Object Relations Therapy and Interpersonal Therapy: Current .' Differences ••••••••••.••.•••.••••••••••••••••..••••••••••••••••• 66
COPYRIGHT AND CITATION CONSIDERATIONS FOR THIS THESIS/ DISSERTATION
o Attribution — You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.
o NonCommercial — You may not use the material for commercial purposes.
o ShareAlike — If you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original.
How to cite this thesis
Surname, Initial(s). (2012) Title of the thesis or dissertation. PhD. (Chemistry)/ M.Sc. (Physics)/ M.A. (Philosophy)/M.Com. (Finance) etc. [Unpublished]: University of Johannesburg. Retrieved from: https://ujdigispace.uj.ac.za (Accessed: Date). I
OBJ C H RAPY A 0 IN A
r uir m nt ( r til
MASTER OF ARTS in CLI N ICAL PSYCHOLOGY
inth
tth
ul " 70 puc soml chrlAds tosechlr, sometimls chinklrs Are At IOSgerhllufs ." whh one Anoth,r not beCAUS' chlir propositions do conflict, but b,CAUSI thl!J fAnc!J thAC ch'!J conflict. 7'b'!I suppose ch,msllv,s to b.. SiYinS AC l'Ast b!J indir,cc impliCAtion riVAl Answers to thl SAm, 'luestions wh,n
chi. i. noc r'All!J th' ~ASI."
GILBERT RYLE -"DILEMMAS" DEDICATION
"Unless he belongs somewhere, unless his life has some meaninganddirection, he wouldjeellike aparticle ojdust and beovercome by Iris individual insignificance"
Erich Fromm EJcape From FRtdom
For
Shem, Jonl, Miry and the late Joe. (i)
ACKNoWL£.D6EM£NTS
I am indebted to the following people:
• Dr. Marietjie Joubert. for her invaluable support, guidance and remarkable patience;
• The Department of Clinical Psychology at the Rand Afrikaans University for plunging me into a "wonderland- of discovery. and nunuring my love for knowledge:
• My colleagues, for the endless hours of discourse, which created the first foundations for Ihis thesis:
• My patients, whoconfounded every theory Jknow...
···000··· (jj)
ABSTRACT
The objective of this thesis is to examine the similarities and differences which exist between Object Relations and Interpersonal theory, specifically in relation to the practice of psychotherapy.
In order to achieve the objective. the histortcal development of Object Relations and Jmerpersonal theory is examined. with specific reference to the development and useof the tools and premises which these two theories bring to the practice oftherapy.
Thereafter. the thesis conducts a comparative analysis of these two schools' view of therapy and identifies the similarities and differences between them as they exist historically, and in current practice. .:
The conclusion is that despite fundamental differences in theory, significant similarities exist in the practice of Object Relations and Interpersonal therapy, panicularly in regard to the use ofIhe therapeutic relationship as a central tool to understanding the process of therapy.
The therapist, inboth Instances, is required to use his own though IS and feelings as a guide to understanding thedynamics and behaviourofthe patient. It is regarded as highly significant that these two divergent Iheories share this core insight since both schools emanate from a philosophical perspective which suggests that ihe therapist should remain objective to the process of therapy.
···000··· (iii)
OPSOMMING
Ole doel van hlerdle navorsing is om die ooreenkomste en verskille wat bestaan lussen Interpersoonllke Teori~ en Objekverhoudings, met spesifieke verwysing na die praklyk van pslgoteraple, teondersoek.
Om hierdie doel te verwesenlik word die geskiedkundige onlwikkeling van Objekver houdings en Inlerpersoonlike Teoriee ondersoek len opsigtevan die bydrae wat die aannames
en werkswyses van hierdie learie! kan lewer 101 die proses van pslgoterapie.
'n Vergelykende studle word onderneem len opsigte van hierdie twee skole se siening van lerapie en die verskille enooreenkomste wat bestaan lussendiehistoriese- en huidige praklyk word gerdentifiseer,
Die studie korn lotdie gevolgtrekking dat ten spyte van die fundamenteJe verskille, duideJike .: ooreenkomste besuan in die praktyk van Objekverhoudings en Interpersoonlike Teoriee, veral ten opsigte van die terapeutlese verhouding as die sentrale proses waardeur die proses van terapie begryp word.
Oil word van dieterapeut verwag om in beide gevalle geJei te word deur sy eie denke as gids om die dinamika engedrag van die pasiem te verstaan. Oil word as baie betekenisvol beskou dal hierdie twee uueenlopeade teorlee di~ kern-insigte deel aangesien beide sienings ontstaan vanuil 'n Illosofiese perspektief wat die slelling onderskryf daldie terapeut objeklief sal bJy lydens terapie-sessles.
..-000••• (jv) TABLE OF CONTENTS
ACKNOWLEDGMENT ••••••••••••••••••••••••••••••••••••••••••...••••••••••• (j) ABSTRACT (ENGLISH) •••••••••••••••••••..••••••••••••••••••••...••••••••••• (ij) ABSTRACT (AFRIKAANS) •••••••••••••••..••••••••••••••••••••...•••••.••••• (iii)
CHAPTER I: INTRODUCTION
1.1 PRELI~fINAR Y ••••••••••••••••••••••••••••••••••••••••••••••••• 1 1.1.1 Diversily or chaos . 1 1.1.2 What isPsychotherapy? •••••••••••••••••••••••••••••••••••••••••• 3--+-
1.2 INTERPERSONAL THERAPY AND OBJECT RELATIONS: A RATIONALE FOR THIS COMPARISON ••••••••••••••••••••••••••••••••••• 4
1.3 THEAIM •••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 6
1.4 METHOD •••••••••••••••••••••..••••••••••••••••••••••••••••••••••• 6
CHAPTER 2: THE DEVELOPMENT OF PSYCHO· ANALYSIS
2.1 THEBEGINNINGS: CLASSICAL PSYCHO· ANALYSIS 8
2.1.1 Theoretical orientation ••••••••.••••.••••••••••••••••.•••••••••••••• 9 2.1.1.1 Theinstlncu •••••••••••••••••••••••••••••••••••••••••••••••••••••••• 9 2.1.1.2 Development of the ego and the superego •••••••••.•••••••••••• 12 2.1.1.3 The dele11CeS •••••••----••••••••••••••••••---••••••- ••--.-••••-. 13 2.1.2 Therapeutic relationship ••••••••••••••••__ . 14 2.1.3 Theappearance of transference . 14 (v)
2.1.4 Dealing with countertransference .. 15 2.1.5 Summary ••••••.••••••••••••...... •.•••••••••.••.••...... •••.••••••••• 15
2.2 TilE REVISIONISTS •...... ••••••.•....••...... •....••••••• 16(±) 2.2.1 The rise of Object Relations: Melanie Klein •..•.•••••••••••••••• 17 2.2.1.1 Broad overview: Theoretical position ••••••••...•••••••••••••••••• 18 2.2.1.2 Technique: The tools of therapy································.· 24 2.2.2 Developments following from Klein ••••••..••...•••••••.••••••••• 26 2.2.2.1 Countertransfercnce and Projective identification •••..•••••••••• 27 2.2.2.2 Transference relationship ••..•..••••- . 30 2.2.2.3 Change. and how it is achieved ••••••••••••••••••••••••••••••••••• 31 .. 2.3 CONCLUSIONS ••••••.•....•...••••••••.•••..•...... ••...••••••.• 34
CHAPTER 3: INTERPERSONAL THERAPY: FIRST ORDER CYBERNETICS
3.1 TilE BEGINNINGS: SULLLlVAN THE FATHER OF THE INTERPERSONAL TRADITION •••••••••••••....•...••••••••••••.••....•.••...•••••••••
3.2 TilE STRATEGIC POSITION .. 39 3.2.1 Theoretical assumptions . 42 3.2.2 Therapy from a Strategic point ofview ••••••..·•••••••.•••••••••• 47 3.2.2.1 The role ofthe therapist . 47 3.2.2.2 FOCUJ on behaviour _••••••••• 48 3.2.2.3 The tools ofchange _ _ •• 49 3.2.2.4 The thclIpetltic relationship . 52 (vi) uas
3.3 INTERPERSONAL THERAPy································ 53 3.3.1 Assumprlons about personality ..·•••••••••••••••···•••••·•••••••••• 53 3.3.2 Psychological problems in lnterpersonal terms ..••••••••••••••••• 56 3.3.J lruerpersonal Psychotherapy·············.········.················· 59 3.3.4 Change ....•.••.••••••••.••...•...... ••••••••••••.••.•..••••••.••••••••• 61
3.4 CONCLUSIONS •••••••••.••.•••••••••••••••••••••.••••••••••••••••• 63
CHAPTER 4: DISCUSSION OFSIMILARITIES AND DIFFERENCES
4.1 CLASSICAL PSYCHOANALYSIS AND INTERACTIONAL STRATEGIC THERAPY DISCUSSION .
4.2 OBJECT RELATIONS THERAPY AND INTERPERSONAL THERAPY: CURRENT .' DIFFERENCES ••••••••••.••.•••.••••••••••••••••..••••••••••••••••• 66
4.2.1 Epislomological differences .•..•••••••••••••.•••..•••••••••••••••••• 66 4.2.2 Differenl percepiions of change •••••••••.•••••••.•.•••••.••••••••••• 67 4.2.3 Techniques inchanging behaviour ••••••••••••.••••••••..•••••••••• ~ 68
4.3 COMMON ELEMENTS IN OBJECT RELATIONS AND INTERPERSOSAL THERAPY ••••••••••••••••.••••••.••••••••••- 69 0 4.3.1 The Ihenpeutic relationship ---.- 69 4.3.2 The tools oftherapy -- 70 4.3.3 Focus on ihe here and now - - 70 4.3.4 Inlerpreulion and meta communication -.-•••- 71 4.3.5 Pathology and how it is seen •••••••••••••••••------.- 71
4.4 CONCLUSIONS •••••••••••••.•••••••••••••••••••••••••••••••-.....- 72 (vii)
f.MiE.
CHAPTER 5: CONCLUSIONS
5.1 Summary and conclusions ••.••.••------.--••--•.••----•.•------73 5.2 Limitations of this study --••.•••------.---.--••.••---••.•------ 76 5.3 Further research suggestions •••••------.--••--••..•••••.••------ 77 5.3.1 The use ofselfas a construct in other theories oftherapy ------ 77 5.3.2 A case study investigatingan Interpersonal approach versus anObject Relations approach to therapy .--••-•••.-----•••------77
REFERENCES ---...------....------.-...-----..------78 CHAPTER I
INTRODUCTION
1.1 PRELIMINARY
1.1.1 Diversity or chaos
Unlike other scientific endeavours, in which a common language is accepted, and certain untcstable premises are taken for granted, the field of psychology is characterised by a splintering of different languages and different ideological premises and methods. Goldfield and Castoguay (J 992) estimate that there are over four hundred different schools or theories of psychology today.
This theory proliferation could be construed as the realisation of the limitations of specific schools of thought "...and the consequent rise of reactionary ideologies' (l.ouw, 1993, p.J), or in more recent times has been characterised as epistomological shifts and differences.
In the author's opinion the abundance of theories is both constructive and destructive. The theories help make sense of a complex reality, but simultaneously, confound with their manifold world views. Attempting to illustrate that one theory has greater intrinsic value is • process that many theorists have adopted in validating their own epistomological position in psychology.
The zealous defence of • panicular theory precludes constructive engagement between opposing theorists and tends to obscure the real similarities and differences between them. This occurs because: 2
(a) depending onthe chosen school ofthought that one adopts, distinctively different concepts will be adhered to with almost religious fervour. Other Iactors which could aid in the process of understanding are dlseoumed, simply because they belong to a differenl world view. or method ofapplying psychotherapy.
(b) Inevilably no 'cross pollination' is permitted, even when this process could further refine or expand lhe existingapproach.
(c) That common ideas or belief systems are adhered to. is generally not acknowledged. perhaps for fear that the uniqueness of a panicular theory be undermined.
(d) Often common principles are obscured by differences in perspectives and language.
There probably will always be epistomological differences. and as long as there are theorists. there will always be competing theories. As Mitchell & Greenberg (1983, p.S) would have it:
-Differenl schools ... have developed out of different intellectual traditions. are based on vastly divergent philosophical and methodological assumptions. and employ different languages. E.ch theory is an intricate network ofconcepts that hu developed through an Internal progression panicular to that theory-.
They argue that theories cannot be meaningfully compared without .....doing violence tothe Inlegrity of each". J It is clearly beyond the scope of this thesis to examine many divergent theories. and accordingly. the author has limited it to the analysis of Object Relations and Interpersonal theories.
Rather than auempting to challenge the basic premises or particular world
views these different schools hold, 8 viable objective is 10 find common tools and premises within the two conflicting schools of thoughl, in tile actual
practice oj psycl,otllerapy. This thesis auempts 10 do this in relation to the Interpersonal and Object relations theories. not in vacuo or in terms of a
philosophical clash of theories. bUI in tile therapy room. The purpose of doing so is not toallempl to fuse the twotheories into a mixing pot. but to understand the process of therapy by identifying the real similarities and differences between them. stripped of semanticsand positions of ideological defence.
1.1.2 What is psychotherapy?
Psychotherapy has it's origins in the Greek words "psyche", meaning soul. mind. and spirit 'Therapia", means to take care of, service. or treatment (Beyers & Vorster, 199». There is however no absolute definition of psychotherapy, most particularly because of the array of different therapeutic models in existence today. The diversity of theory clouds even a common definition ofthe most basic work place in psychology.
At the most basic level. it is generally accepted that psychotherapy involves a therapist and a patient (or patients), and that this interaction is intended to
change people: 10 make them think differently. feel differently, and act differently: It Is amethod of leamlng" (Corsini, 1985. p.5).
According 10 Truax " Carkhuff (1967), pS)'cholherapy is merely I heterogeneous collection of ingredients or psychological conditions that can effect a range or degrees of both positive and deleriotalivc changes in behaviour. .. Regardless of the theoretical framework that a particular iherapisr adheres to, there is eilher a moment or a period during which Ihey feel ignorant and helpless (Casement, 1985).
Bion (in Casement, 1985. p.4) describes this by saying: "In every consulting room there are two frightened people; the therapist and Ihe patient. If they are not. onewonders why they are bothering to find OUI what everyone knows".
II is at this juncture that therapists could rely heavily on the theory of their particular therapy, in order to give them a feeling of knowing in the situation, and to make them feel more secure. As Freud (in Casement, 1985. p.S) said: "...and thus a store of ideas is created, born from man's need to make his helplessness tolerable".
This ultimately can result in a dogmatic use of the theory at hand. with little regard for what is taking place in the room. If common characteristics or features of therapeutic practice can be isolated across different therapeutic models, apparent slavish adherence to theory could be broken down. The role of theory can be placed in it's proper perspective. Theories should not define therapy. but rather, assume their rightful place as therapeutic tools, not therapeutic suait-jackets. It could also encourage therapists 10 broaden their initial conceptualisations, and acknowledge the limitations oftheir own particular paradigm. 1.2 INTERPERSONAL THERAPY AND OBJECT RELATIONS THERAPY: ARATIONALE FOR TillS COMPARISON Early proponents of Interactionalism directly compared Iheir theory to Psychoanalysis u a means of demonstrating their 'uniqueness' and difference. Generally speaking. they perceived themselves to be Ihe anlilhesis of Psycho analysis. 5 As Watzlawick (1967. p.29) stated: (Psychoanalysis and Interactionalism) "belong to different orders of complexity. the former cannot be derived from the tatter, nor can the latter be derived from the former. they stand in the relation ofconceptual discontinuity." Psychoanalysis was rooted in a philosophy which placed emphasis on "a more or less fixed personality structure from which all human behaviour sterns", whereas lnteractionalism "placed the emphasis on the interaction with the environment. Human behaviour. in terms of this model is seen as an interaction between an individual and others In his environment" (Vorsler. 1979. p.13). The wrlter elected 10 identify therapeutic similarities. if any. in these openly antagonislic theories. Should similarity exist in such diversity. it will a fortiori exist in theories which do not define themselves against each other. In the therapeutic arena. the therapist is confronted with the practical reality of " a panicular problem or situation. which requires to beaddressed, The concern here is not so much with maintaining theoretical purity. as with a practical set of ground rules toassist in dealing with the problem at hand. Therefore. if theories as apparently as divergent as Interpersonal therapy and Object Relations or modem Psychoanalysls launch themselves from a common platform. as regards therapy. or at least share similar therapeutic concep tualisations. then the therapist may be entitled to assume that certain fundamental propositions can be accepted as aids to executing the therapeutic process. This thesis alms 10 Identify and examine the therapeulic similarities between these two Ihcories In order co asctrtaln the extent to which the therapbc can operate onthe basis of an assumption ofsimilarities, 6 1.3 TIiE AIM This thesis aims 10 examine whether, and to what extent common ground can be located between Object Relationsand lnterpersonal iherspy. In this examination, the historical development of these two schools will be traced, in an allempllo ascertain: • to what extent the initial concepts developed are sliII adhered to in Object Relations and Interpersonal therapy; • to what extent the differences that existed in the hislory of these two schools' development still exist in currentpractice; whether the similarities that exist between these schools of therapy are central to the therapeutic process. This thesis will focus primarily on the theory of therapy, as opposed to theories of etiology, personality and pathology. 1.4 METIIOD In orderto.chieve the above staled aim, Ihis thesis will : (a) examine the developmentof Psychoanalysis, commencing with its chief proponenu, including Freud (1973, 1980, 1983), and Melanic Klein (1981, J983, 1992), as well u modem day Object Relations lheorisu (Bion, J9S9;Joseph, 1989; Rosenfeld, 1990, Seg.l, 1988). 7 The theory underlying Psychoanalysis and Object Relations will be brieny considered. but the focus will primarily be in tracing the development of the conceptualisation of therapy. In this process. the development of the concepts of transference. coumertrsnsference. projective identification. interpretation and the role of the therapist will be considered. b) examine the development of Interpersonal therapy, considering inter alia the work of H.S. Sullivan 0940; 1953: 1964) Gregory Bateson (J 952), Jay Hayley (J 963: 1980: 1981); John Weakland (J977), and the M.R.I. group 0967: 1974: 1977). as well as Interpersonal therapy (Anchin & Kiesler. 1982). The focus will remain on therapy. (c) compare Classical Psychoanalysis and Strategic I Interactional therapy. and identify and analyse the similarities and differences in Object Relations and Interpersonal therapy. This procedure will examine the extent to which the historical differences have been bridged in current practice ofObject Relations and Interpersonal therapy. Conclusions will be drawn as to the significance of these similarities and differences. 8 CHAPTER2 THE DEVELOPMENT OF PSYCHOANALYSIS 2,1 TIlE BEGINNINGS· CLASSICAL rSYCllOANALYSIS "Who could remain unmoved when Freud sumed sudd~nly to plunge toward the origins? Suddenly he stepped out of the conscious, out of everywhere into nowhere, like some supreme explorer. He walks straight through the wall of sleep and we hear him rumbling in the cavern of dreams. The impenetrable is not impenetrable, unconsciousness is not nothingness... If (Lawrence, D.H., in Greenberg .: & Mitchell, 1983, p.20. In thischapter, anaucmpt is made totrace the development of Object Relations theory, focusing specifically on the development of therapy. This investigation begins with the Classical or freudian conccptualisation of transference, coumenransference and Ihe role of the therapist, which will only be briefly referred 10. How these initial constructs have been refined and developed by Melanie Klein's theory of Object Relations, 'Il'hich is a derivath'c wilhin the broad field of Psychoanalysis will be explored. 9 2.1.1 Theoretical orientation Freud's fundamental vision of the human condition is beSt described as a drive structure model (Greenberg & Mitchell, 1983). The core concept of this model is the idea of drive. Freud implied at times that drive is to be understood as a quasi physiological quantity. which exercises force mechanistically in the mind. In terms of the drive model. social ties are secondary. and are contingent upon the ability of people to facilitate the discharge of drive derived needs (Greenberg & Mitchell. 1983). In other words. the drive was regarded as the determinant of all motivation: "...every human action. from the diffuse discharge of affect in the infant. to the symptoms of the neurotic. to the creations ofthe anist. to the evolution that unties men into civilised groups can be traced in its origin to ultimate irreducible. and qualitatively specifiable instinctual sources." (Greenberg & Mitchell. 1983. pJO). This created the rather unfortunate tendency to view pathology in terms of processes and mechanisms located solely in the individual (Greenberg & Mitchell. 1983). 2.1.1.1 Tht imtincts Freud envisaged three kinds of instlncu, all of which he subsumed under the term "id". These consisted of the self preservation or life instinct, the sexual instinct. commonly referred to as the libido. and the death instinct (Maddi. 1980). Of the three. Freud (1973) focused most extensively on the sexual instinct or libido. His conceptualisation of development centered almost exclusively around the psychosexual stages. which he termed the oral, anal. phallic. latency and genital stages ofdevelopment (Maddi. 1980). 10 In his view. for successful progress through each stage, ibe child should receive enough gralificalion so as not to feel deprived. but simultaneously. not too much gratification so as to want to remain in that phase of development (Maddl, 1980). If any of the pregenital stages were not successfully negoliated.lhis would have a lingering effect on later behaviour (Maddl, 1980). A brief exploration of the four main slages of development is necessary. so as to fully understand ihe classical therapeutic stance. * The oral•Dhase In this stage of development. the sexual instinct is seen to be located in the .: mouth. The child is presumed to crave and enjoy stimulation of the mouth region through touch. taste and the use ofIhe mouth muscle (Maddi, 1980). In Freud's (1973) words: "We obsenve how an infanl will repeat rhe action of taking in nourishment without making a demand for food. here then he is not activated by hunger. We describe Ihis as sensual sucking. and in doing this. he falls asleeponce more with. blissful expression. This shows us that the act of sensual sucking has in ilself. alone brought him satisfaction" (p.355). II • Thc ana/phase It is at this stage that the child is thought to experience the painful and pleasurable stimulation associated with eliminating and relaining faeces (Madd], 1980). According 10 Freud (1973). during this phase. the child might begin to experience the punitive controls from the external world. He says: ..... infants have feelings of pleasure in the process of evacuating urine and faeces. and that they soon contrive to arrange those actions in such a way as tobring them the greatest yield of pleasure. It is here. for the first time ... that they encounter the external world as an inhibiting power. hostile to their desire for pleasure. and have a glimpse of later conflicts. both internal and external. This is where he is first obliged to exchange pleasure for social respectability" (p,357). • The Phamc !tqzc This stage is regarded as the last of the pregenital stages of psychosexual development. It involves thoughts and actions concerning the body as a sexual thing. and Interaction between people IS heterosexual in nature (Maddi. 1980). This stage sees the emergenceof theoedipal connict in which the child desires the opposite sexed parmI. Maddi (1980. p.30J) describes the possible conniclS thaI could arise during Ihls slage: 12 "U the child's unabashed craving for stimulation and for generalised contact with parents and others is severely frustrated .oo then the child will experience severe contllct. Children will also experience intense conflict if their cravings appear to be over-Indulged, for the encouragement to replace the like sexed parent .oo Children experience anxiety not only that they will lose the affections of the opposite sexed parent, but also that the same sexed parent will retaliate by damaging the child's genitalia". • ThcIW;CQ{stazc In Freud's view (1973), the genital stage marks the pinnacle of maturity and development. Here, theorgasm is considered to be the hallmark ofsatisfaction. 2.1.1.2 Dt~'tlopmtnt oftireego and SUptrtgo According to Freud (in Maddi, 1980), as the infant's experiences are accumulated, a pan of the mind differentiates from the id and becomes the-ego. The ego is regarded as having two basic functions, namely: (i) "The pleasure principle function" (Maddi, 1980, p.36) which in effect means that it aids in satisfyinginstincts in theexternal world. (ij) "Reality principle functioning", in which theego takes into account, not only instinctual demands, but the "equally inexorable and unfonunately opposed demands of society". IJ The superego is defined as a .....portion of the mind hitherto devoted to ego processes that becomes differentiated for the purpose of abstract representation of the rules and regulations of society in terms of ideas ofgood and bad, right and wrong" (Maddi, 1980, p.35). According to Freud (in Maddi, 1980), the superego functions on the principles of punishment and guilt Punishment is seen to be transmiued from outside the person, and expresses the societal requirement of communal living, whereas guilt comes from within the person, but isexpressive of the same requirements. 2.1.1.3 77,e dtJtncts Because theinstincts are regarded as antagonistic to the principles of orderly, civilised life, defences serve to ease this conflict. Their primary function is to .....limit expression in action and personal awareness or consciousness, to only that partor form of the instinct that isacceptable to other people, and to one's internalised standards" (Maddi, 1980, p,38). Defences employed include repression, regression, reaction formation, denial, projection, identification, intellecrualisetton. compensation, undoing and· sublimation (Freud, 1973). From I Freudian perspective, even optimal functioning is characterised by defensiveness. He says: "The most accurate description ofthe goal of psychoanalysis•.•• is the substitution for defences that heavily distort truth, for defences that constitute less of a distortion" (Maddi, 1980, p.42). 14 2.1.2 Therapeutic relationship The analytic stance was traditionally defined in terms of the concept of neutrality. This is roughly equated with the rule of abstinence- the analyst was not to offer the patient any "instinctual satisfaction- (Stolorow, Atwood & Brandcraft, 1987, p.90). This technical injunction was directly derived from the theoretical assumption that the primary psychopathological constellations with which psychoanalysis was concerned were products of repressed instinctual drive derivatives (Stolorow, Atwood & Brandcraft, 1987). 2.1.3 The appearance of transference Transference in Freudian terms was regarded primarily as a "libidinal phenomenon" (l.angs, 1981, p.363). In other words, transference was perceived to be predetermined by the patient's early developmental history. It's contents were held to bea (unction of demands made upon early objects, and defences against these demands (Mitchell & Greenberg, 1983). It was suggested that in everyone there existed a cenain number of unsatisfied libidinal impulses, and that whenever some new person came upon the scene these impulses were ready to auach themselves to that person (langs, 1981). It was subsequently viewed as an Intrapsychle phenomenon, with little or no Interplay between this aspect of the patient's responses to the analyst and the analyst's own behaviour and responses (lings, 1981). In other words, Freud realised that to some extent, he had become pan of the patient's problem: the same problems were being repeated with him despite objective differences between himself and others inthepatient'S life. 15 As Freud conceived ii, transference was a clear index ofihe resistance of Ihe patienl's inlemally determined motivations to be inOuenced by different external conditions (Stolorow, Atwood & Brandcratt, 1987). It was therefore the analyst's function to try and give Ihe patient insight into these apparent distortions. The therapeutlc role of transference in the Freudian model followed naturally from increased knowledge. Transference, especially given theanalyst's non-partlcipation, was seen as a recreatlon in the present of old conflicts, which, by virtue of their recreation, were made accessable to interpretation Freud believed Ihat interpretarion led to insight, and insight alone was curative. Analytic change was a result of increased knowledge (Greenberg & Mitchell, 1983). Thephilosophical assumption Ihat pervaded psychoanalysis at this time was the existence of an objectlve reality that was known by Ihe analyst and would eventually be shared with the pnicnt (Stolorow, Atwood & Brandcraft, 1987). 2.1.4 Dealing with countertransference The concept of countertransference would later become one of Freud's most Important comribunons 10 psycbcanalytlc therapy. Classically, coontenransference was defined as the pllienl's palhological lntluence on Ihe therapist's unconscious. From Freud's perspective, countenransrerence represented the analyst's -neurotic transference to the patient's pathology·, and therefore he regarded it as an interference in the analytic work (lvey, 1992, p. 3 I). It was felt atthis time that those feelings evoked in the therapist by the patient needed to be dealt with in a separate analysis. In Freud's view, 16 countertransference feelings were sure evidence of unresolved issues existent In the therapist that needed to be resolved. 2.1.5 Summary In Freud's view, all human drives, anxieties, and desires had an independent life of their own, and were located in the individual, with lillie interplay with Ihe environment The patient came into treatment wlrh self-contained, encapsulated pathogenic conflicts (Mitchell & Greenberg, 1983). According to the classical position, the analyst operated outside of the transference, observing the unfolding of early conflicts. These were regarded as preset and unfolded from within the dynamic structures of the patlent, Change, from this position, came about through increasing the patients knowledge regarding his or her dlstortions ofthe truth (Mitchell & Greenberg, 1983). Countertransference was regarded as an interference to the analytic work. in which the therapist was ideally an 'objective' onlooker 10 the patient's pathology. h is interesting that the very aspect that Freud perceived to be'anti' therapy (i.e, countertransference) would later become acore ingredient in understanding the therapeutic process. 2.2 TilE REVISIONISTS "Is this the propercouch side monner? Th« psychoanalyst is Q human being just like any other andnot a god. Thut is nothing superhuman about him. In fact he has to be human; how els« would he be able to understand other human beings. Ifhe werecoldand unfeeling he would not be abl« to understand other human beings. The ptculiar depth 01 intensity and intimacy established in the theropeutic rtlationship not 11 onlyinvites the patient's pathology but also invokes our own. Part 0/ this isthe patient's attempts to invok« us with some 0/their madness, to make us /eel. experience andendure the depth 0/ their misery. In this sense then. the transference • countertransference lifetime is a necessQry going mad logether.· (Gerkin, in Ivey, 1992. p.2S4) 2.2.1 The rise ofObject Relations: Melanie Klein Although there were a variety of different psychoanalytic splinter movements that emerged during the lace 1930's. probably the most innuential and sustaining was the development of Object Relations therapy. which appears co have largely formed the basis of modem day psychoanalysis. While other derivatives ofPsychoanalysis do exist. (for example. Kemberg's (t 987; 1988) Ego Psychology) this thesis will focus specifically on Object Relations. It is Melanie Klein who is generally regarded as the "mother" of Object Relations therapy (Segal. 1988). While Klein largely did not deviate from the classical route. she did nevertheless develop new concepts that paved the way for a new vision of the analytic space, moving it further away from a purely intrapsychic phenomenon. to a more interpersonal one. Klein scaned in the 1920's by analysing children. Since children eaMOC be asked co free associate. she treated their play in the playroom In the same way as she created verbal expressions. l.e. as symbolic expressions of their unconscious connlcts (Segal, 1988). It is necessary to outline the main aspects of Klein's theory, in order co fully understand her concepts in therapy. 18 2.2.1.1 Broad oveniew: Theoretical position While Klein retained the major psychoanalytical concept of the unconscious, she focused less on the libidinal developmental phases ofFreud, and concerned herselfmore with the development ofthe ego (Hamburger, 1981), She depicts the mental life of the child and the adultas consisting of a complex tapestry of phantasised relations between the self and others, both in the external world and within the imaginary world of internal objects (Greenberg & Mitchell, 1983). The early relationship of the child with its mother is seen as the forerunner of all later relationships. The infant moves from a "position" of feeling that the breast does not feel completely in control of it, and would like10 auack and destroy it, but at thesame time. the infant realises that the destruction of the breast would mean thedestruction of itself, it's very survival (Segal, 1988). In order to ward off the subsequent anxieties, the infant employs a number of different defence mechanisms, one of which is splitting. Unable to tolerate the ambivalence of the objcct the ego splits the object into a good and a bad object, (i.e. the good breast and the bad breast) in order to keep the ideal object far apan from the persecutory object. This mechanism is clearly illustrated in the case of borderline personality disorders whereby the patient either idealises or denegrades and destroys the therapist, almost as if the therapist were two separatepeople (Rosenfeld, 1990). 19 Other defence mechanisms that operate during this period include Introjection in which rhe object istaken in and eventually forms panofthe person's internal world. and projection, in which pans of oneself are projected onto another penon. In boih these instances an idemlfication whh the other person is achieved (Segal. 1988). All these concepts are closely linked. For example. the infant might introject the good object and project the bad object, or sometimes project the good in order to keep it safe from what is felt to be overwhelming internal badness. Introjection of. and identificationwith persecutors in anauempr to gain control of them isanomer mechanism employed (chis rnighl be particularly pertinent in the caseof an infanl whohas an abusive parent). These defences serve to protect the infant (or patientl from perceiving the separateness that exists between himself and his significant caretaker (or the therapist). Once separateness is recognised. loss has to befaced and dealt with (Feldman & Spill ius. 1989: Segal. 1988). As the individual develops. either through normal development or through analytic treatment, these projections lessen and he or she becomes more able to tolerate his or her ambivalence. love, hale and dependence on objects. and moves towards whal Melanie Klein terms as the depressive position. (Feldman &. Spillius. 1989: Segal. 1988 ). Here there is a synthesis between the loved and the hated aspects ofthe complete object. which in the depressive position. gives rise to feelings of mourning and guilt. which are vital advances in adult developmenl. This process can be helped in infancy if the child has a supportive environment. and if the mother is able to tolerate and contain the child's projeclions. and to intuitively understand his or her feelings (Segal, 1988). Although Klein herself did not elaborne much on the type of mothering thlt was required for the infant to develop normally. Bion (in Anderson. 1992) 20 elaborated and extended this aspect of Melanie Klein's work. He suggested the Imponance ofthe mother being able to be used as a container by the infanl. and linked this with the process of commonicarlon in childhood. and with the positive use of countertransference in analysis. IThe issue of countertrans ference will be dealt with in greater detail later on in this thesis. as it forms an imponant part ofmodem day psychoanalysis). Winnicolt (1960) also added much 10this panicular aspect of Kleinian thought, He describes how the infant begins life in a Slate of "unintegration" with scattered blts and pieces of experience. The mother provides a "holding environment" within which the infant feels contained. An infant "who has no one person to gather his bits together starts with a handicap in his own self integrating task" (Winnicolt. 1960. p.150). In healthy functionlng, the mother is perfectly auuned toher infant's wants and needs and (unctions as a mirror. providing the infant with a precise reflection o( his or herexperiences (Wlnnicou, 1960). If the infant is unable to work through the paranoid schizoid position. «(or either internal or external reasons). the depressive position cannot be negotiated. This position. in Kleinian terms is vital to successful adult relationships. The issue is not whether the child can intemalise the good object • but rather whether the child can reconcile both aspects o( the parent or significant other without defensiveness (i.e. splitting. denial. projection) (Segal. 1988). Thus like Freud. Klein believed lhat that our adull world has its roots in infancy. however. the emphasis In Klein was on examining the unconscious processes in early relationships rather than lhe connltlS between Instinctual drlves. Nothing. she believed existed without objectrelations (Segal. 1988). To put lhis In another way. all human drives. Inxleties and symbolic representations are Interdependent on relalionships with others, havina no Independentlile oftheir own. 21 Following from Klein's work. Winnicol stated that •...there is no such thing as a baby. only a nursing couple. the centre of gravity does not stan off in the individual. it is the 10lal set up" (1952. p.99). However. it should also be noted thaI the processes of projection, introjection. and splitting could be considered as unconscious phantasies. and therefore. there is a constant interplay between inlrapsychic conflicts and interpersonal relationships (Hamburger. 1981. Segal, 1988). 2.2.1.1.1 The concept or envy It is impossible to explore Kleinian technique without examining the special attention that she paid to the concept ofenvy. Earlier weexplored the nature of the environment that is required for healthy development. (see Bion in Anderson. 1992. and Winnicou, 1960). In Kleinian terms, this is not always sufficient toensure healthy. normal development. Envy. in Klein's view, is the earliest expression of the death instinct. It stirs as soon as the infant becomes aware of lhe breast as • source of life and good experience. The blissful experience ofsatisfaction which lhis wonderful object can give (i.e, ihe breast andlor mother) increases the infant's desire to possess. preserve and protect it. but it also stirs in him or her the wish tobe the source of such perfeeuon. This leads the infant topainful feelings ofenvy. which carry with them the desire to spoil the qualilies of the objectlhat create such painful feelings (Segal, 1988). The importlnce of extreme envy lies in the fact that it Interferes with the nonnal operation of the schizoid mechanisms. In other words. the splitting of In object Inlo an Ideal and 8 bad object cannol lake place, since Ie is the ideal object that isthe objecl of envy. and therefore hostility. Thus the introjeclion of 22 an ideal obje«, which could become the core of the egoisdisturbed at il's very roots (Rosenfeld, 1990; Segal. 1988). In the analylical situation, extreme envy manifests itself often by negative therapeutic rescricm, As soon as the analysis is fell as good, it has 10 be attacked and desiroyed, Envy clearly brings to bear feelings of hopelessness; not only are bad experiences bad, bUI good experiences also become bad because they slir envy in the patient (Rosenfeld. 1990). In nonnal development. envy is more integrated. In other words. the gratification experienced at the breast silmulares admiration, love and gratitude at the same time asenvy. If the envy is not overwhelming, gratitude overcomes and modifies envy (Segal, 1988). 2.2.1.1.2 Psychopathology In Klelnlan terms Normal development in Object Relations terms is dependent on each of the different phases or positions in development being negotiated and worked through adequately. According to Klcin (in Segal. 1988), all disturbances of a psychotic nature have thelr roots inthe earlier stages of infanlile development which she described as the paranoid schizoid position, (approximately birth to age three months). In normal development, Ihc paranoid schizoid position is characterised by a split between the good and the bad object and Ihe loving and Ihe hating ego, a split in which the good experiences necessarily predominate over the bad ones. When the bad experience predominates over the good experience. for either external and lor inlemal reasons (e.g. excessive envy, or poor parental/object relations), there isno tidy splil between Ihe good object and Ihe bad object. The projected part is metaphorically splintered and disinlegrated into minutc fragmenlS, and it is these mlnure fragments that are projecled into the object. disintegrating il into minute pans. 23 In pathological development, the experience of reality Is felt primarily as persecutory, and therefore, there Is a ,'Iolent hatred or all experience of reallty, either Internal or external. Therefore the spllnlering of the ego is an auempr 10 get rid of all perception, As a consequence of this process of fragmentation, the ego itself is severely damaged by this disintegrating process, and it's allempt to get rid of the painful perceptions, leads to the painful mutilation of the perceptual apparatus itself (Segal, 1988). The fragmentation of the object into minute bits, each containing minute and violently hostile pans of the ego has been described by Bion as "bizarre objects" (Segal, 1988, p.56). Bion (in Spiltius, 1992) describes an infant who lay in his pram from morning to evening inthe garden, gazing atthe leaves in the trees. Instead of developing a mind for thinking this infant's psyche had already become an apparatus for ridding itself ofbad objects. Hegoes on to explain how: ·",the infant used his eyes as channels for projecting unwanted fragments of his personality into external objects. We can understand how the infant under the tree then is free of hunger and terror because his psyche is in fragments in the leaves"(Bion, in Spillius, 1992, p.90. As a result of this process, the psyche is stripped of all its powers of thought and perception, and is used only as I means of evacuating and eradicating all awareness of the self and the object. By pushing bilS of his personality into objects around him or her. the infant or patient is surrounded by bizarre objects each with I life of their own. Bion metaphorically describes this process In the following extnet: 2.. •...if the piece of personality is concerned wilh sight. the gramophone when played is fell to be watching the patient; if with hearing then the gramophone is fell to be listening to the patiem. .... to that extent. the panicle of personality has become a thing" (in Spillius. 1992. p.93). The processes described above are illustrated in the behaviour and perceplions of many schizophrenic/psychotic patients whose perceptions of reality arc extremely fragmented. and often, persecutory and blzarre. How Klein visualised the therapeutic process. which is often viewed as qulte separate and distinct from the theory shall now be explored. 2.2.1.2 Ttchniqut: Tire tools oJllrtrapy 2.2.1.2.1 The Issue of transference Klein does not deviate much from the classical interpretation of transference. although she docs extend it's meaning. Klein maintained Ihal all communication consists oftransferential elements. By transference ismeant not only the "here and now relation tothe analyst. but the relation to the analyst including reference to put relationships as transferred into the analyst. and current problems and relationships in their interrelationship to the transference- (Langs. 1981. p.396). Transference thereby encompasses the past. present and the 'here and now' relationship between patient and therapist. Projection seems 10 be the key concept here. OnIn emotional level. the patient (not exclusively in therapy) relates to. and sees the analyst u if he/she wu not 25 really himself, but rather as some other person or part of a person from his/her past or present (Langs, 1981). Besides only seeing and perceiving the other person as some other object, the person also reacts to and relates to that person as if they were someone else (Hamburger, 1981). In this sense then, the transference is seen more in interactional than purely intrapsychic terms (Ehrenreich, 1989). Unlike classical Freudian theorists, Klein sees the ego as the central concept. Rather than it being seen as a mediator between an inner world and an outer environment, it is the person's perception or misperception (distortion) of reality, rather than a libidinal developmental phase which becomes disturbed (Dicks, 1967). 2.2.1.2.2 Projective identification One of the most important contributions that Klein made to the field of Psychoanalytic therapy was her creation of the concept of projective identification. As will be seen later, this concept has come to form an essential part of modem Psychoanalytic therapy, and in many respects, it has brought Psychoanalysis closer to interpersonal thinking. Klein introduced the concept of projective identification in 1946 in her notes on some schizoid mechanisms (Spillius in Anderson, 1992). This was her first major attempt to describe what she termed the paranoid schizoid position. Projective identification was described as one of the many defences against primitive paranoid anxieties. Klein described this concept as follows: "Split off parts of the ego are also projected onto the mother. These excrements and bad parts of the self are not meant only to injure but also to control and take possession of the object insofar as the mother 26 comes 10 contain the bad parts of the self, she is nOI felt to be separate, bUI is felt to be the bad self. Much of thehaired towards part of the self is now directed toward the mother" (Spill ius in Anderson, 1992, p.59. 60). Klein did not think that the patient literally put things into the analysts mind or body, but thought of projective identification as the palient's phantasy. In other words, in Klein's use of this term, projective identification describes an unconscious acrivity where a therapist or significant other is used to contain feelings orundesired aspects of the patient. As such, it is a phantasy or an act of imagination that mayor may not transform the self or the object (Siegal, 1991). Adhering to classical thought, she did not believe that the therapist should in any way be moved by these phantasies, and if he/she was, she felt that this was clearevidence that this analyst needed further analysis ofhislher own (Segal, in Langs, 1981). " 2.2.2 Developments following from Klein Many new developments have taken place in Object Relations therapy since Klein's initial writings, (Bion, 1959, 1992: Joseph, 1989; Rosenfeld, 1990; Segal,1988). Overall, with some differences inemphasis, most of ihe recent Object Relations writers hive remained more or less faithful to Klein's basic theory of human development and her conceptualisation of personality structure. 27 The major advances that have taken place in recent years have been in regard 10 therapy: more specifically the reconceptuallsatlon or transference and eeunter-tansferenee Iprojecuve identification). 2.2.2.1. Countertransference andprojecd~'e Identification "The classical psychoanalyst saw countertransferenc« as a wall. whereas the modem psychoanalyst sees countertransference as the window" (Siegal. 1991. p.l0). The original conceptualisatlon of projective identification pul forward by Klein as a defence mechanism that purely resides in the phantasy world of the patient, has been gready extended by modem Object Relations theorists (Bion in Spillius, 1992: Joseph, 1989: Rosenfeld. 1990:Spill ius, 1992). The idea of projective identificalion as a mechanism used by the patient 10 avoid separation, to gain controlof the object, 10 project bad parts of the self and 10 keep sore good parts or the self (Segal, 1988), is SliII generally accepted by most analysts. The greatest departure from the original Kleinian understanding ofthis term is in the area of it being purely a phantasy (Bion in Spillius, 1992; Joseph, 19898). It was Bion (959) who first introduced the idea thll projective identification wu not only I manevolent means of controlling an objecl, but was in fact a form ofcommunication. He Initillly observed from his own feelings in a swion thai his palient triedto force the fear of death into him with Ihe idea Ihal, if these fears reposed In Ihe analyst for I while, they could Illef bereintrojected in I modlned form. 28 If the therapist could not accept these projected feelings. the patient would try to force them on him with increasing intensity and violence (Porder. 1987). He likened this experience in the therapy room to the mOlherlinfant relationship. in which the infant feels assaulted by feelings he/she cannot manage. He/she has phantasies of evacuating them into hislher primary object. the mother. If she is able to understand and accept these feelings without her own balance being too disturbed, she can "comaln' the feelings and behave in a way towards her infant that makes the difficult feelings more acceptable. and the infant can take these feelings back into himselflherself in a form that is more manageable (Spillius. 1992. p.6J). Other analysts such as Rosenfeld (1990), Bollas, (1987), O'Shaughnessy (t983), and Malcolm (1970). corroborate Bion's idea of projective identification as an essential process ofcommunication ofexperiences that the patient cannot express in words (Spill ius, 1992). II was also found that the moreprimitive the patient, (i.e. patients stuck in the paranoid schizoid stage of development), the greater hislher use of projective identification as a means of communication (Segal, 1988). Thus, unlike Klein, these theorists maintain that the analyst should explicitly use their own feelings as a source of information about what the patient is doing. Therefore, projective identification isunderstood to form part or the counter transference, (i.e. the analysts responses/feelings towards the client). Nevertheless, these theorists warn that the analyst must constantly be aware of their own intrapsychic issues, and not to confuse this with what the patient Is projecting. Projective identification (or countertransference) thereby gains the status of a therapeutic Instrument, where the therapist is .....invited to experience split 29 off pans ofthe patient. or the roles played by others in the patients lives" (Ivey, 1992. p,38). Building on Bion's ideas. Joseph 0989A). extends these ideas funher by stressing the way patients attempt to induce feelings and thoughts in the analyst, and tries. often very subtly. and without being aware of it. to 'nudge' theanalyst into acting in a manner consistent with the patient's projections. She gives the example of an apparently passive patient who tries to get the analyst to beactive. or an envious patient who will describe situations of which the analyst might well be expected to beenvious. She explains that the analyst's aim is to allow himselfor herself to experience and respond intemally to such pressures from the patient. enough to become conscious ofthe pressure and its content so that he/she can interpret lt. Other theorists, such as Michael. Burke. and Waller (in Anderson. 1992). further stress the purely Interactive aspects of projective identification. They describe how this concept is used by the patient. asa way ofgetting the analyst to feel what they are feeling. In other words, projective identification could also be seen as a communi cation that the therapist is invited to feel and empathise with. An example of this was illustrated by a Dr. Mauro (in Feldman & Spilliu5. 1989. p.140), in his work with a four year old. As the holiday period was approaching the child had been showing behaviour in which he wanted to be near the analyst. He demonstrated this by sticking plaster to him. A couple of days before the holidays, he called the analyst a stupid idiot, threw a small container in the analysts face. tied up his ankles with string, stuck him round with sellotape. got glue and a bitofchewed up chewing gum onto his trousers. The patient talked about the analyst being tied up and unable to move. and indeed the analyst felt quite immobilised. 30 Joseph (19890) analyses this case by saying: .. Here there is manifestly an attempt to tie the analyst up, control and hold on to him before the holidays, but I think that there is another communication going on; that thechild isprojecting into the analyst his own infantile self, with it's experience of being desperate and a stupid idiot of an infant, unable to move, immobilised, stuck in his gluey, gummy faecal nappies, wet and dirty, while his parents came and went and left him alone in his distress, and this is called' holiday's'. This is the only way that he can convey something of his experiences to the therapist that are outside of his verbal range" (in Feldman & Spillius, p.14l). 2.2.2.2. The transference relationship Unlike Freud, and, to a lesser extent Klein, Greenson's (1965) work on transference contributed to the new emphasis on the dyadic nature of the analytic selling, and of the transference Itself. Byseeing the analytic experience as an Interpersonal one. rather than one in which the patient's unconscious unfolds before the analyst's "blank screen" (Ehrenreich, 1989, p.50), the way was opened not only to seeing non-iransference aspects of the relationship, but to seeing the transference itsclf as interpersonal. As Greenberg and Mitchell (1983) would have it: ·Whatever the analyst does shapes the transference paradigm, whether he responds to the patient or fails to respond. The analyst's panicipation exerts a pull on the patienL Similarly, the patient's experience of and behaviour towards the analyst exert pulls on the analyst who can usefully employ his awareness of these pulls in the service of understanding the patient's relational pauerns" (p.389). 31 It is no longer felt that the patient's past "...is like those woolly mammoths scientists dig from the past. perfectly preserved through the millennia" (Wachtel, in Ehrenreich. 1989, p.39). Rather, present behaviour and its consequences playa role in perpetuating and recreating new maladaptive forms of behaviour (Ehrenreich, 1989). These views adhere to Sullivan's premises that "the data gatherer is never an objective reporter, but always a participant observer" (1950a, p.324). The emphasis then, in analytic therapy is very much in the here and now, in the relationship between analyst and patient, and how this impacts/reflects on the past. As will be seen later in the text, this thinking is directly in line with the Interpersonal conceptualisation ofthe therapeutic process. 2.2.2.3 Change. and how tt is achieved Analysis is a process which aims to achieve psychic change through understanding. that is, an emotional experience of learning (Spillius, 1992). The primary tool of this process isinterpretation. Interpretation is a term that is bandied around, both in Psychoanalytic, as well as in non Psychoanalytic groups. It is avague and broad term. Interpretation has two main functions in Psychoanalytic therapy: it is the "tool used to make the unconsciousconsclous" (Strachey, 1981, p.J61.), and, it is the instrument used by the analyst to let the client know that he/she is being fully understood and contained (Segal 1988). This could be likened to the Rogerian 'I concept of empathy. 32 The firsl funclion of Interpreutlon, i.e, "making the unconscious conscious" is misleading. as it seems 10 imply Ihallhe therapist is aware of the unconscious malerial. and merely needs 10 give Ihe palientlhis same insight. II also implies thai all thet is necessary for change is Insight into this unconscious malerial. On this basis, interpretation has been heavily criuclsed and. to some extent misunderstood by many other schools of thought. Swan and Wiehahn (J979) leveled ihe following criticism atinterpretation and insight therapy: .. To understand that you are insecure. tense, withdrawn. and lack assertive qualiries, because ora multitude or factors in your past, does nOI alter your feelings. In (aCI il could make you feel more inadequate" (Swart & Wiehahn, 1979. p.27), Thisquote implies Ihat insight isapurely intellectual, cognitive process. While insight is certainly one of the main aims of analytlc iherapy, this is only one aspect or the interpretation. Furthermore, insight is aimed at being an emotional rather Ihan a purely intellectual experience. Analylic literature makes it qulte clear Ihat for an lnrerpretauon to be change promoting. it needs 10 have emotlonal immediacy in Ihe here and now. (Strachey, 1981). In other words. the patient needs 10 experience what he/she isdoing in the room. Bion (1967 ) puts il succinctly when he says: "Psychoanalytic observation is concerned neither with what is going to happen nor wilh what has happened. but ralher with what is happening" (p.2S9). (This is dirferent from Classical Psychoanalysis in which the analyst is privy 10 an objective reality. Interpretalions are a way of giving thc client insight inlo this rcality) (Greenberg &r. Mitchell. 1983: Ivey, 1992. Siegal. 1991). •• JJ In this way. the interpretation has become a living. dynamic pan of the therapeutic relationship. and certainly not a dry 'rehash' of past events. (Ehrenreich. 1989. p.J9). Furthermore, what is interpreted is not only the verbal or content aspects of the session, but very importantly. it is the projective identification, or the feelings left in the analyst that are scrupulously examined and interpreted. AsJoseph. (1989 C). p.9S) says: .. Interpretations dealing only with the individual associations would touch only the more adult part of the personality. while the pan that is really needing to be understood is communicated nonverbally through the pressures brought on the analyst". The second function of interpretation. i.e. making the client feel fully understood and contained. derives from the premise that as infants. there is a great need to be held both physically and emotionally by the mother (Winnicort. 1955). This holding. Winnicolt states. facilitates psychic development because it allows a time span in which to cope with anxieties (in Salzberger- Wlttenberg, 1970. p.143). Failure to respond appropriately. leads to a feeling that aggression. depression. or terror cannot be tolerated or borne by the other. and in Bion's words a "nameless dread" is experienced that is endless and unspecified 0962. p.42). Following from this. the therapist. through interpretation. demonstrates to the patient that he understands. and is able to tolerate his anxiety. (ear and aggression. The patient. not unlike the infant. will experience relief that someone else is capable of living with these feared pans of himself, and the anxiety is lessened (Salzberger•Willenberg. 1970). •• 34 Related to this. interpretation further clarifies. differentiates. and gives the vague feeling aname. linking i1to what is meaningful. This modulates the pain. and Importantly, lessens anxiety (Bion, 1962). 2.3 CONCLUSIONS It is clear that the major developments that have taken place over the last fony to fifty years in Object Relations has been in the arena of therapy. and the technique and tools of the therapist. The refinement of the terms transference. countertransference. projective identification and interpretation has moved Psychoanalysis from focusing purely on intrapsychic. past oriented phenomena, to more emotionally immediate, interactional phenomena. Within this. the role of the therapist has changed. Whereas previously. the analyst was required to be objective. steering away from any personal feelings orreactions. this. in current Object Relations has become the primary tool for understanding the patient and the process of therapy. It is not information (or insight), alone that is understood to be change producing. but also the relationship that develops around the communi cation. Nevertheless, the belief in the unconscious and phantasy world of the individual, roots current Object Relations in a philosophy which influences how the concepts of transference, countertransference. projective identification and Interpretation are understood. ,. 35 CHAPTER 3 INTERPERSONAL THERAPY: FIRST ORDER CYBERNETICS "Psychotherapeutic practice is in a state 01 transition. There has been a shift in the model used to conceptualise the process. Today the individual person is no longer viewed as a fixed entity Insteadhe is sun as an integralpart01 the physical and interpersonal world in which he exists. Boundaries between the individual and his overall environment are always in a state of complex interpenetration or ecological balance. This point of view is in sharp contrast to the former view of the individual patient as primary object 01 therapeutic exploration and intervention. H (Chrzamowski, G.• 1982, p.2S). 3.1 THE BEGINNINGS: SULLIVAN·THE FATHER OFTHE INTERPERSONAL TRADITION The first systemic articulation of Interpersonal theory was presented by H.S. Sullivan (1940; 1964; 1972). For the first forty years of it's history, Psychoanalysis was relatively homogeneous. It was not until the 1930's that a broad alternative tradition began to emerge, explicitly breaking with Freud's drive structure model. This alternative tradition came to be designated as Interpersonal psychoanalysis, the key figure being Harry Stack Sullivan. (It is important to note that while Objer4 Relations therapy was regarded as a refinement of classical Psychoanalysis, 36 Interpersonal psychoanalysis was regarded as a complete break away from the classical tradition) (Mitchell & Greenberg. 1983). According to Mitchell and Greenberg (t983), Sullivan is perhaps one of the least understood and most underrated theorists. Sullivan's work began primarily as a reaction against the Kraeplin approach to Schizophrenia. Kraeplin, (who is still regarded as the father of modem day Psychiatry), had organised disorders such as catatonia. delusions, hallucinations and hebephrenia under a general disease entity he had termed dementia praecox. He argued that all these subtypes reflected a similar underlying, irreversible deterioration, leading to a total disintegration of mental and emotional functioning (Mitchell & Greenberg. 1983). Sullivan was struck by the disparity between theschizophrenics who he worked with. They appeared to reflect an adaptation to circumstances. and seemed accessible to therapeutic intervention. This led him to become intrigued by the way that scientists Sullivan's early papers on Schizophrenia called for a new methodology that would force the researchers attention onto the person suffering the pathology rather than on the researchers own preconceived formulations. He felt that the major function of these preconceived formulations was to· impan an illusory sense of power, knowledge, and objectivity "(Mitchell & Greenberg. 1983, p.84). The basic principles of Sullivan's (t 964) Interpersonallheory then. were forged' by his effons to disentangle the psychiatry of his day from it's history of blologlsms and pseudo-objectivity. 37 He believed Ihat language itself could be dangerous in Ihat it is possible to attempt 10 fill the gaps of what is not understood wiih all sorts of places and processes, objects and structures, Ihal presumably reside in the patient's head. This, hefelt could be misleadingand hannful. Hesaid of the unconscious: II The unconscious, from the way Jhave actually presented the thing, is quite clearly that which cannot be experienced directly. which fills all the gaps in the mental life. In the broad sense the postulate of the unconscious has. so far asI know. nothing in Ihe world the matter with it. As soon as you begin to arrange the furniture in something that cannot be directly experienced. you are engaged in a work that requires more than parlour magic and you are apt to be embarrassed by some skeptic" (Sullivan, 1964, p.204). Implicit in this is a deep respect for the intricacy and uniqueness of each individual," one must not take one's theory, one's diagnostic concepts. one's explanatlons, 100 seriously. In the end Ihe actuality ofthe living person always eludes the theory and is more complex than the diagnostic formulations" (Sullivan, in Mitchell & Greenberg, 1983, p.90). It is this belief that separates Sullivan from Object relations thinking which elaborates an entire world of unconscious pbantasies, a difference that slill exists between modem Object relatlons and Interpersonal therapy. Sullivan argued that the field of psychiatry is the field of "...interpersonal relations • a personality can never be isolaled from the complex of interpersonal relations in which the person lives and has his being" (Sullivan, 1940, p.lO). All knowledge of snoiher person, he suggested, is mediated 'I through inleractions with that person. by listening to the reports of his interactions and experiences. In this sense. the dall gatherer is never an objective reporter, but always a participant observer(Sullivan, 1940). 38 He further maintained that human experience conslsu of pauems of processes, and not concrete substantial mechanisms (Mitchell & Greenberg, 1983). Hestrongly criticised Freud's conceptualisation of a biological process that was fixed, and in some cases irreversible, and maintained that pathology was a function ofthe patient's early Interactions with others. According to Sullivan, it is inconceivable to perceive ofan infant outside of an Infant-mother dyad. In Sullivan's view, the infant has no psychological existence prior to interactions with his or her caretakers. The expression by the infant ofhis need calls out a complementary need inthe mother; the need to be fed calls out the need in the mother to nurse. Thus, satisfaction of the need is not perceived as an end in itself (as is the case in classical psychoanalytic thinking), but rather functions as a "zone of interaction", providing a channel to the other, and facilitating interpersonal integration (Mitchell & Greenberg, 1983, p.92). In line with this thinking, needs undergo various transfonnations over the course of the individual's development. This begins with the basic need for bodily contact, to other forms of relatedness (for example, the need for collaboration by peers in pubeny, to the need for a loving intimate sexual relationship with another in late adolescence, early adulthood). In other words, eachdevelopmental threshold is introduced by theemergence of the need fora new, more intimate form of relatedness (Mitchell & Greenberg, 1983). The most imponant Interpersonal themes developed by Sullivan have been summarised by Anchin and Kiesler (1982, p.3·4) as (ollows: • "Human personality is the "relatively enduring pattern of recurrenf. interpersonal situations which characterise a human life" (1953B, p. 110-11 1). 39 • "A persons self system is above all Interpersona! in both its development and its current and evolving contents." • "Deviant human behaviour is the consequence of disordered interpersonal relations and is manifested in disordered interpersonal communication." • "Disordered communication includes both the verbal and non-verbal channels." • "Disordered communication reflects a person's "parataxic distonions" which, in the therapy comext, take the form of generalising to the therapist as a present day partner of earlier experiences in interpersonal relatedness. " • "Interpersonal transactions are characterised by continuous negotiations of complementary needs through reciprocal patterns of activity among participants." 3.2 THE STRATEGIC POSITION Subsequent toSullivan, the emergence of two interrelated projects rather than a single individual was responsible for the development of the Interactional or communications approach to therapy. The first organisation was the Double Bind communications project that was begun in 1952 by Gregory Bateson, with Jay Hayley and John Weakland as II members ofthe project (Kiesler, 1982). The work of Gregory Bateson and his colleagues was spurred on by a discontenl with ihe so called Newlonian epistemology evidenced amongst 40 Psychoanalysts in the early part of the twentieth century. Newtonian epistemology is defined as atomlstic, reductionistic and anti-contextual and follows an analytic logic concerned with discreet elements (Keeney. J983). Bateson's research project on communication. which culminated in the development of the "double bind theory" in J956 broke with the previous tradition of treating psychotherapy as a linear. causal Individualistic entity, into the realm ofthinking about systems as entities with lives of their own. While this work was nor directly derived from the work ofSullivan. ir was also borne from a discontent with psychoanalysis and reductionistic thinking. and was also developed through work with schizophrenic patients. The etiology of schizophrenia was viewed as a pallem of habitual communication impasses imposed on one another by persons in a relarionship system (Hoffman, 1981). Haley (in Hoffman, 1981), in discussing a schizophrenic family says of the double bind: .....the double bind could be seen as a tactic in the interchange between two people as they each auempt to gain control of the range of the system. By imposing a double bind a person can effectively prevent another from governing what sort of relationship they will have" (p.22). Bateson and his colleagues (in Horrman, 1981), set our formal condirions 85 prerequisites for parhology producing binds: a) Two ormore persons. b) Repeated experience. The assumprion was made that the double bind' was a recurrent theme inthe experience of the socalled victim, 41 c) Aprimary negative injunclion. The lnjunctlon had either of two forms: (l) "do nOI do Ihal or I will punish you", (2) Mif you do that I will punish you". d) A secondary Injuncticn connicling wilh Ihc first al a more absiract level. The description of Ihis injunclion was regarded as more ditricull for mainly two reasons; (i) il was commonly communicated nonverbally (ii) the secondary injunction may have impinged on any element of ihe primary injunction and thus includes a variely of forms; for example "do nOI regard this as punishingMor "do not regard me as Ihe punisher" and so on. e) Alerliary injuncrion prohibiting Ihe vicum's escape from the field. n All of the mentioned bind producing ingredients did not necessarily need 10 be present once the victim had learned 10 perceive his universe in double bind paucrns . This work created a clear movement away from individual psyche, or incrapsychic structures. and towards interpsychic or inlcrpcrsonal explanations (or pnhology. The second organisllion was the Menial Research Inslilule (M.R.I.) founded by Jackson In 1958. with both Virginia SAlir and Paul Walzlawick as two imporllnt members o( the inslilule .They developed what isloday known as the Stnlegic orInleraclional model 10ps)'cholherapy (Waul.wick.. 1967). The key wumplion of Stralegic Iherapy Is the belief Ihll behaviour occurs u pan of I sequence of ongoing inleraclional recursive evenu (Fish" Piercy. 'I 42 1987). Consequently, symptomatic behaviour is seen as pan of a sequence of ongoing interactional recursive events. The premises that underline this model of psychotherapy are as follows: a) The sysrem governs thebehaviour of the individual (ihrough its specific interactions) : b) Symptoms disappear as behaviours or social relations in the system or family are altered; c) Symptoms will disappear once you change one variable in the system; d) The therapist "acts on" the individual in a specific way with specific goals and interventions, in a supposedly objective way (Watzlawick et al., 1967, 1974,1977). 3.2.1 Theoretical assumptions In order to fully understand the Strategic approach to psychotherapy. it is important to briefly examine some of their theoretical axioms or principles. Thesewill beexplored under the following headings: A) Communication B) Problems as solutions C) Change A) Communication Watzlawick (1974) maintains that it is impossible not to communicate. Therefore, all behaviour in an interactional situation has I "message value (p.SS). II He also suggests that communication does not only convey information, but it also imposes behaviour. In other words, all communication consists of both a report level (the content), and a command aspect (what sort of message it is to be taken as; adefinition of therelationship). Within this line of thinking, Watzlawick (1977) maintains that "crazy" communication tS not necessarily the manifestation ofa sick or disturbed mind, but is a reaction (perhaps the only possible reaction) to an untenable or absurd communicational context. The double bind Building on Bateson's (1956) theory. Watzlawick et al. (1967), expand and refine this original definition by defining the ingredients for a double bind as follows (i) Two or more persons involved in an intense relationship that has a high degree of physical and/or psychological survival value. (m In such a context. a message is given which is structured so that it (a) asserts something: (b) asserts something about its own assertion, and (c) two asscnions are mutually exclusive. (iii) The recipient of the message is unable to step out ofthe frame set by the message either bycommenting or withdrawing. (iv) Where double bind is of long·lasting, chronic duration, it will tum into habitual expectation regarding the nature of human relation ships. 'I 44 (V) The paradoxical behaviour imposed by double binding is in tum of a double binding nature. and this leads to aself perpetuating pauem of communication (p.212.215) Since the message is paradoxical. any reaction to it must be equally paradoxical. It is therefore not possible to be consistent and logical within an inconsistent and illogical context In Watzlawick's view (1967). the double bind theory is a true paradox. The double bind creates a situation in which there is an illusion of choices. and the person is usually "damned if he does. and damned ifhedoes not" (p.222).There is no escape. Punctuation Watzlawick (1974) maintains that punctuation organises behavioural events and is therefore vital to ongoing Interaction. Nevertheless. disagreement about how to punctuate events is. he believes at the root of most relationship struggles. Because punctuation leads to different views of reality, it becomes almost impossible to break this cycle until the communicants are able to metacommunicate (i.e. to talk about their comrnunlcarion) (Watzlawick et al., 1974). According to Watzlawick et al. (1974), disagreement about how to punctuate events is at the heart of many relationship struggles. By way of a case study, they illustrate this as follows: "Suppose a couple have a marital problem to which he contributes passive withdrawal, while her 50 percent is nagging criticism. In explaining their frustrations, the husband will state that withdrawal is his only defense against nagging, while she will label this explanation as a gross and willful distortion of what "really" happens in their marriage, namely, that she is critical of him because of his passivityol' (p.56). 45 At the root of these punctuationconflicts lies the conviction that there is only one reality, and any view that differs from this reality is due to the other partner's irrationality. In this regard, a vicious circle ensues (Watzlawick et al., 1967). B) Problems as solutions According to the M.R.I. group, problems are created by wrong attempts at solving difficulties that individuals find themselves ,in during various stages of development (Watzlawick et al., 1974; Weakland et al., 1977). "We view long standing problems or symptoms not as 'chronicity' in the usual implication of some basic defect in the individual or family, nor even that a problem has become 'set' over time, but as the persistence of arepetitively poorly handled difficulty" (Weakland er al., 1977. p.28l). Watzlawick et al. (1974) believed that fallacious assumptions about the problem are often perpetuated by ihe individual or family. The first of these they termed the utopian syndrome. Here, there is a belief in an ultimate, all embracing solution, and it is often these solutions that become the problem. "Common to all aspects of the utopia syndrome is the fact that the premises on which the syndrome is basedareconsidered to be more real than reality .... when trying to orderhis world within this premise. and seeing his attempts fail, he will typically not examine the premise for any absurd or unrealistic elements of its own, but will blame outside factors, or his own ineptitude" (Watzlawick etat, 1974, p.34). Watzlawick (1974) maintained that the utopia syndrome is an ailment that' manyschools ofpsychotherapysuffer from. To wish, for example. for a client to be selfactualised or to gain insight, might ultimately create the problem. 46 Other than the 'utopian syndrome', Watzlawick et al. (1974) also talk about lithe terrible simplifications" (pAO). In this instance, there is either a complete denial Ihat there is a problem, or a gross simplificalion of the problem. Furthermore, any-one who tries todeal with this problem is regarded as either "...mad or bad - in fact. he may be the source of whatever difficully is admiued" (pAO). In this regard, the original problem becomes compounded by the problems created through it's mishandling (Walzlawick etal., 1974). C) Change According 10 the M.R.I. approach, "...strategic interventions are in the service of disrupling pathological interactions, panicularly those related to the problem solution context" (Israelstam, 1988, p.l85). The M.R.I. researchers speak of therapeutic change occurring once the "more of the same" interaction. or the "game without end" is interrupted (Watzlawick et al., 1974; Weakland et al., 1977). "They auernpt to shift the family/individual from first order auempts at change. i.e. 'cosmetic' changes. 10asecond orderlevel ofchange that involvesa change in the fundamental rules and patterns of Ihe family or system" (Israelstam, 1988, p.185-186). The authors of Change (Watzlawick et al., 1974) succinctly describe the difference between first order change, and second order change. by using the metaphor of driving a car. Pressing the petrol pedal is regarded as first order change. whereas changing gears issecond order change. The M.R.J. approach is mainly concerned with changing gears • changing the way the individual is attempting to bring about change. In oilier words. rather than 8Itempting to alter the problem. they see change occurring when the attempted solutions applied to the problem behaviour are altered. 'I 47 3.2.2 Therapy from a Strategic point of view Unlike the earlier Psychoanalytic approaches to psychotherapy, Strategic therapy aims to be non- utopian (Watzlawick et al., 1974; Weakland et al., 1977). In other words, Strategic therapy aims to solve only the problem that is defined and do not seek to bring about vague utopia's for their clients such as self actuallsation, insight or even happiness. They deal only with the presenting problem. Watzlawick et al. (t974, p.57) stress that therapists should set small reachable goals: ",.lest therapy becomes it's own pathology, it must limit itself to the reliefofsuffering: the quest forhappiness cannot beit'stask". According to the authors of Ch.a.nie (Watzlawick et al, 1974, p.ll0), four stages orsteps should be followed before changecan occur. These are: a) A definition ofthe problem; b) Investigation of the solutions auempted so far; c) A clear definition of the change to be achieved; d) Implementation of a plan to bring about that change. Therapy is perceived 10 proceed according to specific and set schema that are predictable and finite. 3.2.2.1 Th« rol« olthe therapist The Strategic therapist's key role istoalways be in control during the therapy. He or she is perceived to be the expert, innuencing the patient and being responsible for what happens during the therapy. 'I <48 According to Weakland et al, 0977 p.292). the therapist is a "specialist at influenceR; the therapist is wholly responsible for defining the problem. selling the goals and ensuring that change isbrought about! Strategic therapists do not believe that a therapeutic relationship Is necessary for change to occur. but rather it is the techniques or Interventions that are applied by the therapist in a unilateral way that are seen to be the means of implementing change (Weakland et al., 1977). Strategic therapists perceive their goal in therapy as one in which they manipulate and influence. Watzlawick (1974) states that it is impossible not to influence or manipulate while interacting. and say's, "the problem therefore. is not how influence and manipulation can be avoided. but how they can best becomprehended and used in the interest of the patient" (p.xvi). 3.2.2.2 Focus on behaviour As mentioned previously. Strategic therapy sees behaviour 85 occurring as part of a sequence of ongoing interactional recursive events. Because of this. one of the main goals of therapy is to "break the redundant behaviour sequence that maintains symptoms" (Fish & Piercy. 1987. p.122). Their focus is thereby primarily on the behaviour sequences of problem behaviour and solution behaviour (Watzlawick et al., 1974). Fishand Piercy (1987) put it succinctly when they say: "Strategists take the symptom at face value. and the aim then is tq, identify those interactional patterns which maintain the problem" (p.J2J -124). Insight into the problem. or even explanations on the pan of the therapist is not perceived as necessary forchange tooccur: •....if change 49 occurs without the client knowing how or why, that is sufficient (and often preferable)" (Fish & Piercy, 1987, p.12I). Watzlawick et al. (1974) corroborate these ideas by saying that the explanation of the problem adds nothing to the solution. These ideas are in direct contrast with Psychoanalytic therapy, which places great store by the patients gaining ofunderstanding orinsight into the problem. The focus here ison the behaviour ordiscreet sequences of this behaviour. 3.2.2.3 The tools ofchange As mentioned previously, Strategic therapists perceive their techniques or tools as the primary means of changing behaviour. The therapist is regarded as the expert or protagonist in ensuring that these tools are implemented appropriately. Weakland ct al, (t 977) note that the therapist's main task is .....one of taking deliberate action to alter poorly functioning patterns of interaction as powerfully, effectively and efficiently as possible" (p.278). The therapeutic techniques are used in order to interrupt the redundant, recursive pattern of interactions, and to bring about behaviour change: "Once we have formed a picture of current behaviour central to the problem and estimated what different behaviour would lead to the specific goal selected, thetask isone of intervening to promote change" (Weakland et al., 1977, p.287). 'I 50 It is also stressed that in order for an intervention to be successful, it is vital that the therapist 'speak the same language' as the client. In other words, the intervention utilised must 'fit the client's framework', As Weakland et al. (1977) put it: "We auempt early in treatment to determine what approach would appeal most to the panicular patient. to observe "Where he lives", and meet this need, whether it is to believe in the magical, to defeat the expert, to be a caretaker ofsomeone, to face a challenge, or whatever. These characteristics of different individuals are seen not a obstacles, but as potential levers for useful intervention" (p,288), The main techniques or interventions associated with Strategic therapy include two main categories of tasks, namely, reframing or relabelling the problem, and the use ofparadox, (prescribing the symptom, prescribing relapse, re-enactment of symptoms, and behavioural tasks) (Fish & Piercy, 1987; Watzlawick, 1974; Weakland et aI., 197i). 3.2.2.3.1 Rc:l'ramlng Watzlawick et al. (1974) provide the following definition of reframing: "To reframe, then, means to change the conceptual and lor emotional selling or viewpoint in relation to which a situation Is experienced and to place it in another frame which filS the "faclS- of the same concrete situation equally well or even better, and thereby changes its entire meaning (p.95). What ischanged therefore as a result ofreframing is the meanings attached to a II cenainsituation orproblem. 51 Watzlawick et al. (974) illustrate the an of reframing by way of a case example. A man with a Iife·long stammer tries his luck as a salesman. For obvious reasons, this career choice exacerbates his concern over his speech defect. Watzlawick and his colleagues reframed the situation for him as follows: "Salesmen are generally disliked for theirslick, clever ways of trying to talk people into buying something they do not want .... On the other hand, had he noticed how carefully and patiently people will listen to somebody with a handicap like his? Had he ever thought what an unusual advantage his handicap could become in his new occupation?" (p.94·9S). What has been changed here, is not necessarily the presenting problem (i.e, the stammer), but rather, the meanings attached to that problem (Watzlawick et al., 1974). Reframing does not aim to produce insight, or to draw silention to anything. It merely illustrates an alternative framework which makes the old one obsolete (Watzlawick etaI., 1974). 3.2.2.3.2 ParQdox Paradox, or the use of paradoxical instructions involves the "...prescribing of behaviour that appcan in opposition tothe goals". Weakland et al. (1977) suggest that the success of paradoxical inslructions lies in the fact thai the patient feels more in control, of his or her symptoms. They say: ,. 52 MAcling on such a prescription usually resulls in a decrease of the symptom • which is desirable. BUI even if the patient makes the symptom increase, this 100 is good. He has followed the therapists inslruclion, and the resuh has shown that the apparently unchangeable problem can change" (p.290). By the therapist instructing hislher patient 10 perform a symptom, he is, in effecr implying that the patlent has control over hislher symptom. The therapeutic paradoxical injunction places the patient in an untenable position whh regard 10his pathology: "If he complies, he no longer 'can't help it' ... if he resists, he can only do so by nOI behaving symptomaucally, which is the purpose oftherapy" (Watzlawick, 1967, p.24I). The therapeutic doublebind creates asituationwhere the patient is "Changed if he does, and changed if he doesn't (Watzlawick, 1967, p.24l). 3.2.2.4 The therapeutic relationship It is clear from the preceding discussion thai the Siralegic therapist is in a superior, controlling position, actively conirolling the course and direction of therapy. II is this mela or superior poshion Ihal allows him or her the opporlunily 10manipulate and maneuver the patient into the dlrection thai he or she seesfil. Whilethese authors are generally alpains to say Ihalthey donot follow a 'cook book type' Iherapy. and that eachclient needs 10 be considered as an individual (Weakland et 81., 1977; Walzlawick, 1974), Iheir focus is llmited to tbe sequences ofbehaviours. and there is no auernpt to decipher any other aspect of the therapeulic relalionship. •• S3 3.3 INTERPERSONAL THERAPY There have been a number of different developments in the field of Interpersonal therapy since the writings of Watzlawick, Weakland, and Hayley. Kiesler (1982) has set out a conclusive summary (or "Interpersonal manifesto"), of the main assumptions that are common to all Interpersonal theorists about personality. It will be noted that some of these assumptions rest heavily on the work of earlier theorists, but also tend to redirect. extend and broaden these works. 3.3.1 Assumptions about personality The five main points. directly quoted from the text are as follows: I. "Interpersonal study focuses on human transactions, not on the hehal'iour ofindividuals" (Kiesler. ]982, p.5). This assumption reflects Sullivan's theory which stressed the fact that the concept of the individual apart from other persons is a myth. and that personality is manifest in interpersonal situations only. Kiesler (1982) makes the point that even in moments of solitude. our "...self reflected moments or appraisals are interpersonal. Ouranxiety laden moments ofexistential crisis are dominated by our awareness of separation from others" (p.5). 2. "The const11lcl ofselfoccupies a centraltheofttical position. 77tis self is social, interpersonal, transactional in its dtvt!lopmenl and functioning throughout llfe» it is not a hiologically, physiologicallyor,. inrrapsychically restricted notion" (Kiesler. 1982, p.6). 54 In other words, what the individual thinks about himselflherself is inextricably linked to what he/she thinks others think of him/her. As Goffman (1967) stated a person uses various personal perfonnances to create certain effects on his audiences, orinteractional partlclpants, To put this in aanother way. the person sends out covert or oven responses that cue or pull others to respond in a particular way towards him/her. Swenson (in Anchin & Kiesler, 1982, p.e), state: "...literally, to exist as a person, to have a self, to be a personality, one must have others to interact with. If there is no one to interact with, no self. no personality, no human being, as we usually think of the concept can exist". 3. • An lnteractionist position is taken whertby a person's social behaviours are a junction of both his or her predispositions toward transactions and situations/environmental events" (Kiesler. 1982, p.B), This point is an important departure from that of the earlier Interaciionists (e.g, Watzlawick, Hayley, Weakland etc.), It implies that what is important is not only the objective, observable facts of the situation, but also the individual's predisposition, which will effect his orherresponse to agiven event. 4. "In attempting to understand and explain human transactions, Interpersonal theorists adopt a notion 01circular rather than linear causality. Ratherthan viewing aperson's behaviour as a direct effect 01 situational events and intrapersonal motives, the locus instead is on a two person mutual influence. on bi-directional causality" (Kiesler, 1982, p.9). Vorster (1979, p.I3) gives the example of the behaviour between couples. onel partner of which is an alcoholic. He makes the point that rather than trying to ss find the source of particular behaviour pauerns, an auempt is made to determine the purpose of such behaviour; it would seem Ihat the relationship between an alcoholic and the non-drinking spouse is of such a nature that the usage ofalcohol apparently is an important prerequisite for the functioning of the alcoholic (and spouse) in the particular relationship. What is significant here is Ihal there seems to be a slrong tendency for the wife of an alcoholic, should she divorce him. to marry another alcoholic (vorsrer, 1979. p.16). Furthermore, if the alcohol is removed, other problems seem to manifest in the relationship. This illustrates the Imerpersonal assumplion that human relationships are not cause and effect, but are circular; " ... embedded in a feedback network wherein the effecl influences or alters the cause. where the person affects and is affected by the environment" (Kiesler, 1982, p.9). 5. the vehicle lor human transactions is communication, including linguistic and non verbalmessages" (Kiesler, 1982. p.8). Many of Ihe ideas related 10 the above originated from the M.R.I. group (Watzlawick, Beavin & Jackson, 196i). Communication refers to messages sent by an encoder (sender) to a decoder (receiver), and the decoder's reciprocal response. It consists of a complex stimulus panem Ihat includes messages sent simultaneously along the linguistic and non verbal channels (Anchinand Kiesler. 1982). According 10 Walzlawick. Beavin & Jackson (J967), there are two levels of simullaneous messages sent between participants. The one level is where auentlon is usually focused. the "report" level. This includes the manifes\, content ofspeech. information coded symbolically onrhe linguistic level. The second level is usually out of focus and serves as the "ground" or command leve, These Anchin and Kiesler refer to as Ihe .....emotional and self presentatlone] messages we send 10 others primarily through non verbal 56 signals" 0982, p.l O. It is the command or ground level that predominates in the transmission of emotional and relationship communication, and this is often thefocus oflnterpersonal therapy, 3.3.2. Psychological problems in Interpersonal terms According 10 ihe Interpersonal view, normal behaviour is characterised by flexibility in behavior. This implies not only the ability 10change, but also the capacity 10 aCI appropriately in different interpersonal sltuations, and to be open and sensitive to the ways Ihal others behave (Van Kessel & Van der Linde, 1974). Following from this, an individual's behaviour is described as abnormal when he does nOI have flexibility at his disposal which would make it possible to aCI appropriately. Pathology exists when there is a deficit in openness. As a result, rigidiry and stereotyped behaviour occurs. For example, "He (a person having psychological problems) may always choose a submissive dependent role in relation 10 others. and try to maneuver people to react appropriately" (Swan and Wiehahn, 1979, p.19). Leary (in Anchin and Kiesler, 1982, p.l3) states,"...the more extreme and rigid the person, the greeter his interpersonal 'pull'·thegreater his ability 10 shape the relationship with others." Another imponant aspect of disturbed interpersonal relations is apparent in communication. When a person (with psychological problems) finds himself in a situation Ihal he cannot deal with, or that places demands on him that he cannol connol, he will try and deny the fact that he can communicate. It is nevenheless, according to the Inleractionalists, Impossible nOI to communicate, and therefore, the person is forced to find a wayto communicate, but deny that he/she iscommunicating (Watzlawick, Beavin & Jackson, 1967). II 57 Van Kessel and Van der Linde (1974) describes Jhoe WQ)'S in which communication can be confused. and thereby serve ihe purpose of denying lhat communication has taken place. These are discussed. highlighling the advantage that it has for the sender and the effectlhat it has on the receiver: I. S>""ptoms QS interactional arrangements Hayley (1963) describes a symptom as a way of dealing with others in interactton. Symptoms can be seen as Indirect ambiguous communications through which an appeal is made on ihe other person. On a first order level lhe individual communicates a message bUI on Ihe second order level he denies responsibility for his communication because he does not see himself in control of his symptom. 2. Emotional influencing asinteractionalarrangement When the Implicit or covert message is more important than tbe content level, the receiver is involved in an emotional climate in which it is difficult 10 clearly distingulsh the precise nature of the appeal madeon him. Subsequent confusion between the content and the effecl ofthe communicerlcn prevails. 3. Incongruent communications A double message is sent because the way in which the communicalion is expressed is nOI the same as Ihe content of lhe communication, The double bind, first described by Bateson (1956). is another form of confused communication (see p.40 of this text). •• 58 4. Lack ofctarity about who the communication isdirected to When the sender does not feel able to speak to the person who the communication is directed to, he will send the message through another person, then deny that the communication was meant for the person it was initially directed to. This leaves the option open to denyhisown communication. S. Lack ofclarityin the definition ofthe relationship If the sender or the receiver is not clearly identified, the definition of the underlying relationship is also unclear. People do not know what the relational rules are in the relationship, and the meanings auribured to the communicated information remains unclear. Fierman (1965) refers to Kaiser who graphically describes the experience of beingon the receiving end of confused communication. He observed that the patients: "...did not talk straight. They were never completely, never wholeheanedly behind their words. Listening to them rcquired a very special effort. Listening to Ihem almost required some inner struggles almost as if one has to listen to two different speakers talking simultaneously. There was a strange duplicity about their communications. There were words and sentences and whole stories which were quite understandable and made sense inthemselves; but the accompaniment of the tone of voice, facial expressions and gestures Interfered subtly and sometimes grossly with the total communication effect" (p.36-37). In summary, symptoms or psychological problems, expressed either through,. communication or particular kinds of maladjusted behaviour, are viewed as a way of dealing wilh others; a way offunctioning in interpersonal rclationships 59 (Hayley. 1963). and are not viewed as pathology Ihal can be located solely in the individual psyche. 3.3.3 Interpersonal psychotherapy As can be deduced from the Interpersonal view of boih personality and psychological problems, the focus here is on Ihe stqutncts of behaviour, as opposed 10 the traumatic experitncts of a person. The therapist's focus is not on the "source" of particular behaviour patterns, bUI rather an attempt is made to determine the purpose of such behaviour; "Towards what end is the question for which an answer is sought?" (Vorsler. 1979, p.13). Interpersonalists also maintain thai what happens in the therapy room between client and therapist is similar in major waJ's to any other transaction that tire clienthas outside (Kiesler, 1982). This is important in two respects: a) Because of the basic concept of circularity in relationships (discussed previously), the idea of the therapist "acring" on the client is fallacious (Beyers and Vorster, 1990). It follows from this, that raiher than studying or investigating the client unilalerally. the focus is on ihe interaction that lakes place between client and Iherapist • the therapeutic rtlatlonshlp. In Ihis regard, the therapist is. inSullivan's (J 940) words. a participant observer, b) It also follows that the client will display the same self defeating behaviour. and send the same evoking messages that he sends 10 others in his life. and. u a result...... the therapist will experience "live" in the sessions the client's distinctive inlerpersonal style" (Kiesler .1982, p.1 5). I. 60 A major component of identifying the client's distinctive evoking style is through the therapist assessing hislher own emotions or "pulls" experienced in the interaction. In other words, the therapist needs toattend to what impact or effect the client's behaviour/communication is having on himl1ler. Kiesler (1982) mentions four possible classes of impact messages that can be distinguished, namely: 1 Dirtet fetlings: the distinctlve emotions that the client evokes in the therapist, (e.g. sympathy, anger, boredom). 2. Action tendencies: the therapist may experience panicular do's and don'ts while wilh the client, (e.g. totreat him carefully, tosmash his face, erc.), 3. Cognitive attributions: the therapist might entertain various ideas in regard towhat the client is trying to do to him orher, (e.g, he is trying to get me to distrust him). 4. Fantasies: In interaction with the client the therapist might experience vivid images of himself and the client interacting, (e.g. therapist and client making passionate love). If the therapist responds in a complementary way (i.e., gives the response that the client invokes), this will merely reinforce or confinn the clients maladaptive/rigid behaviour. Subsequently,lnterpersonalislS maintain that it is the therapists role to give the a social response, and to 'meta communicate'; i.e. communicate about the communication (Kiesler, 1982, p.16). .1 61 Once the therapist has identified the client's rigid and self defeating evoking style, the task is to replace these with more nexible, and clear communication adaptive toa greater variety ofencounters (Kiesler, 1982). In order to guide the therapist, Swarl and Wiehahn (1979) devised whal is known as an Interactional analysis. This guide to assessing the clients interactional style involves the (ollowing questions: • "How does the client communicate" (verbal and non verbal. e.g, eye contaet, voice tonaluy, ere). • "How does the client communicate about his problems" (indicates Ihe meaning frames that surround the problem). • "Whal (unction does the client's symptom serve" (i.e, the possible (unction that Ihe client's problem serves, both interpersonally and intrapersonally). • MWhat is the nature of the client's relationships" (i.e. the client's habitual prompts and the responses they evoke). • "In what context is the client therapist relationship embedded" (p.28). 3.3.4. Change Unlike Psychoanalysis, which maintains that undentanding, both intellectual and emotional, is sufficient (or change. the Inlerpersonallst suggesl that a substantial price is paid sometimes If the therapisl does not intervene. The perspective described here mainlains thai the therapist must make direcl efforts 10 insligate and direct new behaviour patterns (Wachlel, 1982). " 62 According to Interpersonalists, persistent modes of rhinking, perceiving and relaring are not only maintained by certain psychic structures, bur are kept alive through the patlem's day to day living (Wachtel, 1982), While it is acknowledged that early patterns persist, the person's patterns of experiencing and interacting with others tends to recreate the old conditions again and again (Wachtel, 1982). Furthermore, it is suggested by these authors that it is impossible for the therapist to be what Freud termed a "blank screen", Even ifthe therapist is silent, heorshe is still impacting onthe responses of the patienl.(Wachtel, 1982). Subsequenrly, the Interpersonal therapist uses a number ofdifferent techniques at hislher disposal in order to change this pattem of behaviour, thereby breaking through this vicious circle. It is maintained that psychotherapy seeks to change a person's behaviour in order to "bring the patient to an optimum lnteractlon with his environment" (Wiehahn, 1975, p.170.). Nevenheless, these authors do not exclude interpretation of the maladaptive behaviour orprocesses as one of the many other Interventions that can be used. Someofthe other techniques used include paradox and reframing (Watzlawick, Weakland and Fisch, 1974), and any other active intervention that the therapist feels will do thejob of changing the vicious cycleof maladaptive behaviour, Clearly, there is a lot of emphasis placed on the therapist's own creative skills and Ilexibility in developing the right strategy for the panicular problem or symptom. " 63 3.4. CONCLUSIONS II is clear from the preceding discussion that Interpersonal therapy has developed mainly as an offshoot of the work of Sullivan and the earlier Strategic and Interactional theorists. The earlier Strategic and Interactional theorists' discontent with the deterministic, linear thinking evidenced in Pychoanalysis, led to the development of a theory that focused on the sequences of behaviour, as opposed to the pathology existent in the individual. How the person handled his or her Interpersonal environment became the cornerstone tounderstanding pathological or maladjusted behaviour. Not dissimilar to the development of modem Object Relations therapy, what has been broadened or expanded is the role of the therapist and the Importance or the therapeutic relationship. What needs tobe established now is how much of this current thinking is similar to that of modem Object Relations in regard to therapy. This will be dealt with in chapter four of thisthesis. •• CHAPTER 4 DISCUSSION OF SIMILARITIES AND DIFFERENCES 4.1 CLASSICAL PSYCHOANALYSIS AND INTERACTIONALISTRATEGIC THERAPY: DISCUSSION Interactional psychotherapy developed as a reaction against the detenninistic and linear thinking, such as evidenced in Freudian orclassical psychoanalysis. As a result, many of the concepts contained in Intcractional therapy are in direct opposition to psychoanalysis. The fact that many of the Interactionalists directly compared themselves to psychoanalysis (critically), is borne out by the following quotes: ~The intrapsychic model questions how the personality is constituted, whilst the interactional model asks "ow one person experiences another, and furthermore, how he allows others to respond to him" (Swan & Wiehahn, 1979, p.14). ~On the whole psychoanalysis remained primarily a theory of intrapsychk: processes, so even where the interaction with outside forces was evide, it was considered 'secondary~ as jor instance the concept 01'secondary gain" (Watzlawick, 1967, p.29). "In attempting to explain human behaviour, two basic approaches can be identified. The first 01 thest, and the oldest, can be termed tht "Intraps)'chic· model, which presupposes a mort or less fixed" personality structure from ....hich all human btha~'iour stems. In terms ojthis approach an attempt is made to explain the doings ofthl! human 65 personality and to find causative explanations for human behaviour. Much emphasis is placed on the history oj the existing behaviour patterns. This can be called a deterministic model. A relatively more ncentapproach. the "Interps)'chic" model, places the emphasis on the interaction with the environment. Human behaviour, in terms of this modtl isseen as Q product ojthe interaction between an individual and others in his environment" (Vorsrer, 1979, p,13). All the above quotes suggest an either lor scenario. In other words, Psychoanalysis examines the personality of ihe individual, whereas, Interactional therapy explores the individual's Interaction with the environment. The implicit danger in this type of thinking is thai one is forced to discount certain coneepu, no matter how valuable they are. For example, the focus of Interactional therapy is primarily on the sequence of behaviour, and all constructs that cannot be seen are merely discounted (such as the concept of the unconscious).This is, in the author's opinion, the most important limitation of early Interactional therapy. Ironically, in reacting against the deterministic linear thinking of classical Psychoanalysis, Interactional therapy became guihy of many of the same crimes. This ismost marked in the therapcuric arena, and the perceived role of the therapist. Both Classical Psychoanalysis and Stralegic therapy perceived the therapist as an "al1 knowing" figure. He or she was regarded as the specialist or expert who decided on the course of action for the patient/client. While the focus was different, (the Freudian analysl focused attention on the intrapsychic workings of the patient as opposed to ihe Stralegic therapist who focused on the inleractional behaviour of the client), objectivity was deemed in both instances, not only possible but desirable and cenlral to the effectiveness of the therapy. Countertransference, orthe subjectivc responses of the Iherapist were not taken into account in lhis equation, but werc regarded 10 be 'I 66 interference factors. As a result of Ihis, the therapeutic relationship in both instances was not used in any way tofurtherunderstanding. The development of both Psychoanalysis and Interpersonal therapy have revised this panicular aspect of their history, and ironically, the therapeutic relationship in both instances has become the key to understanding and effective therapy. 4.2 OBJECT RELATIONS THERAPY AND INTERPERSONAL THERAPY: CURRENT DIFFERENCES Both the Object Relations analysts and the Interpersonalists have developed and refined the earlier writings of their predecessors. Before exploring the common elements between these two schools of thought, it is important to establish the differences that still exist. The most fundamental difference resides in their basic world view, orepistemology. 4.2.1 Epistomological differences "What one elects 10 do is based upon what one thinks is wrong in the fint place. One ~ analysis of a problem will predetermine what one decides in the way ala remedy" (Ford & Urban, 1974, p.5). As this quote demonstrates, one's theory, one's way ofthinking determine how and what one observes. Keeney (1983) comments that the most basic epistomological aCI is the drawing of distinctions. It is only via distinguishing one pattem (rom another that we are able to make sense of the world. The Interpersonalists' basic epistomological premise resides on the assumption that ihe past, while relevant ,I 67 10 present behaviour, considering the past, does nor intrinsically add any value 10 the therapy. Thequestion asked in Interpersonal therapy is : "10 what end" is Ihe behaviour being used? (Vorster, 1979. p.l3). The question of "why • a person behaves in a particular way is nor addressed and is deemed 10 be unnecessary in the analysis of the problem. Implicit in Ihis is the belief that once Ihe maladaplive behaviour is changed, so too will the conflicl.S that go hand in hand with Ihat behaviourchange (Vorster, 1979). The interactional style of an individual. and how the person interacts with his or herenvironment is the primary focus of auentlon, On Ihe other hand. the modem Objecl Relations analyst assumes the existence of an unconscious. This unconscious is believed tocarry the past internalised conflicts into the here and now. Subsequently. this impacts on the relationship between therapisl and client Inherent in this is the belief that until past conflicts are resolved, real change is not possible (Corsini, 1985). All the other differences discussed below are rooted in the different world views ofthese two schools of thought 4.2.2 Different perceptions ofchange The basic epislomological differences between Inlerpersonalisl.S and modem Objecl Relallons, lead 10 differentvisions of change, and how this is elicited. Because ofthe Inlerpersonalists' basic assumption that it isonly the here and now of behaviour that is relevant, (Wachlel, 1982). and that once maladaplive interaclional slyies arc changed, intrapsychic change follows. the focus is obviously tochange thai behaviourthat is seen to becounterproductlve, This is achieved through the use of slralegies specifically designed 10 combat Iha~, specific behaviour. 68 Contrary 10 this, Object Relations' assumptlon of an unconscious, and the baggage of past internalised conflicts, leads 10 the belief Ihal until these conflicts arc understood by the clienr (on both an inlellcclual and emotional level), no real change is possible. Therefore the key to change is understanding (Joseph, 1989B; Segal, 1988). Up until now, the differences discussed arc more methodological than technique oriented. The most important difference in regard to technique is in relation 10 the way the therapist elicits change IntheIndividual. 4.2.3 Techniques in changing behaviour According to the Interpersonalisu, understanding alone isoften not sufficient in changing behaviour, and this is why more directive approaches are often employed (Wachtel, 1982). For example, a person who has problems with intimacy might employ certain methods to keep the therapist (and others in his or her life) at a distance. The social response would be 10 react io this communication and keep al a distance. This, according 10 Ihe Interpersonalis! creates a vicious cycle whereby the person becomes more and more isolated and his fear of inlimacy is strengthened. In this Instance then, the Interpersonaiisl mighl use a slralegy that willexaggerate the symptom, in order 10demonstrate 10 Ihe palienl what he/she is doing (for example, the lherapisl might push hislher chair to the other side of me room, ihereby creating an even grealer dlstance between therapisl and paliend (Wiehahn, 1975). II 69 Contrary to this, the Object Relation therapists prime objective is not necessarily to change the behaviour ofthe patient, but rather to understand why the person is behaving as he does (Joseph, 19890). Using the same example, the Object Relations therapist would interpret the (act that the person needed to create distance between himseUt1lersel( and the therapist, and he/she would then explore the reasons why this space was necessary. Nevertheless, it could be argued that interpretation is an indirect strategy in changing particular behaviour. Using the same example, once the therapist has interpreted the client's distancingbehaviour, and made it conscious, it becomes difficult for the client 10 sustain that behaviour. Perhaps the real difference lies in the perception of this change. The Interpersonalist would see the change as an end in itself, whereas, the Object Relations therapist would see thechange as only a part of the process. 4.3 COMMON ELEMENTS IN OBJECT RELATIONS AND INTER PERSONAL THERAPY 4.3.1 The therapeutic relationship Both Interpersonalists and Object Relations Iherapists maintain the view that the therapeutic relationship is representative of other relationships in the patient's life, and therefore, how the patient responds in this relationship, gives a clear indication of how he/she will respond toward others in hisJher life. In Sullivan's words the lnterpersonalist and the Object Relations therapist are "panicipant observers" in the therapeutic relationship (Anchln & Kiesler, 1982, p.14). /I 70 TheObject Relations therapists take this one step further by suggesting thatthe therapeutic relationship gives the analyst insight into the patient's primary relationship, l.e, the mother/infant relationship (Winnicot, 1960). 4.3.2 The tools oftherapy As discussed in chapter two, modem Object Relations therapists explicitly use their own feelings as a source of Information about what the patient is doinglfeeling (see Chapter 2 of this text). Projective identification is the term these analysts use to describe a number of different ways that the patient communicates with the therapist, without actually communicating in words. It is these feelings, phantasies and even desired actions stirred in the analyst, that are used to decipher both the inner phantasies and outer realities of the patient. This process is reflected in the procedure used by Interpersonal therapists in ascertaining the patient's interactional style/interpersonal maneuvers (see Chapter 2 of this text). As described by Kiesler (1982) the therapist unravels the patient's distinctive evoking style through assessing hislher own emotions or pulls experienced during the session. These include direct feelings, action tendencies, cognitive auributions and fantasies the therapist experiences. Therefore, while the terminology used is different, the processes described are extremely similar. 4.3.3 Focus on the'here and now' Both Object Relations therapists and Interpersonalist use the immediate relationship between therapist and patient (the transference relationship) td' attain their goals in therapy. The emotional immediacy of this relationship is deemed by both schools as an essentlal part of the working through process of 71 therapy (Bion in Spillius, 1992: Joseph. 1989A: Joseph. 19890: Kiesler 1982: Wachlel.1982). While the Objecl Relations therapist links the past to present modes of behaviour/thought processes or feelings. the emphasis in the therapy is to encourage the patient to experience what he/she is doing in the therapy room (see Chapter 2of this text}. 4.3.4 Interpretation and meta communication As illustrated earlier on in the text (see Chapter 2), interpretation in current usage in Object Relations therapy is not a dry intellectual 'rehash' of past events, but is a living dynamic part of the therapeutic relationship that examines both the verbal and non-verbal aspects of the patient's communications, and aims at allowing the patient to experience what he/she is doing/feeling and invoking in the therapy room (Bion, 1967; Joseph, 1989D). In many respects, it is similar to the asocial rnetacommunication of the Interactional therapist. Both fonns of therapy digest what the patient is asking of them (both non verbally and verbally), and instead of 'acting out' or giving the person the socially required response. find a way of giving it back to the patient in order that he/she become awareof hislher invoking styleliMcr processes. 4.3.5 Pathology and how it is seen From an Object Relations perspective, the more primitive (pathological) the patient (i,e. those stuck in the paranoid schizoid stage of development), the greater their use of proiective identification as a means of communication. tht more thepatient will try to pressure the analysl into acting in ways consistent withothers in his or her life ( see p.28 ofthis text). 72 This is one of the ways in which the patient can ward off feelings of being separate from the analyst. Although methodological differences exist, this observation is no differenl from the Interpersonalist posltion, An important facet of abnormal behaviour is understood to be a lack of flexibility on the part of the individual. As Leary (1982) puts iI: "...the more extreme and rigid the person, the greater his interpersonal pull· the greater his abillty 10 shape the relationship with others" (p.58 ofthis text). 4.4 CONCLUSIONS From the preceding discussion, iI is clear lhal while theorerlcal differences exist, in practice these two approaches have more in common than would generally beexpected. The real meeting point however seems to be in the lherapeutic arena, specifically with regard 10 the therapeutic relationship, and the tools of therapy, l.e. 'the use ofself', This is significant in that both the Interpersonalists and the Object Relations therapists seem 10 regard this aspect of the therapeutic process as central to understanding what lhe dynamics, pathology or interactional pulls/lnreractional style, of the palienl are. How these feelings are then acted upon seems to depend on the specific focus or epistomological position ofthe therapist. Clearly then, the concept of transference and countertransference. as iI is understood today by modem Psychoanalysts is used extensively in modern Interpersonal psycholherapy. .1 73 CHAPTER 5 CONCLUSIONS 5.1 SUMMARY AND CONCLUSION This thesis has demonstrated that the divergent schools ofInterpersonal therapy and Object Relations therapy share techniques in the practice of therapy. The most important similarities between these two schools of therapy have been identified tobe: (a) The therapist plays a participant role in both Interpersonal therapy and Object Relations. In both instances the therapists role has moved from being an objective onlooker, with almost demi god stature, to an interactionally involved participant observer. Unlike their predecessors, who relied heavily on either the theory of personality, and the unconscious (in Classical Psychoanalysis) or on observable behaviour (in Interactional/Strategic therapy), the modem Interpersonal therapist and the Object Relations therapist rely heavily on their own thoughts and feelings to ascertainthe content of thepatient's communication. (b) In both Interpersonal therapy and Object Relations, there has been a shift towards a more Intuitive, subjective understanding or the therapeutic process, and less reliance on the objective facts, a shiftth3t is reflected in systemic orecosystemic thinking and Constructionism as awhole (Keeney, 1983). (c) Although terminology differs, the therapeutle relationship (trans ference relationship) has become the cornerstone to the execution ofI. therapy in both Interpersonal therapy and Object Relations. The 74 feelings (countertransferencezproiecrive identificalion or interactional pulls) that are evoked through this relationship, has become in both instances, the key to understanding the palien!. The use of self, (or in analytic terms, the use of transference Icounlertransference feelings in the therapeutic arena) is an aspect that has been extended and enriched by both Ihe Inrerpersonallsn and the Object Relations theorlsu, bUI is not found exclusively in these two theories of therapy. Indeed, these concepts have been widely used in the practices ofExistential therapies, but also in second order Cybernetics or Construclionism (see Baldwin & Salir 1987 Hoffman 1990; Yalom, 1980). This could suggestlhat this development has taken place in psychological practice across the spectrum. If the above proposilion is generally accepted tobe correct, then Ihe use of self has become a central ingredient or tool of therapy. Despite differences in theory, both schools have had to take cognisance of the other, in the sense that Object Relations has moved towards a more interactional position, no longer focusing exclusively on the intrapsychic unconscious aspects of the patient, whereas the Intepersonalists have conceded that the unspoken communicatlon is often the more powerful form of communication, thereby acknowledging the presence of an unseen or unconscious process. This movement in both Interpersonal theory and Object Relations suggests, that, while in theory, it might be possible to draw clear distinctions between behaviour and intrapsychic or unconscious processes, the practical constralnu of therapy necessitate that the interrelationship between these two processes be taken Inlo account. Although the 10015 of therapy arc similar. the b.asic epistomological foundations of each of these schools of thought necessitate fundamental differences In '1 .pproach. 75 Forexample, the Object Relarlom practitioner still relies heavily on the Iheory of personalily developed by Melanie Klein in his or her understanding of the patlem, and in implementing change. It operates within acontinual dialectic of cross fertilisalion between the theory and the clinical data (Mitchell & Greenberg, 1983). There is thus an emphasis on ihe workings of the unconscious/phantasy world ofthe individual. On the other hand, the Interpersonal therapist concemrates on the interac tionallbehavioural aspects of the client's presentatlon, This obviously impacts on the final assumptions about change and how it should be implemented. While it is not the aim of this thesis to suggest an eclectic approach to therapy, it does appearthat the therapist cannot ignore one school in favour of another. This does not do justice to the hoi istic nature of the therapeutic relationship. For example, while the Interpersonalists certainly allude to the unconscious, it does not "fit" with their basic epistomological thrust, and therefore, no attempt is made to explore this area further. Likewise. theObject Relations therapist focuses so extensively on unconscious or fantasy aspects that perhaps the oven behaviour and communication of the patient is sometimes overlooked. As Casement says: "By Iislening too readily to accepted theories, and to what they lead the pracrhloner to expect, it is easy to become deaf to the unexpected. When a therapist thinks he can see signs of what is familiar to him, he can become blind to what isdifferent and strange" (1985, p.4.). Nevenheless, it is naive to believe that the differences between these two schools ofthought can be reconciled or eradicated. Object Relations aherap)' i~tl embedded in a philosophy, an entire theory of personality and personality 76 development, whereas Interpersonal therapy appears to be an actlon based, more practical interventlon and theory. In this sense, they do belong to" different orders ofthings" (Watzlawick, 1965 p.29), different conceptual frameworks. Nonetheless, this thesis illustrates a starting point where these two schools of thought domeet; namely in the therapeutic arena. 5.2 LIMITATIONS OF THIS STUDY This thesis has attempted to isolate aspects of therapy and the therapeuuc process that are common to Interpersonal and Object Relations therapy, The use of the therapeutic relationship to decipher the basic feelingsl interactional stylet interpersonal maneuvers/ projective identification of Ihe paiient as a means to understanding Ihe patient and the therapeutic relationship has been isolated asacentral tool in Interpersonal and Object Relations therapy, The nuances that this thesis has tried 10 capture could only have been meaningfully tested if a practical case study was available. This would also have enabled the author to assess how far the epistomological differences impinge on the therapeutic process, and whether the theory or methodology of each of these schools of thought can be separated from the actual practice or doing oftherapy. For example. through a practical case study. it might be found that the epistemological differences between these two schools render the similarities superfluous and insignificant. 'I 77 5.3 FURTHER RESEARCH SUGGESTIONS Areas that could be researched further in the future as a result of this dissertation include the following: 5.3.1 The use ofself as a construct in other theoriesof therapy This thesis has demonstrated the central role that the therapist's personal feelings/intuition plays in modem Psychoanalysis orObject Relations therapy and Interpersonal therapy• Further research could be directed to the role that personal feelings, intuition and use ofself play in other theories of therapy. 5.3.2 A casestudy investigating an Interpersonal approach versus an Object Relations approach to therapy A single case might be used, and two different therapists could apply their particular skills to that case, oneofwhom would be an Interpersonal therapist and the other, an Object Relations therapist. (This method could obviously be applied to assess any other approach to therapy). This methodology could establish the significance ofthe similarities identified in this dissenation • II 71 REFERENCES Anchin, J. and Kiesler, D. (eds). 098V. Handbook 01 interpersonal psychotherapy. New York: Pergamon Press. I Anderson, R. (ed.) (t992). Clinical lectures on Klein and Bion. London: Routledge. Arkowitz, H. Arizona, U.; Tucson, U.S. (t 989). The role of theory in psychotherapy integration. Journal ofEclectic Psychotherapy, 8{/), p.6· J6. Atkinson, B., Heath, A. & Chenail, R. (1991). Qualitative research and the legitimization of knowledge. Journal 01 Family andMarital Therapy•. J7(2). p.l75-J80. Baldwin, M. & Satir, V. (ed.) (1987). The use 01 selfin therapy. New York: The Haworth Press. Bergin A.E. and Garfield, S.L. (1974) Handbook ofpsychotherapy and behal';our change. New York: Brunner Mazel, Beyers. D. & Vorster, C. (1991). Groepterapie en praktyk. Johannesburg: RAU Publikasie. Bion, W.R. (959). Attacks on linking. International Jouf1lQl of Psychoanalysis. 40, p.308-315. Bien, W.R. (1962). Learning from experience, Heinemann Press. .1 79 Casemenl. P.(l985). On teaming from thepatient.London: Tavistock Publicalions. Chrzamowski, J. (1982). Imerpersonal Icrmulations ofpsychotherapy: A contemporary model. In: J. Anchin" D. Kiesler (Eds). Handbook 01 InterpersofIQ/ Psychotherapy. New York: Pergamon. Cooper. A.M. (1988). OUf changing views of the therapeulic action of psychoana lysis: comparing Strachey and Loewald. Psychoanalytic Quarterly. LVII. p.15·27. Corsini. R.J. (1985). Current Psychotherapies. Illinois: F.E. Peacock Publishers. Inc. Dicks. H.V. (1967). Marital Tensions. London: Routledge and Kegan Paul. Dresser. I. (1985). Developments of the concepts of transference and counter transference. Psychoanalytic Psychotherapy. 1()). 13-23. Ehrenreich. J.H. (1989). Transference: one concept or many. The Psychoanalytic Review.76(J). p.37-65. Feldman. M. " Spillius. E.n. (1989). Psychic equilibrium and psychic change. London: Routledge, Fierman, L.B. (Ed).(l965). Effective Psychotherapy: The contributions of Hellmuth Kaiser. New York: Free Press. Fish. L.S.• & Piercy. F.P. (1987). The Iheory and praclise ofstructural and sirategic family therapies: A delphi siudy. JOUf1lQ/ oflNlrital and family therapy. IJ. 113·125. .1 80 Ford. G. &. Urban. H.8. (1974). Some historical and conceptual perspecrives in psychotherapy and behaviour change. In A.E. Bergin &. S.L. Garfield: Handbook o/psychotherapyandbehaviour change. New York: Brunner Mazel. Freud. S. (1973). Introductory leaure: on Psychoanalysis. Greal Britain: Penguin Books. Goffman, E. (1967).lnterrlction ritual. New York: Doubleday Anchor. Goldfield, M.R. &. Castonguay, L. (1992). Psychotherapy inlegrarion. Psychotherapy, 29(1), p.3·20. Greenberg. J.R. &. Mitchell, S.A. (1983). Object relations in psychoanalytic theory. Uniled Siaies of America: Harvard University Press. Haley. J.(l963). Strategies a/psychotherapy. New York: Grune and Stratton, Hayley. J. (1980). Leaving home: The theory 0/ disturbtd young people. New York: Mcgraw-Hill. Haley. J. (1981). Reflections a/therapy and other Essa)'s. Chevy Chase: The Family Therapy Institute of Washington, Hamburger. A.S. (1981) A comparison between the intrapsychic and the interactional approach to psychotherapythrough a studyoja dramotic work. Unpublished Maslers Thesis. Unisa, Pretoria.. Hanna. FJ. &. Puhakka, K. (1991). When psycholherapy works: pinpoinling In element ofchange. Psychotherapy, 28(4), p.598·606. Hof(man, L. (1981). Foundt1tions ojjamily therapy: A conceptua! framcwort: jor systems change. New York: Basic books. '1 II Hoffman, L (990). Consrrucling realities: An an of lenses. Family Process. 29. 1·12. Israelstam, K. (1988). Contrasting four major family Iherapy paradigms: Implicalions for family therapy Iraining. Journal o//amily therapy. 10. 179-196. lvey, G. (1992). Countertransference pathology in South African psychorherapy, Psychotherapy in South A/rica. p.31-45. Joseph. B. 0989A). On Passivity and Aggression: Iheir interrelationship. In M. Feldman & E.B. Spillius (Ed.). Psychic equilibrium and psychic change. London: Routledge. Joseph. B. (l989B). Defence Mechanisms and Phantasy In the Psychoanlylical process. In M. Feldman & E.B. SpiJlius (Eds.). Psychic equilibrium and psychic change. London: Rouiledge, Joseph. B. (l989C). Towards theexperiencing of Psychic Pain. In M. Feldman & E.B. Spillius (Eds.). Psychic equililbrium and psychic change. London: Routledge. Joseph. B.(l989D). On Understanding and nor Understanding: technical issues. In M. Feldman & E.B. Spillius (Eds.). Psychic equilibrium and psychic change. London: Routledge Keeney. B.P. (1983). Aesthetics 0/change. New York: The GuiJdford Press. Kemberg, D.P. (1987). Psychodynamic psychothtrapy 01 borderline patients. United Stales ofAmerica: Basic Books. Kemberg, D.P. (1988). Objecr reillions theory in clinical practise. Psychoanalytic Quarterly, LVII, p.50J. •• 82 Kiesler, OJ. (1982). Interpersonal lheory (or personalily and psycholherapy. In J. Anchin &. D. Kiesler (Eds.). Handbook 01interptnonal psychotherapy. New York: Pergamon. Khan, M.M. (1969). Vicissitudes of being, knowing and experiencing in lhe lherapeulic situation.British Journal ofMedical Psychology, 42. p.J8J·J93. Klein, M. (1989). The Psychoanalysis 01children. London: Virago Press. Langs, R. (1992). Clinical consequences of a (onnal mode of science of psychoanalysis and psychotherapy. American Journal 01 Psychotherapy, XLVI (4), p.611·617. Langs, R. (1984). The contributions of the adaplalional lnteractlonal approach 10 Classical Psychoanalysis. Analytic Psychotherapy and Psychopathology, 1W, p.21·47. Langs, R. (1981). Classics in analytic technique, New York: Jason Aronson. Louw, F. (1993). The aesthetics and pragmatics 01 indtvidua! psychotherapy: A multilevel encounter. Unpublished Masters lhesis, R.A.U., Johannesburg. Maddi, S.R. (1980). Personalily theories: a comparative analysis. Illinois: Dorsey Press. Mitchell, S. (1988). Relational concepts in psychoanalysis: Cambridge: Harvard University Press. Ogden, T.H. (1982). Projective identification and psychotheraptutic techniqu«. New York: Jason Aronson. I' 13 Palazzoli, Boscolo, Cecchin & Prata. (1975) Paradox and tounterparadox: A new model in the Therapy of the Family in Schizophrenia in Transaction. New Jersey: Jason Aronson Inc. Porder, M.S. (1987). Projective identification: an alternative hypothesis. Psychoanalytic Quarterly, LVI, p.431-451. Rawn, M.L. (1991). The working alliance: current concepts and controversies. The Psychoanalytic Review, 78(3), p.379 -389. Rosenfeld, H. (J990).lmpasse andinterpretation. London: Routledge. Salzberger-Wittenberg, I. (1970). Psychoanalytic insight andrekuionships. Routleigh & Kagen Paul. Segal. H.(1981). Melanie Klein's technique. In R. Langs, (Ed.). Classics in analytic technique. New York: Jason Aronson. Segal, H. (1988)./ntroduction to the work ofMelanie Klein. London: H Kamac Books. Siegal, J. (1992). Analysis of projective identification: An object relations approach to marital treatment. ClinicalSocial Work, 19(1). Spillius, E.B. (Ed.). (t992). Clinical lectures on Klein and Bion. London: Routledge. Spillius, E.B. (1988). Melanie Klein today. Developments in theory and practice. Vol. 2. London: Routledge. Spillius, E.B. (1992). Clinical experiences of projective identification. In R. Anderson, (Ed.). Clinical lectures on Klein andSion. London: Routledge. '1 Steiner, J. (1993). Psychic retreats. London: Routledge. Stolorow, R., Brandchafl. B. & Atwood, G. (1987). Psychoanalytic treatmem: An inttrsubjective appl'OQch. Hillsdale NJ: AnalYlic Press. Srolorow, R.D. (1992). Closing the gap belween lhe Iheory and pracuse with beuer psychoanalytlc lheory.lnstitute a/Contemporary Psydoanalys,: p.1S9·/66. Strachey, J. (1981). The neture of the therapeutle action ofpsychoanalysis. In R. Langs (Ed.). Classics in analytictechnique. New York: Jason Aronson. Strupp, H.H. (1992). The future of psychodynamic psycholherapy. Psychotherapy, 29(J), p.21 ·27. Sullivan, H.S. (1940). Conceptions a/modern Psychiatry. New York: Norton, Sullivan, H.S. (1953). The inlerpersonaltheory 0/Psychiatry. New York: Norton. Sullivan, H.S., (1964). The illusion ofpersonal individuality. The fusion 01Psychiatry and social sciences. New York: Norton. Swart, Nand Wiehahn, G. (1979). Interpersonal manoeuvres and behaviour change Pretorle: Academica. Tansey, MJ. & Burke, W.F. (1985). Projective Identification and the empathic process irueractional communications. Contemporary Psychoanalysis. 21(J), p,42·69. Truax, C.B. &. Carkhuff, R.R. (1967). Toward efJtctive counselling and psychotherapy. Chicago: Aldine. Turner, M.S. (1971) Realismandthe uplanation o/Behaviour. New York: Appeltcn Cenlury, Crofts. o. 15 Van Kessel, W. &. Van Der Linden, P. (1974). Een inttrrJktionttl model voorgutoord &tdrag en voor psychothtrapie. Unpublished lectures.Instituut voor Klinishc Industrielc Psychologic: Utrecht, Vorster, C. (1979). Alcoholism: a Way of Handling a Relalionship. Psychoth~rap;a, (2). Wachte], P.L. (1982). Int«personallherapy and aetlve intcrvenlion. In J. Anchin &. D. Kiesler, (Eds.). Handbook 01 interpersonal psychotherapy. New York: Pergamon Press. Watzlawiek, P., Beavin, J.H., &. Jackson, D.O. (1967). Pragmatics 01 human communication. London: Faber and Faber Watzlawick, P.,Weakland, J.H. &. Fisch, R. (1974). Change: Principles 01 problem lonnation andproblem resolution. New York: W.W.Norton. Watzlawick, P., & Weakland,J.H. (Eds.).(l977). The interactional view: Studies at the Palo Alto Institute, 1965·1974. New York: W.W. Norton & Company. Weakland, J.H., Fisch, n., Watzlawick, P. & Bodin, A.N. (1977). Brief Ihcrapy: Focused problem resoletion, In P. Watzlawick &. J.H. Weakland (Eds.). The interactional view: Studiesat the Palo Alto lnstitut~, 1965 - 1974. New York: W.W. Norton & Company. Wiehahn, G. (1975). Strategies olpsychotherapy. Unpublished Lecture. University of Soulh Africa, Pretoria. Wilner, R.S., Miranda, B. t 1m, W.O. (1988). In Defence of strategic Iherapy. ContemporrJryFamily 77rerapy, 10(3), p.169·174. .1 86 WiMicoll, D.W. (1955). The depressive posilion in nonnal emotional development. British Journal 01M~dical Psychology. (28). Winnicot, D.W. (1965). Ego distortion in termsof real and false sel! In MalUftJtional processes and the facilitating environment. pp.140·152, London: Hogarth Press. Wolpe, J. (1958). PsychotheftJpy by reciprocal inhibition. Stanford. California: Stanford University Press. Yalom, I. (1980). Existential psychotherapy. New York: Basic Books. ···000··· \ v. 'I