclusive of the full range of human diversity to reflect an under-
standing of human behavior that accounts for a client’s context, identity,
and intersectionality (American Psychological Association, 2017). To that
end, psychotherapy and the theories that guide it are dynamic and respon-
sive to the changing world around us.
With these two concepts in mind—the central importance of theory
and the natural evolution of theoretical thinking—the APA Theories of
Psychotherapy Series was developed. This series was created by my father
(Jon Carlson) and me. Although educated in different eras, we both had
a love of theory and often spent time discussing the range of complex
ideas that drove each model. Even though my father identified strongly
as an Adlerian and I was parented and raised from the Adlerian perspec-
tive, my father always espoused an appreciation for other theories and
theorists—and that is something I picked up from him. As university
faculty members teaching courses on the theories of psychotherapy, we
wanted to create learning materials that not only highlighted the essence
of the major theories for professionals and professionals in training but
also clearly brought the reader up-to-date on the current status of the
models, future directions with an emphasis on the inclusive application
of the theories with clients representing the range of identities. Often in
books on theory, the biography of the original theorist overshadows
the evolution of the model. In contrast, our intent was to highlight the
contemporary uses of the theories as well as their history and context—
both past and present.
As this project began, we faced two immediate decisions: which
theories to address and who best to present them. We assessed graduate-
level theories of psychotherapy courses to see which theories are being
taught, and we explored popular scholarly books, articles, and conferences

xiii
 SERIES PREFACE

to determine which theories draw the most interest. We then developed a

dream list of authors from among the best minds in contemporary theo-
retical practice. To that end, each author in the series is one of the leading
proponents of that approach as well as a knowledgeable practitioner.
We asked each author to review the core constructs of the theory, bring
the theory into the modern sphere of clinical practice by looking at it
through a context of evidence-based practice, and clearly illustrate how
the theory looks in application.
There are 24 titles planned for the series, and many titles are now in
their second edition. Each title can stand alone or can be put together
with a few other titles to create materials for a course in psychotherapy
theories. This option allows instructors to create a course featuring
the approaches they believe are the most salient today. To support this
end, APA Books has also developed a video for each of the approaches
to demonstrate the theory in practice with a real client. Many of the
videos show psychotherapy over six sessions with the same client.
Contact APA Books for a complete list of available video programs
(https://www.apa.org/pubs/videos).
Preparing the preface for this second edition is quite bittersweet.
Humanity lost a true leader and kind soul in the passing of Jeremy Safran.
Jeremy and I had talked about crafting the second edition of this book
in way that would draw more focus to social justice and the culturally
responsive aspects of psychoanalytic practice. I was excited about this,
but also a bit wary. Jeremy was not the easiest author to work with, but
the reasons why were admirable. He was a complex thinker who truly
cared about each word on the page and the different ways to present
concepts. For me, the first edition of this book and the corresponding
six-session videos were incredibly enlightening. My father, Jon Carlson,
who had witnessed thousands of hours of taping psychotherapy sessions,
shared with me that Jeremy’s six sessions and the corresponding voice-
over of Jeremy explaining his work in those sessions were among the best
teaching tools he had ever created. I was so pleased that Jeremy’s partner
and spouse, Jennifer Hunter, stepped in to develop the second edition of
this incredible book. Together, Jennifer and Jeremy do a masterful job of

xiv
 SERIES PREFACE

expanding people’s knowledge about psychoanalysis beyond Freud into

contemporary practice and modern times. And as with the first edition,
my own knowledge base and appreciation for psychoanalytic thinking has
deepened through my careful read of this book. I am certain that all read-
ers will have the same experience.

xv
 How to Use This Book
With APA Psychotherapy Videos

E ach book in the Theories of Psychotherapy Series is specifically

paired with a video that demonstrates the theory applied in actual
therapy with a real client. Many videos feature the author of the book
as the guest therapist, allowing students to see an eminent scholar and
practitioner putting the theory they write about into action.
The video programs have a number of features that make them
excellent tools for learning more about theoretical concepts:

7 Many video programs contain six full sessions of psychotherapy

over time, giving viewers a chance to see how clients respond to the
application of the theory over the course of several sessions.
7 Each program has a brief introductory discussion recapping the
basic features of the theory behind the approach demonstrated.
This allows viewers to review the key aspects of the approach about
which they have just read.
7 The videos feature volunteer clients in unedited psychotherapy sessions.
This provides a unique opportunity to get a sense of the look and feel
of real psychotherapy, something that written case examples and tran-
scripts sometimes cannot convey.

The books and videos together make a powerful teaching tool for
showing how theoretical principles affect practice. In the case of this

xvii
 How to Use This Book With APA Psychotherapy Videos

book, the video Psychoanalytic Therapy Over Time, which features the first
author as the guest expert, provides a vivid example of how this approach
looks in practice.
For more information, please visit APA Videos at https://www.
apa.org/pubs/videos/

xviii
 Acknowledgments

J eremy Safran, the sole author of the first edition of this book, left us
in 2018. He was a beloved professor, therapist, mentor, friend, uncle,
father, and my husband. As a singular thinker and theory savant, Jeremy
was both the worst and the best choice to write a primer on psycho-
analysis. He was a devotee of history, politics, philosophy, and religion.
He was an expert in the theory of cognitive therapy, psychotherapy inte-
gration, emotion theory, psychotherapy research, and Buddhism as well
as relational psychoanalysis. He conducted groundbreaking research on
rupture and repair in the therapeutic relationship and wrote theoretical
papers about will and agency, intersubjectivity, metacommunication, and
the analytic relationship. He was the worst choice because he was a com-
plex and contextual thinker who did not simplify psychoanalysis for the
reader. This also made him the best choice. To practice psychoanalysis
is to embrace ambiguity and complexity, to appreciate the political and
social context of knowledge, and to accept the limits of what we can under-
stand. Jeremy embodies these perspectives in this wonderful book as he
did throughout his life. This book demonstrates his brilliance, generosity,
clinical acuity, and personal honesty. The reissue is an opportunity to
continue to offer these qualities to new generations of psychoanalytic
students and extend his influence into the future.

xix
 Acknowledgments

I am infinitely grateful to the generous colleagues who shared their

expertise to make this reissue possible: Paul Wachtel, Jessica Benjamin,
Neil Altman, Howard Steele, Chris Muran, Steve Botticelli, Stan Messer,
Catherine Eubanks, Joel Weinberger, Jill Bresler, Steve Reisner, Jennifer
Hay, Kristen Peck. I also thank Joshua Maserow for his editorial support.

—Jennifer Hunter

xx
 Psychoanalysis and
Psychoanalytic Therapies
Second Edition
 1

Introduction

P sychoanalysis has changed the way we think about our minds and
what it means to be human. Its reach includes a groundbreaking
form of psychological treatment, as well as models of psychological
functioning, development, and psychopathology. Many divergent psycho­
analytic theories and treatment modalities have been developed over more
than a century through the writings of a host of different theorists and
practitioners. Nonetheless, it is possible to speak in general terms about
basic principles that cut across all psychoanalytic perspectives. These
include (a) an assumption that all human beings are influenced by wishes,
fantasies, or knowledge that is outside of awareness (the unconscious);
(b) an interest in facilitating the awareness of unconscious motivations,
thereby increasing choice; (c) an emphasis on exploring the ways in

As noted in the Acknowledgments, Jeremy Safran passed away in 2018 during early discussions for the
revision of Psychoanalysis and Psychoanalytic Therapies, Second Edition, which was subsequently completed
by Jennifer Hunter. As in the first edition, “I” statements are used throughout this book to represent
Dr. Safran’s perspective, voice, and work.
http://dx.doi.org/10.1037/0000190-001
Psychoanalysis and Psychoanalytic Therapies, Second Edition, by J. D. Safran and J. Hunter
Copyright © 2020 by the American Psychological Association. All rights reserved.

3
 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

which people avoid painful or threatening feelings, fantasies, and thoughts;

(d) an assumption that people are ambivalent about change and an
emphasis on the importance of exploring this ambivalence; (e) an emphasis
on using the therapeutic relationship as an arena for exploring psycho­
logical processes and actions (both conscious and unconscious); (f ) an
emphasis on using the therapeutic relationship as an important vehicle
of change; and (g) an emphasis on helping clients to understand the
way in which their construction of their past and present plays a role in
perpetuating habitual patterns.
In the early days of psychoanalysis, clients typically saw Freud and
his colleagues four to six times per week, and treatment lasted from
6 weeks to 2 months. As the goals of psychoanalysis evolved from
symptom reduction to more fundamental changes in personality func­
tioning, the length of the average analysis gradually increased over time
to the point at which it became common for an analysis to last 6 years
or longer.
Many contemporary psychoanalysts still believe that long-term,
intensive treatment has important advantages as a treatment modality.
As the empirical evidence shows, although circumscribed symptoms can
improve in short-term, less intensive therapy, more fundamental changes
in personality functioning and underlying psychological structures take
time (e.g., Howard, Kopta, Krause, & Orlinsky, 1986). Moreover, given
that the client–therapist relationship is seen as a central mechanism of
change, the theory holds that longer term, intensive treatment is necessary
to allow this relationship to develop and play a transformative role.
In contemporary psychoanalytic practice, it is common to see clients
once or twice a week for a shorter term, but the basic analytic values and
goals remain.
Psychoanalysis was the first modern Western system of psycho­
therapy, and most other forms of therapy evolved out of psychoanalysis,
were strongly influence by it, or developed partially in reaction to it. The
term psychoanalysis was originated by Sigmund Freud (1856–1939),
a Viennese neurologist who with a number of key colleagues (e.g., Wilhelm
Stekel, Paul Federn, Max Etington, Alfred Adler, Hans Sachs, Otto Rank,

4
 Introduction

Karl Abraham, Carl Jung, Sandor Ferenczi, Ernest Jones) developed a dis­
cipline that combined a form of psychological treatment with a model
of psychological functioning, human development, and theory of
change. The emergence of this discipline was influenced by a variety of
developments taking place at the time in psychiatry, neurology, psychol­
ogy, philosophy, and social and natural sciences. In addition, early psycho­
analysis was influenced by Freud’s attempts to defend against criticism
from outside the field as well as dissenting perspectives and ideas raised
by his own students and colleagues. Significant conflict lead to estrange­
ment from many of his most important early colleagues as they devel­
oped their own divergent ideas; this group includes Jung, Rank, and
Adler (Gay, 1988; Makari, 2008). Freud’s theoretical perspective and ideas
about psychoanalytic technique evolved over the course of his lifetime,
and although his thinking is often presented as a unified and coherent
system of thought, reading his articles and books is more like reading
ongoing work in progress rather than a systematic and unified theory.
Although Freud undeniably was the single most influential figure in
the initial development of psychoanalysis, many other creative thinkers
played a role in its development from the very beginning. Some of their
ideas led Freud to sharpen his thinking in response, some of their ideas
were assimilated and modified by Freud in various ways, and some of
their ideas were not assimilated by Freud but had a subsequent impact
on their own students’ thinking and on future generations of psycho­
analysts (Makari, 2008). Although psychoanalysis began with Freud’s
writing and lectures and the early writing of a small group of colleagues
around him in Vienna, by the time of Freud’s death in 1939, it was
becoming an international movement with important centers in Vienna,
Zurich, Berlin, Budapest, Italy, France, England, the United States, and
Latin America. Each of these centers contributed its unique influence to
the development of psychoanalysis, and a host of different schools and
theories of psychoanalysis have evolved in different countries since 1939
(Makari, 2008). Adherents to different traditions within psychoanalysis
interpret Freud differently and can disagree about major premises and
technical recommendations.

5
 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

PSYCHOANALYSIS TODAY
Although it is understandable for critics to equate psychoanalysis with
Freud, it is important to recognize that the value of psychoanalytic
treatment and the validity of psychoanalytic theory are not tied to
the validity of Freud’s thinking. Freud was one person writing from a
particular historical and cultural place. Some of his ideas were more
valid in their original historical and cultural context than they are in
contemporary times, and some were flawed from the beginning. As
readers will see, there are some dramatic differences between early
psychoanalysis and the form it has today. Relative to Freud’s time,
contemporary American psychoanalysis has a greater emphasis on the
mutuality of the therapeutic relationship; an emphasis on the funda­
mentally human nature of the therapeutic relationship; more of an
emphasis on flexibility, creativity, and spontaneity in the therapeutic
process; and a more optimistic perspective on life and human nature.
Contrary to common belief, there is actually substantial and growing
empirical support for the effectiveness of psychoanalytically oriented
treatments (Leichsenring, Luyten, et al., 2015; Levy, Ablon, & Kaechele,
2012; Shedler, 2010) and the validity of various psychoanalytic con­
structs (Westen, 1998; Westen & Gabbard, 1999). And there has been
a growing emphasis on adapting psychoanalytic theory and practice
in a culturally and politically responsive fashion (Altman, 2010; Aron &
Starr, 2012; Gutwill & Hollander, 2006; Perez Foster, Moskowitz, &
Javier, 1996).
In the United States, psychoanalysis has evolved under the influence
of certain characteristic American attitudes, including a tendency toward
optimism and the philosophy of American egalitarianism. Another
important factor is that many of today’s leading analysts came of age
during the cultural revolution in the 1970s—a time when traditional
social norms and sources of authority were being challenged. In addition,
prominent feminist psychoanalytic thinkers have challenged many of the
patriarchal assumptions implicit in traditional psychoanalytic theory,
raised important questions about the dynamics of power in the thera­
peutic relationship, and reformulated psychoanalytic thinking about

6
 Introduction

gender (e.g., Benjamin, 1988, 1995, 2018; Dimen, 2003; Harris, 2008).
Another influence has been a postmodern sensibility that challenges the
assumption that one can ever come to know reality objectively, maintains
a skeptical attitude toward universalizing truth claims, and emphasizes
the importance of theoretical pluralism. A final influence has been an
influx of clinical psychologists, social workers, people of color, women,
and people with diverse gender identities and sexual orientations into
postgraduate psychoanalytic training institutes in the past few decades.
This has led to significant and intellectually interesting changes in a
discipline that was traditionally dominated by White male psychiatrists.
Unfortunately, many in the broader mental health field and the
general public are unaware of these changes within psychoanalysis and
are responding to a partial or caricatured understanding of the tradition
on the basis of aspects of psychoanalytic theory, practice, and attitude
that are no longer prominent. Although there are many valid critiques
of psychoanalysis in both its past and current forms, I believe that the
current marginalization of psychoanalysis is partially attributable to
certain contemporary cultural biases, especially in the United States, that
are not unequivocally healthy ones. These biases include an emphasis
on optimism, speed, pragmatism, instrumentality, and an intolerance
of ambiguity. Although all of these emphases certainly have their value,
they can underestimate the complexity of human nature and the diffi­
culty of the change process. American culture tends to gloss over the more
tragic dimensions of life, to espouse the belief that we can all be happy
if we try hard enough, and to be biased toward a “quick-fix mentality.”
Psychoanalysis originated in continental Europe—in a culture that had
experienced centuries of poverty; oppression of the masses by the ruling
classes; ongoing religious conflict and oppression; and generations of
warfare culminating in two world wars that were unprecedented in scale,
degree of devastation, and tragedy.
Although American psychoanalysis tends to be more optimistic and
pragmatic than its European counterpart, it still retains many of the
traditional psychoanalytic values, such as the appreciation of human
complexity, a recognition that contentment is not necessarily the same as

7
 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

a two-dimensional version of “happiness,” and a recognition that change

is not always easy or quick. Additionally, there has been movement in
contemporary psychoanalysis toward recovering some of the culturally
subversive, socially progressive, and politically engaged spirit that was
once more characteristic of the discipline. My hope is that this book
will both correct misconceptions about traditional psychoanalysis and
introduce some of the more important recent developments in psycho­
analytic theory and practice. This will be done through discussion of
current theoretical developments and the use of clinical examples that
demonstrate current clinical practice. In the latter, the client names and
identities have been disguised throughout the book.

THE TENSION BETWEEN CONFORMIST

AND SUBVERSIVE THREADS IN PSYCHOANALYSIS
For many years, psychoanalysis was the dominant theory for mental
health practitioners in the United States and many other countries.
From the late 1960s until the present time, however, psychoanalysis in
the United States has become increasingly marginalized within both the
health care system and clinical training programs. There are reasons for
the declining fortunes of psychoanalysis. One important factor is that
during its heyday, psychoanalysis earned a reputation as a conservative
cultural force with a tendency toward orthodoxy, insularity, arrogance,
and elitism. It also earned a reputation as a somewhat esoteric discipline
with a limited interest in grappling with the concrete problems that
many people deal with in their everyday lives and a limited appreciation
of the social and political factors that affect their lives. Instead, psycho­
analysis came to be seen by many as a self-indulgent pastime for the
financially comfortable.
The fact that psychoanalysis came to earn this reputation is ironic.
Although Freud initially began developing psychoanalysis as a treatment
for clients presenting with symptoms that other physicians were unable
to treat, his ambitions and the ambitions of subsequent psychoanalysts
ultimately extended beyond the realm of therapy into social theory and

8
 Introduction

cultural critique. Freud and many early analysts had medical backgrounds.
Nevertheless, Freud came to feel strongly that psychoanalysis should
not become a medical subspecialty and, in fact, prized the cultural and
intellectual breadth that could be brought to the field by analysts with
diverse education backgrounds and intellectual interests. Many early
analysts, including Freud, were members of an emerging, educated
Jewish middle class whose upward social mobility was made possible by
the open, politically progressive policies of the Austro-Hungarian Empire
at the turn of the century and who contributed to the development of
this culture.
The early analysts thus tended to be members of a liberal, progressive
intelligentsia—a traditionally oppressed and marginalized group. They
aspired toward social acceptance but at the same time tended to regard
prevailing cultural assumptions from a critical perspective. This critical
and in some respects subversive stance went hand in hand with a vision
of progressive social transformation. Psychoanalysis began in part as a
radical critique of the illness-producing effects of social suppression
and consequent psychological repression of sexuality. Freud was deeply
interested in broad social and cultural concerns. He was critical of
various trappings of the physician’s privilege, and until the end of his life
he supported free psychoanalytic clinics, stood up for the flexible fee,
and defended the practice of psychoanalysis by professionals without
medical training. Many of the early analysts were progressive social activists
committed to political critique and social justice. Sandor Ferenczi, one
of Freud’s closest colleagues, critiqued social hypocrisy and convention­
alism, founded a free clinic in Budapest, and passionately defended the
rights of women and homosexuals. In Berlin in the 1920s, Karl Abraham,
Ernst Simmel, and Max Etington set up a public psychoanalytic clinic
that became a bastion of social and political progressivism (Danto, 2005).
A number of these analysts were influenced by left wing socialist thinking.
This is not surprising given that they came of age in the politically charged
culture of Vienna and Berlin, where the Marxist critique of capitalism was
widely discussed in intellectual circles. They viewed themselves as brokers
of social change and saw psychoanalysis as a challenge to conventional

9
 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

political codes and as more of a social mission than a medical discipline.

Prominent analysts such as Wilhelm Reich (1941), Erich Fromm (1941),
and Otto Fenichel (1945), among others, were well known for their
socialist or Marxist commitments and their fusion of psychoanalysis
and social concerns.
This subversive trend stands in contrast to the “professionalization”
of psychoanalysis in the United States, by which it became increasingly
conservative and conformist. During the early decades of the 20th century,
when psychoanalysis was beginning to take root in the United States, the
medical community was struggling to upgrade and standardize physi­
cian training. In 1938, a fateful decision was made early by the American
Psychoanalytic Association to restrict formal psychoanalytic training to
physicians. A concern about protecting the professionalism of psycho­
analysis played a role in developing a purist, elitist, and rigid form of
psychoanalysis with a veneer of scientific respectability, a discouragement
of innovation, and a tendency toward social conservatism. As psycho­
analysis became established as a subspecialty of medicine, the social
prestige of the psychoanalytic profession grew as well. Chairs in most
major psychiatry departments were psychoanalysts, and most psychiatry
residency training programs provided at least some training in psycho­
analytically oriented treatment.
The United States became the center of the psychoanalytic world, and
massive amounts of time, effort, and money went into psychoanalytic
training and the development of the profession. Psychoanalysis became
a lucrative, high-prestige, and socially conservative profession, attracting
candidates who often had an interest in becoming respected members of
the establishment rather than in challenging it (Jacoby, 1983; McWilliams,
2004). Unlike the original psychoanalysts in Europe coming from back­
grounds and educational systems that were intellectually rich and scholarly
in nature, many of the candidates entering psychoanalytic training in
the United States came from educational systems that were technical in
nature. There was a tendency for psychoanalysis to be applied as a narrow,
technical approach with rather inflexible ideas about correct and incorrect
technique, analogous to the way one tends to think of medical procedures.

10
 Introduction

Over 50 years ago, Robert Knight, then president of the American Psycho­
analytic Association, remarked on the more “conventional” character of
the psychoanalytic candidates of his era, relative to the more original
and individualistic character of the candidates of the 1920s and 1930s.
According to Knight (1953), the psychoanalytic candidates of the 1950s
were “not so introspective, are inclined to read only the literature that is
assigned and wish to get through with the training requirements as soon
as possible” (p. 218).
In addition, medical education, with its traditional respect for hier­
archy and authority, tended to infuse the training of psychoanalysts with
a sensibility that led to an unquestioning acceptance of the words of one’s
teachers rather than to the development of a critical and reflective spirit.
And this same sensibility tended to color the therapist–client relation­
ship in a way that institutionalized and exacerbated the inherent power
imbalance in the therapeutic relationship instead of encouraging a more
democratic egalitarian relationship (Jacoby, 1983; Moskowitz, 1996).
Meanwhile, various forces at play were about to lead to dramatic
changes in American psychoanalysis. With the rise of biological psychiatry
and the explosion in the development of new psychotropic medications,
psychoanalysis became less favored within American psychiatry. The
publication of the Diagnostic and Statistical Manual of Mental Disorders
(DSM; third ed.; American Psychiatric Association, 1980), which attempted
to purge the DSM of psychoanalytic thinking, further contributed to the
growing marginalization of American psychoanalysis (e.g., Horowitz,
2003). Training curricula within psychiatry residencies shifted away from
introducing residents to the basics of psychoanalytic theory and practice,
and the number of psychiatry residents applying for training in psycho­
analytic institutes decreased dramatically over time.
Around this time, the Division of Psychoanalysis (Division 39) formed
within the American Psychological Association. In 1986, Division 39
filed a class action suit against the American Psychoanalytic Association,
arguing that the refusal to admit psychologists as candidates within psycho­
analytic training institutes was a violation of the antitrust regulations
because, by establishing a monopoly of the field of psychoanalysis by

11
 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

physicians, it was preventing fair competition for clients by psychologists

and depriving them of their livelihood. Ironically, by the time the law­
suit was settled, market forces were already opening the doors of psycho­
analytic training institutes to psychologists, because as the number of
candidates seeking psychoanalytic training continued to dwindle, tradi­
tional institutes became eager to recruit psychologists (McWilliams, 2004;
Moskowitz, 1996).
In the past 30 years, many of the more significant and innovative
contributors to the development of American psychoanalytic theory
have been psychologists. Psychologists have become the torchbearers
for psychoanalysis in this country. This new breed of psychoanalytic
theorist and researcher has played a vital role in transforming psycho­
analysis into a less insular and more intellectually vital discipline,
grounded in an appreciation of contemporary developments in a broad
range of social sciences, including psychology, sociology, political science,
and philosophy. The revitalizing influence of psychology on psychoanalysis
is attributable to certain factors. First, there is more of an emphasis in
clinical psychology training programs on the development of critical-
thinking skills, in contrast to residency training in psychiatry, which
places a greater emphasis on memorization of facts and technical mastery.
Moreover, training in psychology does place more emphasis on the study
of basic psychological, developmental, cultural, and social processes that
are relevant to understanding both psychopathology and the process
of change. In addition, psychologists receive more training in empirical
research methodology than do psychiatrists. Although this does not
necessarily lead psychologists to maintain empirical research programs
after going into psychoanalytic training, it does help to hone their critical
thinking skills and to deepen their appreciation of the limits of various
theoretical constructs.
Another important variable influences the changing character of
American psychoanalysis. Given that pursuing formal psychoanalytic
training in today’s culture is less likely to be a pathway to professional
prestige or financial success, the typical candidate is more likely to be

12
 Introduction

drawn to the field for intrinsic reasons. Especially given the increasingly
marginal status of psychoanalysis within the general culture and within
mainstream clinical psychology, those attracted to the field are less likely
to buy into prevailing cultural and professional values and assump­
tions and are more likely to have a critical perspective. Thus, ironically,
the marginalization of psychoanalysis provides a potential catalyst for
innovative thinking. In this respect, important aspects of the emerging
sensibility in contemporary American psychoanalysis may be closer in
nature to the sensibility of the early psychoanalysts than that of American
psychoanalysis during the mid-20th century.

PSYCHOANALYSIS VERSUS
PSYCHODYNAMIC THERAPY
Traditionally, psychoanalysts have made a clear distinction between
psychoanalysis and what is referred to as psychoanalytic or psychodynamic
therapy. The term psychoanalysis has been reserved for a form of treat­
ment with certain defining characteristics or parameters. The term
psycho­dynamic therapy has been used to refer to forms of treatment that
are based on psychoanalytic theory but that lack some of the defining
characteristics of psychoanalysis. Over the years there has been some
controversy over which parameters of psychoanalysis are defining criteria
and which are not. A common stance has been that psychoanalysis is
long term, intensive (e.g., a minimum of three sessions per week), and
open ended (i.e., no fixed termination date or number of sessions). In
addition, traditional psychoanalysis came to be characterized by a specific
therapist stance that involves refraining from giving the client advice or
being overly directive, maintaining anonymity by reducing the amount
of information one provides about one’s personal life or one’s feeling
and reactions in the session, attempting to maintain the stance of the
neutral party by speaking sparsely, and having the client recline on a
couch while the therapist sits upright, out of view of the client. This
traditional conceptualization of some of the key characteristics of psycho­
analysis came to be known as classical psychoanalysis.

13
 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

HOW DID THE DISTINCTION

BETWEEN PSYCHOANALYSIS AND
PSYCHODYNAMIC THERAPY EMERGE?
In the 20th century, psychoanalysts in the United States often asserted
that only those within the milder range of pathology were suitable for
analysis. They would speak of a client in terms of their “analyzability,”
referring to their ability to tolerate and benefit from intensive analytic
work. Over time, analysts have experimented with treating a broader
range of clients than had initially been the case. As a result, it became
necessary to modify various treatment parameters to adapt the approach
to clients with different characteristics and needs. Some clients find
it too threatening, anxiety provoking, or destabilizing to explore their
unconscious motivation and benefit more from structure, advice, and
help with problem solving. Some require active reassurance and find the
therapist’s reluctance to provide direction or exert direct influence too
frustrating or anxiety provoking. Some feel uncomfortable lying on a
couch and experience it as a form of submission to the therapist. Some
do not have the time or the financial resources to attend frequent sessions
per week or long-term treatment. To adapt to the needs of these clients,
therapists experimented with modifying all of these parameters. These
modified versions of psychoanalysis came to be termed psychodynamic
therapies. This has resulted in inevitable tensions within the professional
communities over what can be considered “pure psychoanalysis.”
Although it is premature to say that debates of this kind have ceased,
I think it is fair to say that many psychoanalysts no longer make such
rigid distinctions. Practitioners today often use the term psychoanalysis
to refer to a depth-oriented treatment performed by a trained analyst,
irrespective of frequency or the fine points of technique. My own per­
spective is that although the distinction between psychoanalysis and
psychodynamic or psychoanalytic treatment has more to do with the
politics of the discipline and professional elitism than any theoretically
justifiable criteria, it is a mistake to assume that all of the parameters
associated with a traditional psychoanalysis are outdated. There is often
an important trade-off with these decisions of technique. For example,

14
 Introduction

the traditional analytic stance of attempting to maintain anonymity

can alienate clients, especially in contemporary American culture, which
tends to be less formal and hierarchical. At the same time, less explicit
discussion of the analyst’s thoughts and feelings can leave more room
for the client’s associations, including assumptions about the analyst that
may be informed by transference. Many clients really do need and value
advice and active feedback, but too much advice can interfere with clients’
ability to develop their own resources and perpetuate a stance of helpless­
ness. Some clients benefit from short-term treatment, but many really do
need longer treatment.
Many analysts have found that using the couch facilitates therapeutic
processes, such as helping clients to direct their attention inwards toward
more important experiences that are subtle in nature and less accessible.
It may be easier to free associate without looking to the analyst for a reac­
tion. However, I feel that there are treatments or times in a treatment
when an ongoing process of face-to-face encounter between the therapist
and client plays a central role in the change process. For example, if the
client comes to treatment with problems in intimacy, the ability to explore
the quality of emotional contact between the therapist and client on a
moment-by-moment basis can be important. It can also be critical for the
therapist to be able to see the client’s face to develop a nuanced sense of
what he or she is feeling and to be able to attune empathically. Or it may
be important for the client to have face-to-face contact with the therapist
to be able to gauge his ongoing emotional reactions. Psychoanalysts are
increasingly viewing the process of ongoing mutual affective regulation
between client and therapist as an important change process. This process
is facilitated when there is visual contact between the two and they are able
to engage in an ongoing process of mutual responsiveness to each other’s
affective experience.

15
 2

History

S igmund Freud was born in 1856 into a relatively poor but upwardly
mobile Jewish family in a small town in what was then the Austro-
Hungarian Empire, approximately 150 miles from Vienna. Despite
his broad interests growing up, he eventually chose to study medicine,
in part because of the allure of science as a possible road to fame and
prestige combined with optimism about science as the ultimate path to
knowledge. Freud’s development of psychoanalytic theory and practice
was influenced by a number of cultural and intellectual trends and scien-
tific models that dominated European circles in the late 19th and early
20th centuries (Gay, 1988; Makari, 2008, 2015). One important foun-
dation for Freud’s more abstract theoretical ideas can be found in the
dominant tradition in German neurology during Freud’s medical training,
which was based on the belief that all psychological phenomena could be
understood in neurophysiologic and mechanistic terms. This emphasis

http://dx.doi.org/10.1037/0000190-002
Psychoanalysis and Psychoanalytic Therapies, Second Edition, by J. D. Safran and J. Hunter
Copyright © 2020 by the American Psychological Association. All rights reserved.

17
 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

on grounding psychology in neurophysiology remained a key influence

in Freud’s thinking throughout his life. Although prescient in his antici­
pation of today’s booming interest and remarkable developments in
neuropsychology and the brain sciences, many of the dominant neuro­
physiological models of Freud’s era are considered outdated by contem­
porary scientific standards. Freud’s effort to synthesize psychology with
developments that were current in the fields of biology and neurophysiology
played a central role in the formulation of what is referred to as his drive
theory of motivation. In drive theory, Freud assumed that human beings
are fundamentally asocial in nature and that the primary motivation is to
maintain psychic energy at a constant level. Psychic energy is, for Freud,
a force that lies on the boundary between the physical and biological
and that drives or propels intrapsychic processes and action. According
to Freud, once psychic energy is activated (through either an internal or
external event), there is a need to discharge it in order to maintain a
constant level of psychic energy in the system. This discharge can take
place in various ways (e.g., becoming preoccupied with a person, an idea,
or a fantasy, or the eruption of symptoms).
Another formative influence on Freud’s early thinking, acquired in his
time studying in Paris with renowned French neurologist Jean-Martin
Charcot, was his exposure to what were then recent developments in
French neurology and psychiatry that were beginning to explore the
role that the splitting of consciousness can play in psychopathology
(Gay, 1988). Charcot had established an international reputation through
his use of hypnosis (or what was referred to as mesmerism) with hysterics.
Hysterics were clients who presented with a variety of dramatic physical
problems that could not be accounted for on an organic basis. These
clients tended to complain of problems such as paralysis of the limbs,
blindness, deafness, and physical convulsions (Gay, 1988). Today, this
particular pattern of symptom presentation and the associated diagnosis
are much less common.
Freud returned to Vienna as a proponent of Charcot, and he began to
synthesize French and German influences on his thinking. Subsequently,
Freud was to build on and then critique Charcot’s position. In 1886, Freud

18
 History

began collaborating with an older colleague, Josef Breuer, a mentor and

patron of Freud’s when Freud was in medical school. Breuer was a highly
respected physician in Vienna known for his dramatic successes treat­
ing clients with hysteria. His approach involved encouraging them to talk
about themselves and helping them to remember traumatic experiences
in their lives that they had forgotten. Breuer found that when these
clients were able to recall these experiences in an affectively charged
fashion, their symptoms would diminish.
Freud and Breuer came to believe that hysterical symptoms were
the result of suppressed affect or emotional experience that had been
cut off at the time of the trauma and thus had to express itself in the form
of physical symptoms. Freud came to believe that by using hypnotic tech­
niques to help clients recover memories of the trauma and to experience
associated affect that had been suppressed at the time, the client could
be cured. In the period from 1893 to 1895, Breuer and Freud published
Studies in Hysteria together—a book consisting of a number of case
histories and a theoretical section outlining their current thinking about
the psychological origins of hysteria (Breuer & Freud, 1893–1895/1955).
By the time Studies of Hysteria was published, however, Freud was
already distancing himself from Breuer, whom he felt he had outgrown,
and Freud had begun to refine both his thinking and treatment of hysteria
(Makari, 2008). At first Freud believed that most neurotic symptoms
were attributable to a history of childhood sexual abuse, a perspective
that Breuer did not share. Over time, Freud shifted his view to believe that
although sexual abuse could play a role in the development of psycho­
logical problems, recovered memories of sexual abuse were often partially
constructed and reflected unconscious or repressed childhood sexual
fantasies propelled by sexual instincts (Gay, 1988; Makari, 2008).
At the turn of the century, Freud began to pursue a long-standing
interest in the role of dreams as a potential window into unconscious
aspects of the human psyche. Freud’s (1900/1953) publication of The
Interpretation of Dreams eventually caught the attention of the highly
respected Eugene Bleuler, the director of the Burgholzli Institute in
Zurich. The Burgholzli Hospital (which specialized in the treatment of

19
 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

patients with schizophrenia) was widely known and respected throughout

Western Europe as a prominent medical and scientific establishment.
Bleuler had a number of talented young psychiatrists on his staff, includ­
ing Carl Jung. Under Bleuler’s guidance, Jung was already establishing an
important reputation in the scientific community for adapting research
methodology from experimental psychology to study unconscious pro­
cesses through word association tests. Bleuler encouraged Jung to read
Freud, and an alliance started to develop between Freud, Jung, Bleuler,
and the group of psychiatrists in Zurich working with Bleuler. Because
of the prominence of Bleuler and his colleagues within mainstream psy­
chiatry, this alliance ultimately played a critical role in contributing to
the acceptance of psychoanalysis in scientific circles throughout Western
Europe (Makari, 2008).
In 1909, Freud and Jung were invited by the American psychologist
Stanley Hall to give a series of lectures at Clark University in Worcester,
Massachusetts. The lectures were well attended and warmly received
by prominent American intellectuals, psychiatrists, neurologists, and
psychologists. This warm reception laid the ground for the subsequent
assimilation of psychoanalysis by American culture and ultimately for
the transformation of the United States into one of the most important
centers of psychoanalysis in the world (Gay, 1988; Hale, 1971, 1995;
Makari, 2008). The years leading up to World War II and the ultimate
declaration of war in 1939 were to have a profound effect on the lives of
most psychoanalysts living in continental Europe and on the develop­
ment of psychoanalysis. In Germany, the growing influence of Nazism
led to the persecution of vast numbers of continental analysts who
were Jewish. Those who had the good fortune to escape immigrated to
countries throughout the world. The United States was the most common
destination, but both England and Latin America became desirable
locations as well. All three regions developed into important centers for
psychoanalysis that ultimately led to a growing number of theoretical and
technical innovations in psychoanalytic thought influenced in different
ways by different cultures over time (Gay, 1988; Makari, 2008). In the
United States, the military began relying heavily on psychoanalytically

20
 History

oriented psychiatrists and psychologists to conduct psychological assess­

ments and treat psychologically traumatized soldiers, and this had a
massive impact on the growth of American psychoanalysis (Hale, 1995).

THE EVOLUTION OF EARLY

PSYCHOANALYTIC THINKING
In this section, I briefly summarize the evolution of early psychoanalytic
theory from the late 1890s to the mid-1920s. I begin with Freud’s early use
of hypnosis to help patients recover traumatic memories, and I continue
on to discuss the innovation of fundamental psychoanalytic principles
such as free association, resistance, and transference. By 1923 Freud
had developed his foundational structural model of the mind, which
distinguishes between three psychic agencies: the id, the ego, and the
superego.

Free Association
Although Freud’s early forays into psychoanalysis used mesmerism or
hypnosis to help clients recover lost memories and associated emotions,
over time he found this technique to be unreliable. Although some clients
were good candidates for hypnosis, many were simply not sufficiently
suggestible. Instead of hypnotizing his clients, Freud began to encourage
them to “say everything that comes to mind without censoring.” This was
the origin of the psychoanalytic principle of free association, in which
clients are encouraged to attempt to suspend their self-critical function
and verbalize fantasies, images, associations, and feelings that are on the
edge of awareness.
Over time Freud and the early analysts came to believe that it was
vital to make a clear distinction between psychoanalysis and the tradition
of hypnosis out of which it had emerged. In addition to the unreliability
of hypnotic techniques, Freud came to distrust the accuracy of many
recovered memories. Freud and his colleagues were eager to establish
psychoanalysis as a treatment that was based on scientific principles. There

21
 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

was a growing sense that one of the important values of psychoanalysis

involved the pursuit of truth. Hypnosis helps people through suggestion or
through fostering a certain type of belief. In contrast, the goal of psycho­
analysis was to help people become more skeptical and face uncomfortable
truths about themselves. Psychoanalysis did not involve indoctrination
to any particular ideas but rather was a counterindoctrination against
cultural and social beliefs and judgments (Reiff, 1966).
This emphasis on distinguishing psychoanalysis from suggestion
came to exert an important influence on early thinking about both the
mechanisms of change and preferred interventions. With respect to the
mechanisms of change, emphasis was placed on insight and understanding
as the curative factors, and the impact of more human qualities of the
therapist and the relational factors were downplayed. The key intervention
was the analyst’s interpretation, which exposed the client to aspects of his
or her unconscious that had been out of awareness. Advice, suggestion,
reassurance, and encouragement were discouraged because they blurred
the boundaries between the truth-seeking aspects of psychoanalysis and
the element of suggestion, and they could potentially compromise the
client’s autonomy by encouraging dependence on the analyst.

Resistance
Freud discovered that his clients were not always able to follow his
instructions to free associate. This led to the development of the notion
of resistance, which was understood as the client’s reluctance or inability
to collaborate with the therapist in the prescribed fashion. This difficulty
is hardly surprising considering that analysands were being asked to face
aspects of themselves that were being kept out of awareness. Facing these
inner experiences could invoke intrapsychic pain, shame, or disorganizing
confusion. At first, Freud used his authority as the doctor to pressure
clients to overcome their resistance and say whatever came to mind
regardless of their tendency toward self-censorship. Subsequently, he and
other analysts came to believe that the therapeutic exploration of the
resistance was a vitally important therapeutic task in and of itself.

22
 History

Transference
A third noteworthy stage in the ongoing evolution of Freud’s thinking
was the development of the concept of transference. Freud observed that
it was not uncommon for his clients to view him and relate to him in ways
that were reminiscent of the way they viewed and related to significant
figures in their childhoods—especially their parents. He thus speculated
that they were “transferring” a template from the past onto the present
situation. For example, a client with a tyrannical father might begin to see
the therapist as tyrannical.
At first Freud saw this transference as an impediment to treatment.
He speculated that it was a form of resistance to remembering traumatic
experiences. The idea was that the client would act out the previous
relationship in the therapeutic setting rather than remember it. Over
time, however, Freud came to see the development of the transference
as an indispensable part of the psychoanalytic process. By reliving the
past in the analytic relationship, the client provided the therapist with
an opportunity to help him or her develop an understanding of how
past relationships were influencing the experience of the present in an
emotionally immediate way. This conceptualization of the potential value
of transference provided additional justification of the therapist retaining
a neutral and uninvolved stance. The idea emerged that the analyst, by
maintaining a certain degree of anonymity (through withholding infor­
mation about his or her own life or personal reactions), could function
as a blank screen that would encourage the development of the trans­
ference and decrease the possibility that it would be contaminated by the
therapist’s real characteristics.

The Abandonment of Seduction Theory

In his early writing, Freud contended that early sexual trauma was often
the root of psychological symptoms. Over time he came to abandon his
earlier theory that all of his clients had been sexually abused as children
(the seduction theory) and instead developed the theory of infantile
sexuality and instinctual drives. Consistent with the work of sexuality

23
 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

researchers of his time, such as Havelock Ellis and Albert Moll, Freud
began to believe, in contrast to the common view that childhood is a time
of sexual innocence, that children actually experience sexual or at least
presexual feelings from the beginning and that these stem from instinc­
tual sources (Makari, 2008). Freud came to believe that these presexual
feelings lead children to have fantasies about having sexual encounters
with adults. As children mature, these fantasies are repressed because they
are experienced as threatening. Freud speculated that often memories of
sexual trauma are actually the product of reconstructed memories that
are based on childhood sexual fantasies, related to the sexual drive, rather
than real sexual trauma. So as the emphasis of his work changed to the
role of the unconscious and of fantasy, he felt that internal conflict over
sexual feelings was the real cause of neurotic problems, although he
never discounted the possibility of actual early trauma.
This shift away from the seduction theory to an emphasis on
unconscious fantasy is controversial when viewed from a contemporary
perspective in relation to issues of recovered memories of sexual abuse.
For many years the actual incidence of childhood sexual abuse was
minimized in the psychiatric literature, and survivors were not believed.
Given the current recognition that child sexual abuse is much more
common than it was once thought to be, Freud’s shift in emphasis from
seduction theory to drive theory can be seen as bolstering this denial.
In addition, Freud’s growing emphasis on the role that endogenous drives
play in the development of emotional problems led to a neglect of the
role that environmental factors, such as the quality of caretaking, play
in the developmental process. Although this neglect has been remedied
in most contemporary psychoanalytic theories, it has been the source of
understandable critique by feminist writers and advocates for survivors
of childhood abuse.

The Development of Structural Theory

In 1923, Freud published The Ego and the Id, which lays out the foun­
dations for what subsequently became known as his structural theory

24
 History

(Freud, 1923/1961). In this paper, he distinguished between three

psychic agencies: the id, the ego, and the superego. The id is the aspect
of the psyche that is instinctually based and present from birth. The
id presses for immediate instinctual gratification without any regard
for realistic concerns about the realities of the immediate situation. The
superego is the psychic agency that emerges through the internalization
of societal values and norms, which would be in conflict with the grati­
fication of id desires. The ego represents the concerns of reality and
helps the individual to reconcile the id and superego. It is thus more
rational in nature. For example, the id presses for immediate sexual
gratification, the superego opposes gratification of that desire, and the
ego allows the individual to delay instinctual gratification or to find
ways of channeling instinctual needs in a socially acceptable fashion
(e.g., skillfully seducing the object of one’s sexual desire or redirecting
one’s sexual desire in a more appropriate direction). The superego often
becomes overly harsh and demanding and can lead to self-destructive
feelings of guilt and a punitive and rejecting stance toward one’s own
instinctual needs and wishes. One of the goals of analysis has been to
help the individual become more aware of the overly harsh nature of
his superego so that he becomes less self-punitive.
When the instinctually derived wishes that begin to emerge are expe­
rienced as dangerous because they are incompatible with the demands of
the superego, the ego signals their presence with anxiety. This anxiety
triggers the use of various psychic processes to keep the wishes, fantasies,
and associated feelings out of awareness. These psychic processes, which
are referred to as defenses, are discussed in detail later. A fundamental
premise emerges out of this structural perspective: there is an ongoing
dynamic tension between instinctually derived wishes and defenses against
them. When this tension or conflict is managed in a relatively healthy way,
the individual is able to be sufficiently aware of both his needs and wishes
and the anxieties they evoke and to find a constructive and adaptive way
of negotiating this tension. However, when this conflict is managed in a
maladaptive way, psychological symptoms can result.

25
 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

PSYCHOANALYSIS BEYOND FREUD

By the time of Freud’s death in 1939, several psychoanalytic traditions
were beginning to emerge, influenced by a number of seminal theorists
writing in a range of different countries and cultural traditions. In this
section, I briefly review some of these traditions, including ego psychology,
Kleinian and post-Kleinian theory, object relations theory, interpersonal
psychoanalysis, relational psychoanalysis, and Lacanian psychoanalysis.

The Development of Ego Psychology in Britain

and the United States
Freud’s structural theory and some of the theoretical developments in his
thinking that led up to it ultimately gave rise to an important tradition of
psychoanalysis that came to be known as ego psychology. Ego psychology
focuses on the ego’s normal and pathological development, its handling
of libidinal and aggressive impulses, and its adaptation to reality. From this
perspective, neurotic symptoms are examined as a compromise between
impulses and defenses against those impulses. For example, a fear of
knives could be seen as an ego-mediated defense, informed by the pro­
hibitions of the superego, against an id-dictated aggressive drive to hurt
others. Treatment relies heavily on defense analysis; the aim is to help
patients understand their own use of defenses so that they can accept their
own desires and make freer choices.
The unofficial leader of the ego psychology tradition was Freud’s
daughter, Anna Freud, who moved to London in 1938 with her father,
1 year before he died. Under the influence of analysts such as Anna Freud
(1936), Wilhelm Reich (1941), and Otto Fenichel (1945), ego psychological
thinking emerged and placed considerable emphasis on the need for under­
standing and interpreting the defensive functioning of the ego in order to
find a way of exploring unconscious drives, fantasies, or wishes.
In the United States, the European émigré Heinz Hartmann (1964)
became one of the key figures in another strand of ego psychology that
was invested in broadening psychoanalysis beyond a psychotherapeutic
tradition into a more general theory of psychological development and

26
 History

psychic functioning. Hartmann and his colleagues were particularly

interested in the adaptive aspects of the ego and in the investigation
of the various ways in which the ego helps the individual adapt to reality.
Ego psychology became the dominant tradition of psychoanalysis in
North America at that time.
Some of the most significant, clinically relevant American psycho­
analytic writing of the time came out of the New York Psychoanalytic
Institute and was synthesized and articulated by Jacob Arlow and Charles
Brenner in particular (e.g., Arlow & Brenner, 1964). Arlow and Brenner
(1964) emphasized the ubiquity of intrapsychic conflict in all aspects
of the individual’s functioning. For example, whereas Hartman argued
that aspects of the ego are sufficiently independent of the id to be
completely rational and conflict free, Arlow and Brenner argued that all
aspects of the individual’s functioning must be understood as compro­
mises between underlying unconscious, instinctually based wishes and
defenses against them.

The Development of Kleinian and Object Relations

Theory in Britain
A second major psychoanalytic tradition emerging out of some of Freud’s
more mature thinking came to be known as object relations theory. When
Anna Freud and her father arrived in London in 1938, there was already
an influential British school of psychoanalysis emerging under the leader­
ship of the Austrian émigré Melanie Klein (1882–1960). Klein, who had
been analyzed by Freud’s close colleagues Sandor Ferenczi (1873–1933)
and Karl Abraham (1949), had immigrated to London in 1926. Origi­
nally a child analyst, Klein was particularly interested in understanding
the early relationship between the mother and the infant, and her theory
laid the groundwork for understanding how psychological maturation
involves developing internal representations of our relationships with
significant others. Klein’s thinking also set the foundation for subsequent
theoretical developments in psychoanalysis that viewed human beings as
fundamentally interpersonal creatures who have a evolutionarily based
relationship to the mother and to other human beings.

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

Object relations theory emphasizes how our internal representations

of early relationships influence the way in which we both choose romantic
partners and friends and experience others. These internal representa­
tions are referred to as internal objects or internal object relations. Much of
the writing about the process through which internal objects or internal
object relations are developed (a process referred to as internalization),
although clinically rich, is conceptually complicated and can be ambiguous
and difficult to grasp (Eagle, 1984; Schafer, 1968).
Once Anna Freud arrived in London and began the process of estab­
lishing her own power base, the theoretical rivalries between Kleinians
and Freudians became intense and vitriolic, threatening the survival of
the relatively new British Psychoanalytic Society. During a series of what
were characterized as “controversial discussions,” Freudians critiqued
many of the central Kleinian ideas. These discussions revolved around
critiques of fundamental Kleinian assumptions such as the degree to which
elaborate unconscious fantasies can be attributed to infants and the
Kleinian tendency to emphasize interpretations of deep unconscious
fantasies in both children and adult clients, without an adequate explora­
tion of defenses that are closer to the client’s conscious awareness. These
discussions (or more accurately, heated debates) ultimately led to further
clarifications in both Kleinian and Freudian thinking.
A so-called gentleman’s agreement was forged between the Freudians
and Kleinians in which it was agreed that the two traditions would
coexist within the British Psychoanalytic Society. Throughout the 1940s
and 1950s, some of the more innovative theoretical and technical work
emerged out of the work of Klein and her followers, who became par­
ticularly interested in working with difficult treatment-resistant cases.
Some of the more prominent Kleinian analysts who emerged during
this period included theorists such as Hannah Segal, Herbert Rosenfeld,
Joan Riviere, Susan Isaacs, Esther Bick, and Wilfred Bion (for a review,
see, e.g., Sayers, 2001).
A third group of psychoanalytic theorists emerging out of the British
Psychoanalytic Society consisted of analysts who were influenced by
both Freudian and Kleinian ideas but were unwilling to formally align

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 History

themselves politically with either tradition. These analysts, who became

known as the British Independents or the Middle Group, consisted of
theorists such as Ronald Fairbairn, Michael Balint, Donald Winnicott,
Marion Milner, Masud Khan, and John Bowlby (for an excellent survey
of the British Independent tradition, see Rayner, 1991). Some of the key
qualities associated with the work of these Middle Group analysts were
an emphasis on the importance of spontaneity, creativity, and therapist
flexibility and the value of providing clients with a supportive and nur­
turing environment. Many developments coming out of the Kleinian and
Middle Group traditions have subsequently been assimilated into more
recent developments in American psychoanalysis. Winnicott (1958, 1965)
in particular has become an important inspiration to many contempo­
rary North American psychoanalysts who place an important emphasis
on creativity, spontaneity, and authenticity. And John Bowlby’s work has
given rise to the extremely fertile area of attachment theory and research.
Different object relations theorists (e.g., Fairbairn, 1952, 1994; Klein,
1955/2002a, 1975/2002b) have different models of internalization. For
example, Klein theorized that internal objects emerge out of the inter­
action of real experiences and unconscious fantasies that are instinctively
derived. According to her, people are born with instinctually based
passions related to both love and aggression that are linked to unconscious
fantasies and images about relationships with others. The unconscious
fantasies linked to these instincts exist prior to any actual encounter
with other human beings and serve as the scaffolding for the perception
of others.
In Klein’s thinking, instinctually based aggression plays a particularly
important role. She believed that infants experience their own aggression
as intolerable. For this reason, they need to fantasize that this aggression
originates in the other (typically the mother in Klein’s thinking) rather than
in themselves. Klein uses the term projective identification to designate
the intrapsychic process through which feelings originating internally are
experienced as originating from the other. These unconscious fantasies
of aggressive, persecuting others (referred to as internal objects by Klein)
become part of the infant’s psychic world. These aggressive “bad” internal

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

objects then color their perception of significant others who they see as
dangerous and persecuting. To retain some perception of the other as
potentially good and not persecutory, infants unconsciously split the
image of the other or the internal object into good and bad aspects. The
good aspect is thus able to remain uncontaminated by the bad aspect.
Over time, as a result of both cognitive and emotional maturation and
ongoing encounters with real significant others, the child is able to begin
integrating the good and bad objects into one whole and to re-own
aggression as emerging from the self.
Fairbairn theorized that internal objects are established when the
individual withdraws from external reality because the caregiver is
unavailable, frustrating, or traumatizing, and instead creates a type of
internal reality as a substitute. According to Fairbairn, to the extent that
one has unsatisfying relationships with actual significant others, one
becomes preoccupied with fantasized relationships, which become repre­
sented unconsciously. These fantasized relationships become important
building blocks for one’s experience of the self because the self is always
experienced in relation to others, whether in fantasy or reality. From
Fairbairn’s perspective, the problem is that defensive attempts to control
significant others by developing fantasized relationships with them, rather
than real ones, are ultimately only partially successful. The reason for this
is that the depriving or traumatizing aspects of the significant other that
provide the raw material for the unconscious fantasy or internal object
inevitably end up becoming part of the internal structure or enduring
psychic organization that is developed.

The Movement Toward Psychoanalytic Pluralism

in North America
Unlike the British analytic establishment, which formally institutional­
ized three psychoanalytic traditions, in the United States of the mid-20th
century only one psychoanalytic tradition was accepted: ego psychology.
American psychoanalysts were by and large unfamiliar with British
object relations theory, and American theorists diverging too far from

30
 History

mainstream ego psychology either resigned from or were forced out of

the American Psychoanalytic Association and started their own schools
of thought.
One of the most notable mavericks was Harry Stack Sullivan
(1892–1949), an iconoclastic American-born psychiatrist who had never
received any formal psychoanalytic training. Sullivan (e.g., 1953) devel­
oped his own model of psychoanalytically oriented psychiatry, which was
strongly influenced by a type of social field theory emerging out of the
Chicago School of Sociology and symbolic interactionist thinking. Unlike
Freud, Sullivan theorized that the need for human relatedness is the
most fundamental human motivation, as opposed to instinctual drives.
He also believed that it is impossible to understand the individual out
of context of relationships with others and that this principle extends to
the therapeutic relationship. In contrast to mainstream psychoanalysts,
Sullivan argued that everything transpiring in the therapeutic relationship
needs to be understood in terms of both the client’s and the therapist’s
ongoing contributions rather than exclusively in terms of the client’s
psychology or the transference. Although Sullivan published very little
(most of his books consist of posthumously published lectures), he had a
formative influence on the training of American psychoanalysts, primarily
through his lectures and supervising.
Sullivan befriended and became a mentor to another American-born
psychiatrist, Clara Thompson (1957). With Sullivan’s encouragement,
Thompson went to Europe to seek training with Sandor Ferenczi, who
was transitioning toward a more interpersonal perspective in his more
mature work. Sullivan and Thompson ultimately formed an alliance with
Erich Fromm. Fromm, a European-born and European-trained psycho­
analyst with a background as a sociologist, had an interest in the synthesis
of psychoanalysis and sociological and political thinking. In addition,
over time he came to incorporate humanistic and existential ideas into
his thinking (e.g., Fromm, 1941). Fromm’s perspective placed consider­
able emphasis on the importance of the authentic human encounter in
the therapeutic relationship. In 1946, Sullivan, Thompson, and Fromm
founded the William Alanson White Institute in New York. The White

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

Institute subsequently was the foremost center of American interpersonal

psychoanalysis.
Another important figure who came to play a key role in the move­
ment toward a more pluralistic perspective in North American psycho­
analysis was Heinz Kohut (1984). Kohut was a European émigré who
completed his medical training in Vienna in 1939 and then immigrated
to Chicago, where he completed both his residency in psychiatry and his
formal psychoanalytic training. For years, Kohut was a well-respected
mainstream ego psychologist. As his thinking and clinical work evolved,
however, he became particularly interested in the treatment of narcissism,
and over time his theoretical formulations diverged increasingly from
mainstream psychoanalytic ideas. Kohut aimed to understand the pro­
cesses through which the individual develops a cohesive sense of the self,
an experience of inner vitality, and a capacity for self-esteem. He placed an
increasing emphasis on the role that the therapist’s empathic stance plays
as a mechanism of change in and of itself, and in the centrality of this
process in repairing ruptures in the therapeutic relationship when they
occur as a result of the therapist’s inevitable lapses in empathy.
Rather than focusing on developing adaptive compromise formations,
Kohut focused on helping clients to develop a cohesive sense of self and
a sense of inner vitality and engagement in meaningful life projects. This
emphasis on transforming an inner sense of emptiness into one of vitality
and authenticity mirrored important developments taking place in the
work of important British Middle Group theorists such as Michael Balint
and Donald Winnicott. Ultimately Kohut broke away from the main­
stream and founded the tradition of self psychology.
The development of relational psychoanalysis was the most impor­
tant stage in the ultimate fragmentation of the monolithic psychoanalytic
perspective that had dominated American psychoanalysis. This was
achieved by bringing together a range of psychoanalytic perspectives
into a new paradigm. A key publication was Jay Greenberg and Stephen
Mitchell’s (1983) book Object Relations in Psychoanalytic Theory. This
book provides a scholarly examination and critique of the work of a broad
range of different psychoanalytic theorists from both the United States

32
 History

and Britain. It provides a framework for schematizing the relationship

between various key psychoanalytic theorists and for understanding
both the intellectual and sociopolitical factors leading to the evolution of
their approaches. Greenberg and Mitchell argued that the entire history
of psychoanalysis can be understood as the attempt to develop an inter­
personal model of motivation and functioning without discarding Freud’s
model of motivation, which is based on drive theory.
Greenberg and Mitchell’s (1983) book accomplished numerous objec­
tives. First, it established a legitimate role for the tradition of American
interpersonal psychoanalysis within the mainstream psychoanalytic
tradition by drawing parallels between what Sullivan was trying to
accomplish theoretically and what more mainstream psychoanalysts were
attempting to achieve (e.g., Heinz Hartmann, Edith Jacobson, Margaret
Mahler, Otto Kernberg). They illustrated the way in which a range of
different theorists, including Sullivan, were attempting to elaborate on
the interpersonal aspects of psychoanalysis that were implicit in Freud’s
thinking but not conceptualized in a theoretically systematic and coherent
fashion. They introduced Sullivan’s interpersonal perspective to an
audience of ego psychologists who were by and large unfamiliar with it.
Just as important, they introduced both interpersonal analysts and
American ego psychologists to the seminal work of British object relations
theorists such as Klein, Fairbairn, and Winnicott.
Subsequent decades have seen many important developments in
theory and practice within a relational framework, which are spelled out
in the subsequent chapters of this book. Of particular note is the work
of analysts, including Phillip Bromberg, who proposed a model of the
mind as consisting of multiple self-states that may be in conflict with one
another and that emerge in different relational contexts (e.g., Bromberg,
1998, 2006; Harris, 2008; Mitchell, 1993; Pizer, 1998). The concepts of
affect regulation and mentalization, coming out of attachment theory,
have been increasingly influential on relational thinkers (Fonagy, Gergely,
Jurist, & Target, 2002). In addition, the work of Lew Aron (1996, 2006)
on mutuality in the therapeutic relationship and the work of Jessica
Benjamin (1988, 2018) on intersubjectivity have been significant historical

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developments in our understanding of the mind and how to work with it

in treatment.

Klein and Post-Kleinian Traditions

in Europe and Latin America
Because this book is aimed primarily at an American audience, the focus
has been on developments that have had the greatest influence on the
American psychoanalytic tradition. At the same time, two additional
developments have been influential in other parts of the world and are
now having an impact on American psychoanalysis. The first develop­
ment can be designated as Kleinian and post-Kleinian thinking. A host
of innovative thinkers in various parts of Europe and Latin America
have built on Kleinian thinking in creative and clinically useful ways.
Of particular note is the Kleinian or neo-Kleinian emphasis on careful
moment-by-moment monitoring of the extent to which the client is
making constructive use of the therapist’s interventions, as well as the
potential role that the client’s feelings of badness and inadequacy and
envy of the therapist’s apparent goodness and bountifulness can play in
his or her inability to make constructive use of therapeutic inter­ventions
(e.g., Joseph, 1989). Examples of extremely influential Kleinian and
post-Kleinian theorists in Latin America and continental Europe include
Heinrich Racker, Willi and Madeline Baranger, Leon Grinberg, Horacio
Etchegoyen, Ignacio Matte-Blanco, and Antonino Ferro (Etchegoyen,
1991; Ferro, 2002). Many of these theorists have also been profoundly
influenced by the prominent neo-Kleinian analyst Wilfred Bion (1970).

Lacanian Theory
A final major psychoanalytic tradition is Lacanian and post-Lacanian
theory. This tradition, which originated in the work of French psycho­
analyst Jacques Lacan (1901–1981), played a central role in the develop­
ment of French psychoanalysis. It has also become highly influential in
Latin America (especially Argentina) and has had an important influence

34
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on psychoanalysis in continental Europe and increasingly in England.

In the United States, the influence of Lacanian thought has mostly been
limited to the areas of literary criticism, the humanities, and feminist
thinking. But Lacanian concepts are beginning to make their way into
American clinical psychoanalysis as well. Lacan is notoriously difficult to
understand, in part because his thinking is embedded in the context of
the French intellectual tradition that is stylistically very different from the
Anglo-American intellectual tradition.
Lacan (1975/1988a, 1978/1988b) was extremely critical of the American
tradition of ego psychology, which he viewed as betraying Freud’s most
radical and important insights about the centrality of unconscious pro­
cesses and of emphasizing conventionality and adaptation to society.
In contrast to American ego psychologists who emphasized the adaptive
aspects of the ego, Lacan argued that the ego (i.e., one’s sense of “I”) is an
illusion. According to Lacan, our identity or sense of “I-ness” is forged
out of a misidentification of ourselves with the desire of the other. This
begins in our childhood when we attempt to satisfy the desire of others,
initially as incarnated in the desires of the mother; in other terms, one could
say that we develop a sense of who we are through the construction of an
identity that is designed to satisfy the needs and fantasies of our parents.
Unlike Winnicott (or for that matter, humanistic psychotherapists),
however, Lacan does not believe that there is a true self waiting to be
discovered, underlying the illusory sense of “I” that we experience. Instead,
there is emptiness, or what Lacan refers to as a lack—a fundamental sense
of alienation from the self. This fundamental experience of alienation or
lack stems from a variety of sources. One of the most important is that our
experience cannot be symbolized or communicated without the medium
of language. The very process of symbolizing our experience through
language, however, results in a distortion of this experience and con­
tributes to the experience of alienation.
If there is no true self waiting to be discovered or uncovered, what
is the essence of cure from a Lacanian perspective? Lacanian theory is
ambiguous on this point. On one hand, Lacan emphasized the importance
of developing a true ownership of one’s own desire and a separation from

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

the desire of the other. On the other hand, he argued that desire by its very
nature can never be satisfied. There is thus a level at which Lacan appears
to be saying that an important goal of analysis is to accept this intrinsic
lack and to come to terms with it (Moncayo, 2008).
Lacan developed an iconic status in French culture because of his
radical challenge to conventional rules and his attacks on traditional
societal standards. Furthermore, Lacan strongly promoted accepting
candidates from a wide range of educational backgrounds into psycho­
analytic training and challenged existing psychoanalytic orthodoxies and
forms of authoritarianism. His intellectual engagement with well-known
French left-wing intellectuals also contributed to his popularity. Psycho­
analysis in France blossomed and emerged as a progressive and revolu­
tionary force at precisely the same time as psychoanalysis in the United
States was becoming a more conservative cultural institution.
In Latin America, Lacanian psychoanalysis emerged as an important
cultural force in the climate of political ferment leading up to the emer­
gence of the dictatorships of the 1970s and 1980s. Unlike France, countries
such as Argentina and Brazil had well-established psychoanalytic estab­
lishments by this time. The dominant psychoanalytic associations were
beginning to splinter into conservative apolitical factions, and a younger
generation of analysts felt that an apolitical or accommodationist stance
in the face of oppressive totalitarian regimes was indefensible. The anti­
authoritarian, politically subversive elements of the Lacanian tradition,
as well as its connection to left-wing intellectual circles, played important
roles in enhancing its appeal. With the downfall of the various dictatorships
in Latin America in the early to mid-1980s, Lacan’s influence blossomed
more fully (Plotkin, 2001).

36
 3

Theory

W hat are the values and goals of psychoanalysis and psycho­

analytically oriented theory and therapy? There is no simple
answer to this question given the host of different psychoanalytic tradi­
tions and the evolving nature of psychoanalysis. Nevertheless, I attempt
to articulate a few of the key values represented within a range of diverse
psychoanalytic traditions, some of them complementary and some existing
in tension with one another.

PSYCHOANALYSIS AS A BOUNDARY DISCIPLINE

Psychoanalysis has been classified alternatively as a medical discipline,
a science, an interpretive or hermeneutic system, a philosophical system,
and a form of cultural criticism. Whereas Freud was intent on establishing
psychoanalysis as a science, many contemporary critics have argued that

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Copyright © 2020 by the American Psychological Association. All rights reserved.

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

it is a “failed science” (e.g., Grunbaum, 1984). At the same time, there is

a tendency among many contemporary proponents of psychoanalysis to
argue that the attempt to think of psychoanalysis as science was misguided
in the first place and that psychoanalysis is more accurately conceptu­
alized as a hermeneutic or an interpretive discipline. Although many
psychoanalytic concepts have not been tested empirically, and many are
unverifiable to begin with, a host of empirical studies support a range of
different psychoanalytic concepts (for a review of some of this empirical
literature, see Westen, 1998; Westen & Gabbard, 1999). A substantial and
growing body of research also supports the effectiveness of psychoanalytic
treatment (Leichsenring, Leweke, Klein, & Steinert, 2015; Levy, Ablon, &
Kaechele, 2012; Shedler, 2010).
Notwithstanding this growing evidence, debates such as whether
it is best to conceptualize psychoanalysis as a science or a hermeneutic
discipline will inevitably continue, I believe, because psychoanalysis lies
on the boundary between various intellectual and scientific disciplines.
This liminal status has led to considerable confusion about how to
think about psychoanalysis, but it has also been an important source
of vitality.

PSYCHOANALYSIS AND THE NATURE

OF MENTAL HEALTH
To begin thinking about the goals of psychotherapy, it is essential to make
some assumptions about what psychological health looks like. Different
forms of psychotherapy and different psychoanalytic traditions hold
different assumptions about what a good life is, which affects the goals
of treatment. Freud’s (1895/1955) oft-quoted remark that psychoanalysis
transforms neurotic misery into ordinary unhappiness is seen by some
as reflecting a pessimistic perspective on life. But it can also be seen as
embodying a certain form of wisdom. Freud believed that life by its very
nature involves various forms of suffering: illness, loss of loved ones and
friends, disappointments, and ultimately death. It is essential, however, to
distinguish what might be termed existential suffering from self-imposed

38
 Theory

neurotic suffering. From Freud’s perspective, one of the goals of psycho­

analysis is to help people learn to grapple with life’s inevitabilities with a
certain degree of equanimity and dignity.
Many contemporary psychoanalysts have emphasized the goal of living
life with vitality. Dimen (2010), paraphrasing author Andrew Solomon,
said that “good treatment restores vitality, not happiness” (p. 264). In
addition, for many contemporary psychoanalysts there is an emphasis on
challenging potentially oppressive normative emphases on singular and
conventional definitions of “mental health” and on replacing them with
a respect for and appreciation of the infinite number of ways of being in
this world and a celebration of this diversity. In the words of influential
British psychoanalyst Donald Winnicott (1958), “We are poor indeed if
we are only sane” (p. 150).
In numerous respects psychoanalysis goes against the grain of many
values that are characteristic of our culture and that are reflected in such
developments as the managed care system and the evidence-based treat­
ment movement. The managed care system, the evidence-based treatment
models, and the dominance of cognitive–behavioral tradition promote
such values as clarity, activity, speed, concreteness, practicality, realism,
efficiency, systematization, and consistency and limit goals to the absence
of diagnosable symptoms.
Psychoanalysis, in contrast, tends to value such dimensions as com­
plexity, depth, nuance, and patience and aims to address character issues
that keep the patient from living fully. These values can be traced back
to some aspects of Freud’s early thinking and are expressed in different
ways in different psychoanalytic traditions. Freud cautioned analysts
that the “furor sanandi” (an excessive zeal to cure) could interfere with
the therapist’s ability to assume the kind of attitude of patience and
acceptance that is necessary to be truly helpful. Wilfred Bion (1970) is
famous for speaking about the importance of approaching every session
“without memory or desire” in order to allow the “emotional truth” of
what is taking place to emerge (p. 57).
The downside of this type of perspective is that it can lend itself to the
type of never-ending analysis that is caricatured in Woody Allen movies

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

and that clients have valid reasons to be concerned about. In fact, some
very prominent analysts have argued that this attitude can too often
degenerate into a failure to grapple with the question of what is genuinely
helpful to clients and is one of the factors that has led to the declining
popularity of psychoanalysis (Renik, 2006). On the other hand, this
emphasis can serve as a valuable corrective to the contemporary Western
tendency to overestimate our capacity for individual efficacy and
mastery and that fails to recognize the limitation of our ability to “have
it all.”

Complexity, Ambiguity, and Curiosity

Psychoanalysis tends toward the view that at a fundamental level, human
beings are complex creatures whose experience and actions are shaped by
multiple and often conflicting conscious and unconscious determinants,
as well as by social and cultural forces. Related to this is an emphasis on the
importance of tolerance of ambiguity. Psychoanalytic thinking assumes
that given the complexity of human experience, there is a fundamental
ambiguity to the therapeutic process. This sense of ambiguity forecloses
the possibility of pat understandings of what is going on with one’s client
or in the therapeutic process. This can lead to a fair amount of anxiety
for novice therapists who want to feel that they can understand what is
going on in a definitive fashion and have clear guidelines for practice.
The positive side of this fundamental ambiguity is that it encourages
genuine curiosity for watching the process emerge and allowing one’s
understanding to unfold and evolve over time (McWilliams, 2004).
This is associated with a genuine respect for the complexity of human
nature and a feeling of humility in the face of the ultimate unknowability
of things.

The Ethic of Honesty

Freud believed in the importance of shedding one’s illusions and coming
to accept the inevitabilities of life. He believed that self-deception is

40
 Theory

ubiquitous, and he valued the process of self-reflection and truth seek­

ing (in the sense of searching for one’s real motives). One could say that
psychoanalysis is associated with an ethic of honesty (McWilliams, 2004;
M. G. Thompson, 2004). Clients are encouraged to strive to be truthful
with themselves about their own motives, and this type of honesty is
expected of therapists as well.
Once we accept the idea of unconscious motivation, we recognize
that we are all, at some level, strangers to ourselves. We begin to see that
we therapists are just as susceptible to self-deception as our clients are.
It is not unusual for trainees in supervision to figure out that they were
intervening in a certain way because of feelings they were completely
unaware of (e.g., competitiveness, insecurity, irritation, a desire for
control) and that our rational or theoretical understanding of why we
are acting as we are as therapists is often only part of the story or an
after-the-fact justification.
Conducting psychotherapy from a psychoanalytic perspective thus
inevitably involves an ongoing process of self-discovery and personal
growth for therapists. It is difficult to work with clients, especially chal­
lenging ones, without being willing to explore one’s own contribution to
what is going on in the therapeutic relationship in an ongoing fashion
and a willingness to reflect on why we are doing what we are doing in a
given session. Many contemporary psychoanalysts believe that in many
successful treatments, both the client and the therapist change as they
learn about themselves.

A Search for Meaning, Vitality, and Authenticity

Freud’s emphasis was on becoming aware of our irrational, instinctually
based wishes and then renouncing or taming them through our rational
faculties. One change in the goals of contemporary psychoanalytic
thinking is an increased focus on creating meaning and revitalizing
the self. This shift in clinical sensibility corresponds to changes in the
cultural landscape from Freud’s time to ours. Psychoanalysis was born
during an era when individualism was in the process of becoming more

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

pronounced. In the Victorian culture of Freud’s time, the self was viewed
as dangerous, and an emphasis was placed on self-mastery and self-control
(Cushman, 1995). Over the last century, the culture of individualism has
continued to evolve, and the people have become increasingly isolated
from community. This is a double-edged sword. On one hand, the more
individuated person of contemporary culture is freer of the potentially
suffocating judgment from community. On the other hand, he or she is
cut off from the sense of meaning and well-being that potentially flows
from integration with a wider community.
The disintegration of the unifying web of beliefs and values that
traditionally held people together has resulted in the emergence of
what Philip Cushman (1995) referred to as the empty self. This empty
self experiences the lack of tradition, community, and shared meaning
as an internal hollowness; a lack of personal conviction and worth; and
a chronic, undifferentiated emotional hunger. In contemporary Western
culture, psychological conflicts are thus more likely to involve a search
for authentic meaning and a hunger for intimate and meaningful rela-
tionships than a conflict between sexual instincts and cultural norms
(Mitchell, 1993; Safran, 2017).
Philosophers and historians tell us that the concept of authenticity
is a relatively novel invention that emerged in 18th-century Europe
(Guignon, 2004; Taylor, 1992). Its emergence was associated with the
rise of the culture of Romanticism. The Romantic movement can be under-
stood as a backlash against the Enlightenment, an attempt to recover
a sense of oneness and wholeness lost with the rise of modernity. The
Romantic movement holds that truth is discovered not through scientific
investigation or by logic but through immersion in one’s deepest feelings.
There is a distrust of society in the Romantic movement and an implicit
belief in the existence of an inner “true self” that is in harmony with
nature. Conventional social rituals are seen as artificial and empty and
as potentially stifling authenticity. Consistent with this sensibility, there
is an important thread in contemporary psychoanalytic thinking that
views the therapist’s authentic responsiveness to the client as a significant
element in the change process. The therapist’s ability to act spontaneously

42
 Theory

or to improvise in response to the demands of the moment is viewed as

a potential antidote to the devitalizing effects of social ritual and confor­
mity in people’s lives (Ringstrom, 2007; D. N. Stern et al., 1998). Irwin
Hoffman has persuasively argued that it is important not to emphasize
the value of spontaneity at the expense of ritual, and vice versa. He has
argued instead for the value of thinking in terms of the dialectical interplay
between ritual and spontaneity in the therapeutic process; the interested
reader is referred to I. Z. Hoffman (1998).

Reflection-in-Action Versus Technical Rationality

At a time when there is a growing emphasis in the psychotherapy field
on the importance of developing evidence-based practices that can be
delivered in a standardized fashion, there is a contrasting trend in
contemporary psychoanalytic thinking to emphasize the unique nature
of every therapeutic encounter and the impossibility of developing
“standardized” interventions or principles of intervention. The idea that
professional knowledge consists of “instrumental problem solving made
rigorous by the application of scientific theory and technique” is referred
to as technical rationality by Schön (1983, p. 21). Of interest, Schön and
others conducting research on differences in the problem-solving styles
of experts versus novices (e.g., Dreyfus & Dreyfus, 1986) have found
that skilled practitioners across a wide range of disciplines (musicians,
architects, engineers, managers, psychotherapists) do not problem solve
in a manner consistent with this model of technical rationality. Instead,
they engage in a process of what Schön termed reflection-in-action. This
entails an ongoing appraisal of the evolving situation in a rapid, holistic,
and (at least partially) tacit fashion. The process involves a reflective
conversation with the relevant situation that allows for modification of
one’s understanding and actions in response to ongoing feedback.
Contemporary psychoanalytic thinkers have argued that this notion
of reflection-in-action provides a better framework for conceptualizing the
therapeutic activities of a skilled therapist than does the model of techni­
cal rationality (Aron, 1999; I. Z. Hoffman, 2009; Safran & Muran, 2000).

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

The therapist can no longer look toward a unitary and universal set of
principles to guide their actions. Instead, therapists are confronted with
a multiplicity of theoretical perspectives that they can use to help them
reflect on how best to act in this particular moment with this particular
client. Any guidelines derived from theory must ultimately be integrated
with a therapist’s own irreducible subjectivity (Renik, 1993) and with the
unique subjectivity of the client to find a way of being that is facilitative
in a given moment.

KEY CONCEPTS
In this section, I outline some of the central concepts of psychoanalytic
thinking. Most, if not all, of these concepts have evolved over time.
In addition, whereas some of these concepts originated in the early days
of psychoanalytic thinking, others emerged at later stages in the evolution
of psychoanalytic theory.

The Unconscious
The concept of the unconscious is central to psychoanalytic theory. Over
time, psychoanalytic conceptualizations have evolved, and these days,
divergent models of the unconscious are emphasized by different psycho­
analytic schools. Freud’s original model of the unconscious suggested that
certain memories and associated affects are split off from consciousness
because they are too threatening to the individual. As Freud’s thinking
about the unconscious developed, he began to use the term primary
process for the unconscious level of cognition. In primary process, there
is no distinction between past, present, and future. Different feelings
and experiences can be condensed together into one image or symbol,
feelings can be expressed metaphorically, and the identities of people
can be merged. The “language” of primary process does not operate
in accordance with the rational, sequential rules of secondary process or
consciousness. Primary process can be glimpsed in dreams and fantasy
and underlies disowned wishes or feelings. Secondary process is more

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conscious and is the foundation for rational, reflective thinking. It takes

the disorderly unconscious and makes it logical and sequential.
Freud came to think of the unconscious not only in terms of traumatic
memories that had been split off but also in terms of instinctual impulses
and associated wishes that are not allowed into awareness because they
are unacceptable through cultural conditioning. These instincts and
associated wishes are often related to the areas of sexuality and aggression.
For example, a woman has sexual feelings toward her sister’s husband but
disavows them or pushes them out of awareness because she experiences
them as too threatening. Freud referred to the process through which
unacceptable wishes are kept out of awareness as repression.
Many contemporary interpersonal and relational psychoanalysts
find it more useful to think of the mind as consisting of multiple self-states
that to varying degrees may be in conflict with one another and that
emerge in different relational contexts (e.g., Bromberg, 1998, 2006; Davies,
1996; Harris, 2008; Mitchell, 1993; Pizer, 1998). From this perspective,
there is no central executive control in the form of the ego. Consciousness
is a function of a coalition of different self-states. It is thus an emergent
product of a self-organizing system that is influenced in an ongoing
fashion by current interpersonal context. From a developmental perspec­
tive, experience taking place in the context of interpersonal transactions
that are intensely anxiety provoking or traumatic can be kept out of
awareness. But there is no hypothetical psychic agency keeping it out of
awareness. Instead, there is a failure to attend to the experience and
construct a narrative about it (D. B. Stern, 1997, 2010). It is therefore
this failure of attention and construction that leads to the splitting off or
dissociation of aspects of experience. And just as the interpersonal context
leads to the dissociation of experience in the first place, we need others
to help us attend to and construct a narrative about it. As Donnel Stern
(2010) put it, the therapist thus serves as an essential “partner in thought”
for the client.
Whether the unconscious is conceptualized in traditional Freudian
terms or in terms of aspects of experience that are not symbolized
(or self-states that are dissociated), the concept of the unconscious is

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central to psychoanalytic thinking. For most psychoanalysts, one of

Freud’s (1920) most important insights is that we are not masters of our
own home. We are all motivated by forces outside of our awareness.

Fantasy
Psychoanalytic theory holds that fantasies play a meaningful role in psychic
functioning and the way in which people relate to external experience.
Fantasies vary in the extent to which they are part of conscious awareness—
ranging from daydreams and fleeting fantasies on the edge of awareness
to deeply unconscious fantasies that are defended against. In Freud’s early
thinking, these fantasies were linked to instinctually derived wishes and
served the function of a type of imaginary wish fulfillment. In this view
of fantasies, they are typically linked to sexuality or aggression. Over time
Freud and other analysts developed a more elaborated view that sees
fantasies as serving a number of psychic functions, including regulating
self-esteem, offering a feeling of safety, aiding in regulating affect, and
helping to master trauma. Because fantasies are viewed as motivating
our behavior and shaping our experience, yet for the most part operate
outside of focal awareness, exploring and interpreting clients’ fantasies
are important parts of the psychoanalytic process.

One-Person Versus Two-Person Psychologies

A significant development that has taken place across a range of different
psychoanalytic schools has been a shift from what has come to be termed a
one-person psychology to a two-person psychology. Freud’s original view of
the therapist as an objective and neutral observer who could serve as a
blank screen onto whom the client projects their transference has been
replaced with a view of the therapist and client as coparticipants who
engage in an ongoing process of mutual influence at both conscious and
unconscious levels. The conceptual shift has important implications for
the evolution of many of the concepts we discuss (e.g., resistance, transfer­
ence, countertransference), as well as for psychoanalytic technique, because

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it implies that the therapist cannot develop an accurate understanding

of the client without developing some awareness of the therapist’s own
ongoing contribution to the interaction. Although the therapist’s goal
still remains one of ultimately understanding and helping the client, this
cannot be accomplished without an ongoing process of self-exploration
on the therapist’s part. This is especially the case with difficult or more
disturbed clients, who tend to evoke complex feelings and reactions
in others. But the process of exploring one’s own contributions to the
therapeutic relationship can help to illuminate subtle aspects of psychic
functioning and interpersonal style in less disturbed clients as well.

Knowledge and Authority

Traditionally psychoanalysis has emphasized the therapist’s ability to
know things about clients that they cannot see themselves. This is both
because we are all inevitably blinded by our own limits to conscious
awareness and because therapists have an advantage with respect to
understanding things as a result of their training, expertise, and own
personal growth. Privileging the therapist’s understanding has exacer­
bated a power imbalance within the therapeutic relationship and can
lead to abuses of the therapist’s authority. This disparity could make
a client feel that they are being denigrated or patronized. Because the
client is the one seeking help from the therapist, he or she is inevitably
less empowered.
In Freud’s time, it was assumed that therapists had a type of objec­
tivity that clients did not have and that because of clients’ unconscious
conflict and inability to break through their own defenses and become
aware of unconscious experience, therapists both by virtue of their
specialized training and personal analysis and their ability to see clients
from the outside had the ability to interpret clients’ unconscious conflicts.
As discussed earlier, in contemporary psychoanalytic thinking there
has been a shift toward a two-person psychology and a greater focus on
the mutuality of the therapeutic relationship. The therapist is no longer
seen as the expert on the client’s unconscious. Moreover, with the growing

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emphasis on the therapist’s inevitable embeddedness in the interpersonal

field and increased transparency, there is more of a sense that reality is
“up for grabs” in the therapeutic relationship.

Defenses
One of an analyst’s most important tools for understanding a client is
their pattern of defensive functioning. A defense is an intrapsychic process
that works to avoid psychic pain by pushing thoughts, wishes, feelings, or
fantasies out of awareness. In traditional psychoanalysis, defenses were
viewed as a way to keep sexual or aggressive impulses out of awareness,
but a more current view sees defenses as serving many purposes, includ­
ing maintaining self-esteem, keeping a sense of connection to others, and
dealing with threatening feelings ranging from anxiety to terror. Defenses
are necessary to deal with everyday life and are often adaptive. We could
not function if we experienced all of our thoughts and feelings all of the
time, and we need to diffuse reactions with techniques such as humor.
However, when defenses are rigid and/or out of awareness, they can be
highly problematic and correlate with pathology. For example, if a person
defends against fear of abandonment by angrily finding fault with the
other, it would be difficult to sustain closeness.
In the heyday of ego psychology, a systematic attempt was made to
conceptualize and categorize defenses. A distinction was made between
higher level defenses and lower level defenses. The higher level or mature
defenses are associated with neurotic functioning; examples include
intellectualization, where using abstract ideas keeps the feelings dis­
tanced, and undoing, where an impulse that is felt to be unacceptable
is transformed into its opposite. Disowned anger toward a friend might
lead to flattery, for example. Lower level defenses are also called primitive
and are associated with character disorders and psychotic symptomatol­
ogy. Three examples are denial, where objective reality is not acknowl­
edged; dissociation, where consciousness is disrupted in an effort to deal
with an upsetting reality; and projection, where internal feelings and
impulses are seen as being outside the self. An example of dissociation

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and denial could be feeling spaced out and “forgetting” that someone
has died.
The pattern of defenses that a person relies on can also be associated
with character. It can be helpful to think about how a given person deals
with anxiety and to differentiate, for example, between an obsessive and
a hysterical defensive style. Someone who is obsessive will want to get all
of the facts, justify difficult feelings, and repeat thoughts over and over
again in their head as a way to not be overwhelmed by affect. This pattern
has been associated with a variety of higher level defenses such as intellec­
tualization, rationalization, and isolation of affect but could also involve
lower level defenses such as denial and schizoid withdrawal. A hysterical
personality style will manifest by someone avoiding acknowledging or
forgetting what they know to be true and having strong affective reactions
as well as a tendency to avoid disturbing affect through actions or somatic
experiences. This style is associated with the defenses of repression, acting
out, and somatization. People do not generally fall into clear and consis­
tent character types; they rely on a broad range of defenses. Nonetheless,
understanding the way they typically defend against painful affect can
be an important tool for the analyst and the patient alike. For example,
a client may come to understand, with the analyst’s help, that when they
agree to something that they do not really want to do, they tend to over­
justify all the reasons why it is a good idea (rationalization) and then later
feel resentful. If they could learn to acknowledge the initial threatening
feeling (anger at being put-upon), they might not fall into this dysfunc­
tional repetitive pattern.
An important defense that has not entered the popular lexicon is
referred to as splitting. Splitting involves keeping different aspects of
a person or relationship unintegrated and not reconciling the distinct
aspects. It is often seen when an individual attempts to see someone as all
good, uncontaminated by negative feelings they have about them until
such time as the script flips and the person becomes all bad. Melanie Klein
believed that children normally have difficulty developing a complex
representation of the mother that includes both the desirable and undesir­
able characteristics, so they establish two separate representations: one that

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is all good and one that is all bad. Klein saw the ability to integrate the
two and experience ambivalence as a developmental achievement. Clients
who never achieve this ability as adults and rely on the defense of split­
ting (e.g., borderline clients) will experience dramatic fluctuations in
their perception of and feelings toward others. These intense fluctuations
make it difficult to maintain stable relationships and difficult to rely on a
therapist in a consistent manner.

Resistance
Resistance is conceptualized as the tendency for the individual to try
not to change or act in a way that undermines the therapeutic process.
Resistance is the way in which defensive processes manifest in the therapy
session so as to interfere with the treatment. For example, the client’s
inability to think of anything to say while in the session may be under­
stood as a form of resistance. The tendency to consistently come late for
sessions or to forget about sessions can be thought of as resistance. In both
examples, a primary motivating factor may be the unconscious wish to
avoid emotional pain (e.g., the pain associated with exploring threatening
feelings or the fear of changing). This tendency to avoid pain or fear
manifests in a behavior that thwarts or impedes the therapist’s agenda and
the process of treatment.
There are many potential sources of resistance, including the avoid­
ance of threatening feelings being evoked by the therapeutic process, the
equation of change with the experience of self-annihilation, a fear that
trusting the therapist will lead to abandonment and more pain, envy of
the therapist, or negative feelings toward the therapist that are in part a
function of the individual’s dynamics.
The concept of resistance, although potentially valuable, can also
be problematic. One problem is that the term resistance tends to have a
connotation of the client doing something wrong, insofar as he or she is
not cooperating with the therapist in the therapeutic process. The concept
can thus have a blaming or pathologizing quality. Over time, a change
in analytic theory and technique has taken place in which resistance has

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come to be seen not as an obstacle but as an intrinsic part of the client’s

psychic functioning or aspect of his or her character that needs to be
illuminated and understood rather than bypassed. Moreover, greater
emphasis has been placed on the self-protective aspects of resistance.
There has therefore been an important shift toward conceptualizing the
notion of resistance in empathic and affirmative terms. One way of
thinking about resistance is to recognize that we have complex and con­
tradictory needs and motivations and that there is a natural tendency to
be ambivalent about changing. We begin therapy wanting both to change
and to stay the same (Bromberg, 1995). This desire to stay the same
(which is typically unconscious) can be grounded in many factors, includ­
ing a fear of losing our identities and a fear that if we give up our habitual
ways of defining ourselves and relating to others, we will experience both
complete abandonment and a loss of a sense of self.
Even if resistance is conceptualized in empathic or affirmative terms,
there is a natural tendency for therapists to experience resistance as
problematic because it obstructs their therapeutic goals and agendas.
It is thus not uncommon for therapists to become frustrated or irritated
with clients when resistance emerges and to respond in an attempt to
break through or interpret away the resistance in order to move on with
the work of therapy. It can be helpful to remember that the process of
exploring the resistance is the essence of the therapeutic process rather
than the work that needs to be done to get to the point at which one can
begin therapy.
Another evolution in the conceptualization of resistance reflects the
previously mentioned shift from a one-person psychology to a two-person
psychology. Whereas a one-person psychology locates the source of the
resistance in the client, a two-person psychology emphasizes that the
therapist often plays a significant role in the development of resistance.
Resistance often emerges in part as a reaction to the therapist’s failure of
accurate empathic understanding. Resistance can also be a function of
more subtle contributions of the therapist to the interaction. For example,
a therapist who unconsciously fears dealing with feelings of grief may
collude with a client in not fully exploring feelings about the loss of a

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loved one. A therapist may collude with the client in the process of keep­
ing the conversation at an intellectual level because the theme resonates
with painful experiences in the therapist’s own life. The exploration or
interpretation of resistance often involves an exploration of the therapist’s
contribution to the resistance (Safran & Muran, 2000).

Transference
Like most psychoanalytic concepts, the notion of transference has evolved
considerably since Freud first developed it in 1905. Transference refers to
clients’ tendency to view the therapist in terms that are shaped by their
experiences with important caregivers and other significant figures from
their early life. Developmental experiences establish templates or schemas
that shape the perception of people in the present. Although this tendency
to transfer relational experience happens in many different contexts, the
analytic relationship is particularly fertile ground. The caretaking role of
the therapist makes him or her a good stand-in for parental figures as
issues of nurturance and authority get activated.
The therapeutic relationship thus provides an opportunity for the
client to, in a sense, bring the memory of the relationship with the parent
or other significant figure from the past (aspects of which are often
unconscious) to life through the relationship with the therapist. This
provides the therapist with an opportunity to help clients gain insight into
how their experiences with significant figures in the past have resulted in
unresolved conflicts that influence their current relationships. Because
transference entails a type of reliving of clients’ early relationships in the
present, the therapist’s observations and feedback can help them to see
their own contributions to the situation in an emotionally alive way.
The resulting insight will have an experiential quality to it that will
lead to change rather than a purely intellectual understanding that has
no ultimate impact on the client.
Early conceptualizations of transference assumed that it involves
a distortion of objective reality. It was common to make a distinction
between transferential aspects of the therapeutic relationship that are

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distorted and nontransferential perceptions that are more accurate or

reality based. The assumption is that the client’s psychological problems
make it difficult for him or her to perceive objective reality accurately, and
therapists have the ability to provide more objectively based feedback that
can correct the client’s distorted perceptions. With the growing influ­
ence of a two-person psychology, transference has come to be viewed
as the joint product of the client’s perceptions and the therapist’s actual
characteristics and actions. This is a critical shift in conceptualization,
and its importance cannot be overestimated.
There are two problems with the traditional perspective. First, the
assumption that the therapist is the ultimate authority on reality exacer­
bates the inherent power imbalance in the therapeutic relationship and
contributes to the client’s feelings of being disempowered and the
therapist’s potential abuse of this power imbalance. Second, although it
is inevitably the case that the client’s perceptions of the therapist will be
influenced by past experiences, it is problematic to assume that his or her
perceptions of the therapist are distorted. What if the client’s perception
that the therapist is critical or withholding (or shy, sadistic, or flirtatious)
has some basis in the therapist’s actual characteristics? Or what if certain
aspects of the client’s behavior elicit reactions on the therapist’s part that
are consistent with the client’s expectations? For example, a client who
anticipates that therapist will be abusive in the same way as his or her
father or mother had been may act in a hostile way toward the therapist,
thereby eliciting hostile or abusive behavior from the therapist. The
client’s perception of the therapist as abusive is thus not a distortion.
It is the client’s construction of the current situation influenced by a
combination of factors, and treating it as a distortion could be damaging
to the client.

Countertransference
Countertransference is the analyst’s counterpart to the client’s transference.
Freud conceptualized countertransference as the therapist’s feelings and
reactions to the client’s transference that are a function of his or her own

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unresolved unconscious conflicts. For example, a male therapist whose

mother tended to play the role of the martyr may have extremely strong
negative reactions to a client who takes a similar stance. From Freud’s
perspective, countertransference reactions were an obstacle to therapy,
and the therapist’s task was to analyze or work through his or her own
countertransference in personal supervision, in therapy, or through
self-analysis.
These days, countertransference tends to be defined more broadly as
the totality of the therapist’s reactions to the client (including feelings,
associations, fantasies, and fleeting images). In the same way that a
two-person psychology makes it impossible to view transference exclu­
sively as the client’s distortion, it is also incompatible with conceptual­
izing countertransference as stemming from the therapist’s unresolved
conflicts. Instead, the analyst’s thoughts and feelings toward the client
are understood as an inevitable by-product of the relational matrix.
Countertransference is viewed as providing the therapist with potentially
valuable information about the client. Treating therapist experience as
clinical information can go too far: Some psychoanalysts assume that their
countertransference provides an infallible source of information about
the client’s unconscious experience and underemphasize the therapist’s
unique contribution to the countertransference.
Different theorists emphasize different ways of making use of counter­
transference. On one end of the spectrum, some analysts recommend
selectively disclosing certain aspects of their subjective experience with
the client as a way of deepening the exploratory process. Certain thera­
pists go as far as to share their fantasies or dreams that might be relevant
to the analytic process. Others are more cautious about the disclosure of
the countertransference experience to clients and instead emphasize the
value of a type of internal work in which one reflects on one’s experience
privately and makes use of it to help formulate thoughts about what
might be going on between the client and therapist and what implications
this might have for understanding the client (e.g., Bollas, 1992; Jacobs,
1991; Ogden, 1994).

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Enactment
Enactments are repetitive scenarios played out in the relationship
between client and therapist that reflect the unconscious contributions
of both parties’ personal histories, conflicts, and characteristic ways of
relating to others. Because client and therapist are always influencing
each other at both conscious and unconscious levels, they inevitably
end up playing complementary roles in these scenarios. The process of
collaborating in the exploration of how each of them is contributing to
these scenarios provides clients with an opportunity to see how their
own relational schemas contribute to the interaction and to then try to
play out new scenarios with other important people in their lives.
The traditional psychoanalytic wisdom was that the therapist should
avoid participating in these enactments and instead try to maintain a
neutral position from which he or she can interpret the client’s transfer­
ence toward the therapist, thereby helping the client to see how the present
is being shaped in maladaptive ways by his or her own unconscious
assumptions, projections, and previous developmental experiences.
One problem with aspiring to therapeutic neutrality as an ideal is that
it sets up unrealistic standards that lead us to place impossible demands
on ourselves, which makes it more difficult to accept and become aware
of aspects of our own contribution to the enactment that we experience as
shameful or unacceptable. This lack of self-acceptance makes it more
likely that we will need to dissociate aspects of our own self-experience,
making it harder to ultimately recognize the nature of our participation
in the enactment and to dis-embed from it. Furthermore, even if it
were possible to avoid participating in enactments with our clients,
the ability to do so would deprive us of the experience of participating
in our clients’ relational worlds and developing a lived experience of
what their relational world feels like. The process of participating in these
enactments thus allows us, in Philip Bromberg’s (1998) words, to know
our clients “from outside in.” Those things that our clients cannot express
to us linguistically are communicated through nonverbal behavior and
action, and the only way we can come to know important dissociated

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aspects of the client’s internal experience is to know the feeling of playing

a complementary role in their relational scenarios.
A common position in contemporary psychoanalytic thinking,
therefore, is that the therapist cannot avoid participating in these enact­
ments no matter how psychologically aware he or she is, because people
are inevitably influenced by complex nonverbal communications from
others that are difficult to decode and therapists, like other human beings,
are never fully transparent to themselves. So the therapeutic challenge is
to recognize enactments as they play out and to work them through with
patients with a sense of mutual participation.

The Therapeutic Alliance

The concept of the therapeutic alliance originated in early psycho­
analytic theory. Although Freud did not use the term explicitly, he did
emphasize the importance of establishing a good collaborative relation­
ship with the client. In a seminal article, Richard Sterba (1934) established
the groundwork for subsequent thinking about the alliance by arguing that
therapy involves a process of developing the capacity for self-observation
by identifying with the therapist’s observing function.
Perhaps the best-known psychoanalytic formulation of the alliance
was articulated by Ralph Greenson in the United States. Greenson (1965)
spoke about the importance of distinguishing between the transferential
aspects of the therapeutic relationship, which are distorted, and the
alliance, which is based on the client’s rational, undistorted perception
of the therapist and on a feeling of genuine linking, trust, and respect.
Greenson emphasized that the caring, human aspects of the therapeutic
relationship play a critical role in allowing the client to benefit from the
interventions of psychoanalysis.
Many contemporary psychotherapy researchers have found Edward
Bordin’s (1979) transtheoretical conceptualization of the alliance to be
particularly useful. Bordin conceptualized the alliance as consisting of
three interdependent components: tasks, goals, and bond. According to
him, the strength of the alliance is dependent on the degree of agreement
between client and therapist about the tasks and goals of therapy and on

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the quality of the relational bond between them. The tasks of therapy
consist of the specific activities (either overt or covert) that the client must
engage in to benefit from treatment (e.g., exploring dreams, exploring the
transference). The goals of therapy are general objectives toward which
the treatment is directed (e.g., symptom reduction, personality change).
The bond element of the alliance refers to the degree of trust that the
client has in the therapist and the extent to which he feels understood by
the therapist. The bond, task, and goal components of the alliance are
always influencing one another. So, for example, to the extent that there
is an agreement between client and therapist about tasks and goals, the
bond will be strengthened. To the extent that the therapeutic tasks or
goals do not initially make sense to the client, a strong bond will make it
easier to develop some agreement or working consensus.
Building on Bordin’s (1979) thinking, as well as developments in
relational psychoanalysis, I, together with my colleagues, have argued
that it is more useful to think of the alliance as an ongoing process of
negotiation between client and therapist about therapeutic tasks and
goals because this emphasizes the importance of mutual attempts by both
client and therapist to find ways of working together, rather than placing
the burden of responsibility on the client to accommodate to the thera­
pist’s way of working (e.g., Safran & Muran, 2000). This ongoing process
of negotiation, which is only partially explicit, is an important element of
the change process in and of itself. It can provide clients with the oppor­
tunity to learn that it is possible to negotiate one’s needs with the needs
of the other, rather than dealing with conflicts by either denying one’s
own needs or adopting a rigid stance toward relationships. The ongoing
negotiation of the alliance in therapy helps the client to learn that healthy
relationships do not have to involve a denial of the other’s subjectivity,
on one hand, and/or an experience of self-effacement or compromise of
one’s sense of integrity, on the other.

The Therapist’s Stance

Classical psychoanalytic thinking prescribed clear guidelines for the ther­
apist’s stance, which are contained within the principles of abstinence,

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anonymity, and neutrality. Abstinence refers to the therapist’s refraining

from gratifying clients’ wishes and requests when their fulfillment is seen
as interfering with the therapeutic process. Early psychoanalytic thinking
was influenced by the experience of working with hysterical clients who
had a tendency to develop erotic transferences, and Freud advised thera­
pists not to gratify erotic wishes but rather to help clients to understand
what was underlying them.
Anonymity refers to the therapist not sharing personal information
and trying to be a blank slate to receive the patient’s projections. Neutrality
refers to respect for the client’s autonomy and attempting to remain
objective and not influence the client’s decisions. The principle of neutral­
ity reflects the value of psychoanalysis to cure through truth seeking and
the uncovering of the unconscious rather than through suggestion.
Although these guidelines still exert some influence on today’s
psychoanalytic thinking, their implementation has been modified if
not completely abandoned by a number of theorists. For example, with
respect to the principle of abstinence, although it may be counterthera­
peutic to agree to a borderline client’s request to meet for coffee, it can be
therapeutic to speak to a client by phone between sessions. It all depends
on the client’s unique needs and the specific context.
With respect to the principle of anonymity, the shift toward a
two-person psychology and the recognition that the therapist is always
conveying information about himself or herself even if attempting to
remain anonymous (e.g., through nonverbal behavior, through the type
of interventions he or she makes, through decisions about when to remain
silent and when to speak) has decreased the emphasis on neutrality as
an essential element of the therapist’s stance. Nevertheless, contemporary
psychoanalytic therapists attempt to retain an ongoing disciplined reflec­
tiveness about the potential impact of disclosing various types of infor­
mation to the client.
I ask myself, Will answering my client’s request for information
about my background, my personal life, or my current feelings about
the client facilitate or hinder the therapeutic process? Why is my client
asking this particular question now? What emotional impact does my

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client’s question have on me? Two clients may ask the identical question
(e.g., how many children I have), and I feel perfectly comfortable answer­
ing the first client, whereas with the second client I feel it would be more
helpful to understand what is behind the query.

Self-Disclosure
As psychoanalytic thinking about the topic of therapist neutrality has
evolved, so too has thinking about the attitude toward self-disclosure.
In classical psychoanalysis, it was believed that analysts should say as
little about themselves as possible in order not to “contaminate” the
transference. The idea was that it would be easier to see patients’ distor­
tions and the repetition they represented if they were reacting to a blank
screen. At times this led to extreme positions such as a reluctance to answer
any questions about details of the therapist’s life outside the therapy
session (e.g., questions about whether the therapist has ever struggled with
issues similar to the client’s, or where the therapist is going for a vacation)
or the therapist’s thoughts or feelings during the session.
Although this perspective on self-disclosure has the advantage of
offering unambiguous guidelines and can be facilitative in certain contexts,
it has the downside of limiting the therapist’s flexibility and in some
cases being unnecessarily off-putting and alienating to the client. Under
some circumstances, it can be extremely facilitative for the therapist to
self-disclose. The therapist’s willingness to answer an innocuous question
may reduce a sense of artificial distance or formality and facilitate the
development of the alliance. In other cases, therapist self-disclosure can
interfere with the therapeutic process or have unintended and potentially
harmful consequences. As clients, we have ambivalent and conflicting
needs about knowing our therapists (Aron, 1996). On one hand, there
is the desire for intimacy, the desire to feel close to the therapist, or the
desire to reduce the power imbalance by knowing that the therapist is a
human being just as we are. On the other hand, we can have the conflict­
ing desire to maintain some aspects of the anonymity of the therapist so
that we do not have to worry about the therapist’s needs or so that we can

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maintain the therapist in the role of the helper who has special qualities
that will allow him or her to be of assistance to us. In contemporary
practice, strict rules about self-disclosure have been replaced with the
ubiquitous “it depends.” It depends on the type of disclosure, it depends
on the unique qualities and needs of the client, and it depends on what is
going on in the therapeutic relationship.
Another type of self-disclosure is when the analyst spontaneously
shares thoughts or feelings within the session. This form of self-disclosure
(often referred to as countertransference disclosure) can provide a useful
way of providing the client with his or her impact on another human being
and may play a vital role in initiating an exploratory process (Ehrenberg,
1992; Safran & Muran, 2000). For example, a therapist who becomes aware
of feeling particularly cautious or tentative with a client may, in a curious
and inquiring manner, say, “I’m not sure what exactly is going on, but
I find myself being very cautious, and tentative with you. . . . It feels almost
as if I’m walking on eggshells.”
Countertransference disclosures of this type can be a useful way of
putting into words something that is taking place implicitly in the thera­
peutic relationship, thereby holding it up to the light of day, where it can
be examined. It is not uncommon in everyday exchanges for people to
unconsciously act in ways that subtly impact on others or elicit complex
and contradictory reactions that are difficult to understand or put into
words. For example, someone may act in a subtly demeaning way toward
others that engenders feelings of inadequacy or competitiveness in them.
Or someone may habitually have a lively, humorous bantering style that
keeps others off-balance and at a distance. The implicit rules of everyday
social discourse do not sanction trying to talk about these subtle inter­
actions. As a result, there is a type of ongoing mystification that is perpet­
uated in relationships, especially for people who are likely to be especially
self-defeating. Therapists have the role-conferred permission to break the
normal rules of social discourse and to step back and attempt to talk about
that which normally goes unexplored.
This tremendously valuable permission provides therapists with
a way to facilitate self-awareness in their clients. Like other forms of

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 Theory

self-disclosure, however, countertransference disclosure can be either

facilitative or hindering, depending on the particular context. For example,
a client whose parents were narcissistically self-absorbed may experience
the therapist’s countertransference disclosure as a form of self-absorption
on the therapist’s part and as a neglect of the client’s needs. A narcis­
sistic client’s sense of self may be so fragile that he or she cannot tolerate
attending to the subjectivity of the other and may experience the thera­
pist’s countertransference disclosure as overwhelming or threatening.
It is thus always important for the analyst to be responsive to the needs of
the specific client and the unique context when using countertransference
disclosure.

Emotion and Motivation

As previously discussed, for Freud, motivation is based on drives:
instinctually derived forces that exist on the boundary between the psycho­
logical and the biological. They are a form of psychic energy. In Freud’s
mature thinking, there are two primary drives: a life instinct and a death
instinct. Motivation is conceptualized as a complex interaction between
these two drives and also as a product of attempts to reestablish situations
that have resulted in satisfaction by facilitating the discharge of psychic
energy. There is no systematic model of emotion in Freud’s thinking.
Freud’s drive model was anchored in neurophysiological theory and
evolutionary models that were commonly accepted in his time but have
since been superseded by other theoretical and empirical developments.
Although over the years theorists have made attempts to develop revised
or alternative motivational models, one meaningful trend in contempo­
rary psychoanalytic thinking is to replace drive theory with a motivational
perspective that is grounded in contemporary developments in emotion
theory and research (Safran & Muran, 2000). From this perspective,
emotions play a central role in human motivation. Emotions function to
safeguard the concerns of the organism. Some of these concerns are bio­
logically programmed, and these correspond to core motivational systems
(e.g., Ekman & Davidson, 1994; Frijda, 1986; Greenberg & Safran, 1987;
Safran & Greenberg, 1991).

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

For example, Lichtenberg (1989) theorized that there are five core
motivational systems: (a) the need for psychic regulation of physiological
requirements, (b) the need for attachment and affiliation, (c) the need
for assertion and exploration, (d) the need to react aversively through
antagonism or withdrawal, and (e) the need for sensual and sexual plea­
sure (e.g., attachment, curiosity). Other concerns are a result of learning.
Many of these learned concerns are the result of values that result from
learning about subgoals that will satisfy the needs of the attachment
system. For example, one can learn that one needs to be dependent to
maintain a connection with the attachment figure, or others might learn
that a type of precocious maturity is important or that sexual desirability
plays a role.

Attachment Theory
John Bowlby believed that Freud’s motivational model was inadequate,
and he developed an attachment-based model that has become increasingly
prominent in mainstream developmental, social and clinical psychology.
Bowlby’s motivational model combines certain basic psychoanalytic ideas
with infant observation research, ethology, and control systems theory
(an interdisciplinary branch of engineering and mathematics that deals
with the behavior of dynamic systems). Attachment theory has generated
a tremendous amount of empirical research in the last few decades and
in fact has become one of the most fertile research areas emerging out of
psychoanalytic theory. Because articles and books on attachment theory
are voluminous (see, e.g., Cassidy & Shaver, 2016, for an excellent review),
I risk oversimplifying things by restricting myself here to detailing a few
fundamental propositions of attachment theory and exploring the way it
fills an important niche in the psychoanalytic perspective on unconscious
motivation.
According to Bowlby, humans have an instinctively based need (what
attachment theorists refer to as a motivational system) to maintain prox­
imity to their primary caregivers (referred to as attachment figures; Bowlby,
1969, 1973, 1980). This motivational system, designated the attachment

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 Theory

system, serves an adaptive function in that it increases the possibility that

the infant will be able to obtain the caretaking and protection that are
essential for survival. Infants develop internal representations of their
interactions that permit them to predict what type of actions will help
to maintain proximity to attachment figures and what type of actions
will threaten the relationship. Bowlby referred to these representations
as internal working models. For many years, Bowlby’s work was ignored
by mainstream psychoanalytic theorists, who regarded his thinking as
simplistic and mechanistic. Nevertheless, through the work of a number
of empirically minded collaborators studying mother–infant inter­
actions, Bowlby’s work became increasingly influential within mainstream
developmental psychology. Of particular note in this respect is the
research of Mary Ainsworth (Ainsworth, Blehar, Waters, & Wall, 1978),
who developed the Strange Situation laboratory procedure for observing
mother–infant interactions and reliably classifying the attachment status
of 1- to 2-year-old infants. This procedure subsequently became the
paradigmatic method in attachment research. The ensuing development
of the Adult Attachment Interview by Mary Main and her collaborators
(e.g., Main, Kaplan, & Cassidy, 1985) has allowed researchers to assess
adults’ internal working models of attachment through a structured
interview and reliable coding system. The development of the Adult
Attachment Interview thus became another critical turning point in the
evolution of attachment research, and it has given rise to a vast body of
empirical research with immensely rich clinical implications (e.g., Steele
& Steele, 2008).
The use of the Adult Attachment Interview and the concept of
Reflective Functioning (Fonagy, Steele, & Steele, 1991) have given rise to
a variety of “mentalization-based treatments” (Bateman & Fonagy, 2016).
These treatments address attachment difficulties with the ultimate goal of
improving the client’s ability to understand and differentiate their own
thoughts and those of others. In addition, clinical interventions aimed at
promoting secure attachments and preventing child maltreatment have
been developed as summarized in the Handbook of Attachment-Based
Interventions (Steele & Steele, 2018).

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 4

The Therapy Process

P sychoanalytic therapy is a rich and complex process. In this chapter,

I articulate some of the elements of this process and provide case
examples illustrating the key aspects of the approach, beginning with the
principles of intervention.

PRINCIPLES OF INTERVENTION
In this section, I discuss the therapy process at the level of principles of
intervention. In other words, what are the general principles that guide
the psychoanalytic therapist’s approach to therapeutic intervention, and
what are the specific interventions that he or she uses?

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Psychoanalysis and Psychoanalytic Therapies, Second Edition, by J. D. Safran and J. Hunter
Copyright © 2020 by the American Psychological Association. All rights reserved.

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

Formulation
As discussed in Chapter 3, it can be helpful for analysts to think about
their clients in terms of character formulation. In formulating their
client’s character, a clinician takes into account such factors as the client’s
characteristic defensive style, ego strengths and weaknesses, capacity for
insight, and the nature of his or her internal object relations. Examples of
ego strengths include impulse control, judgment, capacity for sustained
work, and reality testing.
The topic of case formulation in psychoanalysis is complex, and a
vast literature has been devoted to outlining different considerations
relevant to it. To begin with, given that there are multiple psychoanalytic
theories rather than a uniform psychoanalytic approach, each psycho-
analytic theory will lead the therapist to focus on different dimensions,
and the same case could be described in a disparate manner. One can
formulate a case from the perspective of ego psychology, various models
of object relations theory (e.g., Klein, Fairbairn, Winnicott), interpersonal
theory, self psychology, Lacanian theory, intersubjectivity theory, or
relational psychoanalysis.
Ego psychology or modern conflict theory (the contemporary
American version of ego psychology) tends to formulate clinical problems
in terms of the internal conflict between unconscious wishes and the
defenses against them. For example, an individual might wish to assert
himself but feels uncomfortable with this feeling and defends against his
wish by being overly accommodating.
Object relations and interpersonal/relational theories tend to formu-
late cases in terms of internal object relations that lead the individual to
play out repetitive internalized patterns. For example, a woman whose
father divorced her mother when she was 3 years old and abandoned the
family develops an internalized representation of men as emotionally
unavailable and a pattern of being attracted to emotionally unavailable
romantic partners, in part as a way of recapturing the love of the father
who abandoned her.
There is no reason that a clinical formulation cannot synthesize both
conflict and relational models. For example, Matthew has an internalized

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 The Therapy Process

representation of others as intolerant of aggression and has developed

a pattern of defending against his aggressive impulses and acting in an
overly accommodating way. This relational pattern leads others to take
advantage of him, which incurs resentment, which in turn has to be dis-
owned. Although Matthew is not aware of angry feelings, he neverthe-
less expresses them in a passive-aggressive fashion. This evokes aggressive
responses from others, which he feels are unwarranted. This further
intensified Matthew’s feelings of being an impotent victim.
The process of formulation from a contemporary perspective involves
combining information from a number of different sources. The therapist
looks for recurrent themes that occur in the stories that clients tell about
their current relationships and their past relationships (including their
relationships with their parents). The therapist also pays attention to
patterns or themes that are beginning to emerge in the therapeutic relation-
ship. This process requires therapists to attend to subtle fluctuations in
their own ongoing feelings and experiences and to engage in an ongoing
reflection of the nature of their own participation in the relationship.
Although there are multiple theoretical perspectives to guide case
formulation from a psychoanalytic perspective and many dimensions
that are considered relevant to arriving at an adequate formulation, there
is also a long-standing tradition within psychoanalysis of the importance
of not letting one’s formulations bias or interfere with one’s ability to
be open to emergent information. In early technical papers Freud wrote
about the importance of the therapist learning to cultivate an attitude of
evenly hovering attention so that the therapist is able to hear and see
things that are not necessarily consistent with his or her expectations
(Freud, 1912/1958). But there is a tension even within Freud’s writing
between his emphasis on the importance of the therapist cultivating a
tolerance of uncertainty and ambiguity and his own tendency to write up
his cases in a fashion that has a quality of certainty, reminiscent of the way
in which all the pieces are pulled together when a mystery is solved in a
Sherlock Holmes story.
Nevertheless, this emphasis on the importance of the discipline of
maintaining an open and receptive attitude can be found in the writings

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

of various analysts subsequent to Freud, including Theodor Reik (1948),

Wilfred Bion (1970), to some extent Donald Winnicott (1958, 1965), and
recently such analysts as Thomas Ogden (1994) and Christopher Bollas
(1992). The emphasis is on maintaining an open, receptive mind that
takes in information not just from the client but also from one’s own
unconscious experience. There has been a shift in recent years toward
the importance of being cautious regarding the dangers of approach-
ing the client with an overly tight or coherent formulation that does
not easily lend itself to revision in the face of new information. This is
particularly evident in the work of some British Independent theorists
(e.g., Bollas, 1992; Coltart, 2000; Parsons, 2000) and in the writing of
American relational thinkers who emphasized the importance of learn-
ing from one’s client and being receptive to acknowledging one’s own
ongoing contributions to enactments (Aron, 1996; Bromberg,1998;
Mitchell, 1988, 1993, 1997).
Donnel Stern (1997, 2010), for example, argued that a good psycho-
analytic process involves (what philosopher Gadamer referred to as) a
fusion of horizons in which both client and therapist come to a shared
perspective on reality by allowing themselves to be influenced by each
other. An important thread in contemporary theory emphasizes that
one can never have an objective understanding of how the other is,
because any understanding that develops will inevitably be influenced by
the enactment in which one is engaged. Philip Bromberg (1998, 2006)
emphasized that there are limits to what one can learn about one’s clients
on the basis of their verbal reports because they themselves are not able to
verbalize aspects of their experience that are split off or dissociated. From
this perspective, the only way to truly understand our clients is to enter
into their relational worlds and play out various scenarios with them in
an unconscious way. Clients who have dissociated their experience are
often able only to communicate it through their actions. It is thus only
by allowing ourselves to be used by our clients in this way and experi-
encing and reflecting on our own countertransference that we are able
to make contact with dissociated aspects of their experience. The notion
that we could have an adequate and comprehensive formulation of our

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 The Therapy Process

clients prior to actually establishing a relationship with them and allow-

ing our understanding to emerge out of these relationships is anathema.
In a more traditional perspective, the therapist’s adequate formulation
of clients’ core themes and psychodynamics allows them to make accu-
rate interpretations, which in turn leads to change through insight. In
contrast, the perspective I have outlined suggests that understanding,
relating, reflecting, and communicating about what is taking place in the
therapeutic relationship are all part of one seamless process.

Empathy
Empathy is a fundamental factor that is both clinically powerful itself and
affects the usefulness of all interventions. The ability to identify with our
clients and immerse ourselves in their experience is critical in the process
of establishing an alliance. This capacity to identify ourselves with our
clients and communicate our empathic experience to them is a central
mechanism of change in and of itself. It also has a strong influence on
the way that clinical interventions are experienced. As discussed next,
the same words of interpretation could be heard very differently depend-
ing on how empathically they are delivered. The topic of empathy was
traditionally neglected in psychoanalytic writing, in which the emphasis
was placed on the importance of making accurate interpretations. With
Heinz Kohut and the development of self psychology, however, the topic
of empathy was placed in the foreground. Kohut argued that it is not
enough for an interpretation to be “accurate”; it also has to be experienced
as empathic by the client.
Kohut highlighted the importance of what he termed vicarious intro-
spection, that is, the process of placing oneself in the client’s shoes and
attempting to develop a sense of the client’s phenomenological experi-
ence. In addition, he emphasized the role that the therapeutic process of
empathic mirroring can play in helping clients to develop a cohesive sense
of self (Kohut, 1984). The growing influence of mother–infant develop-
mental research on psychoanalytic thinking has added to the analytic
perspective on empathy. For example, Daniel Stern’s (1985) research on

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

affect attunement in mother–infant relationships has provided a model

for understanding the way in which the therapist’s ability to attune and
resonate to the client’s affective experience can help the client to articulate
and make sense of his or her own emotional experience.

Interpretation
One of the most important interventions at the psychoanalytic thera-
pist’s disposal has been what is called interpretation. An interpretation
is the therapist’s attempt to help clients become aware of aspects of their
unconscious intrapsychic experiences and relational patterns. From a
more traditional perspective, the distinction between interpretation
and empathic reflection can be conceptualized in the following fashion.
Whereas empathic reflection is the therapist’s attempt to articulate
meaning that is implicit in what the client is saying, interpretation is
the therapist’s attempt to convey information that is outside of the
client’s awareness.
There is an important distinction between the accuracy of an inter­
pretation, the extent to which it corresponds to a “real” aspect of the
client’s unconscious functioning, and the quality or usefulness of an
interpretation, in that the client can make use of the interpretation as part
of the changes process. An interpretation can be accurate without being
useful. The dimension of quality is spoken about in a variety of ways—
for example, timing (Is the context right? Is the client ready to hear it?),
depth (To what extent is the interpretation focused on deeply unconscious
material vs. material that is closer to awareness?), and empathic quality
(To what extent is the interpretation delivered in a way that is sensitive
to the impact it has on the client’s self-esteem? To what extent does it
contribute to the client’s experience of being genuinely understood?).
Traditionally, interpretations have been conceptualized as falling
at different levels along the continuum of depth to surface. A deep inter-
pretation is one targeted at material that is deeply unconscious for the
client. An interpretation that is closer to the surface end of the continuum
is targeted at experience that is almost accessible to consciousness, but not

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quite. From this perspective, an empathic reflection can be conceptualized

as an interpretation targeted toward the surface end. Although it is often
true that the most useful interpretations are those that are close enough
to conscious awareness for the client to be on the verge of articulating
them, it is important not to rule out the potential value of deeper inter-
pretations. For example, one of the hallmarks of a Kleinian interpretation
has been that it is often geared toward interpreting deeply unconscious
material that is remote from the client’s experience.
It is not uncommon for clients to complain about experiences with
therapists who have made deep interpretations that made no sense to
them and were experienced as frightening, overwhelming, or disturbing.
Nevertheless, it has been my experience that deep interpretations of this
sort can be experienced as helpful by clients, especially when the therapist
is able to address unconscious anxieties and primitive unconscious fears
(e.g., fears related to destructive rage and aggression or annihilation of
the self) that feel too unbearable for the client to tolerate. In situations
of this type, a therapist’s ability to approach unbearable experience in
a confident way without feeling overwhelmed can feel reassuring and
containing to the client. Here the quality of the therapist’s presence
and state of mind while making the interpretation is a critical factor.
In other words, the therapist’s willingness to touch on nameless dreads
without being overwhelmed by whatever feelings they stir up can pro-
vide the client with a sense of safety and security that typically eludes
the client.
Elyn Saks (2008), in a memoir of her personal struggle with schizo-
phrenia, spoke about her experience with a skilled Kleinian analyst
(whom she called Mrs. Jones) who helped Saks with her interpretations
of the role that factors such as Saks’s deep unconscious envy and her
projection of angry and hostile feeling onto others play in producing
her psychotic symptoms. To quote Saks,

I met with Mrs. Jones three times a week. . . . I reported my delusions

and the forces beyond my control that were unbearably evil. I was
malicious, I was bad, I was a destroyer of worlds. She was not afraid;
she did not look at me with alarm in her eyes. She did not judge,

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

she only listened, and reflected back to me what she heard telling me
what she thought it meant [italics added]. (p. 185)

Following is a dialogue between Saks and Mrs. Jones.

Mrs. Jones: Tell me about your difficulties at university.

Saks:1 I’m not smart enough. I can’t do the work.

Mrs. Jones: You were first in your class in Vanderbilt. Now you’re upset
about Oxford because you want to be the best and are afraid you can’t be.
You feel like a piece of shit from your mother’s bottom.

Saks: I’m closing the curtains from now on because people across the
street are looking at me. They can hear what I’m saying. They are angry.
They want to hurt me.

Mrs. Jones: You are evacuating your angry and hostile feelings onto
those people. It is you who are angry and critical. And you want to control
what goes on in here.

Saks: I am in control. I control the world. The world is at my whim.

I control the world and everything in it.

Mrs. Jones: You want to feel in control because in fact you feel so helpless.

According to Saks (2008),

While the content of what Mrs. Jones said to me was not always a
comfort (more often than not it, it was startling, and had the effect
of catching me up short), her presence in the room was. So calm,
so reasonable, no matter what I said to her, no matter how disgusting
or horrible, she never recoiled from what I said. To her, my thoughts
and feelings were not right or wrong, good or bad; they just were.
(pp. 92–93)

Although this dialogue is quoted from Saks (2008), I have changed Saks’s use of the first person “I” to “Saks”
1

to avoid any confusion in the present context.

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 The Therapy Process

A number of factors influence the extent to which an interpretation

is experienced as empathic. If the interpretation is closer to consciousness
for the client, the client is more likely to feel understood because it seems to
“fit” or make sense to the client and captures an important aspect of
the client’s experience that he or she can’t articulate. An interpretation
that captures or crystallizes a feeling that the client is unable to articulate
can be experienced as empathic in the sense that the client feels “known,”
perhaps in a way that he or she usually doesn’t. This is particularly
important when the therapist is giving voice to feelings or experiences
that are semi-inchoate for the client and contributing to his or her feelings
of confusion and isolation.
Interpretations are most likely to be helpful when the therapist is
able to interpret a disavowed aspect of experience in a way that the
client experiences as validating, supportive, and affirming. For example,
a therapist who is able to interpret underlying experiences of sadness
and pain and at the same time is able to empathically resonate with these
feelings (not just imagine the client’s perspective at a conceptual level
but also temporarily identify with the experience at a personal and emo-
tionally compelling level) will contribute to the client’s sense of feeling
connected and affirmed. In situations of this type, the therapist’s state of
mind (i.e., the extent to which the therapist feels empathically connected
to the client or not) is just as important, if not more important, than the
specific content of his or her interpretation.
When there is a strong therapeutic alliance and the client trusts
the therapist, an interpretation that is potentially threatening can be
experienced in a more benign way because it is being delivered by
somebody whose good will and intention the client trusts. It is also
important to bear in mind that the immediate relational context colors
the meaning of anything that the therapist says (Mitchell, 1993). Inter-
pretations with exactly the same words can be experienced as critical
or caring, depending on whether the client feels respected by and cared
for by the therapist.
Any intervention must be understood in terms of its relational meaning.
In other words, when the therapist makes a specific content interpretation
to the client (e.g., “It is hard for you to trust people because of your

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

history of abandonment, and it is hard for you to trust me right now”),

the meaning of this particular interpretation will be mediated by the
history of the client’s relationships with others, by the therapist’s unique
history, and by the meaning of this type of interpretation to the therapist
given his or her particular dynamics and the way both client and thera-
pist are feeling about themselves and each other in this moment. A deep
interpretation about the client’s unconscious motives may be experienced
as disrespectful or disempowering. Alternatively, it may be experienced as
tremendously reassuring.

Clarification, Support, and Advice

Despite the traditional psychoanalytic emphasis on refraining from
providing excessive reassurance or advice, many contemporary psycho-
analytic therapists find that such support can play a vital role in the
change process. Although we do wish to promote our clients’ ability to
trust in themselves, there is also a recognition that in many circumstances
a genuine word of reassurance can be critically important for a client who
is struggling with a difficult situation or feeling shaky. Similarly, a word
of well-timed advice to a client who is feeling overwhelmed or confused
or is in a state of crisis can be an essential intervention. A traditional
psychoanalytic concern has been that when therapists give advice or share
their opinions with clients, this imposes undue influence on them because
of transference and risks compromising their autonomy. Critics such
as Owen Renik (2006), however, have argued that the practice of with-
holding one’s opinions as a therapist is disingenuous, because our beliefs
implicitly influence the message we convey to our clients without giving
them a chance to fully reflect on our position and disagree with us
if they wish. A therapist’s willingness to give advice, especially when
asked for it, is consistent with reducing the power imbalance, because we
are “playing our cards straight up” with our clients, but it requires a great
deal of self-reflection on the part of the analyst. If analysts are to share
their opinions, they must be very aware of the influence of their personal
values as well as their countertransferential reactions to the client.

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Interpretation of Transference and Countertransference

Transference interpretations, or those that are focused on the relation-
ship between analyst and client, can be some of the most powerful inter-
ventions in psychoanalysis. Exploration of the therapeutic relationship is
a hallmark of analytic technique and something that distinguishes it from
other forms of treatment. Patients will experience the analyst in a manner
that contains aspects of unresolved conflicts with figures in their life,
including their early experience with caretakers. Coming to understand
this and work through the emotions contained within these relational
moments can provide an immediate and impactful experience. Transfer-
ence interpretations can focus exclusively on the therapeutic relationship
or explore similarities between what is taking place in the therapeutic
relationship and other relationships in the client’s life (both present and
past). For example, Doris, a divorced woman in her mid-30s, consistently
complains about romantic partners being emotionally unavailable and
has just been speaking about her supervisor as not being sufficiently
supportive. For the past few sessions I have had the sense that Doris is
frustrated with me, so I say, “I wonder if there is any similarity between
your experience with your supervisor and the way in which you are
experiencing our relationship in this moment?” Interpretations that do
not involve a focus on the here and now of the therapeutic relationship
can run the risk of leading to a purely intellectualized understanding.
It is one thing to conceptually understand one’s role in a self-defeating
pattern and another to have an emotionally immediate experience of it:
the latter is more likely to lead to change.
For many contemporary psychoanalytic therapists, transference
interpretations have become inseparable from the process of the explora-
tion of the transference/countertransference matrix. Consistent with an
emphasis on a two-person psychology, transference is not conceptualized
as a distorted perception arising in a vacuum but as one element in an
evolving transference/countertransference enactment. In practice, then,
transference interpretations often involve an ongoing collaborative
exploration of who is contributing what to the relationship. In my own
writing, I have used the term metacommunication to designate this process

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

of collaborative exploration (Safran & Muran, 2000). Metacommunication

involves an attempt to step outside the relational cycle that is currently
being enacted by treating it as the focus of collaborative exploration,
a process of communicating or commenting on the relational transaction
or implicit communication that is taking place. It is an attempt to bring
awareness to bear on the interaction as it unfolds. There are many forms of
metacommunication. A therapist can offer a tentative observation about
what is taking place between him or her and the client (e.g., “It seems to
me that we’re both being cautious with each other right now . . . does that
fit with your experience?”). A therapist can convey a subjective impres-
sion of something the client is doing (e.g., “My impression is that you’re
pulling away from me right now”). Or the therapist can disclose some
aspect of his or her own experience as a point of departure for explor-
ing something that might be taking place in the therapeutic relationship
(e.g., “I’m aware of feeling powerless to say anything that you might
feel is useful right now”). Any disclosure of this type must be considered
the very first step in an ongoing process of exploring the transference/
countertransference cycle. The therapist does not begin by assuming that
his or her feelings are in any way caused or evoked by the client but rather
that they may offer clues as to something that is unconsciously being
enacted in the relationship.
It is also important to bear in mind that clients can experience
straightforward traditional interpretations of the transference as a
criticism, especially in situations in which the therapeutic alliance is
strained. In other words, the interpretations can be experienced by
clients as the therapist’s attempt to take himself or herself out of the
equation by insinuating something to this effect: “The tension we’re
having in our relationship right now is your fault because you are repeat-
ing something from your past.” This is particularly likely to occur in
situations in which the therapist is caught up in an enactment and is
using the interpretation to deny any responsibility for what is going on
or is defensively blaming the client for a mutually constructed pattern
in the therapeutic relationship.

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 The Therapy Process

Nontransference Interpretations
Although I have been emphasizing the value of transference inter­
pretations because of their emotional immediacy, it is important
not to minimize the potential value of interpretations that don’t make
reference to the therapeutic relationship. In some situations, making a
well-timed, well-worded interpretation about an event taking place in
the person’s relationships outside the therapy situation can be particu-
larly useful. This is especially true if the client is curious about what
is taking place in the situation and is receptive to considering the
possibility that a specific unconscious conflict is playing a role. For the
interpretation to be helpful, however, the client does need to experi-
ence the interpretation as a new and emotionally meaningful way of
looking at the situation rather than just as an intellectualized and arid
attempt to understand what is going on. It is difficult to specify exactly
what facilitates this sense of newness other than to say that the client
needs to be experiencing a genuine sense of confusion and a search for
understanding, and the interpretation must be phrased in such a way
that it facilitates further exploration rather than shutting down. For
example, Peter, a successful professional in his 40s, began treatment
after his wife discovered that he was having an affair with a female
coworker and threatened to leave him. He immediately ended the affair
and sought therapy in the hope of understanding what had led him to
have an affair in the first place. This was the only time he had ever had
an affair, and he experienced it as completely out of character and a
form of compulsion or addiction over which he had no control. After
spending several sessions getting to know him, I began to get a sense of
a man with considerable disowned anger who was feeling devalued by
and emotionally isolated from his wife. I began to interpret his affair
as an attempt on his part to reaffirm his sense of potency and lovability
and as an expression of disowned anger at his wife. He experienced this
interpretation, combined with the process of developing greater owner-
ship of his needs for validation and for emotional intimacy and of his
anger, as extremely helpful.

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Genetic Transference Interpretations

and Historical Reconstruction
A third major type of interpretation is referred to as a genetic transference
interpretation. A genetic transference interpretation involves conveying
a hypothesis about the role that developmental experiences have played
in shaping current conflicts. For example, the therapist may interpret the
client’s tendency to be overprotective of other people, thereby denying
his or her own needs, as stemming from the client’s history of protecting
a depressed and fragile mother. The therapist could look for ways that
this history is playing out in the therapeutic relationship and be sensi-
tive to the client trying to put the therapist’s needs first. Understanding
the effects of childhood relationships on current patterns is particularly
powerful when they can be found in the transference and explored in an
affectively alive manner through a mutual exploration of the therapeutic
relationship.
There has been a tendency in psychoanalytic thinking to emphasize
the importance of childhood-based interpretations. The problem is that
such interpretations can lead to an intellectualized understanding of the
influence of the past on the present without resulting in a real change.
Notwithstanding this potential problem, a good genetic interpretation
can play a valuable role in helping a client to replace a sense of confusion
and perplexity with a sense of meaning and understanding. It can also
help to reduce the client’s tendency to excessive self-blame by helping
the client to see that current patterns are a meaningful and understand-
able result of an attempt to cope with a difficult or traumatic childhood
situation. For example, Howard, a male client in his mid-20s, experienced
a lack of direction in his life, a chronic low-level depression, and a sense
of inadequacy. His father was an extremely successful business execu-
tive whom my client described as charismatic and always the center of
attention. When Howard was 8 years old, his father and mother divorced.
Although Howard maintained a relationship with his father, he felt he was
never able to obtain his approval. Over time, it emerged that whenever
Howard would tell his father about something he had accomplished
or was excited about, he had the impression that his father belittled him.

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In one session, I suggested to Howard that perhaps his father felt the need
to “put him down” because of his own need to be the center of attention
and an associated feeling of being threatened by any success his son
might have. Howard found this interpretation extremely helpful, and it
opened the door for exploring important associated feelings, including
those that occurred in the therapeutic relationship.
Of course, too much emphasis on tracing the historical roots of one’s
current self-defeating patterns can lead to a type of preoccupation with
the past and a tendency to blame others rather than to develop a sense of
agency that can promote change. This is, however, by no means inevitable,
and to the extent that it does take place, it can and should be explored in
the same way that any defense is explored.

The Use of Dreams

Dream interpretation has been considered central to psychoanalytic
practice since its origins. Freud (1900/1953) referred to dreams as the
“royal road” to the unconscious (p. 604), and some of his most important
early breakthroughs in psychoanalytic theory and practice emerged from
the interpretation of his own dreams and the dreams of analysands. Freud
considered dreams to reflect unconscious wishes that seek expression
but are felt to be unacceptable to the dreamer; the underlying wishes
are the latent content of the dream. The mind represses and transforms
the dream content so that it is less anxiety-producing, which yields the
manifest content: the dream that the individual actually experiences or
recalls. It is through “secondary revision” that primary process material,
which is raw and unguarded, is made more acceptable to the dreamer.
By deciphering the dreamer’s associations to the manifest content, an
analyst can get at the original wish or fear or impulse. This idea that
true feelings are disguised within symbolic representations underlies
many psychodynamic techniques, but because dreams are involuntary
and understood to be surreal, the repressed wish may be more easily
accessed in this realm.
In The Interpretation of Dreams, Freud (1900/1953) outlined a few
properties of dreams that, when applied to the content, can aid in their

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interpretation. Freud noted that events or people from the previous day
can show up in the dream; he referred to this as the day residue. Freud also
noted that the dreamer will often use displacement as a form of disguise—
feelings that are held toward one person are expressed in the dream as
being toward another. For example, a patient may report having had
a dream of fighting with an old schoolmate and wonder why such an
insignificant person showed up in their dream. When asked to asso­ciate
about this schoolmate, the patient thinks of their own brother, and
it becomes clear that the feelings the patient experienced are about
the brother.
Freud also referred to symbolic representation as a central way for
the dreamer to disguise the impulse behind the dream. This is where
specific dream content stands in for a deeper issue or conflict. From an
analytic perspective, we know that symbols will have personal meaning
for each individual depending on their life experience, but in many
cultures dream images are taken to have a fixed significance. For example,
dreaming of water may be culturally viewed as predictive of turmoil.
Although Freud sometimes used the concept of universal symbols, he
mostly believed that the unconscious meaning of any particular dream
element could be arrived at only by asking the patient to free associate
and tell the analyst what comes to mind. This is consistent with the way
dream images are understood in current psychoanalytic practice. Any par-
ticular element could have a wide range of meaning to the dreamer, which
could be understood only with detailed inquiry.
Since Freud’s time, a variety of psychoanalytic models have been
developed for conceptualizing the meaning of dreams and working with
them. One particularly useful approach to dream interpretation was devel-
oped by Fairbairn, who conceptualized all figures in a dream to represent
different aspects of the self. For example, I once had a female client who
was terrified to sleep at home alone when her husband was away. At such
times it was common for her to have dreams in which she was being
chased by an ax murderer. When I suggested that she experiment or play
around with the possibility of seeing herself in the role of the ax murderer,
she was able to contact some of the aggressive feelings associated with

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being in the role and ultimately to contact disowned feelings of anger

toward her husband for abandoning her during his frequent business trips.
Dream interpretation is no longer as central to contemporary
North American psychoanalytic theory and practice as it once was, but
most psychoanalysts do find it useful to work with dreams. Dreams can be
particularly helpful when clients have difficulty contacting and expressing
their inner life during treatment. In this situation, suggesting to clients
that they begin to pay attention to and write down their dreams is a
way of providing material for the treatment that emerges spontaneously
while the client is asleep and is not subject to the same type of defensive
processes that can otherwise drastically constrain the range of experiences.
Of course, the client’s recording of the dream and subsequent recounting
of it in the session involve a process of reconstruction, but the fashion
in which it is reconstructed can be of interest in and of itself. Working
with dreams can also be particularly interesting when the client reports
a particularly vivid dream or one with striking or startling imagery and
associated affect. Often these dreams touch on a key issue for the client
and can involve their feelings about the analyst and the treatment.
When listening to dreams, I try to avoid any preconceptions about
what different aspects of dreams may symbolize or preconceived ideas as
to how to work with them. I attempt to listen to the dream with receptive
openness and pay attention to both the client’s way of talking about the
dream and fluctuations in the client’s emotional experiences during the
recollection. I often stop the client at specific points and ask what he or
she is experiencing. I may start by asking what the client thinks of the
dream and request associations to dream elements. Sometimes his or her
interpretation makes perfect sense to me, and sometimes I find that the
ideas that pop into my mind are radically different from the client’s
formulation. At such times I am curious about the large discrepancy
between our interpretations; I may relay some of my own thoughts and
ideas and explore how the client responds.
Perhaps most important, I emphasize to clients that there are infinite
ways of interpreting any dream and that dream material allows us an
opportunity to engage in a kind of interactive play, during which we can

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experiment with different ways of looking at things and explore how

these different alternatives influence both of our understandings. I view
dream work as a kind of co-constructive process that allows clients and
therapists to engage in a playful way of working with the material. This
type of play makes use of intuition and the ongoing process of mutual
influence that is taking place as a vehicle for creating meaning together
in a way that is not constrained by the type of logical, linear thinking
that conversations about clients’ everyday experience often are. And as
is always the case, I pay particular attention to aspects of the dream that
could be construed as referencing our relationship or me (referred to as
allusions to the transference). I provide a clinical illustration of this process
later, when I discuss the case of Simone, a young woman whom I saw in
long-term psychoanalytic treatment.

Working With Resistance and Defense

Almost from the beginning of psychoanalytic thinking, the inter­
pretation of resistance and defense was viewed as a vital technical issue.
Ego psychology was particularly interested in exploring the various ways
in which the ego plays an active role in defending against unconscious
impulses. A central axiom in the ego psychology tradition is that analy-
sis proceeds from surface to depth. In other words, we always begin by
analyzing the client’s resistances and defenses and only gradually more
toward interpreting underlying impulses, fantasies, and wishes as they
become more accessible through the process of resistance analysis. As
previously discussed, from a psychoanalytic perspective the explora-
tion of resistance is intrinsic to the change process. Clients inevitably
have conflicting feelings about changing, and these conflicts manifest
in a variety of ways at different points in the treatment. Moreover,
resistance stems from an infinite number of different sources (e.g., fear
of changing, fear of loss of self, avoidance of painful feelings, nega-
tive feelings about the therapist or the therapeutic process, the need to
individuate from the therapist, secondary gain [i.e., benefits resulting
from maintaining the current symptoms], attachment to old patterns

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of relating, fear of losing the unconscious, symbolic connection to one’s

attachment figures).
Common ways in which resistance is expressed in treatment include
coming late for sessions, missing sessions, extensive periods of silence
or uncommunicativeness, filling the session with superficial chatter or
social conversation, failure to pay fees, overcompliance, and what is
referred to as a “flight into health” (i.e., experiencing a rapid and tran-
sient reduction in one’s symptoms as a way of avoiding exploring deeper
issues). Some actions facilitate progress in some contexts but may func-
tion as resistance in others. For example, the client’s reporting of dreams
may be an important way of deepening the therapeutic process by com-
municating feelings and themes that are not consciously accessible to the
client. But a client who ritualistically begins every session by reporting
dreams may be avoiding the exploration of important feelings or themes
in the here and now.

Defense Interpretation
Innumerable articles and books have been written about the technique of
defense interpretation. As I have just discussed, defenses can be named
and classified, although this does not capture the dynamic nature of
working them through with a client. The following brief descriptions
relate how to work clinically with defenses.
The therapist conveys the rationale for interpreting defenses as part of
the process of establishing an alliance around the task of defense analysis.
For example, I might say to my client,

People often find ways of avoiding feelings, thoughts, wishes, or

fantasies that are threatening to them as a way of avoiding distressing
feelings such as pain or shame. For example, sometimes people have
difficulty staying in contact with feelings of sadness because of a fear
that they will be overwhelmed by them or that they will never pass.
One of my jobs as a therapist will be to help you become aware of
times that you are doing this, as well as how you are doing it, so that
you have more of an ability to choose whether you are willing to stay

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with a particular feeling, fantasy, or wish instead of unconsciously

avoiding it. A fuller awareness of these aspects of your experience
will help you to develop a better understanding of what’s motivating
your actions and will also potentially provide you with important
information that helps us understand more fully what things really
mean to you and what you’re really wanting in any given situation.

Once a rationale has been conveyed to the client, the therapist

begins the task of monitoring the various types and ways in which the
client cuts off or avoids his experience and begins the process of draw-
ing his attention to avoidances or defensive maneuvers. For example,
“I notice that as you talk about your wife leaving you, your voice becomes
very even, and you begin to talk in somewhat of a monotone. Do you
have any awareness of this?”
Sometimes the client is able to become aware of the defensive maneu-
vers the therapist is attempting to immediately draw attention to, and
the therapist can then follow up with questions such as the following:
“Any sense of what was going on in inside of you at that moment?” or
even more directly, “Any awareness of avoiding anything in this moment?”
If the client is able to become aware and begin to explore an internal expe-
rience, the therapist can then follow up with probes such as, “Any sense of
what might be difficult about focusing on these feelings?”
In situations in which clients are not able to initially become aware
of their defensive maneuvers, it can be helpful to reiterate the rationale
for exploring defenses and then remind them that you will try to direct
their attention to them when they occur again. By continuing to draw
clients’ awareness to their defenses as they occur in the present moment,
the likelihood of their observing them in real time is increased. This pro-
vides clients with an opportunity to attend to the moment and engage in
an experientially based discovery process rather than merely speculating.
Therapists can help clients to explore what the processes are through which
they defend against their experience (e.g., feeling spaced out, changing
topics, intellectualizing) and what the unconscious fears, beliefs, and
expectations are that prohibit the experience of certain feelings, wishes,
and fantasies.

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Over time the process of defense interpretation has become more

exploratory, dialogical, and collaborative in nature and less “interpretive”
(in the sense of therapists simply pointing out clients’ defenses to them).
The term exploration of defenses rather than defense interpretation thus is
more accurate. There is no simple road map to indicate when a client is
avoiding emotions, and the therapist has to have an understanding of
the individual. Thus, for example, a preoccupation with talking about
the past can sometimes serve as a defense against exploring the present.
Other times a focus on the present can serve as a defense against explor-
ing the past.
In addition, it is worth noting that although it is important for thera-
pists to always attend to the style and manner of the client’s presentation
and to engage in an ongoing assessment of the extent to which he or she
is contacting or avoiding an emergent experience in the moment, it is
not always advisable to interpret or explore defenses whenever they take
place. Sometimes the process of exploring defenses is experienced as too
confrontative or critical by clients and can interfere with their ability to
contact their experience at a pace that feels safe to them. In other words,
sometimes clients need the therapist to support their defenses or to ally
with them in order for them to feel safe enough to begin disclosing their
inner experience. Defense interpretation should thus be used tactfully,
sparingly, and judiciously.

Working Through Therapeutic Impasses

There is a growing emphasis in psychoanalytic literature on the theo­
retical and technical importance of working through therapeutic impasses
when they emerge (cf. Safran & Muran, 2000). Over time the emphasis
has shifted from a perspective in which impasses in the therapeutic
process are viewed as a function of the client’s resistance to one in which
impasses are viewed as a two-person interactive process in which client
and therapist become locked into a complementary “doer or done to”
position from which it feels impossible for either to escape. Benjamin
(2004), Davies (2004), and Aron (2006), among others, have written

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eloquently about how there are times in the treatment process during
which both client and therapist are trapped because neither is able to
acknowledge the possible validity of the other’s perspective without
feeling that they themselves are wrong or bad in some fundamental
and unacceptable way. For example, the client accuses the therapist of
being critical, and the therapist feels that he is being abused by the client.
Although it might be possible for the therapist to mouth the words
“Yes, you’re right, I’m feeling critical,” the problem is that he doesn’t
really experience himself that way, and therefore it would be impossible
for him to acknowledge it in a genuine fashion.
In situations of this type, neither client nor therapist is able to truly
acknowledge the validity of the other’s perspective because it feels
that doing so would involve a kind of self-violation or compromise of
his or her own integrity. How can the interaction begin to shift out of a
frozen position in which there is no alternative to either (a) the client’s
perspective being valid and the therapist’s perspective being unimportant
or lacking validity or (b) the therapist’s perspective being valid and the
client’s perspective being invalid or unreasonable? The therapist’s task is
to facilitate a movement to a third position (i.e., an alternative to the binary
choice of “You’re right and I’m wrong” or “I’m right and you’re wrong”).
This process requires an internal shift within the therapist that has a
quality of “surrendering” or “letting go” of a position he or she needs to
hold on to tenaciously because of underlying and sometimes unconscious
fears or threats of acknowledging dissociated aspects of self-experience
(Safran & Muran, 2000). For example, perhaps the therapist in the first
illustration finds it too threatening or intolerable to experience aspects of
himself that are indeed mean. Perhaps this therapist is threatened by fully
acknowledging to herself complex feelings of anger and shame around the
experience of “being taken advantage of.”
To the extent that therapists are able to acknowledge and accept
dissociated aspects of their own experience, they begin to experience the
psychological freedom to fully appreciate and empathize with the valid-
ity of the client’s subjective experience without experiencing an internal
compromise or a sacrifice or submersion of their own subjectivity. This

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shift thus involves a movement toward a type of intersubjectivity, in which

one is able to experience the other as a subject rather than an object while
holding on to one’s own subjectivity (Benjamin, 1988, 1990, 2004).

Termination
Termination is one of the most important phases of treatment. A well-
handled termination can play a vital role in helping clients to consolidate
any gains that have been made in treatment. Conversely, poorly handled
terminations can have a negative impact on the treatment outcome.
In a treatment that is not time limited, the topic of termination can be
initiated by either client or therapist. Ideally, by the time termination
takes place, the client and therapist will have spent some time talking
openly and constructively about the process, and the decision to terminate
will be mutual. Often clients who are contemplating termination will have
difficultly bringing it up directly, and it is important for the therapist to
be attuned to cues that the client may be considering ending treatment.
For example, the client begins to consistently arrive late for sessions or
cancels sessions, seems less engaged in treatment, or asks general questions
about how long people typically stay in treatment.
Termination in open-ended treatment is often somewhat messier than
the idealized way it is presented in many textbooks. Often termination is
the result of extraneous factors (e.g., the client moves to another city).
When the factors leading up to termination are not extraneous, it is more
common for clients to initiate termination than therapists. This may
be because therapists can have more ambitious goals for change that are
guided by theoretical concerns, or it may be because the client becomes
dissatisfied with the treatment. There are also occasions when both client
and therapist feel that the client has achieved the initial therapeutic
goals, and the client is the first one to recognize this and to bring it up.
When the client brings up the topic of termination in a fashion that feels
premature or precipitous for the therapist, it is important for the therapist
to carefully explore the client’s reasons for wishing to terminate. Some-
times, for example, the client initiates the topic of termination because of
feelings of dissatisfaction with the treatment or anger or disappointment

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with the therapist but has difficulty bringing this up directly. In such situ-
ations it is the therapist’s task to provide a climate that maximizes the
client’s sense that the therapist is genuinely interested in and receptive to
hearing any concerns about the treatment that the client has and that it is
safe to talk about negative feelings or concerns. The subject of termina-
tion may be a peek into the client’s experience of an enactment that they
have been reluctant to discuss. The therapist needs to convey respect for
the client’s right to privacy, respect for the validity of his or her ultimate
decision, and curiosity about what this may mean in light of the client’s
particular issues.
An important thread to analytic work involves looking beneath the
surface explanation to find deeper meaning or unconscious motivation.
If the therapist explores the client’s reasons for initiating termination in
a sensitive and respectful manner, with a genuine receptivity to hearing
negative or ambivalent feelings about the therapy or therapist, in some
circumstances it can lead to the exploration of feelings such as resent-
ment, mistrust, or disappointment, which if listened to empathically can
strengthen the therapeutic relationship and lead to the client’s recommit-
ment to therapy. However, when the therapist fails to accept the client’s
stated reasons for wanting to leave and repeatedly attempts to badger the
client into admitting feelings or motivations that he or she either doesn’t
experience or is unaware of, the client can feel undermined, coerced, or
pathologized. The therapist thus needs to strike a balance between, on one
hand, trying too hard to hold on to a client who wants to terminate and,
on the other hand, failing to adequately explore the client’s underlying
motivations for terminating.
When the process of exploring the client’s desire to leave treatment
does lead to a final decision to terminate, it is useful to establish a contract
to meet for a certain number of final sessions to provide an opportunity to
terminate in a constructive fashion. This process of termination involves
numerous principles, such as reviewing the changes that have taken place
in treatment, constructing a shared understanding of the factors that
have led to change, helping the client to recognize his or her own role
in the change process, creating a space that allows the client to express a
range of feelings about the termination and the treatment (both positive

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and negative), exploring or interpreting defenses against experiencing these

feelings, exploring potentially painful feelings around loss or fear of sepa-
ration, and exploring any feelings of disappointment with the treatment
and accepting them in a nonjudgmental and nondefensive fashion.

Exploring Ambivalent Feelings in Termination

It is normal for clients who are terminating therapy to have ambivalent
feelings about the treatment and the therapist, just as it is normal for
human beings to have ambivalent feelings about all relationships. Clients
may experience a range of feelings, including gratitude for the changes
that they have made in their lives, fear of ending treatment, relief at no
longer having to be in therapy, sadness about the loss of the therapist,
abandonment, disappointment about the changes that have not taken
place, and resentment toward the therapist because of the failure to realize
some of their initial treatment goals or other disappointments with the
therapy and the therapist. These feelings are not mutually exclusive. It is
important for the therapist to provide a safe place for clients to explore
and express the full range of feelings they may have about termination
to allow them to obtain a greater degree of closure about the experience
of therapy. Some clients may have difficulty acknowledging any negative
feelings because of fears (both conscious and unconscious) that they will
spoil the positive feelings or hurt or anger the therapist. Other clients may
have difficulty contacting and expressing feelings of gratitude. Owning
mixed feelings helps clients to learn to tolerate ambivalent feelings. It is
also important for therapists not to shrug off positive feelings expressed
by the client. The process of experiencing and expressing gratitude and
having it graciously acknowledged by the other is a significant part of the
growth process.

Working Constructively With Countertransference

Feelings During Termination
Termination is bound to be fraught with a range of feelings for therapists
in the same way as it is for clients. It is inevitable that, as therapists,

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we want to be helpful to our clients and successful with their treatment.

It can be difficult to deal with the discomfort that may emerge when clients
are not as pleased with the treatment outcome as we would like them to be.
Negative feelings are particularly likely to emerge for the therapist when
he has experienced a client who is unilaterally terminating as difficult to
work with, especially when the therapist has struggled unsuccessfully in
an attempt to meet the client’s needs or has been an ongoing object of
criticism or passive-aggressive behavior by the client. In such situations it
can be difficult for the therapist to tolerate negative sentiments from the
client without wanting to blame the client for any lack of progress. This in
turn may take work on the therapist’s part, either in personal therapy or
supervision, to become more accepting of his or her own personal failures
and limitations. And yet it is critical to remember that for the client, the
opportunity to feel that the therapist failed and to express negative feelings
about this without retaliation and without feelings of having excessively
hurt or destroyed the therapist may be a valuable part of the change pro-
cess. For example, it may help the client to know that the feelings of the
other do not need to be protected or that negative feelings are not toxic
and do not have to be hidden. This in turn can help to free the client inter-
nally to ultimately be able to experience feelings of closeness and gratitude
toward the therapist and others.

Cultivating a Climate That Tolerates Ambiguity

and Lack of Closure
An important aspect of the termination process involves making sense
of the entire experience of therapy and establishing a sense of closure.
But it is also important for the therapist to recognize and convey an
appreciation for the fact that there are limits to the extent of closure that
can be obtained on the journey that the therapist and the client have taken
together and on their relationship. The meaning of the time that the
client has spent in therapy and the meaning of the relationship that
he has developed with the therapist will evolve over time, as the client has
other life experiences. The therapist often has a sense that over the course

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of treatment, certain threads running through the client’s life story and
way of being in the world have emerged, been more clearly fleshed out,
and been made sense of, whereas other threads have remained more vague
or elusive. Some themes that play out in the therapeutic relationship and
unfold over time, or patterns of relating to one another that are frustrat-
ing or troubling, can be worked through constructively and understood
in ways that help clients gain a sense of movement and mastery in their
life. Other themes are less clearly understood by the end of therapy and
remain mysteries that may make more sense to the client in the light of
subsequent experiences and changes that occur later in the client’s life.
Learning to live with ambiguity and a lack of complete closure is a signifi-
cant developmental achievement. In fact, the empirical research on the
topic of wisdom has suggested that this type of tolerance of ambiguity is a
more advanced cognitive-affective developmental stage (Sternberg & Jor-
dan, 2005). The cultivation of this ability to tolerate such ambiguity can
be an important by-product of therapy, especially if the therapist is able
to see the cultivation of this kind of tolerance as one of the by-products of
a “good enough” termination.

CHANGE MECHANISMS
Now that I have discussed principles of intervention, I discuss some of
the underlying mechanisms that are hypothesized to be active in the
change process. How does change actually take place in a psychoanalytic
treatment?

Making the Unconscious Conscious

Psychoanalytic theory postulates a host of different change mechanisms,
and a multitude of new ways of conceptualizing the change process con-
tinue to emerge as psychoanalytic theories evolve and proliferate. At the
most basic level, there is an understanding that change often has something
to do with making the unconscious conscious, or in Freud’s (1933/1965)
oft-cited axiom “Where id was, there ego shall be” (p. 100). Although

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Freud’s understanding of the nature of the change process evolved over

the course of his lifetime, central to his mature thinking was the idea that
we are driven by unconscious wishes that we are unaware of, and this
lack of awareness compromises psychological freedom and perpetuates
self-defeating behavior. For Freud, we delude ourselves as to reasons
for doing things, and this self-deception limits our choice. By becoming
aware of our unconscious wishes and our defenses against them, we
increase the degree of choice available to us. In a sense, then, we decrease
the degree to which we are driven by unconscious factors and assume a
greater degree of agency.
Developing an awareness of unconscious motives is one of the
earliest principles of change delineated in psychoanalytic treatment.
Freud’s fundamental assumption was that we are motivated by forces that
we are not aware of and that this lack of awareness deprives us of choice.
In addition, our motives are complex and often contradictory. In psycho­
analytic terms, this is referred to as the principle of overdetermination.
Although we might think we understand how we make choices, there are often
a multitude of motives. For example, an individual cultivates an attitude
of humility and self-sacrifice through his exposure to spiritual teachings.
The desire to be humble and prize the welfare of others is genuine. At the
same time, that stance of humility may mask or partially defend against
a need to be recognized as special, and the ethic of self-sacrifice may be
partially an expression of a self-righteous desire to be morally superior to
the other, combined with disowned anger and aggression. To the extent
that we are unaware of our motives, our degree of choice is reduced.
We do things for reasons that are opaque to us and are then surprised and
disappointed by the results. This contributes to a sense of being a victim
rather than an agent. Next I discuss a variety of mechanisms that can aid
in the process of self-awareness in treatment.

Emotional Insight
One of the central methods for making the unconscious conscious is the
use of verbal interpretations that give clients insight into the unconscious

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factors that are shaping their experience and actions. One hopes that this
is not merely an intellectual recognition; ideally the client can achieve
emotional insight—that is, combining the conceptual with the affective
so that the client’s new understanding has an immediate quality. It has
long been held that one of the key ways of increasing the possibility that
the insight will be emotional is through the use of transference inter­
pretations (Strachey, 1934), which leads clients to reflect on their imme-
diate experience of the therapeutic relationship rather than to construct
an abstract formulation. In other words, by directly observing the way in
which they are construing the present moment and acting in the here and
now, clients are able to develop an experience of themselves as agents in
the construction/creation of their own experience.
Early on, psychoanalytic insiders such as Otto Rank and Sandor
Ferenczi raised concerns about a tendency for some psychoanalysts to
veer toward a more intellectualist approach that they felt was of limited
value (Ferenczi & Rank, 1925/1956). And there is no doubt that the 1960s
maverick psychoanalysts such as Fritz Perls (the founder of gestalt therapy)
developed an intensely anti-intellectual stance in reaction to what they
saw as the tendency toward overintellectualization in psychoanalysis.
In general, my impression is that the contemporary American psycho-
analytic sensibility has taken the critique of the intellectualist tendencies
of psychoanalysis to heart and has placed an important emphasis on the
affectively grounded experiential aspects of the change process.

Articulation of Feelings and Wishes

The process of articulating feelings and wishes is another key mechanism
of change in psychoanalytic treatment. As discussed earlier, emotions
are a biologically based form of information about the self in interaction
with the environment that are wired into the species through an evolu-
tionary process and that play an adaptive role in the survival of the species.
Healthy functioning involves the integration of affective information with
higher level cognitive processing to act in a fashion that is grounded in
organismically based need but not bound by it. Emotions are associated

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with wishes, which when experienced and articulated can lead to adaptive
behavior. Thus, for example, the individual who has difficulty experiencing
anger in an appropriate context may be deprived of information that will
help him or her to act in an appropriately aggressive or self-assertive way.
An individual who has difficulty experiencing feelings of sadness may
have difficulty seeking comfort or nurturance from others.
A variety of intervention principles in psychoanalytic treatment help
clients to access emotions and associated wishes that are being defended
against. These include the communication of empathy, the interpretation
of dissociated experience, and the interpretation or exploration of the
defenses that interfere with the experience of potentially adaptive wishes
and experience. At a more implicit level, the client’s experiencing and
expressing feelings and associated wishes in the context of a safe and vali-
dating therapeutic relationship can play an important role in challenging
the unconscious relational schemas that interfere with the experience of
these wishes.

Creating Meaning and Historical Reconstruction

People often come to therapy with difficulty in the construction of
meaningful narratives about their lives. These failures of meaning can
include both the lack of a coherent understating of their experience and
the presence of self-defeating narratives. It can be helpful to construct a
viable narrative account of the role that childhood experiences played in
contributing to current problems. Emotional problems often arise from
psychological coping strategies that were adaptive and made sense in the
context of a dysfunctional childhood situation but are maladaptive in
the present context. When this is articulated and understood, a client
can become more tolerant and accepting toward himself and begin the
process of developing better strategies.
Often the problems that clients bring to therapy extend beyond a
concern with specific symptoms to a more pervasive sense of meaningless-
ness and existential despair. When this is the case, the process of exploring
and clarifying their own values and engaging in a meaningful dialogue

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with the therapist can help clients to reorient themselves and develop a
more refined sense of what is meaningful to them. For clients, this pro-
cess of meaning construction often involves becoming more aware of and
articulating the nuances of their emotional experience in the context of
the relationship with the therapist so that they can begin to get a sense of
feeling more vitally alive and in touch with their inner experience.

Increasing the Experience of Agency

Clients often begin treatment with a diminished sense of personal agency.
They experience themselves to be at the mercy of their symptoms or to
be victims of misfortune or of other people’s ill intent or neglect. They
often fail to see the relationship between their symptoms and their own
internal and interpersonal conflicts. As clients gain a greater appreciation
of the connections between their symptoms and their ways of being, and
of their contributions to the conflictual patterns in their lives, they come
to experience a greater degree of choice in their lives and to experience
themselves as agents rather than as victims. This growing awareness or
understanding of one’s personal agency must be experientially based
rather than purely conceptual.

Appreciating the Limits of Agency

Coming to experience a sense of agency is, however, only half the battle.
The other half involves coming to appreciate and accept the limits of
our agency (Safran, 1999). In a culture that promotes the myth that
we can “have it all” if only we drink the right wine or drive the right car,
it is easy to feel that if we do the right thing we can have everything we
desire. Realizing the limits to agency can be part of the growth process of
analysis. Winnicott (1958, 1965) spoke about the importance of what
he referred to as optimal disillusionment in the maturational process.
According to him, as children we begin without a clear distinction between
fantasy and reality and with the expectation that our needs will magically
be taken care of. As we mature and experience inevitable frustrations

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and disappointments of living in the real world, we undergo a process of

disillusionment. If our parents and our environment are unresponsive to
our needs, then this disillusionment can be traumatic and we can lose our
inner sense of vitality, possibility, and authenticity. We can become over-
adapted to the needs of others and develop what Winnicott (1958, 1965)
referred to as a false self—that is, a way of being that is responsive to the
demands of external reality but that loses contact with an inner sense of
vitality and realness. If, however, our parents are sufficiently responsive
to our inner needs, then this inevitable process of disillusionment takes
place in an optimal or “good enough” fashion, and we surrender some
aspects of our childhood fantasies without having the vitality and playful-
ness of our childhood completely extinguished. Building on Winnicott
as well as other sources, some contemporary psychoanalytic writers have
spoken about this as an experience of “surrender” in which we are able
to let go of the idea that we can have it all and accept things as they are
(Aron, 2006; Benjamin, 2004; Ghent, 1990; Safran, 1993, 1999, 2016).
This sense of the role of surrender in the psychoanalytic change process
comes closer to a paradoxical Eastern perspective on change than to
the traditional Western emphasis on change through willpower and
determination.

New Relational Experience and Internalization

of the Therapeutic Relationship
Psychoanalytic theory emphasizes the role that the therapeutic relation-
ship itself plays as a change mechanism. By acting in a way that is different
from the way in which the client’s parents did, the therapist can provide
the client with a new relational experience that challenges his or her mal-
adaptive relational schemas, working models, or internal object relations.
This thread in psychoanalytic theory can be traced back to the 1930s to the
work of Sándor Ferenczi (1980a, 1980b) and to a seminal article by James
Strachey (1934). In the 1940s, Franz Alexander, a Hungarian analyst who
had immigrated to the United States, developed a theory of change that
he termed the corrective emotional experience (Alexander, 1948). Alexander

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argued that it was essential for the therapist to develop a formulation of

the client’s distorted beliefs about the nature of relationships with other
people and to then intentionally position himself or herself in a way
that challenged it. For example, for the client whose parents were overly
intrusive, it might be important for the therapist to be particularly respect-
ful of the client’s need for privacy. Alexander’s position was extremely
controversial at the time, as it was seen by his contemporaries as manipu-
lative. It also hit a nerve among analysts who had always believed that
what distinguished psychoanalysis from other therapeutic approaches
was its emphasis on discovering the truth rather than on the use of the
power of suggestion to heal.
Loewald (1960), in a classic work, also emphasized the therapeutic
relationship itself as a mechanism of change, but unlike Alexander he
made it clear that he was not advocating for a new technical procedure.
Instead, he argued that in the same way that children grow through
identifying with their parents and internalizing interactions with them,
patients grow through internalizing interactions with their therapists.
According to Loewald, the therapist’s interpretive activity provides a
regulating and integrating function for the client, and it is the client’s
internalization of this integrative experience with the therapist that leads
to change.
Modified versions of Alexander’s and Loewald’s positions are widely
accepted by contemporary psychoanalytic theorists who have argued
that the therapist’s ability to function as a new object for the client
(rather than an old object who resembles his or her parents) is a key
mechanism of change (Cooper, 2000; Greenberg, 1986). According to
this perspective, clients unconsciously try to replicate the relationships
with which they are most familiar even though aspects of these dynamics
have caused them pain. For example, the client who had critical or sadistic
parents will act in ways that evoke critical or sadistic behavior from the
therapist. As discussed earlier, the therapist’s task is to gradually disembed
from the relational scenario that is being played out so that the thera-
peutic relationship can ultimately function as a new relational experience
rather than a repetition of an old one. In contrast to the notion of the

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corrective experience, the contemporary perspective does not suggest that

the therapist should or can develop an a priori formulation of the type
of new relational experience that the client needs and then intentionally
play a particular role. Rather, the emphasis is on accepting the inevitability
of playing the role of an old object (i.e., being recruited into one of the
client’s characteristic relational scenarios) and then working toward under-
standing this enactment together with the client and extricating from this
role in order to give the client a different relational experience.

Affect Communication
There is a basic assumption in psychoanalytic theory that an important
portion of the communication that takes place between people occurs at
an unconscious level. What exactly is meant by this? References to this
notion of unconscious communication can be found in Freud’s early
technical papers. For example, in one early work, Freud recommended
that the analyst turn his own unconscious toward the transmitting
unconscious of the client.

He must adjust himself to the client in the way that a telephone receiver
is adjusted to the transmitting microphone. Just as the receiver con-
verts the electric oscillations in the telephone line back into sound
waves, the doctor is able, from the derivatives of the unconscious that
are communicated to him, to reconstruct the original wish or drive
that determined the client’s free associations. (Freud, 1912, p. 115)

Contemporary research on emotion has suggested that people are

remarkably good at reading others’ affective displays without conscious
awareness (e.g., Parkinson, 1995). Many contemporary analysts who are
influenced by developmental research have argued that early mother–
infant communication takes place at an affective, bodily felt level prior to
the development of any conceptual or symbolic abilities on the infant’s
part. Developmental researchers such as Ed Tronick (2007) and Beatrice
Beebe (Beebe & Lachmann, 2002) have observed that there is an ongoing
process of mutual influence in the nonverbal behavior between mother

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and infant (e.g., gaze, posture, affective tone), in which both mother and
infant communicate with each other through nonverbal language or at a
presymbolic level. Our first relational experiences thus take place outside
the verbal domain and are symbolized or encoded at a presymbolic level,
or as what Lyons-Ruth et al. (1998) called implicit relational knowing.
Implicit relational knowing is a felt sense that is expressed not in what we
say but rather in the way we act and feel in relationships. It is thus a kind
of procedural knowledge, a knowing about being in relationships that is
not encoded at a linguistic level.
Psychoanalysis provides the opportunity for clients to verbalize
implicit relational experiences and reflect on the way in which their
prelinguistic, implicit, or unconscious assumptions shape the way they
understand relationships, construe other people’s actions and intentions,
and act in relationships. Furthermore, the affective nonverbal exchange
can be curative in and of itself as a new relational experience.

Containment
One of the most important skills for therapists to develop is an internal
skill, rather than a technical one. This internal skill involves attending
to our emotions when working with clients and cultivating the ability
to tolerate and process painful or disturbing feelings in a nondefensive
fashion. How do we help our clients hold on to some sense of faith that
things will work out when we ourselves are beginning to feel hopeless?
How do we work with our own feelings as therapists when working with
an extremely hostile or devaluing patient? How do we work with our
own feelings when we begin to feel the same sense of despair that our
client feels?
The British psychoanalyst Wilfred Bion (1970) referred to this process
as containment. According to Bion, as part of the normal developmental
process, children defend against feelings that are too threatening or toxic
for them to experience by projecting them onto the parent. Bion argued
that children (and clients) not only imagine that unacceptable feelings
belong to the caregiver or therapist but also exert subtle pressures that

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evoke the dissociated feeling in the therapist. So, for example, the client
who experiences nameless feelings of dread and terror dissociates these
feelings and in subtle ways evokes these feelings in the therapist. Bion also
theorized that children need their parents to help them process their raw
emotional experience and learn to tolerate, symbolize, and make sense of
this raw experience.
How do children or clients evoke powerful and sometimes dis­
sociated feelings in parents or therapists? Although Bion did not elab-
orate on the precise mechanisms, contemporary emotion theory and
research suggests that (a) it is not uncommon for people to experience
the nonverbal aspects of emotion in the absence of conscious awareness,
and (b) as indicated earlier, people are remarkably good at reading and
responding to other people’s emotion displays without conscious aware-
ness (e.g., Ekman, 1993; Greenberg & Safran, 1987). The process of con-
tainment is conceptual and affective in nature. Helping the child or client
to put feelings into words is certainly one component of it. The more
challenging component involves processing and managing powerful
feelings that are evoked in us as parents or as therapists so that our own
affective responses can help to regulate the other’s emotions rather than
to further disregulate them.

Interactive Affect Regulation

The increasingly influential subject of affect regulation has tremendous
implications for therapeutic practice. Beebe and Lachmann (2002) argued
that the psychologically healthy individual has the capacity to flexibly
move back and forth between (a) using his or her own self-soothing skills
to regulate distressing emotional experience and (b) using the relationship
with the other to help regulate emotions. The ability to regulate internal
emotional states begins in infancy in the relationship with the primary
caregiver. It turns out that mother–infant observational research has found
that attachment security tends to be associated with a midlevel degree
of affect attunement between mother and infant. Not surprising, infants
whose mothers are consistently affectively misattuned tend to be insecurely

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attached. These infants can be overly reliant on the use of self-regulation

strategies. These may involve activities such as thumb-sucking or gaze
aversion or distraction. Perhaps less obvious, infants whose mothers are
consistently affectively attuned tend to be insecurely attached as well. It
may be that excessive attunement on the mother’s part reflects an anxiety
about the infant’s independence or separation, or alternatively that exces-
sive vigilance on the infant’s part reflect insecurity about the relationship,
or both. The pattern of mutual attunement that tends to be associated
with attachment security is in the midrange—somewhere between the
two extremes of emotional neglect and preoccupation with affective
connection.
Self-regulation plays an extremely important role in the individual’s
functioning from birth onward. Self-regulation consists of various strat-
egies and actions used to manage arousal, maintain alertness, dampen
arousal when overstimulated, process and manage various feelings, and
make constructive use of affective feedback. Self-regulation plays a critical
role in the capacity to pay attention to and engage with the environment.
As previously indicated, for infants, self-regulation strategies include
activities such as gaze aversion and thumb-sucking. In adults, the activi-
ties can be daydreaming, fantasy, symbolic elaboration, defenses, rational
self-coping strategies, and self-reassurance.
The ability to regulate one’s emotional experience is an important
component of healthy development. Infants develop this ability through
being part of an interpersonal system in which they have the experience of
both influencing and being influenced by the caregiver. For example, the
infant cries, the mother soothes, the infant calms down, and the mother in
turn feels soothed. It takes time after the infant is born for the caregiver to
adapt to the specific temperament and characteristic patterns of shifting
mood states of the infant. But over time and through a process of mutual
adaptation, a certain predictability in the interpersonal system develops.
Each partner in the system transforms and in turn is transformed through
a process of moment-to-moment coordination of rhythms of nonverbal
behavior. Both partners come to trust the predictability of the system, and
this implicit trust allows the infant to become self-regulating, even if the

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caregiver is not attending at the moment, and at the same time to know
how to take comfort from the caregiver when necessary.
Similar processes can be observed in psychoanalysis. For example,
James, a 50-year-old lawyer, began treatment with me 1 year after
having recovered from serious major depression. Although he was not
chronically depressed, this had been his second major depression, and
he was eager to begin the process of treatment to reduce the possibility
of future relapse. One of the things that impressed me about James
early on was his self-contained style. He showed very little emotion in our
sessions, and although he seemed eager for help from me, there was
another level at which I felt that he had difficulty finding value in any-
thing I said or did. James was an intelligent, well-educated, and thought-
ful man who had read much psychology, and there was a way in which
he seemed to have all the answers in advance. Over time, as I developed
an understanding of his developmental history, I came to speculate
that he was excessively reliant on the use of self-regulation skills and
had tremendous difficulty making use of relationships with others to
regulate emotional experience.
In contrast, Elizabeth presented with a desperate need for soothing,
comfort, and reassurance from me. She seemed to have no capacity for
emotional self-regulation. Furthermore, although sometimes the things
I said or did seemed momentarily reassuring or soothing to her, the
effects were always short-lasting. She also had a tendency to express
her need for reassurance and comfort from me in an intense, angry, and
coercive fashion, as if she anticipated that whatever she needed from
me would not be forthcoming. Over time I began to get a sense that
Elizabeth’s parents had been emotionally misattuned and neglectful and
that she had often been left alone in states of overwhelming emotional
terror. Without the presence of a containing environment, Elizabeth was
not able to develop self-regulation skills, and her desperate attempts to
coerce soothing from others reflected both this lack and a pained and
angry expectation of continuing neglect by others.
With both James and Elizabeth, part of the therapeutic process
involved an ongoing attempt to understand how their styles of self and

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interactive regulation made it difficult to provide them with what they

needed. This attempt included an ongoing exploration of what was
happening between us in the therapeutic relationship. It also involved
a process of thinking out loud together about how important develop­
mental experiences may have played a role in the development of their
current affect regulation styles. Just as important, if not more important,
however, was a type of organic process through which our evolving
relationships helped me to develop a greater capacity to regulate my own
affective experience while we were working together. Simultaneously,
James’s and Elizabeth’s evolving shift in implicit relational knowing
allowed them to be more open to what I could provide and to make use
of our relationship in ways that they were not able to at the beginning.
There was thus a kind of mutual evolving relational dance taking place
that allowed both me and my clients to change at the same time.

Rupture and Repair

Relationship ruptures are part of the human experience. Tronick (2007)
demonstrated that in normal mother–infant face-to-face interactions,
affective coordination between the two occurs less than 30% of the
time. Transitions from coordinated to miscoordinated states and back
to coordinated states occur about once every 3 to 5 seconds. Tronick
hypothesized that this ongoing process of interactive disruption and
repair plays an important role in the normal developmental process. It
helps the infant develop an implicit relational understanding that both
the self and the other are capable of repairing disruptions in relatedness.
This ability allows people to negotiate their ongoing needs for attunement
and relatedness throughout the life span and provides them with both
the sense of self-efficacy and faith in others to know that interpersonal
conflicts and misunderstandings do not have to be catastrophic. In the
same vein, working through the inevitable misunderstandings and disrup-
tions in relatedness that take place between client and therapist improve
a client’s implicit relational knowing.
The principle of relationship rupture and repair has come to assume
a central role in the thinking of many psychoanalytic theorists as an

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important element of the change process. For example, Heinz Kohut

(1984) came to see the process of working through the therapist’s inevi-
table empathic failures as a central therapeutic mechanism. From his
perspective, when the therapist is able to empathize with the client’s expe-
rience of having been failed, a process takes place in which clients begin
to internalize the therapist’s empathic presence and results in a type of
structural change for clients that allows them to take over some of the
therapist’s empathic or mirroring functions. These functions are essential
for the individual to be able to maintain a sense of self-cohesiveness.
Along similar lines, I have written about the role that repairing
ruptures in the therapeutic alliance can play as a vitally important change
process (e.g., Safran, 1993, 1998; Safran, Crocker, McMain, & Murray,
1990; Safran & Kraus, 2015; Safran & Muran, 1996, 2000, 2006). This
emphasis on the importance of repairing ruptures in the therapeutic
alliance has now received attention from theorists and researchers across a
range of therapeutic traditions, and a growing body of empirical evidence
supports the between rupture repair and good outcome (Eubanks, Muran,
& Safran, 2018; Safran, Muran, Samstag, & Stevens, 2001, 2002).

Mentalization
In recent years the theoretical and empirical work on affect regulation and
mentalization has become increasingly influential among psychoanalysts
(e.g., Fonagy, Gergely, Jurist, & Target, 2002). Building on attachment
theory and research, Fonagy and colleagues conceptualized the capacity
for mentalization or reflective functioning as the ability to see ourselves
and others as beings with psychological depth. It is a capacity to go beyond
the superficial reality and access and reflect on our own thoughts, feelings,
and motivations as well as the mental states of others. As such, mentaliza-
tion can be thought of as a combination of or perhaps a dialectic between
self-awareness and perspective taking (Holmes, 2010).
In this respect, the construct of reflective functioning can be further
clarified by elaborating on Benjamin’s (2004) previously mentioned con-
ceptualization of intersubjectivity. According to Benjamin, the capacity

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for intersubjectivity is a developmental achievement that involves an

ability to hold on to one’s own experience of oneself as a subject with a
valid perspective while experiencing the other as a subject with his or her
own independent wishes, needs, and beliefs that are important in their
own right (Benjamin, 1988, 2004, 2018). To the extent that one has the
capacity for intersubjectivity, one is able to access one’s feelings, wishes,
and desires and accept their fundamental validity while able to appreciate
the other as a subject with equally complex and meaningful wishes, inten-
tions, and needs rather than as an object or a character in one’s own
internal drama. One of the ways that therapy can facilitate change is thus
through promoting an improved capacity to mentalize. An improvement
in this capacity is significant because mentalization plays an important role
in allowing the individual to recognize and accept his or her own feelings
and needs while managing the complexity of interpersonal relation­ships
in an adaptive fashion and negotiate the needs of self and other.
How does the therapeutic process lead to an improvement in the
client’s capacity to mentalize? First, as is the case in a healthy develop-
mental process, the therapist’s ability to serve as a secure attachment figure
for clients helps clients explore feelings and intentions that have previously
been dissociated. Second, the process of exploring the transference and
countertransference allows clients to have a greater capacity for mental-
ization by helping them to become more aware of their internal experience
and the way in which their actions impact the therapist’s experience.
Judicious self-disclosure by the therapist in this context can help the client
to develop a greater appreciation of the other’s subjectivity.
Third, the process of working through ruptures in the therapeutic
alliance (therapeutic impasses) also helps clients to develop a greater
capacity to mentalize. It is inevitable that therapists will at times fail to
live up to their clients’ idealized fantasies of what they can provide (e.g.,
perfect attunement, magically transforming the client’s life). When this
happens, the therapist’s task is to work through these ruptures construc-
tively and to empathize with the client’s wishes and desires even if he or
she is not always able to fulfill them. As described earlier, this leads to a
type of optimal disillusionment that helps clients to begin experiencing
the therapist as good enough (Winnicott, 1958, 1965) and as a real subject

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rather than an idealized object of their fantasies. At the same time, the
therapist’s capacity to empathize with the client’s unmet needs and wishes
helps the client to experience his or her desires as valid even if they cannot
be fulfilled (Safran, 1993, 1999).
Finally, when a therapist holds a representation of the client in mind,
it helps the client see themselves through their therapist’s eyes as separate
subjects with their own valid feelings and experiences. Especially in the
case of more disturbed clients (e.g., clients with borderline pathology),
a growing appreciation that the therapist is able to hold them in mind
between sessions or during breaks in the therapy plays a role in helping
them develop an experience of object constancy (i.e., they are able to hold
on to a representation of the therapist as a real person who cares about
them even in his or her absence).

PRINCIPLES OF LONG-TERM VERSUS

SHORT-TERM PSYCHOANALYTIC TREATMENTS
In this section, I discuss the principles of both long-term and short-term
psychoanalytic treatment. Although there are important similarities,
there are important differences as well. I also provide clinical illustrations
of both modalities.

Long-Term, Intensive Treatment

Although it can be helpful to see an analyst three or four times a week,
contemporary culture, with its emphasis on speed and efficiency, does
not readily support this type of intense involvement in the work. Health
insurance rarely covers intensive treatment, and this limits who can
benefit from it. At one time it was believed that frequent sessions per week
and long-term treatment were necessary for the transference to develop.
These days a more common perspective is that both transference and
countertransference are present from the very beginning. Nevertheless,
it can take time and frequent contact for more intense feelings that are
typically kept out of consciousness to emerge. The more important the
therapist becomes in the client’s life, the more likely it is that experiences

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within the therapeutic relationship will have a constructive impact on

the client.
I am sometimes asked by students whether it is possible to do real
psychoanalytic work that involves the development of intense transfer-
ences and the careful exploration of transference/countertransference
dynamics when the client comes only once a week. My experience is that
it depends on the client. Some clients are able to form a strong alliance
with the therapist and also have the capacity to explore intense and
conflicting feelings about the therapeutic relationship when frequency
of treatment is kept to once a week. With others, this is more diffi-
cult, and more frequent contact is important. Some clients simply do
not have the psychological and emotional capacity to benefit from this
intense exploration of what is taking place in the therapeutic relation-
ship, no matter how frequent their sessions. This does not mean that they
cannot benefit from psychoanalysis or psychoanalytically oriented therapy,
but it does mean that the exploration of transference/countertransference
dynamics cannot be a primary vehicle of change for them.
One of the important features of long-term, open-ended psychoana-
lytic treatment is a sense of evolving process, discovery, and openness to
the emergence of new themes. This stance requires a certain tolerance
of ambiguity by both client and therapist. In situations in which the
client presents with an urgent need or is in crisis, this type of open-ended
approach may be frustrating. In such cases, it is critical for the therapist
to be responsive to the client’s need to focus on the specific problem in a
more active and directive fashion. Once the immediate crisis or sense of
urgency has passed, the client may be interested in continuing treatment
in a more open-ended manner or alternatively may feel that it is time to
terminate treatment. Either way, it is important for the therapist to be
responsive to the client’s needs.

Simone: An Illustration of Longer Term

Psychoanalytic Treatment
Simone was in psychoanalysis with me; we met three times per week for
4 years. At the start of treatment, she was 26 years old. Simone initially

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sought treatment because of a “general feeling of emptiness” as well as

a moderate problem with bulimia, which involved both binging and
purging. She was working in a health food store on a part-time basis and
was primarily supported by her father. In college, Simone had majored
in fine arts, but at the time she was in treatment with me, she was not
doing anything related to her education. She was an extremely attrac-
tive, intelligent, and well-dressed African American woman. From the
beginning I was struck by her lively and playful manner and her sense of
humor. I also began to notice early on a tendency on her part to vacil-
late between states of narcissistic grandiosity during which she denied
any needs or self-doubts and (less frequently) states of openness and
vulnerability during which she was able to admit to feeling extremely
alienated and lonely.
Simone was brought up in a middle-class family in the suburbs and
attended a predominantly White school. When I asked what the experi-
ence of being one of the only Black children in the school had been like
for her, she denied any feelings of discomfort or of not belonging. She
told me that most of her friends throughout her life had been White and
that she had never given it much thought. During the course of treatment,
we explored whether being in treatment with a White therapist had any
significance for her. At first she denied that this was the case, but gradually
over time, we were able to examine this issue in greater depth.
Simone had two older brothers and one younger sister. Her father had
an MBA and was a business executive. Her mother was a nurse. Simone’s
father left her mother when Simone was 6 years old. Her father and
mother had maintained an on-and-off-again relationship over the years,
and her mother had always maintained the hope of reuniting with him.
When Simone was a child, her father’s presence was very unpredictable.
He would periodically (e.g., once every 1 or 2 months) come home to
spend a weekend and then invariably leave early after having a fight with
her mother. Simone described poignant memories of running down the
road after his car, crying. She maintained that initially she would be very
excited when she knew that her father would be visiting. Eventually she
stopped feeling any excitement (as a form of self-protection) and then

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transitioned into a third state in which she experienced no feelings but

pretended to be excited to avoid alienating her father.
Simone’s father continued to be unpredictable in the relationship
with her as she grew older; he would periodically contact her, take her
out for lunch or dinner, make plans to see her again, and then disappear
from her life. When Simone spoke about her father, there was a romanti-
cally charged quality. Simone never reported a literal sexual boundary
violation in the relationship, and it seemed to me quite possible that
there never was one. However, she conveyed a sense of awkwardness and
shame about their interactions, and her perception was that her father felt
awkward (“as if he was on a date”) as well. Another factor contributing
to my speculation that there may have been some kind of sexual boundary
violation in Simone’s childhood was that she sometimes spoke about
experiencing a type of “disgusting energy” emanating from her that drove
people away (my experience has been that feeling disgusting in some
fundamental way is not unusual for clients who had been sexually vio-
lated as children). The possibility of a sexual boundary violation having
taken place in Simone’s childhood was not a topic that we ever fully
explored in our work together, but I did wonder whether it may have
impacted her way of relating to me and her difficulty in accepting support
and nurturance from me.
Simone maintained that when she was a child, her mother had been
erratic, alternating between episodes of intense anger and periods of
fragility and dependency on her. She remembered learning to be vigi-
lant to shifts in her mother’s mood to avoid triggering an outburst. She
also remembered learning to take care of her mother emotionally. She
described her mother as very emotionally needy and dependent and felt
judgmental of her. This critical perspective on her mother contrasted with
an idealized view of her father, whom she viewed as independent and with
whom she identified.
Simone was extremely shy in school and saw herself as “ugly.” Her
first romantic relationship was at the end of high school. She was involved
with a boy for 1 year but had no sexual relationship with him. When he
left to attend college, Simone became briefly involved with his best friend.

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On one occasion, she had sexual intercourse with him and found it
traumatic. When she described the reasons why she had experienced the
event as traumatic, I began to get a sense of some pockets of semi­
delusional ideation in Simone’s thinking that were generally kept well
contained. Simone told me that prior to this incident, she had believed
that she would give birth to a child through immaculate conception and
that now this could never happen.
After this relationship, she began to have same-sex relationships
and was involved with a woman at the start of treatment. Simone’s
longest romantic relationship (besides her first high school boyfriend)
had lasted 1 month. Her typical pattern would be to end romantic relation-
ships when she began to experience her partner as being too “emotionally
needy.” When Simone began treatment, she did not see the absence of
long-term romantic relationships in her life as a problem or as some-
thing she wished to change.
Over the course of treatment, Simone and I spent considerable time
exploring the factors contributing to her feelings of emptiness, as well as
her binging behavior. She fluctuated dramatically (both within sessions
and various stages of the treatment) in her ability to look at her own
feelings and actions in a self-reflective fashion. But at times when she was
feeling safer and more open, she was able to express a desire to improve
the quality of her relationships with people, a wish to be in a long-term
romantic relationship, and a curiosity in understanding interfering
factors. We explored the way in which her father’s unpredictability had
contributed to the development of a counterdependent stance on her
part. In addition, we explored the way in which she had identified with
her father (and his apparent emotional aloofness) and repudiated the
more vulnerable dependent aspects of herself that she associated with her
mother (whom she saw as pathetic). We also explored the way in which
her binging was connected to a desire to fill an experience of emptiness
inside of her and the relationship between her dissociation of depen-
dent feelings related both to her feelings of disgust when she experienced
romantic partners as “needy” and to her own difficulty in allowing others
to relate to her in a nurturing fashion.

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Simone revealed additional elements of semidelusional ideation

(e.g., a belief that certain people she met had special powers, a belief
that she could read other people’s minds). At such times, Simone dis-
closed information tentatively and with a somewhat self-deprecatingly
humorous style, as if to say, “I don’t take this completely seriously.”
She vacillated in terms of how trusting of me she felt and how willing
she was to reveal beliefs of this type. Her fear that I would not under-
stand or could not fully embrace her beliefs was an ongoing focus of
discussion.
Throughout the treatment Simone was preoccupied with new age
beliefs and ideas; she would spend hours browsing bookstores in what
seemed like a desperate attempt to fill what she described as a “hole” or
“emptiness” inside her. Inevitably Simone would leave the store feeling
unsatiated—bored with the activity and not fulfilled. In time we came
to understand this activity as similar in function to her binging behavior
(i.e., a desperate attempt to fix an internal experience of emptiness).
A few months after beginning treatment with me, Simone became
involved with a cult, and this involvement continued and intensified over
the first 2 years of her treatment. An important focus of exploration was
her concern that her spiritual interests were incompatible with psycho-
therapy. In addition, the impact of Simone’s dissociated dependency
needs emerged more fully in the cult. The allure for her of being able to
completely surrender to the cult and its leader became more and more
apparent. The prospect of having somebody take charge of her life com-
pletely and tell her what to do and what not to do in any given situation
was undeniably appealing to her.
As discussed previously, there was a continuous alternation in
treatment between periods when Simone seemed quite open and able
to engage in an exploratory process and periods when she was highly
defended and rejected any attempt on my part to explore underlying
feelings or look for deeper meaning. Although these alternating states
never completely disappeared, over the course of treatment they became
less frequent and intense, and Simone became better able to explore both
her internal experience and the meaning of our relationship to her.

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At the beginning of treatment I had the sense that Simone had

one foot in and one foot out of therapy. She would often miss sessions
(claiming that she had forgotten) or arrive 15 to 20 minutes late. For the
most part, she would resist any attempt to explore feelings or factors
underlying her inconsistent and late attendance. I found myself feeling
anxious that she would leave treatment precipitously and concerned
that any attempt on my part to explore her ambivalence would hasten
her departure. I also found myself feeling concerned that she would
experience my attempts to explore her ambivalence as reflecting my own
neediness, and I was more hesitant than I usually am to explore a client’s
ambivalence about treatment as a result. I began to conceptualize what
was taking place as an enactment in which Simone’s own anxieties about
dependency led to a lack of investment in our relationship, which in turn
fueled feelings on my part of both anxiety and shame about my insecurity.
My own conflicts about dependency and a concern about seeing myself
as needy were being triggered by Simone’s avoidant style and interfering
with my ability to constructively explore Simone’s contribution to what
was taking place between us.
Over time I became aware of the quality of narcissistic grandiosity in
Simone—a belief on her part that she had all the answers and that nobody
else, including me, had anything of value to say to her. This attitude is
not one that emerged explicitly at first but rather gradually as I became
aware of my own countertransference feelings of not being able to
say things that she really took in, and I was able to use my feelings as a
point of departure for exploring what was going on in our relationship.
Gradually Simone was able to acknowledge belief that I did not have
anything useful to say to her. She was able to articulate an underlying fear
that if she did become more receptive, she would become dependent on
me and vulnerable to abandonment. Simone and I were able to collabora-
tively make sense of her counterdependency and narcissistic defenses in
terms of her experiences of abandonment as a child, and she became more
open to input from me. A central dilemma that emerged for her was the
conflict between, on one hand, fearing dependency on others and feeling

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that nobody (including me) had anything of value to offer her and, on the
other hand, desperately wishing that others would be able to introduce
their subjectivity in a way that would help her feel less alone. We explored
these themes in a variety of ways throughout treatment. To provide one
example, I describe the way in which a dream that Simone reported in
the 5th month of our work together led to an exploration of her ambiva-
lent feelings regarding dependency in our relationship and provided hints
of her complex feelings about sexuality, men and dependency, and our
relationship. She reported this dream shortly after her father had invited
her to temporarily move into an apartment he owned, where he would
stay periodically when he came to the city on business trips.

Simone: I’m with some people on a beach and they’re playing with a
puppy. And they’ve got the puppy partially submerged under the water . . .
maybe to soothe it. But it’s not happy. And so I decide to take over. . . .
I see a male dog who I think is its father . . . but it’s interesting because
this male dog has udders. So I take the puppy and put it on its father’s
udders, and then the puppy seems happy.

Safran: What do you make of the dream?

Simone: Well, maybe the dog is actually my father, and maybe it has to do
with me moving into his place.

Safran: That makes sense . . . and I’m also thinking . . . and this is really
just playing around with the images . . . so don’t take what I’m saying
too seriously, maybe the male dog is me [I say this in a very tentative way,
so it will be easy for her to dismiss without feeling too dismissive, but also
in an attempt to gauge how capable she is of acknowledging feelings of
intimacy and dependency in our relationship at this point].

Simone: I hadn’t thought of that.

Safran: How does it feel?

Simone: I don’t know. . . . I’d have to think about it.

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She then goes on to tell me another dream fragment.

Simone: And then in the dream, I see my old advisor from college,
Emma. . . . She’s a woman, but then I look at her shadow and it’s the
shadow of a man.

Safran: What do you make of it?

Simone: I don’t know.

Safran: I know from what you’ve told me previously that last time you
visited Emma you felt uncomfortable with her because she felt needy
to you.

Simone: Well, it’s like the way she was always trying to look after me and
offer me guidance, it felt like there was a kind underlying desperation . . .
or neediness . . . like maybe she needs to relate to me as a daughter or
something.

I wonder to myself if this might be another reference to our relation-

ship. Perhaps Simone experiences my attempts to help her as representing
a form of neediness on my part. But I decide not to explore this potential
allusion to our relationship because of a concern that she will find it too
threatening. Simone continues talking about the dream at the following
session.

Simone: I was thinking about that dream I had about that male dog with
the udders . . . and it makes me feel uncomfortable.

Safran: Are you willing to explore what feels uncomfortable about it?
[This is a form of defense analysis.]

Simone: Well, there’s something yucky about it. I don’t really like to think
of myself as getting nurtured by you. There’s something scary about it.

Safran: Scary in what way?

Simone: Well, it would mean that I’m dependent on you, and that brings
up a whole bunch of feelings.

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We continue to explore the range of feelings it brings up: fear, yearning,

revulsion, fear of abandonment, and so on.

Simone: You’re not really a father figure for me. . . . It’s like you’re not
really male. It’s like you just exist in my head.

Safran: Can you say more about me not being male?

Simone: Well, you don’t give me advice or tell me what to do.

Safran: Would you want me to give you advice?

Simone: No.

Safran: Why not?

Simone: Because then I would become dependent on you. You’re not like
my father that way. Things are complicated with him.

At this point Simone transitions into talking about her complicated

feelings about what she refers to as the “sexual energy” between her and
her father. She speaks about how her father always makes it clear to people
that she is his daughter when he takes her out to dinner, as if to ensure that
no one assumes they have a romantic relationship. She speaks about the
fact that on occasion she has slept at her father’s place when he is out of
town and that she feels uncomfortable sleeping in his bed because she
knows that he “entertains people there.”
I speculate to myself that it is important for Simone to desexualize me
in her mind because the potential of my playing a paternal role with her
may have threatening sexual connotations for her. But again, I don’t say
anything at this point because I feel it would be premature.
The following session, Simone spontaneously brought up the possi-
bility that maybe the male dog with udders in her dream does represent
me. We continued to explore what this possibility meant to her during
this session, and the intertwined threads of conflict around dependency,
sexuality, and romantic relationships with both men and women continued
to unfold and become further illuminated throughout the treatment.

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Approximately halfway through treatment, Simone became roman-

tically involved with Jim, a 30-year-old African American musician.
Jim was the first male Simone had been romantically involved with since
her adolescence. Over a period of time Simone was able to genuinely
contact her desire for Jim and her hope that things would work out
between them. Although Simone was not able to explain her new interest
in a romantic relationship with a man, I speculated to myself that perhaps
the process of becoming more trusting of me, a male therapist, helped her
to begin to experience men in general as safer and less likely to abandon
her in the same way that her father had. This possibility was not, how-
ever, something I felt Simone was ready to explore explicitly in treatment,
so I did not introduce it.
Ultimately Jim rejected Simone. My impression was that she expe-
rienced this as excruciatingly painful and subsequently shut down and
began again to deny her need for him or for anyone else, including me.
She flirted with the idea of leaving both treatment and the city to enter an
ashram associated with the cult she had joined. After a futile and extended
attempt on my part to explore what was going on for her, I settled into
providing more of a supportive, containing environment for her in which
I would try to mirror or empathize with the manifest level of her experi-
ence. After approximately two months, Simone began to become more
emotionally open again, more receptive to exploration, and she stopped
talking about leaving treatment.
Subsequent to this, she began dating a number of men and ulti-
mately settled into a relationship with a man named Scott. It was in the
context of this relationship that she had sexual intercourse with a man
for the first time since her adolescence. She moved in with Scott in a
rather precipitous fashion and continued living with him for approxi-
mately three months. She struggled with intensely ambivalent feelings
about the increased intimacy and fears of dependency and engulfment.
We spent considerable time in therapy exploring the difficulty she had
in negotiating between his needs and her own, and we explored the
parallel between the issues emerging in her relationship with Scott and
the transference.

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Simone found living with Scott increasingly intolerable, alternating

between feeling that he was too needy and very occasionally acknowledg-
ing fears of abandonment and rejection. Eventually she left him to move
in with another man who was a member of the cult. At the same time, she
began to discuss the possibility of leaving treatment again, maintaining
that she was feeling better and that she had accomplished the goals she had
at the beginning of treatment. I gently and tentatively explored with her the
possibility that her wish to leave treatment was motivated (at least in part)
by a desire to avoid the type of intensely ambivalent feelings evoked by
the intimacy of our relationship. Gradually she came to acknowledge that
this was true and then began to settle into a phase of treatment during
which she remained considerably more trusting and open for an extended
period of time.
Although Simone continued to vacillate between periods of self-
reflection and periods of shutting down and emotional withdrawal from
me, the intensity of these swings decreased considerably. Also, during
this phase Simone substantially decreased her binging behavior and
became less preoccupied with eating. She began to work on her art for
the first time since ending college and was able to experience this as a
source of satisfaction. Simone and I continued to explore her feelings
of ambivalence about intimacy and her fear of dependency both in our
relationship and in relationships in general. She also began to talk more
openly about feelings of being “different” because most of her friends
were not Black, and we started to explore ambivalent feelings about
being in therapy with a White therapist. We explored the way in which
Simone did not feel completely at home in either the White world or
the Black world and the way this contributed to her general feeling of
alienation and isolation.
In the final 6 months of our work together, Simone became romanti-
cally involved with a man named Jamal, and this relationship developed a
more stable quality than her previous relationships. Although she was not
without feelings of ambivalence, she was better able to tolerate her feelings
of dependency on Jamal and was less self-critical of her need for him. She
began working more consistently at the health food store and developed

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a plan to save up enough money to return to college with the help of her
father to take some specialized courses in graphic design.
Two months before ending treatment, Simone raised the possibility
of termination. This time, however, things had a different feeling about
them than they had previously. It was clear to both of us that she had
made some important changes in her life, and although it was far from
clear what the future would hold in terms of her current romantic relation-
ship or her plans to return to college, there was a mutual sense that
she had started on a different path than the one she had been on at the
beginning of treatment. We set a termination date in advance and, over
the remaining time, explored the ways in which she had changed over the
course of our work together and her feelings about termination.
At first she denied any ambivalent feelings about leaving treatment
and expressed an eagerness to “do things on her own” now that she no
longer needed my help. I wondered to myself whether it might be a bit pre-
mature for her to leave treatment and had some concern that she would
not be able to maintain the gains she had made. I also wondered whether
her plans to terminate were once again related to her fears of intimacy and
abandonment and distaste for dependency. At the same time, however,
I considered the possibility that my reactions reflected my own reluctance to
let go of her and perhaps an overestimation of the significance of my own
role in her life. I disclosed some of these feelings to her, and this facilitated
an ability on her part to begin to explore some of her ambivalent feelings
about leaving treatment. She was ultimately able to acknowledge anxiety
about becoming too dependent on me, fears about how her life would go
after she left treatment, and—toward the end—feelings of sadness about
ending our relationship. When we ended treatment, I made it clear that
she was welcome to contact me any time, just to let me know how things
were going or to schedule another session if she wished.
I received a letter from her about 2 years later. She wrote that things
were basically going well in her life. She had left Jamal approximately
4 months after she terminated with me. Three months later she had
become romantically involved with another man, and they were still
in a stable relationship. She was working for a small group as a graphic

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designer and was finding the work challenging but satisfying. Simone wrote
that periodically she would still lapse into periods of binging, especially
during difficult times. But she wrote that in general, her binging was much
more in control than it had been when she began treatment. Overall
Simone felt that her treatment with me had been helpful, and I concurred.
I had a sense that our work together had reached a depth that allowed
her to make some significant changes in her life and significant internal
changes as well. I also had the sense that there were many themes left
unexplored and that Simone could have benefited from more treatment.
It seems possible that she may go into treatment again at some point in
her life. At the same time, however, I believe that no story ever completely
unfolds in any treatment and that at any given point a specific client and
therapist are able to reach the depth and accomplish what they are both
ready and able to accomplish at that time.

Short-Term Treatment
Although psychoanalysis has become almost synonymous with long-
term open-ended treatment, brief-term psychoanalytic treatments have
a long history and have become increasingly common in the last 20 years.
As previously indicated, the original psychoanalytic treatments were not
nearly as long as contemporary psychoanalyses. Sándor Ferenczi experi-
mented with a wide variety of active interventions to speed up the process
of change, including the establishment of time limits. Ferenczi also collabo-
rated with Otto Rank (Ferenczi & Rank, 1925/1956) to write about the
use of active and directive interventions to promote a more rapid and
effective treatment. Rank (1929) subsequently experimented with the use
of short-term time-limited treatments as a way of mobilizing the client’s
will and highlighting dependency and separation issues.
Many short-term psychoanalytic or short-term dynamic treatments
have been developed. Messer and Warren (1995) categorized existing forms
of short-term psychoanalytic treatment into two types: drive/structural
and relational. Drive/structural approaches all subscribe to an ego
psycho­logical approach and emphasize the interpretation of wish/defense

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conflicts as a central ingredient of change. These tend to be quite con-

frontational in nature and by and large assume a one-person psychological
perspective, paying little attention to the therapist’s contribution to
enactments that are taking place. Some of the best-known examples of
the drive/structural approach are the approaches of David Malan (1963)
and Peter Sifneos (1972).
The best-known variants of the relational approach are the approaches
of Lester Luborsky (1984) and Hans Strupp and colleagues (Binder, 2004;
Levenson, 2017; Strupp & Binder, 1984). These approaches conceptualize
problems as the result of recurrent maladaptive patterns of interpersonal
behavior resulting from internal object relations, which are themselves
the result of disturbances in relationships with early caretakers. Although
these approaches do not preclude an emphasis on wish/defense inter­
pretation, they pay particular attention to the relationship between the
interpersonal context of these conflicts and the way in which they occur
in the client’s everyday life and in the therapeutic relationship.
Although there are important theoretical and technical differences
in these two general types of short-term treatments, most share certain
features that distinguish them from longer term psychoanalytic treat-
ments. These features include the following characteristics: an emphasis
on developing a case formulation early in treatment, the use of this
formulation to establish and maintain a focus throughout the treatment,
a high level of therapist activity, the establishment of a set number of
sessions or a clear termination date in advance, and an emphasis on
working through the meaning of termination for the client. In addition,
many of the short-term psychoanalytic or dynamic approaches use termi-
nation as an opportunity to focus on issues of separation–individuation
and loss that are conceptualized as playing a central role for people in
their lives.
Because contemporary psychoanalytic practice tends to be long term
and open-ended in nature, it is often a challenge for therapists who are
trained in a traditional psychoanalytic model to make the shifts in attitude
relevant to doing short-term therapy. As Messer and Warren (1995)
pointed out, the emotional challenges for therapists include feelings of

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guilt over not being able to offer the client more, struggling with one’s
grandiose and perfectionist ambitions in light of the constraints of a short-
term approach, and dealing with feelings revolving around separation and
termination (e.g., feeling guilty about abandoning or rejecting a client,
mourning the end of a meaningful relationship).
Short-term dynamic therapists use many of the interventions used
by long-term psychoanalytic therapists, including interpretation of
unconscious feelings, wishes, and defenses; interpretation of the resistance;
transference interpretations; extratransference interpretations; and genetic
transference interpretations. There is often a higher level of therapist
activity in short-term dynamic therapy and a likelihood of making more
frequent transference interpretations to maximize the impact of the treat-
ment in the short time available. In practice, there is often more of a
confrontational nature to short-term dynamic therapies than in many
approaches to long-term therapy given the need to speed up the change
process. This was particularly true in the first generation of popular short-
term dynamic approaches (e.g., Davanloo, 1980; Sifneos, 1972), although
more recent developments in the short-term dynamic approach appear to
be learning from experience and now place more emphasis on emotional
attunement, establishing an alliance, and allowing clients to work at their
own pace (e.g., Fosha, 2000; McCullough Valliant, 1997).
As previously indicated, the majority of short-term dynamic
approaches attempt to deal with the time constraints by establishing an
explicit formulation of a core dynamic theme for the client to serve as a
guiding focus for interventions throughout the treatment. The assump-
tion is that this type of focus is essential to make efficient use of the time
(Safran & Muran, 1998). Although formulation plays an important role
in any psychoanalytic approach, this emphasis on setting up an explicit
formulation so early in the treatment is in some respect at odds with the
sensibility of a long-term open-ended psychoanalytic treatment that
emphasizes the importance of cultivating an openness to the emergent
process. In other words, establishing an early formulation is in tension
with the stance of evenly suspended attention, which is designed to allow
the therapist’s unconscious processes and associations to be receptive

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to the client’s associations and the unconscious processes to which they

are linked.
An approach to short-term treatment that has been extensively
influenced by recent developments in relational psychoanalysis is brief
relational therapy (BRT; Muran et al., 2009; Safran, 2002; Safran &
Muran, 2000). BRT is an integrative approach that shares a number of
similarities with other short-term dynamic treatments, but it is also
distinguished by the fact that its development has been substantially
influenced by principles emerging out of relational psychoanalysis and
by findings emerging from our empirical research program on ruptures
in the therapeutic alliance. The key characteristics of BRT are as follows:
(a) it assumes a two-person psychology, (b) it involves a focus on the
here and now of the therapeutic relationship, (c) it involves an ongoing
collaborative exploration of both the client’s and the therapist’s contri-
bution to the interaction, (d) it emphasizes in-depth exploration of the
nuances of the client’s experience in the context of unfolding enactments
and is sparing in the use of interpretations that draw links between the
transference and other relational patterns, (e) it makes use of counter-
transference disclosure and therapeutic metacommunication, and (f ) it
assumes that the impact of any intervention is always mediated by its
relational meaning. Consistent with a two-person psychology, BRT
emphasizes that the therapist’s formulation must always be informed
by an evolving understanding of the nature of his own participation in
relational scenarios that are being enacted with the client. BRT thus places
less of an emphasis than many other short-term dynamic approaches on
the importance of developing a clear-cut dynamic formulation early
in the treatment.

Amanda: An Illustration of a Short-Term

Psychoanalytic Treatment
The case of Amanda provides an illustration of psychoanalytically ori-
ented treatment administered in a highly abbreviated form. This case has
some unique characteristics because I treated Amanda for an American

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Psychological Association (APA) video illustration of psychoanalytic

therapy. Because of the nature of the series, I saw her for only six sessions,
which is certainly toward the low end of the continuum (short-term
therapies that are typically studied in randomized clinical trials are usually
in the range of 12 to 25 sessions). Amanda is someone who would be
suitable for longer term, open-ended treatment and given the chronic
and severe history of her problems, her history of abandonment (which
I discuss shortly), and her potential receptiveness to long-term treatment,
I would not normally recommend short-term therapy as the treatment
of choice for her.
It is also important to bear in mind that our work together was
inevitably influenced by the fact that it took place in a production studio
with cameramen and high-tech equipment present and that both Amanda
and I were aware that this was not “ordinary therapy” but rather a treat-
ment conducted specifically for purposes of filming a training video. This
placed a considerable amount of pressure on both Amanda and me and
certainly compromised the type of privacy and safety that under normal
conditions are so critical to psychotherapy. On the other hand, my feeling
is that the process that unfolded as we worked was sufficiently similar to
the process that takes place in a regular psychoanalytic treatment to make
it a useful illustration, especially since the video is available from APA
and allows for a more detailed examination of the process.2 Furthermore,
the exploration of the impact of the videotaping on the treatment became
a central focus of our work, thus allowing for an exploration of the
impact of this aspect of the therapeutic frame on the transference and
countertransference.
Prior to beginning the process, the video production team asked what
type of client to select for the demonstration, and I decided to screen for
someone who felt that this seemed like a meaningful way of working.
Accordingly, I wrote a statement providing a rationale for psychoanalytic

2The video which can be accessed at https://www.apa.org/pubs/videos, is titled Psychoanalytic Therapy Over
Time and is copyrighted by the American Psychological Association. Please note that the client’s name
and other identifying information have been changed here to protect her confidentiality. The reader who
watches the video may notice some discrepancies.

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treatment, which was to be given to the client. The rationale emphasized

the importance of exploring unconscious feelings and thoughts, examin-
ing self-defeating patterns that are enacted unconsciously, and using the
therapeutic relationship as a specific focus of exploration to shed light on
unconscious patterns that are potentially enacted in other relationships.
I mention this here because it became particularly relevant in my third
session with Amanda.
Amanda was a young White woman from a working-class background
with a history of serious depression and substance abuse. Before seeking
treatment with me, she had experienced three serious and incapacitating
major depressive episodes, and she claimed that she had been depressed
for as long as she could remember. She also had a long history of addiction
to both street and prescription drugs. In addition, she had a history of
involvement in romantic relationships with abusive men. At the time of
our first interview, Amanda had already begun to make some important
changes in her life. She had joined Narcotics Anonymous and had been
drug free for more than a year. She also had been in remission from major
depression for more than a year and was working part time. Her stated
goal in seeing me for six sessions was to continue working on developing the
psychological resources to change her pattern of self-destructive romantic
involvements.
Session 1 with Amanda was spent for the most part gathering infor-
mation about her presenting problems and goals, history of problems,
personal history, and current life situation and level of functioning in an
attempt to develop a sense of whether I could be at all helpful to her in
this context. I also attempted to lay the groundwork for the establishment
of a therapeutic alliance by both empathizing with her and working
collaboratively with her to develop a shared understanding of her prob-
lem and her goals and how we were going to work toward them. I was
also beginning to attend to my own countertransference feelings to see if
I could begin to get a hint or a felt sense of what it would be like to relate to
her. For the most part, my sense was that things flowed smoothly between
me and Amanda in this session. There was a quality of synchrony between
us, almost a dance. I felt that I was able to empathize with her and that she
was able to take in my empathy.

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I also noticed that on the few occasions when I asked Amanda more
open-ended questions and allowed her an opportunity to take the lead
and elaborate, things started to feel a bit awkward. At these points she
would talk about feeling “on the spot,” and I found myself automatically
rushing in to pick up the slack. It felt as if I had to do this to keep things
running smoothly, and I found myself noting these feelings to myself and
filing the experience away for potential exploration at some later point.
In the session, Amanda recounted a traumatic childhood. Her bio-
logical father abandoned the family when she was 4 years old. Her step-
father (whom her mother married when Amanda was 6 years old) was a
firefighter. He was also an alcoholic and physically abusive toward her
mother. She had memories of her stepfather coming home in a drunken
rage, getting into arguments with her mother, breaking furniture, and
hitting her mother. When these episodes would occur, Amanda recalled
playing the role of the mediator, trying to break up the fights by actually
placing herself physically between her mother and stepfather and sepa-
rating them. Amanda remembered that at one point when she was 9 or
10 years old, she had called the police to break up the fight and that her
mother had to be taken to the hospital. In contrast to this physical vio-
lence toward her mother, Amanda claimed that her stepfather was never
abusive toward her. She described him as her “best friend when sober.”
Amanda’s stepfather committed suicide when she was 15, and over the
years she had a whole range of feelings about this: guilt for not being
able to save him, hurt, anger, betrayal, and abandonment.
In this session, I began to have a preliminary sense of interpersonal
themes in Amanda’s life that might be relevant to developing a working
formulation. I began to wonder if abandonment was a recurrent issue
in her life. I also began to think about her role as the mediator between
her mother and her stepfather. It’s not unusual for this type of develop-
mental experience to lead to parentification and a precocious maturity as
children in this position feel helpless and abandoned and simultane-
ously feel special and empowered by their role in the family dynamics.
But these feelings of power and specialness are often hidden or partially
unconscious. This type of experience can thus lead to the development

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of a way of being with others in which an individual adapts by learning

to take care of other people’s needs rather than his or her own (what
Winnicott, 1965, referred to as a false self organization). This can develop
into a sense of overwhelming personal responsibility, difficulties in truly
depending on others, and unconscious or semiconscious feelings of both
grandiosity and resentment.
Despite her traumatic background and history of serious psycho-
logical problems, Amanda had a number of significant emotional and
psychological strengths. She was intelligent, had completed an under-
graduate college degree, and had a network of friends she could rely on
(through Narcotics Anonymous). I was also beginning to get a glimpse
of a feisty and lively side to her and a sardonic sense of humor, which
intrigued me. By the end of our first session, I found myself admiring
Amanda’s strength, resilience, and feistiness. I also found myself deeply
concerned about her and wanting to help her. At the same time, I sensed
a hint of underlying wariness or mistrustfulness in her. Although our
first session went relatively smoothly, I wondered to what extent this
smoothness would continue over our time together.
In our second session, the dynamic that had begun to emerge between
Amanda and me in subtle ways started to come through more clearly.
I sensed that as long as I was taking the lead and asking her factually
oriented questions, things would continue to go relatively smoothly. And
I found myself doing this reflexively, while continuing to make a mental
note of it, wondering where it was leading. I began the session by con-
tinuing to collect background information. I asked about her relationship
with her mother and her biological father (whom she had gotten to know
again as an adult), in part because I felt it could provide context for her
difficulties but also perhaps partially because I sensed that a more active
stance on my part would help to maintain Amanda’s anxiety at a manage-
able level and help to build the alliance.
At the same time, I was beginning to develop a vague sense that
there may have been something a little off about the quality of Amanda’s
affective engagement in the session. I found myself wondering if she was
talking about something that was emotionally vital and alive for her in the

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moment or, alternatively, was only dutifully responding to my questions.

And I was becoming increasingly aware of a feeling of pressure on my
part to continually introduce new topics. As these feelings intensified,
I decided that rather than continuing to pick up the slack, or to inten-
tionally shift to a less active role (which I speculated might lead to a power
struggle or an impasse), I would attempt to explore what was going on
between us. So I began to metacommunicate with her—to engage her in
the process of collaboratively exploring what was taking place between us
by explicitly focusing on our relationship.
I thus said something to the effect of, “I find myself reflexively moving
toward asking you more questions, in part I think as a way of keeping
things going smoothly between us. But I’m also a bit concerned that if
I continue doing this, it will get in the way of you talking about what feels
most alive and important for you.”
As I finished speaking, I felt Amanda tense up, and a sense of awkward-
ness began to emerge more clearly between us. She responded by saying,
“I have no idea what you want me to talk about.” I then made a number
of attempts to explain what I was trying to get at and how exploring
this further might be helpful. Rather than responding to my invitation
to explore what was going on between us, however, it felt as if she was
consistently trying to put the ball back in my court in an attempt to get
me to take the lead again.
I considered the possibility of going back to asking for more factual
information as a way of easing the tension but now felt at a loss for
something to ask her. I was also beginning to feel that even if I could find
more questions to ask Amanda, it would just be a way of going through
the motions rather than talking about what was really happening, which
is what seemed most meaningful to me at the moment. I began to get a
sense of the two of us moving into an impasse. At the same time, experi-
ence has taught me that impasses of this type, although uncomfortable, are
often part of an important emerging enactment that, if worked through
constructively, can be a crucial part of the change process.
At this point, however, rather than risk alienating Amanda by trying
to explore further, I attempted to strengthen the alliance by reiterating

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the rationale for my intervention (thereby increasing the possibility of

collaboration on the therapeutic task). I attempted to explain to her that
by exploring what was going on between us in the moment, we might
be able to begin to shed some light on dynamics and relational patterns
that were relevant to her current problems. She responded by saying,
“I don’t know what you’re talking about. I don’t understand.”
I was aware of starting to feel inadequate, frustrated, and—to be
frank—somewhat irritated. I found myself wondering if anything I said
would be adequate for her right now. And I was beginning to wonder
whether there was more to Amanda than was immediately apparent. At
one level, I had begun to develop a sense of her as this sweet, fragile young
woman who needed to be taken care of. Yet at the same time, I felt that
she was putting me on the spot and that I was squirming. And as is often
the case in these types of situations, I was not sure how much to trust my
own countertransference feelings. To what extent were my growing feelings
of inadequacy and irritation providing meaningful information about
Amanda, and to what extent were my feelings simply “my problem”—
something that I was bringing to the table?
At this point, in an attempt to clarify the connection between my
attempts to explore what was going on between us and the problems that
brought Amanda into treatment in the first place, I made the following
interpretation: “It seems to me that one of the things you and I are strug-
gling with right now in our relationship is the question of who is going to
take the lead. I’m wondering in your relationships with men in general,
who tends to take the lead?”
In response, she began to elaborate on a history of getting into relation-
ships with domineering, abusive men who “take charge” in the relation-
ship and whom she tended to “submit to.” It emerged that she was used
to following their lead rather than expressing her own needs and desires.
Amanda described a need on her part to know what men want so that
she would be able to provide it for them. She would then find herself
submitting and feeling resentful. She also described a common pattern in
her interactions with boyfriends in which initially she might explicitly dis-
agree with them about something, but inevitably they would talk her into

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relinquishing her position and she would submit to them. And I began
to wonder if there might be some element of this scenario being enacted
in our relationship, in which my attempts to convince her of the value of
exploring our relationship were fitting this template.
As the discussion continued, I began to speculate to myself about
the nature of the enactment that might be playing out between us—I felt
provoked by her but tried to maintain a sympathetic and understanding
stance. Despite my best efforts to control my feelings of irritation and
frustration, I worried that I would express my hostility indirectly and play
the role of the perpetrator in a sadomasochistic enactment. To complicate
things further, I was feeling badly about having negative feelings. I certainly
don’t like to think of myself as sadistic. And to be frank, knowing that
we were being filmed, I was particularly concerned about coming across
as cruel. In this context, my experience of internal conflict about my
countertransference feelings was intensified by the unusual setting, but
it is important to note that therapists often experience internal conflict
about their countertransference feelings and that recognizing and working
through these feelings of conflict are important parts of the therapist’s
internal work. For the time being, however, it felt as if we had returned to
safer ground. I was asking questions about Amanda’s relationships, she
was responding cooperatively, and the feeling of tension between us had
receded into the background.
Following a rather extensive and revealing discussion of Amanda’s
habitual pattern of getting into relationships with men who take the lead,
as well as the price she pays for this, I attempted to make the link between
this pattern and what was going on in our relationship. To my surprise,
she denied seeing any connection between the two themes and did not
acknowledge the possible value of exploring a potential connection.
Furthermore, she continued to push me to explain the possible relevance
of this type of exploration to her problems despite the fact that I had just
struggled to do so. I again returned to my experience of feeling on the
spot, inadequate, and speechless.
I responded with another attempt to provide Amanda with a ratio-
nale, and it once again fell on deaf ears; increasingly it seemed to me that

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any such attempts on my part would be futile. As the session came to an

end, I attempted to reestablish some sense of collaboration with her by
telling her that prior to the next session, l would think of how to explain
things in a way that would be meaningful to her and encouraged her, in
turn, to think about what we had been discussing and to reflect on whether
she might be able to make sense of any part of what I had said or come up
with any questions to ask me that might help clarify things for her.
Over the week between Sessions 2 and 3, I gave considerable thought
to our session. At one level, it seemed likely that our current impasse was
an enactment that was related in meaningful ways to a core theme in
Amanda’s problematic pattern in romantic relationships. On the other
hand, part of me couldn’t let go of the fantasy that if I could just come up
with the right words, she would see what we were doing as meaningful
and feel that I really was trying to help her. I considered the possibility of
giving her various materials to read that would provide a more clear-cut
rationale for the value of the type of exploration in which I was attempting
to engage her.
And then I remembered the write-up that had been given to Amanda
to read prior to her agreeing to participate in the project. At that point,
I printed out a copy and read it. I was struck by the fact that it would be
difficult for me to improve on what I had already written. “And this,”
I thought (feeling indignant and vindicated), “is the rationale that she
had read and said made sense to her, before she agreed to participate in
the project!” I toyed with the idea of actually reading it to her in the next
session. Then it occurred to me that doing so might well be my way of
continuing to play out the current enactment—a way of meanly proving
to her that I was right and she was wrong.
Instead, I came up with a tentative plan for the next session of self-
disclosing the nature of my internal processes between sessions as a way
of leading into exploring and beginning to collaboratively make sense
of the enactment that was taking place between us. I nevertheless put
a copy of the rationale in my pocket so that I could refresh my memory
just before the session, in case I ended up finding myself, once again,
struggling to explain the purpose of the approach to her.

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Toward the beginning of our third session, as a prelude to telling

Amanda about my thinking between sessions, I asked her if she remem-
bered the written statement she had read before starting our work
together. To my surprise, she denied having ever seen the rationale.
Now I was feeling completely stuck. I could try to explain it another time,
but it was difficult for me to imagine any such attempt being more mean-
ingful to her than it had been previously. Moreover, I anticipated that
given my complicated feelings of anxiety, inadequacy, hopelessness about
her being receptive, and irritation, it would be difficult for me to convey
the rationale in a particularly articulate or compelling way. And then,
in an act of desperation, I found myself reaching into my pocket to pull
out a crumpled copy of the rationale. Perhaps I felt that reading from
the written version that I had put considerable thought into composing
would give me a greater sense of security and help me manage complex
feelings that I anticipated were likely to undermine my ability to convey
the rationale in an articulate and compelling way.
I began to read the rationale to Amanda, checking in with her periodi-
cally to see how she was reacting and whether things made sense to her.
As this process continued, I began to experience a sense of confidence and
mastery. Moreover, to my surprise, Amanda seemed to be engaging with
me as I was reading and checking in with her. She was nodding, asking
questions that I felt I could answer meaningfully, and apparently beginning
to “get it.”
At one level, I found myself skeptical that the rationale really made
sense to her in a way that it hadn’t in our previous session. I was essentially
repeating what I had said before. Yet at the same time, I was sensing that
something was beginning to shift in the dynamic of our relationship.
In retrospect, I wonder if what really influenced the shift was not that
I had conveyed new information to her but rather that my internal move-
ment toward greater confidence and my assumption of a more authorita-
tive, dominant stance allowed her to engage with me in a way that was
more comfortable and familiar to her, that is, following the lead of a
dominant male who was taking charge in the relationship. In retrospect,
perhaps that was unconsciously part of my motivation for choosing to

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read the rationale in the first place—it was an attempt to regain some
sense of mastery and control. Once I had finished reading, I felt that some-
thing was different, and I asked Amanda if the rationale made sense to her
now. She responded, “Yes.” And then after a short pause, she asked me,
“But does it work?”
Amanda’s stance was beginning to move from one of “I don’t under-
stand” to an articulation of an underlying skepticism and a desire for me
to reassure her that I could help her. This allowed an opening for me
to begin exploring her skepticism, a critical psychoanalytic process that
can be conceptualized as a form of resistance analysis. As we continued
to explore her underlying skepticism and she was able to experience me
listening in an empathic and validating way, the alliance continued to
strengthen.
After some exploration, I became concerned that to continue in this
vein might feel too overwhelming to Amanda, especially given her previ-
ous reluctance to talk about our relationship and what was happening
between the two of us in the here and now. I checked in with her to ask
how she would like to proceed at this point (i.e., continue talking about
her skepticism or move on to another topic). True to form, she responded,
“What do you think?”—once again asking me to take the lead.
As in the previous session, I make an observation about the process
between us (i.e., “It feels like I’m asking you to take the lead and you’re
asking me to take the lead”). Now however, something had shifted, and
Amanda seemed more open to exploring the process. In response to
my observation, she explained, “I turn to you because you’re in charge
here. You’re the doctor.” I was now struck by the fact that she was
experiencing a vast power imbalance in our relationship. Although
Amanda’s perception of this power imbalance was completely under-
standable, until now it had been hard for me to fully grasp it at an expe-
riential level, given that I had been feeling anything but authoritative
in my relationship with her. This shift in my experience of Amanda in
conjunction with her growing receptiveness allowed me an opening
to explore further. In response to my exploration, she continued to
open up. She spoke about not wanting to disappointment me and not

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wanting to “screw up” my “agenda.” After all, she said, “We are here to
produce a videotape.”
And then it struck me that the same dynamic that tends to play
out in many of Amanda’s relationships—her pattern of trying to take
care of the needs of the other person, submitting to their needs rather
than asserting her own and then feeling resentful—might be playing
out between the two of us as well. And although it might be tempting to
simply see this as a form of transference on her part (i.e., a tendency to play
out her typical patterns in the context of the therapeutic relationship),
there was more to it than that. Her attempt to take care of my needs at
the expense of her own was not taking place in a vacuum. Therapists
always bring their own needs to the situation, whether it is the need for
validation, the need for self-esteem, the need to help, or financial need.
In this situation I had a pressing need to provide a good demonstration
of my skills as a therapist. A clash in needs can be part of the underlying
subtexts of any therapy and sometimes must be addressed explicitly and
worked through.
My sense was that although Amanda was enacting a characteristic
pattern of submitting to the needs of others, feeling resentful, and express-
ing her resentment in a passive-aggressive fashion, she was also demonstrat-
ing what I was coming to think of as a characteristic ability to read the
subtlety of interpersonal situations and the courage to speak out and
in a sense “talk about the elephant in the room.” I was impressed by her
perceptiveness and inner strength (which she has a tendency to disown),
and I felt that it was important for me to validate her perceptions. Rather
than commenting on her characteristic pattern of accommodating to
others (an intervention that I was concerned she would experience as
critical), I sensed it was more important to validate her perception and
to highlight her disowned strengths. I thus acknowledged to Amanda that
she was right that at least part of my agenda was selfish even if I was try-
ing to help her. And I commended her on her ability to pick up on this.
In retrospect, my impression is that my acknowledgment and acceptance
of responsibility for my mixed agenda was another critical point in the
positive shift in our alliance. The particular form of my mixed agenda

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(i.e., wanting to help vs. wanting to demonstrate a successful treatment

for the video) was shaped by the context of the APA project in which we
were both participating. It is important to point out, however, that as
therapists we always have mixed agendas that are part of the context of
the work, even if they are not talked about explicitly (I. Z. Hoffman, 1998;
Slavin & Kriegman, 1998). The most obvious one is that we are there to
help the client, and at the same time we are there to earn money.
In any event, Amanda seemed to appreciate my recognition of her
perceptiveness, courage, and strength and my willingness to acknowledge
my own conflicting agendas with her. And this paved the way for her to
begin recognizing the way in which her tendency to look after my needs
was preventing her from using this situation as an opportunity to meet
some of her needs by making use of what I had to offer her. In the rest of
this session, we continued to explore and work together in a much more
collaborative fashion.
We developed a style of shifting seamlessly back and forth between
focusing on Amanda’s current life situation, her past, and our own
relationship, and this helped to deepen the depth of exploration of her
feelings, thoughts, and previously unarticulated experience in all three
areas. From the very beginning of our work together, I had been struck
by her sense of fragility, and subsequently I began to see a stronger side
of her. As the sessions progressed and I came to experience an oscillation
between the two of us in the roles of aggressor and victim, I developed
a tentative formulation of Amanda as tending to dissociate her healthy
aggression as part of her long-standing role of playing the caretaker and
then needing to express her aggression indirectly or passive aggressively
rather than through healthy self-assertion of her needs.
I continued to give Amanda feedback about my experience of these
two different sides of her (i.e., strength vs. fragility), and she was intrigued
and interested in exploring both sides. She acknowledged feeling pleased
by my feedback about her strength and courage but also a little afraid,
overwhelmed, and reluctant to fully take this feedback in. This led to an
exploration of her fears of seeing and acknowledging her strengths as well
as the defensive function of her fragile posture. If she were to fully accept

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her own strength and healthy aggression, without being able to retreat
into her defensive posture of fragility, it would be too much responsibility
for her to bear at that time. Rather than attempting to break through or do
away with this aspect of her defensive style, I thus framed it in affirmative
terms (i.e., it serves as kind of a safety net for her, and it’s essential for her
to hold on to that safety net as long as she needs it).
At one point in the context of exploring Amanda’s tendency in her
life to put other people’s needs before her own (as she had been doing in
our relationship), I asked her if she could remember how it had felt for her
to play the role of the mediator between her mother and stepfather when
she was a child. She recalled feeling a tremendous sense of responsibility,
always having to make sure that things didn’t get out of hand between the
two of them. I empathized with the dread and pain that she must have
experienced as well as the heavy burden. In response, she acknowledged
that indeed it was only in the context of our work together that she was
beginning to see how this whole experience must have (in her words)
“screwed me up.” At the same time, she said, she was also beginning to
see that this developmental experience was part of where her current
resources and strengths had come from. I responded something to the
effect of, “Obviously there was a tremendous negative side to it, in that
you were scared and had an overwhelming responsibility, but I imagine
that the flip side is that it may have made you feel important, maybe
even powerful.”
This interpretation reflected an emerging semiarticulated formula-
tion on my part of Amanda experiencing a type of secret narcissism and
grandiosity. She responded, “I thought of that word but didn’t want to say
it.” This led to an exploration of her fears of acknowledging her strengths
and the dangers of not having the safety net of her stance as a victim to
retreat to. Session 3 ended with Amanda expressing positive feelings about
our work together and an impression on my part that a vitally important
shift in the therapeutic alliance was beginning to take place.
In Sessions 4 and 5, our relationship continued to deepen, and
Amanda gradually became more trusting and open. Among other things,
she explored how difficult it had been in the past for her to trust and

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depend on other people, as well the ongoing impact of her need to take
care of other people. As she spoke about both her fears of dependency and
her fears about changing (an exploration of her resistance), the quality of
her speech had a type of freshness and vitality that marked it as a genuine,
emotionally immediate exploratory process. She then transitioned into
speaking about her growing sense of trust or faith that things would work
out for her and that she would be able to continue to change after the end
of our work together. In general I was impressed by how engaged and
animated she seemed in Sessions 4 and 5. In contrast to earlier sessions in
which it felt like I had to work hard to generate questions to keep things
going, Amanda seemed to be bringing herself to the session in a sponta-
neous and authentic way. During these sessions, she expressed a range of
feelings, including sadness, hopelessness, and optimism about the future.
Now there was no question on my part (as there had been, e.g., during
Session 2) as to whether we were talking about things that felt affectively
alive and meaningful to her. During these sessions, Amanda also showed
more of the feisty and lively quality that I had begun to get a glimpse of in
our first session, and our relationship was beginning to develop somewhat
of a playful quality to it.
Session 6 (our final session) was a difficult but meaningful one. It had
a tense, rough feeling to it not unlike some of our earlier sessions. Often,
important themes reemerge around the time of termination, as both
client and therapist deal with the realities of impending separation. I had
a concern that, given Amanda’s history of loss and the fact that she had
begun to open up to me and trust me, she would experience the end of
our work together as an abandonment.
I believe it is important to emphasize here that from a psychoanalytic
perspective, Amanda would benefit from a longer term treatment in
which she would have the opportunity to develop and sustain a trusting
relationship with a therapist over a period of time. She could learn to trust
someone and gradually modify her sense of implicit relational knowing or
her internal object relations over time, through her experience of develop-
ing a relationship with a trustworthy and reliable therapist. A six-session
treatment is extremely short for someone with her history, and I had been

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concerned that she would begin to open up and trust, only to be trauma-
tized by a feeling of abandonment at the end.
All things considered, I believe it was a meaningful final session with
moments of real engagement and connection between us in reviewing our
time together. I remember feeling pressured and tense at the beginning
of the session and wanting things to end on a good note. And I imagine
Amanda may have had similar feelings. I normally consider it important
to explore clients’ feelings about termination and find that they are
typically ambivalent. Clients are often reluctant to fully explore their
disappointments. They can also be reluctant to fully explore their feelings
when things go well. In these circumstances clients often have feelings
of gratitude mixed with feelings of loss, abandonment, anxiety, and
sometimes resentment about some of the things they did not get from
their therapist.
In Amanda’s case, however, I was particularly concerned about not
wanting to pressure her to talk about feelings that might be difficult for
her to fully experience, acknowledge, and express, especially given how
difficult it had been for her to open up in the first place. I am thinking
here of the dynamic that had emerged between us in the early stages of
our work together, in which she would experience open-ended questions
as difficult and invasive and respond by clamming up or putting the ball
back in my court. I could easily imagine the same dynamic reemerging in
our last session if I pushed too hard.
At the beginning of the session, I already sensed more reserve and
cautiousness on Amanda’s part than had been the case in the previous two
sessions. And I, in turn, felt more cautious and more of a need to tread
delicately. I began somewhat warily by asking her how she felt about this
being our last session. In response, she acknowledged experiencing some
ambivalent feelings: feelings that she would miss our sessions, combined
with a sense of relief that she would no longer have to perform in front
of a camera. I acknowledged having similar feelings as a way of helping
to emphasize the mutual aspects of our relationship and of countering
Amanda’s tendency to feel powerless in our relationship and resentful
because of this. By self-disclosing my own ambivalent feelings, I wanted

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to implicitly give her permission to speak more about her ambivalent

feelings without putting any pressure on her to do so.
I asked Amanda if there was anything in particular that she wanted to
talk about today, and she responded with an abrupt “Nope.” Now I had a
sense that if we were going to avoid getting into a power struggle, it would
be important for me (at least at this juncture) to do more of the talking
and to take more of the lead again. I told her that during our previous
session, she had seemed to be “on a roll” and I had been reluctant to speak
too much because she seemed very present and vitally alive, and I didn’t
want to interrupt her.
She responded that she didn’t feel “on a roll” in this session. I told her
that there were many things I wanted to ask her but that I felt cautious
about not wanting to pressure her and put her on the spot. She seemed
to relax with this disclosure, and then I told her that I felt curious about
what she made of the time we had spent together, and whether there was
anything in particular that stood out for her on reflection.
Amanda then told me that she was feeling a considerable difference
between now and when we had first started. She felt that our time together
had helped confirm her sense that she had made important changes in her
life over the past year or so and that since we had started working together,
she felt she had made even more progress. She was feeling more confident
and more aware of her own strengths. She was feeling more trust in me,
more trusting in general, and more hopeful about the future. She also said
that she was beginning to have greater faith in herself and her ability to be
more discriminating in her romantic choices.
I responded that what she was saying made perfect sense and that
rationally I felt fine about us ending as well. I told her that, nevertheless,
I felt sad ending our work together and concerned about not being able to
be there for her in the future. My hope was that by disclosing this aspect
of my experience, I would be giving her permission to contact any com-
plementary feelings that she might have, even if she was not able to fully
acknowledge or talk about them. At the end of the session, I gave Amanda
some information about a local therapy clinic with a sliding scale. When
the camera was turned off, the two of us walked over to the corner to

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briefly say goodbye. She spontaneously gave me a big hug, and I felt a sense
of sadness and warmth toward her.
One year later, Amanda emailed me to let me know that she was doing
well. She was still drug free and depression free, had gone into open-ended
therapy with someone at the clinic to which I had referred her, and was
finding the ongoing treatment helpful. She was also working full time and
had begun a romantic relationship that sounded healthier than her previous
romantic relationships.
In this chapter, I have discussed principles of intervention and under-
lying mechanisms of change in psychoanalytic treatment. I have also
provided illustrations of change principles and the mechanisms through
which they are hypothesized to operate in the context of both long-term
and short-term psychoanalytic treatment.

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 5

Evaluation

M any psychoanalysts are coming to realize that conducting research

will be essential to the survival of psychoanalysis. Psychoanalysts
have been slow to respond to the demand for empirically supported treat-
ment and have often been dismissive of the efforts of psychoanalytically
oriented investigators who do attempt to conduct this type of research.
The well-documented gap between researchers and clinicians (Bergin &
Strupp, 1973; Goldfried & Wolfe, 1996; Persons & Silberschatz, 1998; Rice
& Greenberg, 1984; Safran, Greenberg, & Rice, 1988; Safran & Muran, 1994;
Talley, Strupp, & Butler, 1994) that cuts across therapeutic orientations
is particularly large in the psychoanalytic world. It is not unusual for
psychoanalytic researchers to have no formal postgraduate psychoanalytic
training and limited clinical practices.
The reasons for this are practical in part. It is extremely difficult to
engage in the time-consuming activity of going through postgraduate

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psychoanalytic training while being a productive empirical researcher,

making one’s way up the formal ranks of academia in a university, and
finding the time to successfully apply for the grant funding necessary
to support good empirical research. And within the world of academic
clinical psychology, psychoanalytically oriented researchers are fighting
an uphill battle, as psychoanalysis becomes increasingly marginalized
within the university system.
When it comes to government-supported research funding, the bias
toward biological and neurophysiological research is making it increas-
ingly difficult to receive funding for psychotherapy research in general.
The common misconception that psychoanalytic therapy “lacks empirical
support” makes it even more difficult to receive funding for psycho­
analytically oriented research (I can testify to this on the basis of my
experience serving on National Institute of Mental Health Grant review
committees).
It is clear that the traditional psychoanalytic dismissiveness toward
rigorous empirical research has been self-destructive and has had harmful
effects on the development of the discipline. Although this attitude often
reflects a narrow-minded dogmatism and insularity, it is also important
to recognize that many psychoanalysts have valid concerns about
the relevance to the practicing clinician of much of the psychotherapy
research that is published. There are well-founded concerns about the limits
of existing research paradigms and their abilities to capture the complexity
of the therapeutic process.

THE NEED FOR RANDOMIZED CLINICAL TRIALS

The gold standard for psychotherapy research is the randomized clinical
trial (RCT), which was borrowed from medication research that assumes that
it is possible to evaluate the efficacy of a particular medication indepen-
dent of the interpersonal context in which it is delivered. In this frame-
work, the medication is the “active ingredient,” and all the other elements
that may have an impact on its efficacy (e.g., client expectations, therapist
interpersonal skill, quality of the therapeutic relationship) are extraneous,

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 Evaluation

nonspecific factors that can be controlled for. The problem with apply-
ing this “drug metaphor” (Stiles & Shapiro, 1989) to psychosocial treat-
ments is that in psychotherapy, any active ingredient of the treatment is
conceptually inseparable from the so-called nonspecific factors (e.g., the
emergent properties of the client–therapist relationship). It is thus
conceptually impossible to separate out the therapy from the therapist
(or more accurately, the therapeutic dyad). In fact, a large and growing
body of evidence indicates that factors such as the therapeutic relation-
ship and the individual therapist variable contribute considerably more
to the outcome variance than the particular brand of psychotherapy being
practiced (Safran, 2003; Safran & Muran, 2000; Safran & Segal, 1990;
Wampold, 2001).
It is clear that it is vital to conduct RCT research on psychoanalytically
oriented treatment for the purposes of influencing public attitudes and
the attitudes of policymakers (both government and private insurance
companies). Some of the most important empirical results are detailed
next. However, it is important to carefully consider the rigorous and
thoughtful critiques of those who argue that there are dangers of whole-
heartedly embracing the enterprise of documenting the value of psycho-
analytically oriented treatments through RCTs (e.g., Cushman & Gilford,
2000; I. Z. Hoffman, 2009). As I indicated earlier, Cushman and Gilford
(2000) argued that some of the implicit assumptions underlying the
evidenced-based treatment paradigm (e.g., speed, concreteness, efficiency,
systematization) can have a harmful impact on the way we understand
the therapeutic process. They argued that this paradigm conceptualizes
the therapist as a type of psychotechnician who delivers a standardized
technique in a maximally efficient fashion. This lends itself implicitly
to a view of the client as a passive recipient of this technique who varies
in terms of the extent that he or she is compliant with the treatment
protocol. Along similar lines, I. Z. Hoffman (2009) argued that the
problem with overemphasizing the importance of demonstrating the
“scientific validity” of the psychoanalytic enterprise is that valid critiques
of the relevant underlying philosophical and epistemological assump-
tions can become marginalized. According to Hoffman, the evaluation

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of manual-based treatments ignores the uniqueness of each therapeutic

dyad and the intrinsic indeterminacy of the therapeutic process. More-
over, from his perspective, making the claim that one can know what will
be most helpful for a particular client on the basis of empirical evidence
is a form of technical rationality that masks the therapist’s personal
responsibility for making value-based choices as to how to respond in
any given moment. Finally, our assumptions about what constitutes treat-
ment effectiveness implicitly involve value judgments about how to define
healthy functioning. Such questions cannot and should not be adjudicated
entirely by “science.” To the extent that we give the authority of science
the power to arbitrate these choices, we are falling into the worst kind of
scientism, in which moral positions masquerade as scientific “findings”
(I. Z. Hoffman, 2009, p. 1049).
My own perspective is that the efforts of psychoanalytically oriented
researchers are vital to the survival of psychoanalysis. The failure to con-
duct RCT research on psychoanalytically oriented treatments allows for
the perpetuation of the distorted perception that psychoanalytic treatment
does not have empirical support. People want straightforward concrete
answers about “what works,” and they have little time or inclination to
follow what can seem like esoteric debates among professionals.

RESEARCH SUPPORTING THE

EFFECTIVENESS OF PSYCHOANALYSIS
AND PSYCHOANALYTIC THERAPY
In an influential American Psychologist article, Shedler (2010) reviewed
the results of eight meta-analyses of studies evaluating the efficacy of
psychodynamic therapy. The studies in these meta-analyses included only
well-designed RCTs comparing psychoanalytically oriented treatments
with a range of different control conditions, including cognitive and
behavioral treatments. Client populations in these studies included adults
presenting with a range of disorders including depression, anxiety, panic,
somatoform disorders, eating disorders, substance-related disorders, and
personality disorders. The majority of the psychodynamic treatments

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 Evaluation

included in these studies were short term in nature (which is typically the
case for RCTs). The meta-analyses reviewed found substantial effects for
psychodynamic treatments, with effective outcomes as large as or larger
than those commonly found for cognitive and behavioral treatments.
In addition, the results indicate that clients who receive psychodynamic
therapy maintain therapeutic gains and appear to continue to improve
after treatment ends.
More recently, the research team of Leichsenring extensively reviewed
RCTs of psychodynamic psychotherapy. They found that psychodynamic
psychotherapy is effective for a variety of diagnoses, including anxiety and
depression (Leichsenring, Klein, & Salzer, 2014; Leichsenring, Luyten, et al.,
2015). Moreover, this was the case when applying the criteria employed
by the Task Force on Promotion and Dissemination of Psychological
Procedures to identify effective treatments (Chambless & Hollon, 1998;
Leichsenring, Leweke, Klein, & Steinert, 2015), meaning that the psycho-
dynamic treatment earned the designation of “empirically validated.”
Abbass et al. (2014) obtained similar results using the Cochrane Database,
which was set up as an independent source of evidence to inform health
care decisions.
Recent rigorous meta-analyses supported these conclusions as well
and found that psychodynamic psychotherapy was superior to control
treatments and just as effective as alternative treatments (Driessen et al.,
2015; Keefe, McCarthy, Dinger, Zilcha-Mano, & Barber, 2014; Kivlighan
et al., 2015). Moreover, the effects lasted just as long for psychodynamic
treatment as for alternative treatments (Kivlighan et al., 2015).
Barber, Muran, McCarthy, and Keefe (2013, in press) presented a
comprehensive and very nuanced discussion of the meta-analyses of
dynamic therapies for (a) mood, (b) anxiety, and (c) personality disorders,
then reviewed the literature on dynamic change processes and mecha-
nisms, such as insight, defenses, rigidity, object relations, reflective func-
tioning, and therapeutic alliance (including rupture-repair). In regard to
personality disorders, Barber et al. (in press) concluded, “Unambiguously,
DTs [dynamic therapies] should be considered viable and efficacious
treatments for personality pathology.” This chapter and the Norcross

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

and Lambert (2018) article go beyond looking at outcome and are able to
provide meta-analytic reviews of such dynamically informed relationship
variables as the alliance, rupture-repair, and countertransference.
In addition to the studies included in these meta-analyses, recent
studies provided evidence that psychoanalytically oriented treatments
can be effective in the treatment of borderline personality disorder and
challenged the conventional wisdom that dialectical behavior therapy
(DBT) is the only treatment of choice for this population. In the first
study involving a head-to-head competition between DBT and a psycho-
analytically oriented treatment that makes extensive use of transference
interpretations, Clarkin, Levy, Lenzenweger, and Kernberg (2007)
randomly assigned borderline clients to either DBT or the psycho­
analytically oriented treatment and found the analytically oriented treat-
ment to be as effective as or more effective than DBT. Finally, they found
that clients in the analytically oriented treatment were significantly
more likely than DBT clients to change their attachment status from
the insecure to the secure category as assessed by the Adult Attachment
Interview.
Bateman and Fonagy (2008) evaluated the effectiveness of a psycho-
analytic treatment that they developed, designated as mentalization-based
treatment, which is designed as an intervention for clients with border-
line personality disorder. Their research demonstrated that with this
population, mentalization-based treatment is significantly more effective
than treatment as usual (partial hospitalization) on a range of outcome
measures at both termination and at an 18-month follow-up. In a longer
term follow-up study with the same sample, Bateman and Fonagy (2008)
found that 5 years after discharge, the clients treated psychoanalytically
continued to show statistical superiority to treatment-as-usual clients on
a number of important dimensions, including suicidality (23% vs. 74%),
service use (2.0 years vs. 3.5 years of psychiatric outpatient treatment),
use of medication, global function above 60 (45% vs. 10%), vocational
status (employed or in education 3.2 years vs. 1.2 years), and diagnostic
status (13% vs. 87% continued to meet diagnostic criteria for borderline
personality disorder).

146
 Evaluation

Finally, McMain et al. (2009) evaluated the efficacy of DBT combined

with medication relative to psychodynamically informed treatment com-
bined with medication for clients diagnosed with borderline personality
disorder. Treatment length in both conditions was 1 year. This was the
largest RCT that included DBT as a treatment modality to date. Counter
to McMain et al.’s expectation, both treatment groups showed signifi-
cant improvement across a range of outcome measures at termination,
and there was no significant difference between the two groups. Although
there is nothing dramatic about findings that fail to find a significant
difference, these findings are surprising given the widely acknowledged
researcher allegiance effect in psychotherapy research (i.e., the finding that
the theoretical allegiance of the researcher is the most powerful predictor
of treatment outcome; Luborsky et al., 1999) and the fact that McMain is
a DBT proponent.
Certain practical and logistical problems make it extremely difficult
to conduct RCTs of long-term intensive treatments of any type, includ-
ing psychoanalysis. One practical problem is that tracking the progress of
clients over a significant length of time in treatment (4–6 years or more)
requires a significant investment of time and resources. In addition, it is
extremely difficult to find clients who are willing to be randomly assigned
to one of two treatments that differ radically with respect to both treat-
ment duration and intensity. Because of these constraints, many studies
evaluating the effectiveness of long-term psychoanalysis tend to be of a
more naturalistic nature (e.g., clients either self-select their treatments
or are assigned to the treatment condition on the basis of assessed suit-
ability) and are thus subject to various methodological problems. The
majority of the research on the effectiveness of medium to long-term
psychoanalytic and psychoanalytically oriented treatment is conducted
in European countries in which the public health care system covers the
cost of long-term psychoanalytically oriented treatment. For example,
in Germany, Leichsenring, Biskup, Kreische, and Staats (2005) reported
the results of a naturalistic study of the effectiveness of psychoanalytic
therapy for 36 clients seeking treatment for chronic psychological
problems (e.g., depression, anxiety, obsessive-compulsive disorder, and

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

nonorganic sexual dysfunction), with the majority of clients presenting with

comorbid diagnostic pictures. Although there was no control group, the
effect size of a control group from another study was used as a point
of reference. The average duration of treatment was 37.4 months, and
on average, 253 sessions were conducted. In general, improvement was
found for symptoms, interpersonal problems, quality of life, and the
target problem formulated by the clients themselves at the beginning of
treatment. These changes were stable at 1-year follow-up, and in some
areas they actually increased.
An extremely ambitious naturalistic outcome study conducted
in Sweden by Sandell et al. (2000) evaluated outcome for more than
400 clients who received either psychoanalysis or psychoanalytically
oriented psychotherapy. The mean duration of treatment in psycho­
analysis was 51 months, and the mean frequency was 3.5 sessions per
week. The mean length of treatment in psychotherapy was 40 months,
and the mean frequency of sessions was 1.4 times per week. In general
both treatments were found be effective, but (a) at the 3-year follow-up
interval clients in psychoanalysis achieved a better outcome on a number
of dimensions than clients in psychotherapy, and (b) more experienced
psychoanalysts achieved a better outcome than therapists with less psycho-
analytic training and experience.
An important study by Huber, Henrich, Gastner, and Klug (2012)
used a partially randomized, quasi-experimental design to evaluate differ­
ences in the effectiveness for depressed patients of intensive psycho­
analytic treatment (average duration was between 160 and 240 sessions;
session frequency were two to three sessions per week), less intensive
psychodynamic treatment (average duration was 50–80 sessions; session
frequency was one time per week), and cognitive behavior therapy
(average duration was between 45 and 60 sessions; session frequency was
one time per week). At termination, significantly more clients in the
psychoanalytic group (91%) than clients in the cognitive behavior therapy
condition (53%) no longer met diagnostic criteria for depression. Patients
in the less intensive psychodynamic condition fell in between, with 68%
no longer meeting criteria for depression.

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 Evaluation

At 1-year follow-up, 89% of the psychoanalytic clients, 68% of the

psychodynamic clients, and 42% of the cognitive-behavioral clients
no longer met diagnostic criteria for depression. The differences were
significant between psychoanalytic and cognitive behavior therapies,
between psychoanalytic and psychodynamic therapies, and between
psychodynamic and cognitive behavior therapies. The findings indi-
cating significant differences between psychodynamic and cognitive-
behavioral conditions at follow-up were striking, given the fact that the
two treatments were provided at approximately the same duration and
intensity.
Finally, there are extensive reviews of a large number of naturalistic
studies investigating the effectiveness of intensive, long-term psycho-
analytic treatments (e.g., Fonagy et al., 1999; Galatzer-Levy, Bachrach,
Skolnikoff, & Waldron, 2000; Richardson, Kachele, & Renlund, 2004).
In general, the results are quite promising.
In summary, a growing body of empirical evidence supports the
efficacy of psychoanalytically oriented interventions for a range of dis­
orders. Moreover, an emerging body of evidence suggests that the impact
of psychoanalytically oriented interventions continues to increase after
termination (a finding that is not emerging to the same extent in the case
of cognitive-behavioral interventions). At this point in time, for practical
and logistical reasons, the evidence for the effectiveness of intensive
long-term psychoanalysis is garnered from naturalistic studies rather
than RCTs.
It would be a mistake, however, to ignore the findings of the many
naturalistic studies supporting the effectiveness of long-term psycho­
analysis. In fact, as many have argued (e.g., Seligman, 1995; Westen,
Novotny, & Thompson-Brenner, 2004), naturalistic studies (despite their
limitations) have certain advantages over RCTs with respect to external
validity and generalizability. Unlike subjects in RCTs, in real life clients
choose the type of therapy they are receiving, as well as their therapists,
and they remain in treatment until they decide that it is time to terminate.
Moreover, therapists as a rule do not adhere to standardized rigid protocols
and are more likely to modify what they are doing in response to the client’s

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needs in any given session and over time. Empirical research inevitably
purchases internal validity (the ability to infer causation and rule out
alternative hypotheses) at the expense of external validity (generalizability
to real-life situations). If the yield of psychotherapy research is to be of
any real value, it is essential for us to adopt a pluralistic perspective that
weighs the evidence produced by a range of different methodologies in
light of an understanding of the strengths and weaknesses of any given
methodology (Safran, 2001).

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 6

Future Developments

M uch ink has been spilt over the years on the topic of whether
psychoanalysis has a future. I start this section with the assump-
tion that psychoanalysis does indeed have a future and that this future
will come in a variety of shapes and forms. One form will involve the
ongoing integration of psychoanalytic ideas into other forms of treat-
ment, especially cognitive therapy. In the early to mid-1990s, I published
a number of articles and books with collaborators, advocating for the
use of psychoanalytic conceptualizations of the therapeutic relationship
within cognitive therapy. I argued that these conceptualizations could
facilitate the assessment and formulation process, help to work through
therapeutic impasses, increase treatment maintenance, and enrich our
understanding of the relationship between emotion and cognition
(Greenberg & Safran, 1987; Safran, 1984, 1998; Safran & Greenberg, 1991;
Safran & Segal, 1990). Contemporary cognitive therapy now includes

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features that were once considered irrelevant, including exploring the

therapeutic relationship, using the therapeutic relationship as a vehicle
of change, helping clients to become aware of feelings they are avoiding,
exploring the client’s past, and extending the length of treatment.
Another form will be the extension of psychoanalysis as it reconciles
to the realities of current practice and integrates techniques from other
traditions to flexibly meet clients’ needs. I believe that psychoanalysis will
continue to survive as a distinct tradition but that to flourish and main-
tain its vitality, it will have to continue to evolve. There is a discrepancy
between the psychoanalysis that candidates in traditional institutes are
trained to conduct and value and contemporary practice. The psycho-
analysis of the future will need to continue to abandon the elitist emphasis
on ideological purity and come in a range of different forms, treatment
lengths, and intensities. Psychoanalytic training institutes will also need
to broaden their curricula to offer training in a variety of important areas
that are not commonly covered, including brief-term therapy; integrating
psychoanalysis with other treatment modalities; working with intersectional
identities; marital, family, and group therapy; and working with specific
populations such as trauma victims and severe personality disorders.
Many curriculum changes of this type are already taking place, especially
within the more innovative, nontraditional psychoanalytic institutes. But
it will be important for changes like this to become more widespread.

PRACTICAL PSYCHOANALYSIS
In a culture in which psychoanalysis has come to be associated with a form
of indulgent self-preoccupation for the idle and financially comfortable
elite, the term practical psychoanalysis seems like an oxymoron. There is
no doubt that psychoanalysis values deep changes in personality structure
and relational dynamics. At the same time, there is a growing realization
among psychoanalysts that the reluctance to focus on client symptoms and
to concern themselves with relief can represent a failure to take clients’
suffering seriously and to provide them with the type of help they are
seeking. Owen Renik (2006) made the following argument:

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 Future Developments

People who seek the help of mental health caregivers want a therapy
that will provide maximum relief from emotional distress as quickly
as possible. Most clinical psychoanalysts offer instead a lengthy
journey of self-discovery during which too much concern with
symptom relief is considered counterproductive. “Self-awareness”
is the main goal; symptom relief is of secondary importance and
is expected to arrive, if at all, only after a while. (p. 1)

From Renik’s (2006) perspective, this type of stance is unfortunate

because it all too often fails to provide clients with relief for the suffering
that brings them to treatment in the first place. Although a psychoanalytic
therapist may be able convince a client that the project of self-discovery is
worthwhile, there is always a danger that the client will stay in therapy as
a form of compliance even if client’s symptoms are not addressed or leave
treatment because he or she doesn’t find it to be of any value.
Renik (2006) thus argued for the importance of collaborating with
clients in the ongoing process of establishing shared treatment goals.
When the therapist has a different perspective on these issues than the
client, Renik argued that it is important for the therapist to be explicit
about these differences to give the client an opportunity to take another
perspective into consideration and decide whether he or she wishes to
be influenced by it. From Renik’s perspective, this type of candidness,
far from using the therapist’s authority to unduly influence the client
(a traditional concern for psychoanalysts), actually “levels the playing
field” by letting the client know explicitly where the therapist is coming
from so that he or she does not end up being manipulated by a hidden
agenda. He also encouraged therapists to engage in an ongoing process
of explicitly exploring with the client the extent to which he or she feels
that the treatment is beneficial
Many other analysts over the years (e.g., Bader, 1994; Connors, 2006;
Frank, 1999; Wachtel, 1977, 1997) have argued for the importance of
taking the client’s symptoms seriously and using a range of more active
interventions to help the client obtain symptom relief. An emphasis on
the client’s symptoms does not have to neglect the underlying meaning of
these symptoms or the interpersonal context in which they are embedded.

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Moreover, experiencing symptom relief may pave the way for the client to
begin to explore other issues of a deeper nature.
Many years ago while working in a psychiatric hospital, I super-
vised a young trainee in the use of behavioral interventions to treat a
client presenting with a needle phobia that prevented her from seeking
any medical treatment because of the threat of receiving an injection.
Although the behavioral treatment was apparently successful, a year
later the client returned to a different clinic in the same hospital to seek
treatment. She was referred back to our clinic for an assessment, and
I met with her. It turned out that she had indeed been helped by her treat-
ment with us and was no longer troubled by the same presenting problem.
Now, however, she said that she was ready to work on some interpersonal
concerns that, in her words, she “hadn’t been thinking about so much”
at the time she had initially been treated in our clinic. In recounting this
case, I want to be clear that I am not rehashing the old psychoanalytic
argument that treating the symptom is pointless because it is a manifesta-
tion of a deeper underlying problem, which will ultimately result in the
emergence of a new symptom. Quite the contrary, I am arguing for the
importance of “meeting clients where they are.” If we had attempted ini-
tially to treat this client with an insight-oriented approach, she may well
have dropped out of treatment. Instead, perhaps the process of engaging
her at the level that was meaningful to her helped her begin to develop the
sense of trust and safety to subsequently pursue deeper, more threatening
psychological issues.

INTEGRATING APPROACHES
As part of the flexibility required to meet all of the complex goals of
psychotherapy, many psychoanalysts have advocated for integrating
interventions from other therapeutic perspectives into psychoanalytic
practice. In The Handbook of Psychotherapy Integration, Norcross and
Goldfried (2019) pointed out that integrating techniques from different
clinical approaches is now the norm for practitioners and no longer the
exception. Numerous models for how psychotherapy integration can

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 Future Developments

take place have been proposed; the most relevant is assimilative integra-
tion. Assimilative integration is a mode of conducting psychotherapy
in which a technique, concept, or perspective is incorporated into one’s
preferred therapeutic approach (Messer, 2015). For example, an analyst
could practice a relaxation exercise in session. This stands in contrast
to eclecticism, in that the clinician still primarily identifies with one
“home” orientation.
Consistent with the movement away from orthodoxy that has taken
place in psychoanalysis over the past 40 years, analysts have looked toward
other practices in order to have more technical flexibility and choice.
Wachtel (1977, 1997, 2011, 2014) was an early advocate of the potential
usefulness of incorporating behavioral interventions and systemic under-
standing into psychoanalytic practice, arguing in his theory of cyclical
psychodynamics that such interventions can actually facilitate changes at
a psychodynamic level and that psychoanalytic theory could add a valuable
dimension to understanding factors causing and maintaining problems
that are manifested at a behavioral level.
Frank (1999) has written extensively about the way in which the
relational turn in psychoanalysis (i.e., the emergence of relational psycho­
analysis) provides a theoretical framework that is compatible with the
use of active behavioral interventions by psychoanalytically oriented
therapists and with more contemporary theoretical developments in
psychoanalysis, and he has provided illuminating clinical examples
illustrating the potential fruitfulness of integrating psychoanalytic and
behavioral approaches. Bresler and Starr (2015) provided us with a highly
informative collection of examples of relational analysts incorporating
techniques and perspectives from other traditions. These include cognitive
behavior therapy, Zen Buddhism, dialectical behavior therapy, neuro-
feedback, and body-focused therapeutic techniques.
It is important to keep in mind that if an analyst uses a behavioral
technique, for example, he would do so while retaining a psychodynamic
perspective. An analyst will always be considering the deeper meaning
behind all activity in the treatment, including his or her own choices.
He will be considering the meaning of the active intervention in light of

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the client’s personal history and dynamics and will be sensitive to the
transference implications. The use of a technique introduced by the
analyst will inevitably be part of an enactment in the treatment dyad
that needs to be understood on an ongoing basis. For example, the
introduction of a relaxation exercise in session could reflect the analyst’s
discomfort with the client’s affective experience and could unwittingly
cause the client to be more circumspect about sharing certain feelings.
Conversely, it could elicit a regressive dependence in a client, which the
analyst might experience as making him feel more powerful. These inter-
locking dynamics would have to be understood in the same way that all
other interpersonal enactments are. Gold and Stricker (2015) argued,
interestingly, that not using a helpful technique could also be understood
as an enactment within the treatment, with the analyst taking on the role
of a passive, neglectful, or helpless parent. They suggested some active
interventions that can comfortably be assimilated into a dynamic treat-
ment, including social skills training and the assignment of homework.

PSYCHOANALYTIC TREATMENTS
AND SOCIOCULTURAL IDENTITIES
Psychoanalysis was originally developed as a form of treatment by and
for educated middle-class Western Europeans, yet the principles were
regarded as universal to all people, irrespective of culture or class. As
psychoanalysis became the dominant theoretical influence within the
public health care system in the United States, a paradoxical process took
place. Therapists influenced by psychoanalytic thinking were placed in
the position of treating a broad range of clients from different cultures
and social classes. At the same time, they were being guided by theoretical
premises and intervention principles ill-equipped to fit the diversity of
clients being treated. In recent years, as the field has become more diverse
and democratic, psychoanalysts have written extensively about the
importance of recognizing middle-class Euro-American biases of psycho­
analytic theory and practice. They have also written extensively about
the importance of modifying theory, clinical stance, and interventions

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in a fashion that incorporates an understanding of the cultural attitudes,

assumptions, and structural social ramifications salient to a full range of
different cultures and social classes (see, e.g., Altman, 2010; Gentile,
2013; Gutwill & Hollander, 2006; Leary, 2000; Padrón, 2019; Perez Foster,
Moskowitz, & Javier, 1996; Pogue White, 2002; Saketopoulou, 2011;
Tummala-Narra, 2016; Yi, 2014). The discussion of themes such as
individualism/collectivism, social hierarchy and respect for authority,
gender roles, spirituality, and cultural difference in emotional expression
has been afforded greater primacy in contemporary psychoanalytic
thinking after having been neglected by the field for many years.
What psychoanalysis can uniquely contribute to questions concerning
the relationship between mind and culture is its recognition of unconscious
material, including biases and prejudices, about race, culture, and class
and how these shape our daily interactions. We inevitably internalize
societal prejudices, and these unconscious internalized attitudes influ-
ence the way in which we relate to others and to ourselves. Internalized
attitudes about culture and race play out unconsciously in the transference/
countertransference matrix for both client and therapist (Akhtar, 2006;
Altman, 2000; Leary, 2000; Pogue White, 2002). Neil Altman (2000)
wrote a candid article about a treatment with an African American client:
Together they became embroiled in a social and relational process that
Leary (2000) called racial enactment. Racial enactments are interpersonal
sequences shaped by unconscious attitudes regarding race (Leary, 2000).
In this case, Altman, a middle-class Jewish American psychoanalyst, treated
an African American client, whom he called Mr. A, for marital problems
and panic attacks. Altman initially found himself feeling tremendously
admiring of Mr. A for having achieved so much even though the deck
was stacked against him. Early in treatment, however, a pattern began
to emerge in which Mr. A would miss appointments with Altman and
bounce checks. Although Altman attempted to address the situation with
Mr. A, he failed to explore the potential meaning of what was taking place
between them as fully as he might with another client. In retrospect,
Altman recognized that even before the first check had bounced, a mar-
ginal thought had occurred to him that Mr. A might end up not paying

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him. In Altman’s words, the thought went something like, “I can’t believe
that this man, who has fought his way up from poverty and who still
struggles to make ends meet, is going to give substantial sums of money to
a privileged person like me.” At a somewhat deeper level, Altman admits
to having the racially prejudiced thought that Mr. A might stiff him
because he was Black and because of Altman’s own semiconscious racist
stereotypes involving “Black people, irresponsibility, and criminality”
(p. 594), together with a self-referring, complementary, and shame-
inducing anti-Jewish stereotype surrounding greed. In retrospect, Altman
speculated that his own feelings of shame about his semiconscious racist
feelings and his internalized anti-Semitism prevented him from exploring
the situation as constructively as he might have with Mr. A. Although
there is no way of knowing if a deeper exploration of the potentially
unconscious racial undertones to the enactment might have been bene­
ficial for the treatment, I believe that Altman has provided a valuable
example of the way in which semiconscious or unconscious race-related
attitudes can potentially play out in a transference/countertransference
enactment.
Moving beyond the scope of the previous example, there is a growing
trend within certain pockets of the psychoanalytic community to use
an intersectional approach in their case conceptualization and practice.
Intersectionality, a term coined by the Black feminist scholar Kimberlé
Crenshaw in the twilight of the 1980s, refers to a way of understanding
people, their identities, and their social standing within society. It holds
that social categories—such as race, gender, sexual orientation, and
class—weave together to determine a person’s standing within a social
hierarchy and shape their experience of themselves in relation to
others in a society that privileges some identities at the expense of others
(Crenshaw, 2020). Although psychoanalysis has often neglected struc-
tural social and identity-related factors in thinking about the relationship
between patient and clinician, there has been a recent change toward an
intersectional perspective. This turn toward the impact of social reality
on the treatment frame has focused, particularly, on how intersecting
identities and the sociopolitical positions of the patient and clinician shape

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the transference/countertransference matrix and treatment (Gentile,

2013; Padrón, 2019; Saketopoulou, 2011; Tummala-Narra, 2016; Yi, 2014;
Young-Bruehl, 2006).
To illuminate how this approach works, Gentile (2013) wrote about
how a psychoanalytic psychotherapy might be complicated by the uneven
distribution of power and privilege within social and cultural reality.
She explored how her intersecting identities, as a White female psycho­
therapist, interact with the interleaving identities of a female Latina
patient reckoning with complex sexual trauma (Gentile, 2013). Gentile
articulated the dilemmas of identification shaping the patient–therapist
relationship, paying close attention to how broader structural social
factors constrain the expression and reception of empathy within the
dyad. She articulated the link between relational dynamics and socio­
cultural contingencies and how the respective social positions of patient
and clinician influence the potential for closeness, support, identification,
and healing within the therapeutic dyad.
To illustrate, Gentile (2013) described the case of an anxious 23-year-
old Latina psychology student she called Vasialys. Vasialys lived with her
mother, two teenage brothers, and an 8-year-old sister, and she entered
treatment before her father was about to be released from jail after serving
8 months for driving on a suspended license. She presented with dissociated
trauma linked to her father’s physical and verbal abuse of both her and
her mother. Her father had sexually abused her when she was between the
ages of 6 and 10, a violence she spoke of as if it no longer impacted her.
Gentile wrote that she narrated her trauma in a flat, low, and disconnected
tone, noting that “she did not have a verbal language to describe what had
happened” (p. 460). Much of the treatment involved working through
Vasialys’s feeling of responsibility for the abuse she suffered, toward being
able to identify her father as an aggressor who abused her. Here, Gentile
illuminated, from an intersectional vantage point, the vexed relational
possibilities for identification existing between them that threatened to
toxify the empathy expressed by Gentile toward Vasialys.
Gentile (2013) drew attention to how an intersectional outlook
requires that clinicians reflect deeply on their own subjectivity, their social

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standing, and its complementary structural culpability. She acknowledged

with refreshing frankness her own struggle, as a White clinician in the
United States, in finding adequate empathic therapeutic pathways that
did not automatically deem Vasialys’s Latina identity guilty for the
transgressions of her father. Gentile recognized that to move forward in
the treatment—to cocreate a language with Vasialys that would allow her
to discover her own agency—she needed to acknowledge and analyze
her own intersecting identities and social standing beyond the walls of
her office. Gentile stressed the cultural bind in which Vasialys, as a Latina,
found herself unconsciously mired: To acknowledge the violence wrought
on her by her father, a Latino, with a White clinician, she had to implicate
her cultural identity “in yet another violent crime, when the dominant
culture already casts Latinos primarily as criminals” (p. 463). To unequivo-
cally receive Gentile’s support, empathy, and solidarity, Vasialys had to
accuse Latino culture.
Whereas Gentile demonstrated what an intersectional approach has
to offer psychoanalysis, Carlos Padrón, with roots in Venezuela, articulated
what the process of psychoanalysis has to offer patients struggling with
identity-related psychic suffering. In Padrón’s vision of the therapeutic
action of psychoanalytic process, the emergent interaction between patient
and clinician creates space for the exploration and transformation of the
dynamic interaction between the sociopolitical, historical, and cultural
forces that constitute the patient’s identity. This affords the patient the
freedom to move beyond a reified self-understanding in order to “imagine
[themselves] otherwise” (Padrón, 2019, p. 190). Both Gentile and Padrón
are committed to, to borrow the words of Pratyusha Tummala-Narra
(2016), “bringing social context into the foreground of psychoanalysis”
to help patients contend with the depth and complexity of their inter-
and intrapsychic conflicts and experience. Although some psychoanalytic
clinicians and scholars may shy away from an intersectional approach
because of the complex and entangled nature of our social identities,
it becomes ever more vital to embrace as psychotherapy contends with a
rapidly changing and globalizing society.
As I have discussed throughout the book, a contemporary psycho-
analytic perspective emphasizes the role of a host of change mechanisms,

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including relational, sociopolitical, and cultural experience; containment;

and affective communication and regulation. Intersectional psycho­
analytic approaches recognize the role of sociological, political, and cultural
forces that form patients’ identities and experiences of themselves operating
within an unequal society. To echo Padrón (2019), who harkened back
to the subversive origins of psychoanalytic thinking, the psychoanalytic
process facilitates the exploration, insight gain, and working-through of
the dynamic interaction between a patient’s conscious and unconscious
psychic activity and their social, political, and cultural realities.

SOCIAL, CULTURAL, AND POLITICAL CRITIQUE

Psychoanalysis has not always been a progressive force in society. For
example, in the mid-20th century, mainstream analysts endorsed a con-
servative heteronormative definition of mental health, which pathologized
people with other sexual orientations (Drescher 2008). However, over
recent decades analysts have begun to reclaim a subversive, critical perspec-
tive on societal issues. Psychoanalytic thinking can be fruitful in helping
us understand everything from the fantasies that underly the election
of certain leaders to the denial of annihilation, which disables us from
acting decisively on climate change. From Botticelli’s (2004) perspective,
“We need to take ourselves more seriously and to hold onto the strength
of our relational convictions after we leave our offices” (p. 649). He
argued that it is imperative for clinicians not to divorce the psychological
from the political or to retreat exclusively to the psychological realm,
as a defensive reaction to hopelessness and our fears that actions in the
political realm will prove futile.
Nancy Caro Hollander, a professor of Latin American history and a
psychoanalyst, has written about the role that politically engaged psycho­
analysts played in the fight for human rights under Latin American military
regimes during the 1970s and 1980s (e.g., Hollander, 1997, 2006, 2010).
In her book Love in a Time of Hate, Hollander (1997) documented the
experiences of a number of politically active psychoanalysts from Argen-
tina, Uruguay, and Chile who found ways of struggling for democracy

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and human rights under dictatorships in their countries. Some of them

were imprisoned and tortured by the military governments, and others
escaped to countries such as Mexico, Cuba, and France.
Hollander (2006, 2010) has pointed out parallels between the situa-
tion in Latin America and in the United States right now. With the grow-
ing infringement of American civil liberties, following the attacks on the
World Trade Center, Hollander urged her colleagues in the United States
to learn from the experience of Latin American psychoanalysts who had
lived through the experience of their countries’ slow drift from demo-
cratic to totalitarian forms of government. She also warned against the
dangers potentially resulting from mental health professionals dissociating
the psychological from the political.
In recent years, psychoanalysts in the United States have been connect-
ing the psychological and the political and have taken action. Following
the invasion of Afghanistan, the American government made a decision
to engage in coercive interrogation practices that violate the protections
guaranteed by the Geneva Convention regarding detainees in detention
sites such as Abu Ghraib and Guantánamo Bay. A series of articles in
The New York Times, and elsewhere, alleged that professionals and other
health professionals were playing an integral role in devising and con-
sulting on abusive interrogation techniques at Guantánamo that were
“tantamount to torture.” The International Committee of the Red Cross
(ICRC) described this as “a flagrant violation of professional ethics”
(Lewis, 2004). Congressional investigations revealed that psychologists
had designed and helped to implement torture programs for the Depart-
ment of Defense at Guantánamo and for the CIA at various “black sites”
around the world.
In response, many psychologists urged the American Psychological
Association (APA) to establish policy that would explicitly prohibit
psychologists from working at certain military sites. Among the leaders
of this effort were members of APA’s Division of Psychoanalysis (39),
including Neil Altman, Ghislaine Boulanger, Ruth Fallenbaum, Steven
Reisner, Stephen Soldz and Frank Summers. Although APA’s (2017) ethics
code prohibited violations of human rights, the involvement of military

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psychologists in enhanced interrogation of detainees was the subject of

controversy, and activist psychologists who felt that any such participa-
tion was a violation of human rights and should be banned brought a
referendum before the entire APA membership. The aim of the refer-
endum was to prohibit psychologists from working “in settings where
persons are held outside of, or in violation of, either International Law
or the U.S. Constitution unless they are working directly for the persons
being detained or for an independent third party working to protect
human rights.” The membership voted overwhelmingly in favor of the
change and, in 2008, the Council voted to amend existing APA policy to
make it consistent with the member-initiated referendum (for reviews of
this issue, see Altman, 2008; Harris & Botticelli, 2010; Hollander, 2010;
Soldz, 2008).
It took many additional years of relentless opposition by dedicated
dissident psychologists, again with members of the Division of Psycho-
analysis at the forefront, before APA retained outside counsel to conduct
an independent investigation regarding its relationship with the military.
The investigators concluded that there had been collusion between APA
and members of the military in order to ensure that APA policy was kept
at a high level to permit the military to engage in the enhanced inter-
rogations of national security detainees. Once the secret collaboration
between APA and military psychologists was exposed, the APA council
voted 157-1 in favor of a new policy that resolved that “psychologists
shall not conduct, supervise, be in the presence of, or otherwise assist any
national security interrogations for any military or intelligence entities”
(APA, 2015, p. 5). As a result of these efforts, as of January 2016, psycholo-
gists were removed from Guantánamo Bay.
More recently, psychoanalysts have had much to say in regard to the
current refugee crises. In 2015, the American Psychoanalytic Association
issued a Refugee Resettlement Position Statement, which highlights the
tendency to emphasize difference and hence lose empathy for populations
in need. The statement goes on to argue that we need to be sensitive not
only to the trauma that refugees suffer but also to the trauma that we will
cause ourselves and following generations because of complicity with the

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persecution of helpless people. Similarly, certain analysts have discussed

the “othering” that takes place in political discourse and made the point
that psychoanalysis and our understanding of the unconscious could help
to combat these tendencies (Koritar, 2017; Volkan, 2017). For example,
Varvin (2017) powerfully explained some of the ways that we can under-
stand xenophobia from a psychoanalytic stance:

Collective memories of past traumatization and humiliation may

fuel various fantasies: of revenge or rectification of wrong-doing;
the demand for sameness and purity being threatened by elements
that endanger cohesiveness and unity; the other being cast in the role
of unwanted, projected parts of the self; or, competition for scarce
jobs by desperate refugees. As a defense against the perceived threat,
political factions may use paranoid rhetoric stimulating fantasies
against a defined enemy: the refugees. (p. 376)

Family separation is another important area in which psychoanalysis

has much to offer in critique of governmental policies. The long-lasting
effects of family separation and the associated trauma has been much
discussed in the press and the professional literature (e.g., Santa-Maria &
Cornille, 2007). The current administration has increased the practice of
separating immigrant children from their families, and this has caught the
attention of the psychology community. APA president Jessica Henderson
Daniel, PhD, spoke out in May 2018 on the science behind this policy
and the impact on children and families, noting in a statement and in
The New York Times that

the administration’s policy of separating children from their families

as they attempt to cross into the United States without documentation
is not only needless and cruel, it threatens the mental and physical
health of both the children and their caregivers. (Hirschfeld Davis &
Nixon, 2018, para. 18)

A psychoanalytic lens helps us deepen this discussion as we bring issues of

dissociation, emotional dysregulation, and attachment disturbances into
the discourse.

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 Future Developments

In describing the role that psychologist/psychoanalysts play in

responding to societal dilemmas, I am not making the claim that psycho-
analysts are a uniquely ethical group. Indeed, psychoanalysts have a long
history of being on both sides of important ethical divides in different
cultures and historical areas. The point, rather, is that their role in help-
ing to shape the public response to political situations can be seen as the
contemporary rekindling of the socially progressive and politically engaged
roots of psychoanalysis. There is something intrinsic to psychoanalysis’s
fundamental recognition of the limits of human rationality, the pervasive-
ness of self-deception, and the long-standing interest in broader social
and cultural concerns that establishes a context for this type of active and
progressive political engagement.

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 7

Summary

T he goal of this book is to provide an overview of key theoretical

concepts and principles of intervention in contemporary psycho­
analysis and psychoanalytic therapy. It describes a range of different
mechanisms of action hypothesized by contemporary psychoanalysts
to underlie the process of therapeutic change. The book also provides,
as context, the historical and cultural background necessary to understand
how psychoanalysis evolved and the factors shaping recent developments in
contemporary theory and psychoanalytic practice. One of my objectives
has been to correct misconceptions about psychoanalysis and psycho­
analytic therapy that are based on caricatures of a style of psychoanalysis
that is no longer dominant in the United States.
Psychoanalysis originated more than 100 years ago and has evolved
dramatically over time. In North America it has evolved to adapt to
current cultural values and needs. With the relational turn, it has become

http://dx.doi.org/10.1037/0000190-007
Psychoanalysis and Psychoanalytic Therapies, Second Edition, by J. D. Safran and J. Hunter
Copyright © 2020 by the American Psychological Association. All rights reserved.

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

more flexible, less authoritarian, more practical, and more responsive to

the needs of a wider range of clients. A growing body of empirical evidence
supports the effectiveness of psychoanalytically oriented treatments.
American psychoanalysis has also become more democratic, changing
from a tradition that was dominated by White male physicians to one
that includes diverse psychologists, social workers, licensed psychoanalysts,
and other mental health professionals.
Nonetheless, psychoanalysis has retained the qualities that define
it as a distinct and powerful treatment approach and theory of mind.
It remains a form of treatment that emphasizes careful listening for
unconscious material, and particularly internal conflict; an understanding
of the influence of developmental experiences on current functioning;
and an emphasis on the importance of the therapeutic relationship as
both a source of information and a curative factor. It remains an open-
ended and potentially long-term form of therapy that allows for deep
engagement.
Psychoanalysis has been criticized by both the behavioral tradition
and the tradition of humanistic psychology. The behavioral tradition has
critiqued psychoanalysis for its lack of scientific legitimacy. The tradi-
tional antipathy of many psychoanalysts to empirical research has been
a serious problem—one that has served to maintain the insularity of the
tradition, forestalled critical self-reflection, and led to treating theory
as if it were fact. For these reasons, the current resurgence of interest in
empirical research among psychoanalysts is all to the good. Neverthe-
less, it would be a mistake to disregard or devalue those dimensions of
psychoanalysis that fall outside of the natural sciences—those aspects of
psychoanalysis that are more accurately conceptualized as a hermeneutic
discipline, a critical theory, a philosophy of life, a wisdom tradition,
or a craft.
The humanistic critique of psychoanalysis for its mechanistic stance,
which can lead to a failure to appreciate and affirm the fundamental
nobility and dignity of human nature, is also valuable. It is important
to acknowledge that people have reported traumatic experiences with
psychoanalytic therapy where they left treatment feeling fragmented,

168
 Summary

objectified, and pathologized rather than appreciated, understood, val-

ued, and whole. Marvin Goldfried, one of the founders of the cognitive-­
behavioral tradition and a leader in the psychotherapy integration
movement, conducted a research project in which he and his students
used rating scheme to code transcripts of therapy sessions identified by
either psychodynamic or cognitive behavior therapists as “good sessions”
(Goldfried, Raue, & Castonguay, 1998). When he presented the study at
conferences, he would often summarize their findings (somewhat tongue
in cheek) in the following way: Whereas the cognitive therapists conveyed
the message to clients that “you’re better off than you think,” the psycho-
dynamic therapists tended to convey the message that “you’re worse off
than you think.”
This summary of the findings makes sense. The emphasis in psycho-
analysis has always been to help clients become aware of and acknowledge
aspects of themselves that they are defended against. Traditionally the
cognitive-behavioral emphasis has been on helping clients to see the way
in which they selectively focus on the negative rather than the positive.
The optimistic flavor of cognitive therapy and the emphasis on the posi-
tive is consistent with a long tradition of optimism and positive thinking
characteristic of American culture. It can be seen in the massive success
of the self-help industry and the new age emphasis on healing through
positive thinking.
Optimism is an important American “natural resource.” It inspired
the establishment of a modern democracy and provided opportunities
to immigrants who lived lives of persecution, oppression, and poverty in
their homelands. It has also fueled technological innovations that were
once unimaginable. At the same time, however, our American optimism
can lead to an oppressive attitude that marginalizes and silences those
who are suffering and judges them as failures or implicitly as morally
inadequate. In a book written in the wake of her own personal struggle
with breast cancer, the journalist Barbara Ehrenreich (2009) critiqued
what she referred to as our “relentless promotion of positive thinking”
in America and pointed out that despite this value Americans rank only
23rd in self-reported happiness relative to other nations. In this book,

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

Ehrenreich spoke about her tremendous sense of isolation while strug-

gling with breast cancer because of the cultural pressure to deal with her
experience in a “positive way.” For example, she wrote that at one point
she posted a statement on a breast cancer support group bulletin board
that conveyed some of her despair and anger. In response, Ehrenreich
reported receiving a “chorus of rebukes” (p. 32).
The late Stephen A. Mitchell (1993), one of the founding fathers
of relational psychoanalysis, described the difference between Freud’s
perspective and a more contemporary American psychoanalytic perspec-
tive in the following fashion: “Freud was not a particularly cheerful fellow
and his version of the rational scientific person is not an especially happy
person. But this person is stronger, more grounded, more in line with
reality even if it’s a somber reality” (p. 305). According to Mitchell, the
emphasis in contemporary psychoanalysis has shifted away from Freud’s
emphasis renouncing instinctual wishes and illusions toward the creation
of personal meaning and the revitalization of the self. Mitchell wrote the
following:

Many patients (these days) are understood to be suffering not from

conflictual infantile passions that can be tamed and transformed
through reason and understanding, but from stunted personal
development. . . . What today’s psychoanalysis provides is the oppor-
tunity to freely discover and playfully explore one’s own subjectivity,
one’s own imagination. (p. 25)

My sense is that contemporary American psychoanalysis has come to

incorporate some of the more positive, creative, and affirmative qualities
of the humanistic psychology of the 1960s. At the same time, I believe that
it will be important for the future of psychoanalysis not to discard what
many have described as Freud’s tragic sensibility—his belief that there is
an inherent conflict between instinct and civilization, his emphasis on the
importance of acknowledging and accepting the hardships, cruelties, and
indignities of life without the consolation of illusory beliefs. As indicated
earlier, Freud saw the goal of psychoanalysis as one of transforming
neurotic misery into ordinary human unhappiness. This can be interpreted

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 Summary

as a modest and pessimistic perspective, but it can also be viewed as a

realistic and profoundly liberating perspective—not unlike the Zen per-
spective that enlightenment involves letting go of the fantasy of escaping
the realities of everyday life.
There is a well-known anecdote that when Freud was crossing the
Atlantic with Jung and Ferenczi to deliver his lectures at Clark Univer-
sity, Jung spoke excitedly and enthusiastically about the growing inter-
est in psychoanalysis by Americans. Freud was much more measured in
his reaction and is reputed to have replied, “Little do they realize we are
bringing the plague” (Fairfield, Layton, & Stack, 2002, p. 1). As psycho-
analysis became increasingly popular in the United States, many Euro-
pean analysts responded ambivalently. On one hand, it is difficult to argue
with success. On the other hand, they were concerned that American psy-
choanalysis was losing the more radical and subversive qualities that were
intrinsic to the original vision of psychoanalysis. Historian Nathan Hale
(1971), for example, wrote the following:

The Americans modified psychoanalysis to solve a conflict between

the radical implications of Freud’s views and the pulls of American
culture. . . . They muted sexuality and aggression, making both
more amiable. They emphasized social conformity. They were more
didactic, moralistic, and popular than Freud. They were also more
optimistic and environmentalistic. (p. 332)

Psychoanalysis has a potentially powerful voice in response to current

societal and political controversies and in response to the trend toward
oversimplification in psychotherapy theory. Although this voice has been
marginalized within the psychology community, excellent books have
been published that are designed to reach out to an audience beyond the
professional world. These books attempt to present a more contemporary
version of American psychoanalysis that is in tune with a contemporary
cultural sensibility (Gabbard, 2010; Leiper & Maltby, 2004; Lemma, 2003;
Maroda, 2009; McWilliams, 1994, 2004; Renik, 2006; Summer & Barber,
2009; Wachtel, 2007, 2014). Additionally, Nancy McWilliams (2004) has
done a superb job of writing about psychoanalysis in a voice that makes it

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 PSYCHOANALYSIS AND PSYCHOANALYTIC THERAPIES

accessible to a broad contemporary audience. This has been my objective

as well. At the same time, however, I hope that I have managed to convey
my belief that although today’s psychoanalysis is very different from
Freud’s psychoanalysis or the orthodox American analysis of the mid-
20th century, it has retained the essential elements that changed the way
we think about our minds. From the very beginning, psychoanalysis had
a revolutionary and subversive quality to it that challenged conventional
cultural norms and values.
The marginalization of psychoanalysis has brought things full circle,
back to the early days where it liberated us from conventional thinking.
No longer an expression of the status quo, psychoanalysis has a renewed
potential of expressing its intrinsic search for truth and becoming a
constructive countercultural force. It has the opportunity to recover and
build on some of its revolutionary, subversive, and culturally progres-
sive qualities and be an important voice in psychotherapy theory as well
as in the social and political challenges of our time. Psychoanalysis has
changed the way we regard our minds and the human endeavor, and now
its embrace of the search for truth beyond cultural limits has the potential
to help change our world.

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 Glossary of Key Terms

ALLIANCE (THERAPEUTIC ALLIANCE, WORKING ALLIANCE)  

The client’s and therapist’s ability to collaborate in the therapeutic
process or to negotiate a constructive collaboration.
ATTACHMENT THEORY   A developmental theory originating in the
writing of John Bowlby that stipulates that human beings have a bio-
logically wired-in propensity for maintaining proximity to attachment
figures (e.g., their parents).
COMPROMISE FORMATION   A theoretical proposition emerging
from the ego psychology tradition that stipulates that all experience
and action is the result of a compromise between an underlying instinc-
tually derived wish and a defense against it.
CONTAINMENT   A model of development and therapeutic change
originating in the work of Wilfred Bion that stipulates that the thera-
pist’s ability to process the client’s difficult or “intolerable” affective
experience in a nondefensive fashion, and to help him or her make sense
of it, is a central therapeutic mechanism.
COUNTERTRANSFERENCE   Historically conceptualized as the ther-
apist’s responses to the client that are influenced by the therapist’s
unresolved conflicts. In contemporary psychoanalytic theory, counter­
transference tends to be conceptualized as the totality of the thera-
pist’s experience while with the client and as an important source of
information.

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 Glossary of Key Terms

DEFENSE   An intrapsychic process that functions to avoid emotional

pain by in one way or another pushing thoughts, wishes, feelings, or
fantasies out of awareness. Common examples of defenses are intellec-
tualization, repression, reaction formation, splitting, and projection.
DISSOCIATION   A partial or complete disruption of the normal inte-
gration of a person’s conscious or psychological functioning resulting
from anxiety or trauma. Involves the splitting of different self-states or
self-experiences from one another.
ENACTMENT   Takes place when client and therapist unwittingly get
caught in playing out a particular relational scenario that is influenced
by both the client’s and therapist’s unique personalities, relational
styles, blind spots, sensitivities, and so on. Enactments are ubiquitous
in psychotherapy.
EVENLY SUSPENDED ATTENTION (EVENLY HOVERING ATTEN-
TION)   An attentive, open, and receptive listening style in which
the therapist attempts to listen to whatever the client says without
allowing his or her preconceptions or expectations to shape what he
or she attends to.
INSIGHT   A mechanism of change that has always been considered as
important by psychoanalysts. Insight involves becoming aware of a
feeling, wish, fantasy, thought, or memory that has previously been
unconscious. Insight can also involve becoming aware of how one’s
previous experiences or current unconscious expectations or beliefs
are shaping self-defeating interpersonal patterns in the present.
INTERNALIZATION   The process of developing an internal represen-
tation of relationships with others that shapes our ongoing experience
and actions. There are many different theories of internalization. Inter-
nalization is considered to play an important role in the developmental
process and to be an important mechanism of change in psychotherapy.
INTERNAL OBJECTS (INTERNAL OBJECT RELATIONS)   Hypothet-
ical psychic structures developed through a combination of real inter-
actions with others, fantasy, and defensive (self-protective) processes.
These psychic structures shape our experience of others, the type of
partners we tend to choose (romantic and otherwise), and the way in
which we experience relationships with others. There are many different

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models of internal object relations, each with its own assumptions

and both theoretical and practical implications.
INTERPRETATION   The therapist’s attempt to help make sense of the
client’s experience, articulate a hypothesis about the client’s unconscious
experience, or draw the client’s attention to unconscious self-defeating
interpersonal patterns.
INTERSECTIONALITY   The interconnected nature of social factors
such as race, class, and ethnicity and the associated discrimination as
applied to individuals or groups.
INTRAPSYCHIC CONFLICT   A conflict between unconscious wishes
and defenses against them.
MENTALIZATION   The capacity to see ourselves and others as beings
with psychological depth and underlying mental states including desires,
feelings, and beliefs. Mentalization is also the capacity to access and
reflect on our own thoughts, feelings, and motivations and to reflect
on the mental states of others.
METACOMMUNICATION   An intervention that involves engaging
the client in the process of stepping back collaboratively and exploring
what is implicitly taking place in the therapeutic relationship.
ONE-PERSON PSYCHOLOGY   The perspective in traditional or classical
psychoanalysis that assumes it is possible to understand the client’s
intrapsychic processes out of context of the therapist’s ongoing contri-
butions to the interaction. From this perspective, the client’s transference
is viewed as a distorted perception influenced by the client’s past and
projected onto a neutral stimulus.
PRIMARY PROCESS   A raw or primitive form of psychic functioning
that begins at birth and continues to operate unconsciously throughout
the lifetime. In primary process, there is no distinction between past,
present, and future. Different feelings and experiences can be con-
densed together into one image or symbol, feelings can be expressed
metaphorically, and the identities of different people can be merged.
Primary process can be seen operating in dreams and fantasy.
RESISTANCE   Conceptualized as the tendency for the client to resist
change or act in a way that undermines the therapeutic process. There
are multiple factors underlying resistance, such as ambivalence about

175
 Glossary of Key Terms

changing, a fear of losing one’s sense of self, and a reaction to a prob-

lematic intervention by the therapist. The exploration of resistance is
viewed as a central objective in psychoanalysis.
RUPTURE (RUPTURE IN THE THERAPEUTIC ALLIANCE, RUP-
TURE IN THE THERAPEUTIC RELATIONSHIP, THERAPEUTIC
IMPASSE)   Viewed as an inevitable occurrence in therapy that varies
in intensity, duration, and frequency. The process of working through
alliance ruptures or therapeutic impasses constructively is viewed as an
important mechanism of change.
SECONDARY PROCESS   The style of psychic functioning associated
with consciousness. It is the foundation for rational, reflective thinking.
It is logical, sequential, and orderly.
TRANSFERENCE   The client’s tendency to view the therapist in terms
that are shaped by his or her experiences with important caregivers and
other significant figures in his or her developmental process. In con-
temporary psychoanalytic theory, the transference is always influenced
to varying degrees by the therapist’s real characteristics.
TWO-PERSON PSYCHOLOGY   The perspective common to many
contemporary psychoanalytic models that assumes that both therapist
and client are always contributing to everything that takes place in the
therapeutic relationship. From this perspective, one cannot develop a
meaningful understanding of the client’s intrapsychic processes and
actions without developing an understanding of the way in which they
are being influenced by the therapist.
UNCONSCIOUS   A central psychoanalytic construct that is conceptu-
alized in different ways by different psychoanalytic theories. Common
threads running through all of these theories are the premises that
(a) our experience and actions are influenced by psychological processes
that are not part of our conscious awareness and (b) these unconscious
processes are kept out of awareness in order to avoid psychological pain.

176
 References

Abbass, A. A., Kisely, S. R., Town, J. M., Leichsenring, F., Driessen, E.,
De Maat, S., . . . Crowe, E. (2014). Short-term psychodynamic psychotherapies
for common mental disorders. Cochrane Database of Systematic Reviews,
2014(7), CD004687. http://dx.doi.org/10.1002/14651858.CD004687.pub4
Abraham, K. (1949). Selected papers of Karl Abraham. London, England: Hogarth
Press.
Ainsworth, M., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment:
A psychological study of the Strange Situation. Hillsdale, NJ: Erlbaum.
Akhtar, S. (2006). Technical challenges faced by the immigrant psychoanalyst.
The Psychoanalytic Quarterly, 75, 21–43. http://dx.doi.org/10.1002/j.2167-
4086.2006.tb00031.x
Alexander, F. (1948). Fundamentals of psychoanalysis. New York, NY: Norton.
Altman, N. (2000). Black and white thinking: A psychoanalyst reconsiders
race. Psychoanalytic Dialogues, 10, 589–605. http://dx.doi.org/10.1080/
10481881009348569
Altman, N. (2008). The psychodynamics of torture. Coercive interrogations
and the mental health profession. Psychoanalytic Dialogues, 18, 658–670.
http://dx.doi.org/10.1080/10481880802297681
Altman, N. (2010). The analyst in the inner city: Race, class, and culture through a
psychoanalytic lens. New York, NY: Routledge.
American Psychiatric Association. (1980). Diagnostic and statistical manual of
mental disorders (3rd ed.). Washington, DC: Author.
American Psychoanalytic Association. (2015). Refugee resettlement position
state­ment. Retrieved from http://www.apsa.org/sites/default/files/Final%20
Draft%20-%20Position%20Statement%20on%20Refugee%20Resettlement.pdf

177
 References

American Psychological Association. (2015). Resolution to amend the 2006

and 2013 Council Resolutions to clarify the roles of psychologists related to
inter­rogation and detainee welfare in national security settings, to further
implement the 2008 Petition Resolution, and to safeguard against acts of
torture and cruel, inhuman, or degrading treatment or punishment in all set-
tings. Retrieved from http://www.apa.org/independent-review/psychologists-
interrogation.pdf
American Psychological Association. (2017). Ethical principles of psychologists
and code of conduct (2002, Amended June 1, 2010, and January 1, 2017).
Retrieved from http://www.apa.org/ethics/code/index.aspx
American Psychological Association. (2017). Multicultural guidelines: An ecologi-
cal approach to context, identity, and intersectionality. Retrieved from http://
www.apa.org/about/policy/multicultural-guidelines.pdf
Arlow, J., & Brenner, C. (1964). Psychoanalytic concepts and the structural theory.
Oxford, England: International Universities Press.
Aron, L. (1996). A meeting of minds: Mutuality in psychoanalysis. Hillsdale, NJ:
The Analytic Press.
Aron, L. (1999). Clinical choices and the relational matrix. Psychoanalytic
Dialogues, 9, 1–29. http://dx.doi.org/10.1080/10481889909539301
Aron, L. (2006). Analytic impasse and the third: Clinical implications of inter-
subjectivity theory. The International Journal of Psycho-Analysis, 87, 349–368.
http://dx.doi.org/10.1516/15EL-284Y-7Y26-DHRK
Aron, L., & Starr, K. E. (2012). A psychotherapy for the people. New York, NY:
Routledge.
Bader, M. J. (1994). The tendency to neglect therapeutic aims in psychoanalysis.
The Psychoanalytic Quarterly, 63, 246–270. http://dx.doi.org/10.1080/21674086.
1994.11927414
Barber, J. P., Muran, J. C., McCarthy, K. S., & Keefe, R. J. (2013). Research on
psychodynamic therapies. In M. J. Lambert (Ed.), Bergin and Garfield’s hand-
book of psychotherapy and behavior change (6th ed., pp. 443–494). New York,
NY: Wiley & Sons.
Barber, J. P., Muran, J. C., McCarthy, K. S., & Keefe, R. J. (in press). Research on
psychodynamic therapies. In M. Barham, W. Lutz, & L. Castonguy (Eds.),
Bergin and Garfield’s handbook of psychotherapy and behavior change (7th ed.).
New York, NY: Wiley & Sons.
Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for border­
line personality disorder: Mentalization-based treatment versus treatment as
usual. The American Journal of Psychiatry, 165, 631–638. http://dx.doi.org/
10.1176/appi.ajp.2007.07040636

178
 REFERENCES

Bateman, A., & Fonagy, P. (2016). Mentalization-based treatment for personality

disorders. Oxford, England: Oxford University Press. http://dx.doi.org/10.1093/
med:psych/9780199680375.001.0001
Beebe, B., & Lachmann, F. M. (2002). Infant research and adult treatment.
Hillsdale, NJ: The Analytic Press.
Benjamin, J. (1988). The bonds of love. New York, NY: Pantheon Books.
Benjamin, J. (1990). An outline of intersubjectivity: The development of recogni-
tion. Psychoanalytic Psychology, 7, 33–46. http://dx.doi.org/10.1037/h0085258
Benjamin, J. (1995). Sameness and difference: Toward an “overinclusive” model
of gender development. Psychoanalytic Inquiry, 15, 125–142. http://dx.doi.org/
10.1080/07351699509534021
Benjamin, J. (2004). Beyond doer and done to: An intersubjective view of
thirdness. The Psychoanalytic Quarterly, 73, 5–46. http://dx.doi.org/10.1002/
j.2167-4086.2004.tb00151.x
Benjamin, J. (2018). Beyond doer and done to: Recognition theory, intersubjectivity
and the third. New York, NY: Routledge.
Bergin, A. E., & Strupp, H. S. (1973). Changing frontiers in the science of psycho-
therapy. Chicago, IL: Aldine.
Binder, J. (2004). Key competencies in brief dynamic psychotherapy. New York, NY:
Guilford Press.
Bion, W. R. (1970). Attention and interpretation. London, England: Routledge.
Bollas, C. (1992). Being a character: Psychoanalysis and self experience. New York,
NY: Routledge.
Bordin, E. (1979). The generalizability of the psychoanalytic concept of the
working alliance. Psychotherapy: Theory, Research, & Practice, 16, 252–260.
http://dx.doi.org/10.1037/h0085885
Botticelli, S. (2004). The politics of relational psychoanalysis. Psychoanalytic
Dialogues, 14, 635–651. http://dx.doi.org/10.1080/10481880409353130
Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. New York, NY: Basic
Books.
Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation, anxiety and anger.
New York, NY: Basic Books.
Bowlby, J. (1980). Attachment and loss: Vol. 3. Sadness and depression. New York,
NY: Basic Books.
Bresler, J., & Starr, K. (Eds.). (2015). Relational psychoanalysis and psychotherapy
integration: An evolving synergy. New York, NY: Routledge. http://dx.doi.org/
10.4324/9781315747422
Breuer, J., & Freud, S. (1955). Studies on hysteria. In J. Strachey (Ed. & Trans.),
The standard edition of the complete psychological works of Sigmund Freud

179
 REFERENCES

(Vol. 2, pp. 1–305). London, England: Hogarth Press. (Original work published
1893–1895)
Bromberg, P. M. (1995). Resistance, object-usage, and human relatedness.
Contemporary Psychoanalysis, 31, 173–191. http://dx.doi.org/10.1080/00107530.
1995.10746903
Bromberg, P. M. (1998). Standing in the spaces: Essays on clinical process, trauma,
and dissociation. Hillsdale, NJ: The Analytic Press.
Bromberg, P. M. (2006). Awakening the dreamer: Clinical journeys. Hillsdale, NJ:
The Analytic Press.
Cassidy, J., & Shaver, P. R. (Eds.). (2016). Handbook of attachment: Theory,
research, and clinical applications. New York, NY: Guilford Press.
Chambless, D. L., & Hollon, S. D. (1998). Defining empirically supported
therapies. Journal of Consulting and Clinical Psychology, 66, 7–18. http://
dx.doi.org/10.1037/0022-006X.66.1.7
Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating
three treatments for borderline personality disorder: A multiwave study.
The American Journal of Psychiatry, 164, 922–928. http://dx.doi.org/10.1176/
ajp.2007.164.6.922
Coltart, N. (2000). Slouching towards Bethlehem. New York, NY: Guilford Press.
Connors, M. (2006). Symptom-focused dynamic psychotherapy. Hillsdale, NJ:
The Analytic Press.
Cooper, S. (2000). Objects of hope: Exploring possibility and limit in psychoanalysis.
Hillsdale, NJ: The Analytic Press.
Crenshaw, K. (2020). On intersectionality: Essential writings. New York, NY:
New Press.
Cushman, P. (1995). Constructing the self, constructing America. Reading, MA:
Addison-Wesley.
Cushman, P., & Gilford, P. (2000). Will managed care change our way of
being? American Psychologist, 55, 985–996. http://dx.doi.org/10.1037/0003-
066X.55.9.985
Danto, E. (2005). Freud’s free clinics. New York, NY: Columbia University Press.
http://dx.doi.org/10.7312/dant13180
Davanloo, H. (Ed.). (1980). Short-term dynamic psychotherapy. New York, NY:
Aronson.
Davies, J. M. (1996). Linking the “pre-analytic” with the post-classical: Integration,
dissociation, and the multiplicity of unconscious process. Contemporary Psycho-
analysis, 32, 553–576. http://dx.doi.org/10.1080/00107530.1996.10746336
Davies, J. M. (2004). Whose bad object are we anyway? Repetition and our elusive
love affair with evil. Psychoanalytic Dialogues, 14, 711–732. http://dx.doi.org/
10.1080/10481881409348802

180
 REFERENCES

Dimen, M. (2003). Sexuality, intimacy, power. Hillsdale, NJ: The Analytic Press.
Dimen, M. (2010). Reflections on cure, or “I/Thou/It.” Psychoanalytic Dialogues,
20, 254–268. http://dx.doi.org/10.1080/10481885.2010.481612
Drescher, J. (2008). A history of homosexuality and organized psychoanalysis.
Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry,
36, 443–460. http://dx.doi.org/10.1521/jaap.2008.36.3.443
Dreyfus, H. E., & Dreyfus, S. L. (1986). Mind over machine. New York, NY: Free
Press.
Driessen, E., Hegelmaier, L. M., Abbass, A. A., Barber, J. P., Dekker, J. J. M.,
Van, H. L., . . . Cuijpers, P. (2015). The efficacy of short-term psychodynamic
psychotherapy for depression: A meta-analysis update. Clinical Psychology
Review, 42, 1–15. http://dx.doi.org/10.1016/j.cpr.2015.07.004
Eagle, M. (1984). Recent developments in psychoanalysis. New York, NY:
McGraw-Hill.
Ehrenberg, D. (1992). The intimate edge. New York, NY: Norton.
Ehrenreich, B. (2009). Bright-sided: How the relentless promotion of positive
thinking has undermined America. New York, NY: Macmillan.
Ekman, P. (1993). Facial expression and emotion. American Psychologist, 48,
384–392. http://dx.doi.org/10.1037/0003-066X.48.4.384
Ekman, P., & Davidson, R. J. (Eds.). (1994). The nature of emotions: Fundamental
questions. New York, NY: Oxford University Press.
Etchegoyen, H. (1991). The fundamentals of psychoanalytic technique. London,
England: Karnac Books.
Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair:
A meta-analysis. Psychotherapy: Theory, Research, & Practice, 55, 508–519.
http://dx.doi.org/10.1037/pst0000185
Fairbairn, W. R. D. (1952). Psychoanalytic studies of the personality. London,
England: Routledge and Kegan Paul.
Fairbairn, W. R. D. (1994). Psychoanalytic studies of the personality. New York,
NY: Routledge/Taylor & Francis.
Fairfield, S., Layton, L., & Stack, C. (Eds.). (2002). Bringing the plague: Toward a
postmodern psychoanalysis. New York, NY: Other Press.
Fenichel, O. (1945). Problems of psychoanalytic technique. New York, NY: Psycho-
analytic Quarterly.
Ferenczi, S. (1980a). Final contributions to the problems and methods of psycho-
analysis (M. Balint, Ed. and E. Mosbacher, Trans.). London, England: Karnac
Books.
Ferenczi, S. (1980b). Further contributions to the problems and methods of psycho-
analysis (J. Richman, Ed. and J. Suttie, Trans.). London, England: Karnac Books.

181
 References

Ferenczi, S., & Rank, O. (1956). The development of psychoanalysis. New York, NY:
Dover. (Original work published 1925)
Ferro, A. (2002). In the analyst’s consulting room. New York, NY: Routledge.
Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentaliza-
tion, and the development of self. New York, NY: Other Press.
Fonagy, P., Kachle, H., Krause, R., Jones, E., Perron, R., & Lopez, L. (1999).
An open door review of outcome studies in psychoanalysis. London, England:
University College.
Fonagy, P., Steele, H., & Steele, M. (1991). Maternal representations of attachment
during pregnancy predict the organization of infant–mother attachment at one
year of age. Child Development, 62, 891–905. http://dx.doi.org/10.2307/1131141
Fosha, D. (2000). The transforming power of affect: A model for accelerated change.
New York, NY: Basic Books.
Frank, K. A. (1999). Psychoanalytic participation, action, interaction, and integra-
tion. Hillsdale, NJ: The Analytic Press.
Freud, A. (1936). The ego and the mechanisms of defense. Honolulu, HI: Hogarth
Press.
Freud, S. (1912). The dynamics of transference. In The standard edition of the
complete psychological works of Sigmund Freud (Vol. 12). London, England:
Hogarth Press.
Freud, S. (1920). A general introduction to psychoanalysis (G. S. Hall, Trans., p. 247).
New York, NY: Boni and Liveright.
Freud, S. (1953). The interpretation of dreams. In The standard edition of the
complete psychological works of Sigmund Freud (Vols. 4–5; J. Strachey, Trans.
& Ed.). London, England: Hogarth Press. (Original work published 1900)
Freud, S. (1955). Studies on hysteria. In The standard edition of the complete
psychological works of Sigmund Freud (Vol. 2; J. Breuer & S. Freud, Eds.).
London, England: Hogarth Press. (Original work published 1895)
Freud, S. (1958). Recommendations to physicians practising psychoanalysis.
In The standard edition of the complete psychological works of Sigmund Freud
(Vol. 12, p. 115). London, England: Hogarth Press and the Institute of Psycho-
analysis. (Original work published 1912)
Freud, S. (1961). The ego and the id. In The standard edition of the complete psycho-
logical works of Sigmund Freud (Vol. 19, pp. 3–66; J. Strachey, Trans. & Ed.).
London, England: Hogarth Press. (Original work published 1923)
Freud, S. (1965). New introductory lectures on psychoanalysis. In The standard
edition of the complete psychological works of Sigmund Freud (Vol. 22, p. 100;
J. Strachey, Trans. & Ed.). London, England: Norton. (Original work pub-
lished 1933)

182
 REFERENCES

Frew, J., & Spiegler, M. (2012). Contemporary psychotherapies for a diverse world
(1st rev. ed.). New York, NY: Routledge.
Frijda, N. H. (1986). The emotions. New York, NY: Cambridge University Press.
Fromm, E. (1941). A man for himself. New York, NY: Rinehart.
Gabbard, G. O. (2010). Long-term psychodynamic psychotherapy. Arlington, VA:
American Psychiatric Publishing.
Galatzer-Levy, R., Bachrach, H., Skolnikoff, A., & Waldron, S. (2000). Does psycho-
analysis work? New Haven, CT: Yale University Press.
Gay, P. (1988). Freud: A life for our time. New York, NY: Norton.
Gentile, K. (2013). Bearing the cultural in order to engage in a process of
witnessing. Psychoanalytic Psychology, 30, 456–470. http://dx.doi.org/10.1037/
a0032056
Ghent, E. (1990). Masochism, submission, surrender: Masochism as a perversion
of surrender. Contemporary Psychoanalysis, 26, 108–136. http://dx.doi.org/
10.1080/00107530.1990.10746643
Gold, J., & Stricker, G. (2015). Assimilative psychodynamic psychotherapy:
An active, integrative psychoanalytic approach. In J. Bressler & K. Starr (Eds.),
Relational psychoanalysis and psychotherapy integration: An evolving synergy
(pp. 39–56). New York, NY: Routledge.
Goldfried, M. R., Raue, P. J., & Castonguay, L. G. (1998). The therapeutic focus in
significant sessions of master therapists: A comparison of cognitive-behavioral
and psychodynamic-interpersonal interventions. Journal of Consulting and
Clinical Psychology, 66, 803–810. http://dx.doi.org/10.1037/0022-006X.66.5.803
Goldfried, M. R., & Wolfe, B. E. (1996). Psychotherapy practice and research.
Repairing a strained alliance. American Psychologist, 51, 1007–1016. http://
dx.doi.org/10.1037/0003-066X.51.10.1007
Greenberg, J. (1986). Theoretical models and the analyst’s neutrality. Contem-
porary Psychoanalysis, 22, 87–106. http://dx.doi.org/10.1080/00107530.1986.
10746117
Greenberg, J., & Mitchell, S. A. (1983). Object relations in psychoanalytic
theory. Cambridge, MA: Harvard University Press. http://dx.doi.org/10.2307/
j.ctvjk2xv6
Greenberg, J., & Safran, J. (1987). Emotions in psychotherapy: Affect, cognition,
and process of change. New York, NY: Guilford Press.
Greenson, R. R. (1965). The working alliance and the transference neurosis.
The Psychoanalytic Quarterly, 34, 155–181. http://dx.doi.org/10.1080/21674086.
1965.11926343
Grunbaum, F. (1984). The foundations of psychoanalysis: A philosophical critique.
Berkeley: University of California Press.

183
 REFERENCES

Guignon, C. (2004). On being authentic. London, England: Routledge. http://

dx.doi.org/10.4324/9780203646793
Gutwill, S., & Hollander, N. C. (2006). Class and splitting in the clinical setting:
The ideological dance in the transference and countertransference. In L. Layton,
N. C. Hollander, & S. Gutwill (Eds.), Psychoanalysis, class, and politics: Encounters
in the clinical setting (pp. 92–106). New York, NY: Routledge.
Hale, N. (1971). Freud and the Americans: The beginnings of psychoanalysis in
the United States, 1876–1917 (Vol. 1). Oxford, England: Oxford University
Press.
Hale, N. (1995). The rise and crisis of psychoanalysis in the United States: Freud and
the Americans 1917–1985 (Vol. 2). Oxford, England: Oxford University Press.
Haley, J. (1997). Leaving home: The therapy of disturbed young people. New York,
NY: Routledge.
Harris, A. (2008). Gender as soft assembly. Hillsdale, NJ: The Analytic Press.
Harris, A., & Botticelli, S. (2010). First do no harm: The paradoxical encounters of
psychoanalysis, warmaking, and resistance. New York, NY: Routledge.
Hartmann, H. (1964). Ego psychology and the problem of adaptation. New York,
NY: International Universities Press.
Hirschfeld Davis, J., & Nixon, R. (2018, May 29). Trump officials, moving to
break up migrant families, blame Democrats. The New York Times. Retrieved
from https://www.nytimes.com/2018/05/29/us/politics/trump-democrats-
immigrant-families.html
Hoffman, I. Z. (1998). Ritual and spontaneity in the psychoanalytic process:
A dialectical-constructivist view. Hillsdale, NJ: The Analytic Press.
Hoffman, I. Z. (2009). Doublethinking our way to “scientific” legitimacy:
The desiccation of human experience. Journal of the American Psychoanalytic
Association, 57, 1043–1069. http://dx.doi.org/10.1177/0003065109343925
Hollander, N. C. (1997). Love in a time of hate. New Brunswick, NJ: Rutgers
University Press.
Hollander, N. C. (2006). Psychoanalysis and the problem of the bystander in times
of terror. In L. Layton, N. C. Hollander, & S. Gutwill (Eds.), Psychoanalysis,
class, and politics: Encounters in the clinical setting (pp. 154–165). New York,
NY: Routledge.
Hollander, N. C. (2010). Uprooted minds: Surviving the politics of terror in the
Americas. New York, NY: Routledge.
Holmes, J. (2010). Exploring in security: Towards an attachment-informed psycho-
analytic psychotherapy. New York, NY: Routledge.
Horowitz, A. V. (2003). The making of mental illness. Chicago, IL: Chicago
University Press.

184
 REFERENCES

Howard, K. I., Kopta, S. M., Krause, M. S., & Orlinsky, D. E. (1986). The dose-
effect relationship in psychotherapy. American Psychologist, 41, 159–164.
http://dx.doi.org/10.1037/0003-066X.41.2.159
Huber, D., Henrich, G., Gastner, J., & Klug, G. (2012). Must all have prizes? The
Munich Psychotherapy Study. In R. Levy, J. S. Ablon, & H. Kaechele (Eds.),
Evidence-based psychodynamic psychotherapy II (pp. 51–69). Totowa, NJ:
Humana Press. http://dx.doi.org/10.1007/978-1-60761-792-1_4
Jacobs, T. (1991). The use of the self: Countertransference and communication in
the analytic setting. Madison, CT: International Universities Press.
Jacoby, R. (1983). The repression of psychoanalysis: Otto Fenichel and the political
Freudians. Hillsdale, NJ: The Analytic Press.
Joseph, B. (1989). Psychic equilibrium and psychic change. London, England:
Tavistock and Routledge.
Keefe, J. R., McCarthy, K. S., Dinger, U., Zilcha-Mano, S., & Barber, J. P.
(2014). A meta-analytic review of psychodynamic therapies for anxiety dis-
orders. Clinical Psychology Review, 34, 309–323. http://dx.doi.org/10.1016/
j.cpr.2014.03.004
Kivlighan, D. M., III, Goldberg, S. B., Abbas, M., Pace, B. T., Yulish, N. E.,
Thomas, J. G., . . . Wampold, B. E. (2015). The enduring effects of psycho-
dynamic treatments vis-à-vis alternative treatments: A multilevel longitudinal
meta-analysis. Clinical Psychology Review, 40, 1–14. http://dx.doi.org/10.1016/
j.cpr.2015.05.003
Klein, M. (2002a). The writings of Melanie Klein: Vol. 1. Love, guilt, and repara-
tion and other works, 1921–1945. New York, NY: Free Press. (Original work
published 1955)
Klein, M. (2002b). The writings of Melanie Klein: Vol. 3. Envy and gratitude and
other works, 1946–1963. New York, NY: Free Press. (Original work published 1975)
Knight, R. P. (1953). The present status of organized psychoanalysis in the
United States. Journal of the American Psychoanalytic Association, 1, 197–221.
http://dx.doi.org/10.1177/000306515300100201
Kohut, H. (1984). How does analysis cure? Chicago, IL. University of Chicago Press.
Koritar, E. (2017). Shining a psychoanalytic light on alienation, otherness, and
xenophobia. American Journal of Psychoanalysis, 77, 341–346. http://dx.doi.org/
10.1057/s11231-017-9114-5
Lacan, J. (1988a). The seminar of Jacques Lacan: Book 1. Freud’s papers on
technique, 1953–1954 (J. Miller & J. Forrester, Trans. & Ed.). New York, NY:
Norton. (Original work published 1975)
Lacan, J. (1988b). The seminar of Jacques Lacan: Book 2. The ego in Freud’s theory
and in the technique of psychoanalysis 1954–1955 (J. Miller & S. Tomaselli,
Trans. & Ed.). New York, NY: Norton. (Original work published 1978)

185
 References

Leary, K. (2000). Racial enactments in dynamic treatment. Psychoanalytic

Dialogues, 10, 639–653. http://dx.doi.org/10.1080/10481881009348573
Leichsenring, F., Biskup, J., Kreische, R., & Staats, H. (2005). The Göttingen study
of psychoanalytic therapy: First results. The International Journal of Psycho-
Analysis, 86, 433–455. http://dx.doi.org/10.1516/XX6F-AU0W-KWM3-G6LU
Leichsenring, F., Klein, S., & Salzer, S. (2014). The efficacy of psychodynamic
psychotherapy in specific mental disorders: A 2013 update of empirical evi-
dence. Contemporary Psychoanalysis, 50(1–2), 89–130. http://dx.doi.org/10.1080/
00107530.2014.880310
Leichsenring, F., Leweke, F., Klein, S., & Steinert, C. (2015). The empirical status
of psychodynamic psychotherapy—an update: Bambi’s alive and kicking.
Psychotherapy and Psychosomatics, 84(3), 129–148. http://dx.doi.org/10.1159/
000376584
Leichsenring, F., Luyten, P., Hilsenroth, M. J., Abbass, A., Barber, J. P., Keefe,
J. R., . . . Steinert, C. (2015). Psychodynamic therapy meets evidence-based
medicine: A systematic review using updated criteria. The Lancet Psychiatry,
2, 648–660. http://dx.doi.org/10.1016/S2215-0366(15)00155-8
Leiper, R., & Maltby, M. (2004). The psychodynamic approach to therapeutic
change. London, England: Sage.
Lemma, A. (2003). Introduction to the practice of psychoanalytic psychotherapy.
Chichester, England: Wiley & Sons. http://dx.doi.org/10.1002/9780470713426
Levenson, H. (2017). Brief dynamic therapy (2nd ed.). Washington, DC: American
Psychological Association. http://dx.doi.org/10.1037/0000043-000
Levy, R., Ablon, J. S., & Kaechele, H. (Eds.). (2012). Evidence-based psychodynamic
psychotherapy (2nd ed.). New York, NY: Humana Press. http://dx.doi.org/
10.1007/978-1-60761-792-1
Lewis, N. A. (2004, November 30). Red Cross finds detainee abuse in Guantánamo.
Retrieved from https://www.nytimes.com/2004/11/30/politics/red-cross-finds-
detainee-abuse-in-guantanamo.html
Lichtenberg, J. (1989). Psychoanalysis and motivation. Hillsdale, NJ: The Analytic
Press.
Loewald, H. W. (1960). On the therapeutic action of psycho-analysis. The Inter-
national Journal of Psycho-Analysis, 41, 16–33.
Luborsky, L. (1984). Principles of psychoanalytic psychotherapy: A manual for
supportive-expressive treatment. New York, NY: Basic Books.
Luborsky, L., Diguer, L., Seligman, D. A., Rosenthal, R., Krause, E. D.,
Johnson, S., . . . Schweizer, E. (1999). The researcher’s own therapy allegiances:
A “wild card” in comparisons of treatment efficacy. Clinical Psychology: Science
and Practice, 6, 95–106. http://dx.doi.org/10.1093/clipsy/6.1.95
Lyons-Ruth, K., Bruschweiler-Stern, N., Harrison, A. M., Morgan, A. C., Nahum,
J. P., Sander, L., . . . Tronick, E. Z. (1998). Implicit relational knowing: Its role

186
 References

in development and psychoanalytic treatment. Infant Mental Health Journal,

19, 282–289. http://dx.doi.org/10.1002/(SICI)1097-0355(199823)19:3<282:
AID-IMHJ3>3.0.CO;2-O
Main, M., Kaplan, N., & Cassidy, J. (1985). Security in infancy, childhood,
and adulthood: A move to the level of representation. Monographs of the
Society for Research in Child Development, 50, 66–104. http://dx.doi.org/
10.2307/3333827
Makari, G. (2008). Revolution in mind: The creation of psychoanalysis. New York,
NY: Harper Collins.
Makari, G. (2015). Soul machine: The invention of the modern mind. New York,
NY: Norton.
Malan, D. H. (1963). A study of brief psychotherapy. New York, NY: Plenum Press.
Maroda, K. (2009). Psychodynamic techniques: Working with emotion in the
therapeutic relationship. New York, NY: Guilford Press.
McCullough Valliant, L. M. (1997). Changing character: Short-term anxiety
regulating psychotherapy for restructuring defenses, affects, and attachment.
New York, NY: Basic Books.
McMain, S. F., Links, P. S., Gnam, W. H., Guimond, T., Cardish, R. J., Korman, L.,
& Streiner, D. L. (2009). A randomized trial of dialectical behavior therapy
versus general psychiatric management for borderline personality disorder.
The American Journal of Psychiatry, 166, 1365–1374. http://dx.doi.org/10.1176/
appi.ajp. 2009.09010039
McWilliams, N. (1994). Psychoanalytic diagnosis: Understanding personality
structure in the clinical process. New York, NY: Guilford Press.
McWilliams, N. (2004). Psychoanalytic psychotherapy: A practitioner’s guide.
New York, NY: Guilford Press.
Messer, S. B. (2015). How I have changed over time as a psychotherapist. Journal
of Clinical Psychology, 71, 1104–1114. http://dx.doi.org/10.1002/jclp.22220
Messer, S. B., & Warren, C. S. (1995). Models of brief psychotherapy. New York,
NY: Guilford Press.
Mitchell, S. A. (1988). Relational concepts in psychoanalysis. Cambridge, MA:
Harvard University Press.
Mitchell, S. A. (1993). Hope and dread in psychoanalysis. New York, NY: Basic Books.
Mitchell, S. A. (1997). Influence and autonomy in psychoanalysis. Hillsdale, NJ:
The Analytic Press.
Moncayo, R. (2008). Evolving Lacanian perspectives for clinical psychoanalysis.
London, England: Karnac Books.
Moskowitz, M. (1996). The social consequence of psychoanalysis. In R. M. Perez
Foster & R. A. Javier (Eds.), Reaching across boundaries of culture and class:
Widening the scope of psychotherapy (pp. 21–46). Northvale, NJ: Aronson.

187
 REFERENCES

Muran, J. C., Safran, J. D., Gorman, B. S., Samstag, L. W., Eubanks-Carter, C.,
& Winston, A. (2009). The relationship of early alliance ruptures and their
resolution to process and outcome in three time-limited psychotherapies for
personality disorders. Psychotherapy: Theory, Research, & Practice, 46, 233–248.
http://dx.doi.org/10.1037/a0016085
Norcross, J. C., & Goldfried, M. R. (2019). Handbook of psychotherapy integration
(3rd ed.). Oxford, England: Oxford University Press.
Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III.
Psychotherapy: Theory, Research, & Practice, 55, 303–315. http://dx.doi.org/
10.1037/pst0000193
Ogden, T. (1994). Subject of analysis. Northvale, NJ: Aronson.
Padrón, C. (2019). The political potentiality of the psychoanalytic process.
In P. Gherovici & C. Christian (Eds.), Psychoanalysis in the barrios: Race, class
and the unconscious (pp. 189–202). New York, NY: Routledge.
Parkinson, B. (1995). Ideas and realities of emotion. London, England: Routledge.
Parsons, M. (2000). The dove that returns, the dove that vanishes: Paradox and
creativity in psychoanalysis. London, England: Routledge.
Perez Foster, R. M., Moskowitz, M., & Javier, R. A. (Eds.). (1996). Reaching across
boundaries of culture and class: Widening the scope of psychotherapy. Northvale,
NJ: Aronson.
Persons, J. B., & Silberschatz, G. (1998). Are results of randomized controlled
trials useful to psychotherapists? Journal of Consulting and Clinical Psychology,
66, 126–135. http://dx.doi.org/10.1037/0022-006X.66.1.126
Pizer, S. A. (1998). Building bridges: The negotiation paradox in psychoanalysis.
Hillsdale, NJ: The Analytic Press.
Plotkin, M. B. (2001). Freud in the Pampas: The emergence and development
of psychoanalytic culture in Argentina. Stanford, CA: Stanford University
Press.
Pogue White, K. (2002). Surviving hate and being hated: Some thoughts about
racism from a psychoanalytic perspective. Contemporary Psychoanalysis, 38,
401–422. http://dx.doi.org/10.1080/00107530.2002.10747173
Rank, O. (1929). The trauma of birth. New York, NY: Harcourt, Brace.
Rayner, E. (1991). The independent mind in British psychoanalysis. Northvale, NJ:
Aronson.
Reich, W. (1941). Character analysis. New York, NY: Orgone Institute Press.
Reiff, P. (1966). The triumph of the therapeutic: Uses of faith after Freud. Chicago,
IL: University of Chicago Press.
Reik, T. (1948). Listening with the third ear: The inner experience of a psycho-
analyst. New York, NY: Farrar, Straus, & Giroux.

188
 REFERENCES

Renik, O. (1993). Analytic interaction: Conceptualizing technique in light of the

analyst’s irreducible subjectivity. The Psychoanalytic Quarterly, 62, 553–571.
http://dx.doi.org/10.1080/21674086.1993.11927393
Renik, O. (2006). Practical psychoanalysis for therapists and patients. New York,
NY: Other Press.
Rice, L. N., & Greenberg, L. S. (1984). Patterns of change: Intensive analysis of
psychotherapy process. New York, NY: Guilford Press.
Richardson, P., Kachele, H., & Renlund, C. (2004). Research on psychoanalytic
psychotherapy with adults. New York, NY: Karnac Books.
Ringstrom, P. A. (2007). Scenes that write themselves: Improvisational moments
in relational psychoanalysis. Psychoanalytic Dialogues, 17, 69–99. http://
dx.doi.org/10.1080/10481880701301303
Safran, J. D. (1984). Assessing the cognitive-interpersonal cycle. Cognitive
Therapy and Research, 8, 333–347. http://dx.doi.org/10.1007/BF01173309
Safran, J. D. (1993). Breaches in the therapeutic alliance: An arena for negotiating
authentic relatedness. Psychotherapy: Theory, Research, & Practice, 30, 11–24.
http://dx.doi.org/10.1037/0033-3204.30.1.11
Safran, J. D. (1998). Widening the scope of cognitive therapy: The therapeutic
relationship, emotion, and the process of change. Northvale, NJ: Aronson.
Safran, J. D. (1999). Faith, despair, will, and the paradox of acceptance.
Contemporary Psychoanalysis, 35, 5–23. http://dx.doi.org/10.1080/00107530.
1999.10746378
Safran, J. D. (2001). When worlds collide: Psychoanalysis and the empirically
supported treatment movement. Psychoanalytic Dialogues, 11, 659–681.
http://dx.doi.org/10.1080/10481881109348635
Safran, J. D. (2002). Brief relational psychoanalytic treatment. Psychoanalytic
Dialogues, 12, 171–195. http://dx.doi.org/10.1080/10481881209348661
Safran, J. D. (2003). The relational turn, the therapeutic alliance and psycho-
therapy research: Strange bedfellows or postmodern marriage? Contemporary
Psychoanalysis, 39, 449–475. http://dx.doi.org/10.1080/00107530.2003.10747215
Safran, J. D. (2016). Agency, surrender, and grace in psychoanalysis. Psychoanalytic
Psychology, 33, 58–72. http://dx.doi.org/10.1037/a0038020
Safran, J. D. (2017). The unbearable lightness of being: Authenticity and the
search for the real. Psychoanalytic Psychology, 34, 69–77. http://dx.doi.org/
10.1037/pap0000093
Safran, J. D., Crocker, P., McMain, S., & Murray, P. (1990). Therapeutic alliance
rupture as a therapy event for empirical investigation. Psychotherapy: Theory,
Research, & Practice, 27, 154–165. http://dx.doi.org/10.1037/0033-3204.27.2.154
Safran, J. D., & Greenberg, L. S. (1991). Emotion, psychotherapy, and change.
New York, NY: Guilford Press.

189
 REFERENCES

Safran, J. D., Greenberg, L. S., & Rice, L. N. (1988). Integrating psychotherapy

research and practice: Modeling the change process. Psychotherapy: Theory,
Research, & Practice, 25, 1–17. http://dx.doi.org/10.1037/h0085305
Safran, J. D., & Kraus, J. (2015). Relational techniques in a cognitive-behavioral
therapy context: “It’s bigger than the both of us.” In N. C. Thoma & D. McKay
(Eds.), Working with emotion in cognitive-behavioral therapy: Techniques for
clinical practice (pp. 333–355). New York, NY: Guilford Press.
Safran, J. D., & Muran, J. C. (1994). Toward a working alliance between research
and practice. In P. F. Talley, H. H. Strupp, & J. F. Butler (Eds.), Psychotherapy
research and practice (pp. 206–226). New York, NY: Basic Books.
Safran, J. D., & Muran, J. C. (1996). The resolution of ruptures in the thera-
peutic alliance. Journal of Consulting and Clinical Psychology, 64, 447–458.
http://dx.doi.org/10.1037/0022-006X.64.3.447
Safran, J. D., & Muran, J. C. (Eds.). (1998). The therapeutic alliance in brief
psychotherapy. Washington, DC: American Psychological Association. http://
dx.doi.org/10.1037/10306-000
Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational
treatment guide. New York, NY: Guilford Press.
Safran, J. D., & Muran, J. C. (2006). Has the concept of the therapeutic alliance
outlived its usefulness? Psychotherapy: Theory, Research, & Practice, 43, 286–291.
http://dx.doi.org/10.1037/0033-3204.43.3.286
Safran, J. D., Muran, J. C., Samstag, L. W., & Stevens, C. (2001). Repairing
alliance ruptures. Psychotherapy: Theory, Research, & Practice, 38, 406–412.
http://dx.doi.org/10.1037/0033-3204.38.4.406
Safran, J. D., Muran, J. C., Samstag, L. W., & Stevens, C. (2002). Repairing
alliance ruptures. In J. C. Norcross (Ed.), Psychotherapy relationships that
work (pp. 235–254). New York, NY: Oxford University Press.
Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy.
New York, NY: Basic Books.
Saketopoulou, A. (2011). Minding the gap: Intersections between gender, race,
and class in work with gender variant children. Psychoanalytic Dialogues, 21,
192–209. http://dx.doi.org/10.1080/10481885.2011.562845
Saks, E. (2008). The center cannot hold: My journey through madness. New York,
NY: Hyperion Press.
Sandell, R., Blomberg, J., Lazar, A., Carlsson, J., Broberg, J., & Schubert, J. (2000).
Varieties of long-term outcome among patients in psychoanalysis and long-term
psychotherapy. A review of findings in the Stockholm Outcome of Psycho-
analysis and Psychotherapy Project (STOPP). The International Journal of
Psycho-Analysis, 81, 921–942. http://dx.doi.org/10.1516/0020757001600291

190
 REFERENCES

Santa-Maria, M. L., & Cornille, T. (2007). Traumatic stress, family separations,

and attachment among Latin American immigrants. Traumatology, 13(2),
26–31. http://dx.doi.org/10.1177/1534765607302278
Sayers, J. (2001). Kleinians: Psychoanalysis inside out. Oxford, England: Blackwell.
Schafer, R. (1968). Aspects of internalization. Madison, CT: International Univer-
sities Press.
Schön, D. (1983). The reflective practitioner. New York, NY: Basic Books.
Seligman, M. E. P. (1995). The effectiveness of psychotherapy. The Consumer
Reports study. American Psychologist, 50, 965–974. http://dx.doi.org/10.1037/
0003-066X.50.12.965
Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American
Psychologist, 65, 98–109. http://dx.doi.org/10.1037/a0018378
Sifneos, P. E. (1972). Short-term psychotherapy and emotional crisis. Cambridge,
MA: Harvard University Press.
Slavin, M. O., & Kriegman, D. (1998). Why the analyst needs to change:
Toward a theory of conflict, negotiation, and mutual influence in the
therapeutic process. Psychoanalytic Dialogues, 8, 247–284. http://dx.doi.org/
10.1080/10481889809539246
Soldz, S. (2008). Healers or interrogators: Psychology and the United States
torture regime. Psychoanalytic Dialogues, 18, 592–613. http://dx.doi.org/
10.1080/10481880802297624
Steele, M., & Steele, H. (2008). Clinical applications of the Adult Attachment
Interview. New York, NY: Guilford Press.
Steele, M., & Steele, H. (2018). Handbook of attachment-based interventions.
New York, NY: Guilford Press.
Sterba, R. (1934). The fate of the ego in analytic therapy. The International
Journal of Psycho-Analysis, 15, 117–126.
Stern, D. B. (1997). Unformulated experience. Hillsdale, NJ: The Analytic Press.
Stern, D. B. (2010). Partners in thought: Working with unformulated experience,
dissociation, and enactment. New York, NY: Routledge. http://dx.doi.org/
10.4324/9780203880388
Stern, D. N. (1985). The interpersonal world of the infant: A view from psycho-
analysis and developmental psychology. New York, NY: Basic Books.
Stern, D. N., Sander, L. W., Nahum, J. P., Harrison, A. M., Lyons-Ruth, K., Morgan,
A. C., . . . the Process of Change Study Group. (1998). Non-interpretive
mechanisms in psychoanalytic therapy. The ‘something more’ than inter-
pretation. The International Journal of Psycho-Analysis, 79, 903–921.
Sternberg, R., & Jordan, J. (Eds.). (2005). A handbook of wisdom: Psychological
perspectives. New York, NY: Cambridge University Press. http://dx.doi.org/
10.1017/CBO9780511610486

191
 REFERENCES

Stiles, W., & Shapiro, D. (1989). Abuse of the drug metaphor in psychotherapy
process-outcome research. Clinical Psychology Review, 9, 521–543. http://
dx.doi.org/10.1016/0272-7358(89)90007-X
Strachey, J. (1934). The nature of the therapeutic action of psychoanalysis.
The International Journal of Psycho-Analysis, 15, 127–159.
Strupp, H. H., & Binder, J. L. (1984). Psychotherapy in a new key: A guide to time
limited dynamic psychotherapy. New York, NY: Basic Books.
Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York, NY:
Norton.
Summer, R. F., & Barber, J. P. (2009). Psychodynamic therapy: A guide to evidence
based practice. New York, NY: Guilford Press.
Talley, F., Strupp, H., & Butler, S. (1994). Psychotherapy research and practice:
Bridging the gap. New York, NY: Basic Books.
Taylor, C. (1992). The ethics of authenticity. Cambridge, MA: Harvard University
Press.
Thompson, C. (1957). Psychoanalysis: Evolution and development. New York, NY:
Atlantic Monthly Press.
Thompson, M. G. (2004). The ethic of honesty: The fundamental rule of psycho-
analysis. New York, NY: Rodopi.
Tronick, E. (2007). The neurobehavioral and social-emotional development of
infants and children. New York, NY: Norton.
Tummala-Narra, P. (2016). Psychoanalytic theory and cultural competence in
psychotherapy [Kindle edition]. Washington, DC: American Psychological
Association. http://dx.doi.org/10.1037/14800-000
VandenBos, G. (2015). APA dictionary of psychology (2nd ed.). Washington, DC:
American Psychological Association.
Varvin, S. (2017). Our relations to refugees: Between compassion and dehuman-
ization. American Journal of Psychoanalysis, 77, 359–377. http://dx.doi.org/
10.1057/s11231-017-9119-0
Volkan, V. (2017). Immigrants and refugees: Trauma, perennial mourning,
prejudice and border psychology. London, England: Karnac.
Wachtel, P. L. (1977). Psychoanalysis and behavior therapy: Toward an integration.
New York, NY: Basic Books.
Wachtel, P. L. (1997). Psychoanalysis, behavior therapy, and the relational world.
Washington, DC: American Psychological Association. http://dx.doi.org/
10.1037/10383-000
Wachtel, P. L. (2007). Relational theory and the practice of psychotherapy. New York,
NY: Guilford Press.
Wachtel, P. L. (2011). Therapeutic communication: Knowing what to say when.
New York, NY: Guilford Press.

192
 REFERENCES

Wachtel, P. L. (2014). Cyclical psychodynamics: The inner world, the intimate

world, and the world of culture and society. New York, NY: Routledge. http://
dx.doi.org/10.4324/9781315794037
Wampold, B. (2001). The great psychotherapy debate: Models, methods, findings.
Northvale, NJ: Erlbaum.
Westen, D. (1998). Unconscious thought, feeling, and motivation: The end of a
century long debate. In R. Bornstein & J. Masling (Eds.), Empirical perspectives
on the psychoanalytic unconscious. Empirical studies of psychoanalytic theories
(pp. 1–43). Washington, DC: American Psychological Association. http://
dx.doi.org/10.1037/10256-001
Westen, D., & Gabbard, G. (1999). Psychoanalytic approaches to personality.
In L. Pervin & O. John (Eds.), Handbook of personality: Theory and research
(pp. 57–101). New York, NY: Guilford Press.
Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The empirical
status of empirically supported psychotherapies: Assumptions, findings, and
reporting in controlled clinical trials. Psychological Bulletin, 130, 631–663.
http://dx.doi.org/10.1037/0033-2909.130.4.631
Winnicott, D. W. (1958). Through paediatrics to psycho-analysis: Collected papers.
New York, NY: Basic Books.
Winnicott, D. W. (1965). The maturational process and the facilitating environ-
ment. New York, NY: International Universities Press.
Yi, K. (2014). Toward formulation of ethnic identity beyond the binary of white
oppressor and racial other. Psychoanalytic Psychology, 31, 426–434. http://
dx.doi.org/10.1037/a0036649
Young-Bruehl, E. (2006). Coming of age in New York City: Two homeless
boys. The Psychoanalytic Quarterly, 75, 323–343. http://dx.doi.org/10.1002/
j.2167-4086.2006.tb00042.x

193
 Index

Abandonment, 50, 89 Ainsworth, Mary, 63

Abbass, A. A., 145 Alexander, Franz, 96–97
Abraham, Karl, 9, 27 Allen, Woody, 39–40
Abstinence, 57–58 Alliance. See Therapeutic alliance
Acting out, 49 Allusions to the transference, 82
Activity (evidence-based treatment), Altman, Neil, 157–158, 162
39 Ambiguity
Adler, Alfred, 5 fundamental, 40
Adult Attachment Interview, 63, intolerance of, 7
146 and termination, 90–91
Advice tolerance of, 67, 90–91
discouragement of, 22 Ambivalence, 51, 88, 89
level of, 15 American Psychoanalytic Association,
in therapy process, 74 10, 31, 163
Affect attunement, 70 American psychoanalytic tradition
Affect communication, 98–99 and assimilation of psychoanalysis,
Affect regulation 20–21
and fantasy, 46 changing character of, 11–13
interactive, 100–103 cultural factors in, 6, 7, 15
and intersectionality, 161 development of, 12, 171
origins of concept of, 33 ego psychology in, 30–31
Affiliation, 62 and Lacanian tradition, 35
Agency, 92, 95–96 and Middle Group, 29
Aggression pluralism in, 30–34
defenses against, 48 relational theory in, 68
and fantasy, 46 American Psychological Association
in Kleinian theory, 29 (APA), 11–12, 162–163
and the unconscious, 45 American Psychologist (journal), 144

195
 INDEX

Anger. See also Aggression Biskup, J., 147

defenses against, 48 Bleuler, Eugene, 19–20
and termination, 87–88 Body-focused therapeutic techniques,
Anonymity, 23, 58, 59–60 155
Anxiety Bollas, Christopher, 68
defenses against, 48, 49 Bond (therapeutic alliance), 57
and infant independence, 101 Borderline personality disorder,
research on treatment of, 144, 145 146–147
APA (American Psychological Bordin, Edward, 56–57
Association), 11–12, 162–163 Botticelli, S., 161
APA Dictionary of Psychology, xii Boulanger, Ghislaine, 162
Arlow, Jacob, 27 Bowlby, John, 29, 62–63
Aron, Lew, 33, 85 Brenner, Charles, 27
Assertion, 62 Bresler, J., 155
Assimilative integration, 155 Breuer, Josef, 19
Attachment system, 62–63 Brief relational therapy (BRT), 122
Attachment theory Brief-term therapy, 152
contributions of, 33 British Independent theorists, 29, 68
defined, 173 British Psychoanalytic Society, 28
and family separation, 164 Bromberg, Philip, 33, 55, 68
and mentalization, 104 BRT (brief relational therapy), 122
and need for attachment, 62 Burgholzi Institute (Zurich), 19–20
overview, 62–63
research, 146 Case formulation, 66–69
Authenticity, 29, 41–43, 96, 157 Central Intelligence Agency (CIA), 162
Authority, 47–48, 153 Certainty, 67
Autonomy, 74 Change
ambivalence toward, 51, 82
Balint, Michael, 29, 32 speed of, 7–8
Baranger, Madeline, 34 Change mechanisms, 91–106
Baranger, Willi, 34 affect communication, 98–99
Barber, J. P., 145 agency, 92, 95–96
Bateman, A., 146 articulation of feelings and wishes,
Beebe, Beatrice, 98, 100 93–94
Behavioral interventions, 155–156 containment, 99–100
Behavioral psychology, 168 creation of meaning and narrative,
Benjamin, J., 33, 85, 104–105 94–95
Bick, Esther, 28 emotional insight, 92–93
Bion, Wilfred in evaluation of psychoanalysis, 143
and case formulation, 68 and free association, 22
and containment, 99–100 interactive affect regulation,
and history of psychoanalysis, 28, 34 100–103
and psychoanalytic theory, 39 and intersectionality, 158–161

196
 Index

making unconscious conscious, emphasis on personal meaning

91–92 in, 170
mentalization, 104–106 and power, 6–7
new relational experience, 96–98 Control systems theory, 62
rupture and repair, 103–104 Corrective emotional experiences, 96–97
tolerance of ambiguity, 90–91 Couch, 15
Character disorders, 48, 49. See also Countertransference
Personality disorders and advice, 74
Charcot, Jean-Martin, 18 and case formulation, 68
Chicago School of Sociology, 31 defined, 173
Childhood sexual abuse, 19, 23–24, 159 interpretation of, 75–76
Chile, 161 and intersectional identities, 159
CIA (Central Intelligence Agency), 162 and long-term treatment, 107
Civil liberties, 162 and mentalization, 105
Clarification, 74 overview, 53–54
Clarity, 39 and termination, 89–90
Clarkin, J. F., 146 Countertransference disclosure, 60–61
Clark University, 20, 171 Couples therapy, 152
Class (social status), 158 Creativity, 29
Crenshaw, Kimberlé, 158
Classical psychoanalysis, 13
Cuba, 162
Clinical psychologists, 7
Curiosity, 40
Closure, 90–91
Cushman, P., 42, 143
Cochrane Database, 145
Cognitive–behavioral therapies Daniel, Jessica Henderson, 164
dominance of, 39 Davies, J. M., 85
and evaluation of psychoanalysis, Daydreams, 46, 101
145, 148–149 “Day residue,” 80
and integration of therapy Death instinct, 61
approaches, 155 Deep interpretation
positive bias in, 169 client reactions to, 71
Cognitive therapy, 151–152 defined, 70–71
Collectivism, 157 Defense analysis, 26
Collusion with client, 51–52 Defense interpretation, 83–85
Complexity, 39, 40 Defenses. See also specific headings
Compromise formation, 32, 173 in case formulation, 66
Concreteness, 39 and change mechanisms, 94
Conformism, 8–13 defined, 174
Consistency, 39 and dreams, 81
Containment in evaluation of psychoanalysis, 145
as change mechanism, 99–100 increasing client awareness of, 169
defined, 173 in psychoanalytic theory, 48–50
and intersectionality, 161 as self-regulation, 101
Contemporary psychoanalysis, 12–13 in therapy process, 82–83

197
 INDEX

Denial, 48–49 Ego

Depression, 144, 145, 148–149 and ego psychology, 26–27
Depth, 39 overview, 25
Determination, 96 and self-states, 45
Developmental experiences The Ego and the Id (Freud), 24–25
in attachment theory, 62–63 Ego psychology, 26–27
and transference, 52 case formulation based on, 66
Diagnostic and Statistical Manual of categorization of defenses in, 48
Mental Disorders (DSM), 11 and depth of treatment, 82
Diagnostic status, 146 Lacanian criticism of, 35
Dialectical behavior therapy, 146, 147, in North America, 30
155 and short-term treatment, 119–120
Dimen, M., 39 Ego strengths and weaknesses, 66
Dissociation Ehrenreich, Barbara, 169–170
and case formulation, 68 Ellis, Havelock, 24
as defensive process, 48–49 Emotion(s)
defined, 174 articulation of, 93–94
and family separation, 164 and cognition, 151
interpersonal context of, 45 cultural differences in expression
interpretation of, 94 of, 157
of negative feelings, 100 in psychoanalytic theory, 61–62
Division 39 of APA (Psychoanalysis), Emotional dysregulation, 164
11–12, 162–163 Emotional insight, 92–93
“Doer and done to,” 85 Empathic mirroring, 69
Dread, 100 Empathic reflection, 70–71
Dreams Empathy, 32, 69–70, 94, 105
in history of psychoanalysis, Empirically supported treatment. See
19–20 Evidence-based treatment
primary process in, 44 Empty self, 42
therapist disclosure of, 54 Enactment
in therapy process, 79–82 in brief relational therapy, 122
Drives defined, 174
early conceptualization of, 61 and metacommunication, 76
and short-term treatment, overview, 55–56
119–120 racial, 157
Drive theory, 18 and termination, 88
DSM (Diagnostic and Statistical Encouragement, 22
Manual of Mental Disorders), 11 Enhanced interrogation techniques,
162–163
Eastern cultural perspectives, 96 Enlightenment, 42, 171
Eclecticism, 155 Envy, 50
Efficiency, 39 Erotic transference, 58
Egalitarianism, 6 Etchegoyen, Horacio, 34

198
 Index

Ethology, 62 Ferenczi, Sandor

Etington, Max, 9 and American interest in
Eurocentrism, 156 psychoanalysis, 171
Europe, 34 and change mechanisms, 93, 96
Evaluation of psychoanalysis/ and history of psychoanalysis, 9,
psychoanalytic therapy, 27, 31
141–150 and short-term treatment, 119
effectiveness research, 144–150 Ferro, Antonino, 34
growing body of, 168 “Flight into health,” 83
and need for randomized clinical Fonagy, P., 104, 146
trials, 142–144 Formulation, 66–69
Evenly hovering attention, 67, 174 Frank, K. A., 155
Evidence-based treatment Free association
and evaluation of psychoanalysis, and dreams, 80
141, 143 overview, 21–22
and psychoanalytic theory, 39 Free psychoanalytic clinics, 9
Evolutionary models, 61 Freud, Anna, 26–28
Existentialism, 31 Freud, Sigmund
Existential suffering, 38–39, 94 and affect communication, 98
Exploration, 62, 85 and change mechanisms, 91–92
External validity, 149, 150 and contemporary
psychoanalysis, 6
Fairbarn, Ronald, 29, 30, 33, 80 and countertransference, 54
Fallenbaum, Ruth, 162 cultural context of, 41–42
False self, 96, 126 death of, 26
Family separation, 164 and dream interpretation, 79–80
Family therapy, 152 drives described by, 61
Fantasy early life and training of, 17–21
primary process in, 44 and erotic transference, 58
in psychoanalytic theory, 46 and evenly hovering attention, 67
and reality, 95 and frequency of psychoanalysis, 4
and resistance, 82 and “furor sanandi,” 39
as self-regulation, 101 and honesty, 40–41
therapist disclosure of, 54 major contributions of, 21–25
Feedback, 15 medical background of, 9, 17–18
Feelings. See Emotion(s) and origins of psychoanalysis, 4–5
Fees, 83 and psychoanalysis as science, 37–38
Feminism psychoanalytic viewpoint of,
and contributions to 170–172
psychoanalysis, 6 and therapeutic alliance, 56
and Lacanian thinking, 35 and therapist knowledge, 47
and seduction theory, 24 and transference, 52
Fenichel, Otto, 10, 26 and the unconscious, 44–46

199
 INDEX

Fromm, Erich, 10, 31 Happiness, 38–39

“Furor sanandi,” 39 Hartmann, Heinz, 26–27
Future developments, 151–165 Helplessness, 15
and critical perspectives, 161–165 Henrich, G., 148
and integration of approaches, Here-and-now focus, 122
154–156 Hermeneutics, 38
for practical psychoanalysis, 152–154 Heteronormativity, 161
and sociocultural identities, 156–161 Higher-level defenses, 48. See also
specific headings
Gastner, J., 148 Historical reconstruction, 78–79,
Gaze aversion, 101 94–95
Gender, 7, 157, 158 History of psychoanalysis, 17–36
Genetic transference interpretations, early psychoanalytic thinking in,
78–79 21–25
Geneva Convention, 162 ego psychology in, 26–27
Gentile, K., 159–160 Freud’s major contributions in,
Germany, 20, 147 21–25. See also Freud,
Gilford, P., 143 Sigmund
Goals of therapy, 56–57. See also Kleinian tradition in, 27–30, 34
Change mechanisms Lacanian tradition in, 34–36
Gold, J., 156 North American pluralism in,
Goldfried, Marvin, 169 30–34
Government-supported research object relations tradition in, 27–30
funding, 142 overview, 17–21
Grant funding, 142 Hoffman, I. Z., 43, 143–144
Gratitude, 89 Hollander, Nancy Caro, 161, 162
Greenberg, Jay, 32–33 Homework, 156
Greenson, Ralph, 56 Honesty, 40–41, 153
Grief, 51–52 Huber, D., 148
Grinberg, Leon, 34 Humanistic traditions, 31, 168–169
Group therapy, 152 Humanities field, 35
Guantánamo Bay, 162, 163 Human relatedness, 31
Guilt, 121 Human rights, 162–163
Humility, 92
Hale, Nathan, 171 Hypnosis, 18, 21–22
Haley, J., xii Hysteria, 18–19
Hall, Stanley, 20 Hysterical personality styles, 49
Handbook of Attachment-Based
Interventions (Steele and ICRC (International Committee of
Steele), 63 the Red Cross), 162
The Handbook of Psychotherapy Id, 25
Integration (Norcross and Immigrants, 164
Goldfried), 154 Impasses, 85–87

200
 Index

Implicit relational knowing, 99 Intimacy, 15, 59

Impulse control, 66 Intrapsychic conflict, 27, 175
Inadequacy, 34 Intuition, 82
Individualism, 41–42, 157 Isaacs, Susan, 28
Infant observation research, 62 Isolation of affect, 49
Insight
and case formulation, 66 Judgment, 66
defined, 174 Jung, Carl, 5, 20, 171
in evaluation of psychoanalysis,
145 Keefe, R. J., 145
and free association, 22 Kernberg, O. F., 146
Instrumentality, 7 Khan, Masud, 29
Integration of psychotherapy Klein, Melanie
approaches, 154–156, 169 in history of psychoanalysis,
Integrity, 57 27–30, 34
Intellectualism, 93 and interpretations, 71
Intellectualization, 48, 49 and relational psychoanalysis, 33
Interactive affect regulation, 100–103 and splitting, 49–50
Internalization, 28, 29, 96–98, 174 Klug, G., 148
Internal object relations, 28, 96, Knight, Robert, 11
174–175 Knowledge, 47–48, 99
Internal objects, 28–30, 174–175 Kohut, Heinz, 32, 69, 104
Internal validity, 150 Kreische, R., 147
Internal working models, 63, 96
International Committee of the Lacan, Jacques, 34–36
Red Cross (ICRC), 162 Lacanian theory
Interpersonal psychoanalysis, case formulation based on, 66
33, 66. See also Relational in history of psychoanalysis, 34–36
psychoanalysis Lachmann, F. M., 100
Interpretation. See also specific Lambert, M. J., 146
headings Language, 35
and change mechanisms, 94 Late attendance, 50, 83
defined, 70, 175 Latin America, 20, 34, 36, 161–162
emotional insight stemming from, Leary, K., 157
92–93 Left-wing politics, 9–10
and free association, 22 Leichsenring, F., 145, 147
of resistance, 52 Lenzenweger, M. F., 146
in therapy process, 70–74 Levy, K. N., 146
The Interpretation of Dreams (Freud), Life instinct, 61
19–20, 79–80 Lichtenberg, J., 62
Interrogation techniques, 162–163 Loewald, H. W., 97
Intersectionality, 152, 158–161, 175 Long-term treatment, 15, 106–119
Intersubjectivity, 33, 66, 105 Love, 29

201
 INDEX

Love in a Time of Hate (Hollander), Mood, 145

161 Mothers
Lower-level defenses, 48–49. See also infant ruptures with, 103
specific headings research on infant dyads with,
Luborsky, Lester, 120 69–70, 98–101
Lyons-Ruth, K., 99 and splitting, 49–50
Motivation, 61–62
Main, Mary, 63 Motivational system, 62
Malan, David, 120 Muran, J. C., 145
Managed care system, 39 Mutual attunement, 101
Marital therapy, 152 Mutuality, 33
Marxism, 9–10
Matte-Blanco, Ignacio, 34 Narcissism, 32, 61
Mature defenses, 48 Narcotics Anonymous, 124
McCarthy, K. S., 145 Narratives, 94–95
McMain, S. F., 147 Naturalistic studies, 147–149
McWilliams, Nancy, 171–172 Nazism, 20
Meaning, 41–43, 94–95, 170 Neurofeedback, 155
Meaninglessness, 94 Neurology, 17–18
Mechanisms of change. See Change Neurotic functioning
mechanisms defenses associated with, 48
Mechanistic understandings, in ego psychology, 26
17–18, 32 and suffering, 38–39
Medical professionals, 9–11 Neutrality, 58
Medication research, 142, 147 New relational experience, 96–98
Mental health, 38–44 New York Psychoanalytic Institute, 27
Mentalization New York Times, 162, 164
as change mechanism, 104–106 Nontransference interpretations, 77
defined, 175 Nonverbal behavior, 55
theory of, 33 Norcross, J. C., 145
Mentalization-based treatments, 63, Nuance, 39
146
Mesmerism, 18 Object Relations in Psychoanalytic
Messer, S. B., 119–121 Theory (Greenberg and
Meta-analyses, 146 Mitchell), 32–33
Metacommunication, 75–76, 122, 175 Object relations theory, 27–30, 66,
Metaphors, 44 145. See also specific headings
Middle Group, 29, 32 Obsessive personality styles, 49
Milner, Marion, 29 Ogden, Thomas, 68
Mitchell, Stephen, 32–33, 170 One-person psychology, 46–47, 51,
Modern conflict theory, 66–67. 175
See also Ego psychology Openness, 107
Moll, Albert, 24 Optimal disillusionment, 95–96, 105

202
 Index

Optimism, 6, 7, 169–170 defined, 13, 14

Overcompliance, 83 empirical support for, 6
frequency of visits in, 4
Padrón, Carlos, 160, 161 misconceptions about research
Panic, 144 on, 142
Patience, 39 origins of, 4–5
Patriarchal assumptions, 6 psychodynamic therapy vs., 13–15
People of color, 7 Psychoanalytic theory, 37–63
Perls, Fritz, 93 and attachment theory, 62–63
Personality disorders, 144–147, 152 change mechanisms in, 91. See also
Personality functioning, 4 Change mechanisms
Perspective taking, 104 countertransference in, 53–54
Pessimism, 38, 169–171 defenses in, 48–50
Phenomenological experience, 69 emotion and motivation in, 61–62
Physiological requirements, 62 enactment in, 55–56
Pluralism, 30–34, 150 fantasy in, 46
Postmodernism, 7 interdisciplinary nature of, 37–38
Power knowledge and authority in, 47–48
and contemporary psychoanalysis, and mental health, 38–44
6–7 one-person vs. two-person
and imbalance in therapeutic perspectives in, 46–47
relationship, 11 resistance in, 50–52
and knowledge, 47–48 self-disclosure in, 59–61
and sociocultural identities, 159 and therapeutic alliance, 56–58
and therapist self-disclosure, 59 therapist stance in, 58–59
and transference, 53 transference in, 52–53
Practical psychoanalysis, 152–154, 168 the unconscious in, 3, 44–46
Pragmatism, 7 Psychodynamic therapy
Primary process, 44, 175. See also defined, 13
The unconscious psychoanalysis vs., 13–15
Primitive defenses, 48 research on effectiveness of,
Principle of overdetermination, 92 144–150
Privilege, 159 Psychotic symptomatology, 48
Problem solving, xi Public health care system, 147
Procedural knowledge, 99
Projection, 48 Race, 158
Projective identification, 29 Racial enactment, 157
Psychic agency, 45 Racker, Heinrick, 34
Psychoanalysis, 3–15, 167–172. Randomized clinical trials (RCTs),
See also specific headings 142–144
conformist and subversive threads Rank, Otto, 5, 93, 119
in, 8–13 Rationalization, 49
contributions of, 3–5 Rational self-coping strategies, 101

203
 INDEX

RCTs (randomized clinical trials), Rosenfeld, Herbert, 28

142–144 Rupture and repair
Realism, 39 as change mechanism, 103–104
Reality testing, 66 defined, 175–176
Reassurance, 22 and mentalization, 105
Reflection-in-action, 43–44
Reflective functioning, 63, 104, 145. Safety, 46, 71, 154
See also Mentalization Saks, Elyn, 71–72
Refugee crisis, 163–164 Sandell, R., 148
Refugee Resettlement Position Schizoid withdrawal, 49
Statement (American Schizophrenia, 20
Psychoanalytic Association), 163 Schön, D., 43
Reich, Wilhelm, 10, 26 Science, 37–38
Reik, Theodor, 68 Scientific validity, 143
Reisner, Steven, 162 Secondary process, 44–45, 176
Relational psychoanalysis Seduction theory, 23–24
case formulation based on, 66–68 Segal, Hannah, 28
change mechanisms in, 96–98 Self-analysis, 54
development of, 32–33 Self-awareness, 104, 153
and effects of relational turn, Self-deception, 40–41, 92
167–168 Self-disclosure
and integration of psychotherapy and countertransference, 54
approaches, 155 and metacommunication, 76
self-states in, 45 in psychoanalytic theory, 59–61
short-term approaches to, 120–122 Self-esteem, 46, 48
and therapeutic alliance, 57 Self-help industry, 169
Relational schemas, 96 Self psychology, 32, 66
Relaxation exercises, 155, 156 Self-reassurance, 101
Renik, Owen, 74, 152–153 Self-reflection, 41
Repression, 19, 45, 49 Self-regulation, 101
Research. See Evaluation of Self-states, 33, 45
psychoanalysis Sensuality, 62
Researcher allegiance effect, 147 Separation–individuation, 120
Resistance Sexual abuse, 19
defined, 175–176 Sexuality
overview, 22 conflict between cultural norms
in psychoanalytic theory, 50–52 and, 42
in therapy process, 82–83 defenses against, 48
Respect, 56 and fantasy, 46
Rigidity, 145 as motivational system, 62
Ritual, 43 and the unconscious, 45
Riviere, Joan, 28 Sexual orientation, 158, 161
Romanticism, 42 Shared treatment goals, 153

204
 Index

Shedler, J., 144 Supervision, 54

Short-term treatment, 15, 119–139 Support, 74
Sifneos, Peter, 120 Sustained work, 66
Silence, 83 Sweden, 148
Simmel, Ernst, 9 Symbolic elaboration, 101
Social hierarchy, 157 Symbolic interactionist thinking, 31
Social skills training, 156 Symbolization, 35, 44, 79–80
Social workers, 7 Symptom relief, 153–154
Sociocultural identities, 156–161
Soldz, Stephen, 162 Task Force on Promotion and
Solomon, Andrew, 39 Dissemination of Psychological
Somatic symptoms, 18 Procedures, 145
Somatization, 49 Tasks of therapy, 56–57
Somatoform disorders, 144 Technical rationality, 43–44
Speed, 7–8, 39 Termination
Spirituality, 157 and evaluation of psychoanalysis, 148
Splitting, 49–50 in therapy process, 87–90
Spontaneity, 29, 43 Terror, 48, 100
Staats, H., 147 Theory, xii–xiii. See also
Starr, K., 155 Psychoanalytic theory
Sterba, Richard, 56 Therapeutic alliance
Stern, Daniel, 69–70 defined, 173
Stern, Donnel, 68 in evaluation of psychoanalysis, 145
Strachey, James, 96 and interpretation, 73
Strange Situation laboratory and metacommunication, 76
procedure, 63 and psychoanalytic theory, 56–58
Stricker, G., 156 and rupture repair, 104
Structural theory, 24–25, 119–120 and self-disclosure, 59
Strupp, Hans, 120 Therapeutic impasses, 85–87. See also
Studies of Hysteria (Breuer and Freud), Therapeutic rupture and repair
19 Therapeutic relationship. See
Subjectivity. See also Intersubjectivity also Countertransference;
and impasses, 86–87 Transference
and intersectionality, 159–160 and American psychoanalysis, 31–31
and reflection-in-action, 44 in contemporary psychoanalysis, 6
and therapeutic alliance, 57 dream references to, 82
Substance-related disorders, 144 enactments in, 55–56
Subversion, 8–13, 36, 161, 171–172 in evaluation of psychoanalysis, 143
Suffering, 38–39 and free association, 22
Suggestion, 22 internalization of, 96–98
Sullivan, Harry Stack, 31, 33 patterns in, 67
Summers, Frank, 162 power imbalance in, 11
Superego, 25 in psychoanalysis, 4

205
 INDEX

Therapist factors, 143 Totalitarian regimes, 36, 162

Therapist stance, 58–59 Transference
Therapy process, 65–139 and advice, 74
affect communication in, 98–99 and assumptions about analyst, 15
agency in, 95–96 in brief relational therapy, 122
articulation of feelings and wishes defined, 176
in, 93–94 erotic, 58
case examples, 107–119, 122–139 interpretation of, 75–76, 93, 146
case formulation in, 66–69 and intersectional identities, 159
clarification in, 74 and long-term treatment, 107
containment in, 99–100 and mentalization, 105
creation of meaning and narrative overview, 23
in, 94–95 in psychoanalytic theory, 52–53
defense interpretations in, 83–85 and self-disclosure, 59
emotional insight in, 92–93 Transtheoretical conceptualization of
genetic transference therapeutic alliance, 56–57
Trauma
interpretations in, 78–79
of American soldiers, 21
interactive affect regulation in,
of family separation, 164
100–103
and fantasy, 46
interpretation in, 70–74
resulting from psychoanalytic
and long-term treatment, 106–119
treatment, 168–169
making unconscious conscious in,
and seduction theory, 23–24
91–92
and the unconscious, 45
mentalization in, 104–106
victims of, 152
new relational experience in, 96–98
Treatment goals, 153
nontransference interpretations Treatment-resistant cases, 28
in, 77 Tronick, Ed, 98, 103
resistance and defense in, 82–83 Trust
role of empathy in, 69–70 collaborative development of, 154
rupture and repair in, 103–104 and resistance, 50
and short-term treatment, in self, 74
119–139 and therapeutic alliance, 56
support and advice in, 74 Truth, 97
termination in, 87–90 Tummala-Narra, Pratyusha, 160
therapeutic impasses in, 85–87 Two-person psychology
tolerance of ambiguity in, 90–91 and anonymity, 58
transference and in brief relational therapy, 122
countertransference countertransference in, 54
interpretations in, 75–76 defined, 176
use of dreams in, 79–82 one-person psychology vs., 46–47
Thompson, Clara, 31 and resistance, 51
Thumb-sucking, 101 transference in, 53
Torture, 162 and transference interpretations, 75

206
 Index

Uncertainty, 67 Varvin, S., 164

Uncommunicativeness, 83 Vicarious introspection, 69
The unconscious Vitality, 41–43
and affect communication, 98
creating conscious awareness of, Wachtel, P. L., 155
91–92 Warren, C. S., 119–121
and deep interpretation, 70–71 Western cultural perspectives, 96
defined, 176 William Alanson White Institute,
dreams as “royal road” to, 79 31–32
early research on, 20 Willpower, 96
facilitating awareness of, 3 Winnicott, Donald
in Lacanian theory, 35 in history of psychoanalysis, 29, 32,
and object relations theory, 29 33, 35
in psychoanalytic theory, 3, 44–46 on optimal disillusionment, 95–96
Understanding, 22 on sanity, 39
Undoing (defense), 48 Wisdom, 91
United States. See American Wishes, 93–94
psychoanalytic tradition Withdrawal, 62
U.S. Department of Defense, 162 Word association tests, 20
U.S. military, 20–21 Working alliance. See Therapeutic
alliance
Validity World War II, 20
external, 149, 150
internal, 150 Xenophobia, 164
of other perspectives, 86, 88, 105
scientific, 143 Zen Buddhism, 155, 171

207
 About the Authors

Jeremy D. Safran, PhD, was a professor of psychology and former

director of clinical training at the New School for Social Research in
New York City. He was also senior research scientist at Beth Israel
Medical Center. He was a faculty member at the New York University
postdoctoral program in psychotherapy and psychoanalysis and a
member at the Stephen A. Mitchell Center for Relational Studies. He
was also past president of the International Association for Relational
Psychoanalysis and Psychotherapy. He was a founding board member
of the Sandor Ferenczi Center.
Dr. Safran was an associate editor for the journal Psychoanalytic
Dialogues and was on the editorial boards of Psychotherapy Research and
Psychoanalytic Psychology. He published more than 100 articles and
chapters and several books, including Negotiating the Therapeutic Alliance:
A Relational Treatment Guide, Emotion in Psychotherapy, The Therapeutic
Alliance in Brief Psychotherapy, Interpersonal Process in Cognitive Therapy,
and Psychoanalysis and Buddhism: An Unfolding Dialogue.
Dr. Safran and his colleagues conducted research on the topic of
therapeutic impasses for more than 2 decades. He was also known for his
work on emotion in psychotherapy and for his integration of principles
from Buddhist psychology into psychoanalysis and psychotherapy.

Jennifer Hunter, PhD, is an adjunct professor in the counseling program

and a clinical supervisor at Brooklyn College. She has a private practice

209
 About the Authors

in New York City. She is also a clinical associate at the New School for
Social Research and is on the board of the Sandor Ferenczi Center. She
is a graduate of the New York University Clinical Psychology doctoral
program and received an Advanced Certification in Couples and Family
Therapy from the New York University Postdoctoral Program in Psycho-
therapy and Psychoanalysis.

210
 About the Series Editor

Matt Englar-Carlson, PhD, is a professor of counseling and director of

the Center for Boys and Men at California State University–Fullerton.
A Fellow of the American Psychological Association (APA), Dr. Englar-
Carlson’s scholarship focuses on training helping professionals to work
more effectively with boys and men across the full range of human diversity.
His publications and presentations are focused on men and masculinities,
social justice and diversity issues in psychological training and practice,
and theories of psychotherapy. Dr. Englar-Carlson coedited the books
In the Room With Men: A Casebook of Therapeutic Change, Counseling
Troubled Boys: A Guidebook for Professionals, Beyond the 50-Minute Hour:
Therapists Involved in Meaningful Social Action, and A Counselor’s Guide
to Working With Men, and he was featured in the APA-produced video
Engaging Men in Psychotherapy. He was named Researcher of the Year,
Professional of the Year, and he received the Professional Service award
from the Society for the Psychological Study of Men and Masculinities,
and was one of the core authors of the APA Guidelines for Professional
Psychological Practice With Boys and Men. As a clinician, Dr. Englar-Carlson
has worked with children, adults, and families in school, community, and
university mental health settings. He is the coauthor of Adlerian Psycho-
therapy, which is part of the Theories of Psychotherapy Series.

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