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Principles of Psychoanalytic Psychotherapy

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Principles of Psychoanalytic Psychotherapy PRINCIPLES OF PSYCHOANALYTIC PSYCHOTHERAPY This page intentionally left blank HOANALYT HOTHERAPY A Manua Supportive-Expressive Treatment LESTER LUBORSKY A Member of the Persew Books Group Library of Conp~sCatdoging in Publiation Data Luborsky, kaster, rqzo- Principles of psyebaanalytic psyehothmapy. Ref-erencm: p. 241 Xncfudes index. I. Psychoanalysis. 2. f syehotherapy, 1. Title. [DNLM: I. Psycltoanalytie therapy, WM 460.6 Lgzgpj KC504.t83 1984 616.89'17 83-45377 XSBN 0-4654328-4 Copyright @ 1984 by Basic bks, Inc. Prjnted in the Unit& Shtes of America DESIGNED BY VINCENT TORRE IQ9876 FEB ON DEMAND To 'T'hree Generations To the First: Sigmund Freud, the tounder of most of these methods. To the Semd: The Menninger Faundatim's mentars, the transmitters of skill in using them. To the Third: Pgychotherapy researchers, the persevering evaluators of these methods. This page intentionally left blank Contents Foreword, Philip S. Holzman, Ph.D. Author" Preface PART I The Background and Use of the Manual 1 The Purposes of the Book and the Qualities of the Treatment The Purposes of the Book A DEFINITIVE: ACCWNT OF PSYCHOWALVTECALLY ORIENTED IPSYCWQTWERAPV 4 A TREATMENT GUIDE IN A MANUAL FORMAT 4 A SET OF SCALES FOR MEASURING TWER~P~STS' 60NFQRMlTY TQ THE MANUAL'S RECQMMENDATXONS 5 A TMININE TWL FOR THEMPXSTS, SUPERVISORS, AND mAGNERS 5 A GUIDE TO EVALUATfNG AND STRENGTHENING THE SUPPORTIVE REMnOEVSN1F 6 A MANUAL FOR BmH SHORT-TERM AND OPEN-ENDED FSYCHOTWE~PY 6 A TREATMENT ADAmABILE TCl A BROAD UNGE QF PATIENTS 7 i(tN INTECMmON OF CLINlCAL, AND RESEARCH FINDINGS ''7 fie Eggencg of Psyehoeznalytiealiy Qrz"ent~d Psychothfierapy 7 THE DISTINCTIVE TREATMENT PRINCIPLES 9 ne Plan of the Book 12 vii Con tents 2 The Psychoanalytic Theory of Psychotherapeutic Change Question I: mat changes? Desrtion 2: How Does Change Come About? CUMTIVE FACTORS 2 1 neRekti~e Fower of Curatile Factors I and 2 Achieving Understanding veraus Achieing a Helphl Relationship %e Relat;rve Curative Power of Trgatment fietom Versus aher Factors 3 Psychotherapy Manuals: A Small Revolution in Research and Practice A Short. Higtoty of Psychotherapy Manuals Research Findings Basczd on Non-Manual-Based Psyehother~pies Research Findings Based on R/lanual-Bassd Psychofheropies &Cure Research Afiplicatr'otzs MORE OBJECTIVE COMPARISONS OF PSYCHOTHEMPIES IN RESMRGH STUDIES @ MORE PRECISE MEASUREMENT OF THE DEGREE TQ XST PROVIDED WHAT WAS RECOMMENDED IN THE MORE: FACILITATION OF" THE TWINING OF THERAPISTS IN TEE SPECIFIC FORM OF PSYCHOTHERAPY 41 4 HOWto Use the Manual Learning the Mdnual Cancurrent Stlpemisz'ort SUPERVISION PRmEDITRES THE THEWIST'S PERSONALITY AS A FACTOR IN THE TRAINING 47 THE THEMPIST AS SELF-SUPERVISOR AND PMCTICE SUPERVISOR OF OTHER TWEMPISTS 48 Mtch Makz"ng PREPARING THE PATIENT 58 A PRELIMINARY SOGIIALIZATION INTERVIEW 50 Contents SELEmING THE: TNEUFIST 5 1 SELECTING THE PATIEBT 54 PART I1 The Manual 5 Beginning Treatment Seft_l'ngGoals ELXCXTENGwhjts 62 MONITQRXXIJG PRWRESS BY REFERENCE TO COALS 62 Explezining the Treament Pxoec5ss Making Arrangemen& for the Treahnent Establishiw a Relalionship of Trust artd Rapport Beginning to Un&rs&nd and Regpond 60 the Patient "srobbms 6 Supportive Relationships Deciding midhknh Require Shengthening of the WodiveReldtionship by Sug;rpor6ive Medns Evaluating the Patient "setping Alliancg Fdcill'&Gng the Pa E-t'ent"fxperignee of a Hc5tpl'ng Alliance WRE r 82 maE 2 METHODS 87 7 Expressive Techniques: Listening and Understanding Acguiring Undergtanding: The Four Phases PHASE 1 LISTENING 91 PHASE 2 UNDERSTMDfP66 93 fin&ple I. Understanding Symflt~msin the Context of Relationship8 g4 fincible 2, Attending to Shifts in the ""Slates of Mind" 97 Ptineiele 3a. Fonnvhh'ng the Core Confi"iehralRelal"ionshi9 %erne (CCR by Clinical Me&ods 98 fi~ciple ?b. Fomulating the Relationship nzenze by the CCR 'iP Metihod l o7 Pkneifile q. A~endi~~gin Zirm to Each %here of the Relalionskip Tk~dI I o Contents P~ncifiIe5, Further Rwiwing Fmds to Produce FizrGher Understanding I r jr Pri'neipIe 6. Seeing ttlze S2lmptoms as Probkm-Soluhn or CMitlg A &m@& I 14 Eneiple 7. Agedin& to the Patient"serceplion of the Rergflist's Behmior I 15 Pn'nciph of Inferenm Mdking I)rin&pbe r, A~endingto PierEunakmcy r r 8 Pn'nciple 2. Attgnding to Temporal GontiguiQ r i8 Pn'neiple j, A~endingtto $hi@$ in S&k I r g 8 Expressive Techniques: Responding and Listening Again Responding PRINCIPLES OF RESPONDING 12 l finetpie I. &@ling with the Main Relatknship Probhms 121 &tlciple a. Facilitiacl'ng tlze Workiq nrough 123 fi~+le 3. Recognizing the Patient's Need to Test the Rela~onship 125 Pt-in@le q. Recognizing the DficulV of Expression Abut the Relah'anshi~,wi& the %era_pkt 127 Kncr'ple 5. Skayiq with t-he Relationship Reme PrrwiOis a Peas I3r Principle 6 Achimang the Goals Requir~gDiflerenf heels of Insight for Palrent 132 finciple 7- Mate)iiq of Pasienf "sand %@rapist"se8saga Seee8 as a RgsWnse Me&sure 133 Pt.inci"pe 8, Emiq Bmed on the Pah'ent "smdiness to Become Aware r35; Prr'nkple 9. Limiting the Extensiveness of Each Response 136 Principle ro, Res&eining interpretation Unlib Undershndi~g is Adequate I 36 P~nciplet r, Kmiw Based on the Nedmess to the fid of the Session 137 P~neipleI z. Countering Counteptransferenee I 37 Pn'neiple r 5 Near-resflondx Prmictes Undem&anding 140 Phase I 5 R Reh-lnting to LbtRening 9 Ending Treatment Reclart'fring thi4re Time S~ehrl-ck Noting Cues About the Patient's Conditions for Tenni~at-ion Contents Narkiw TwatmeJzfPhases So lltey Senre as Milestones Recognizing the 'Xm"valP'~t Termination in Terns of Goals Having Been Reached Achieving Goals Does Not Mean the Relationship Pmblems Am All Gone rlealing With the Xndimtion ta End the ;fteawent Prgmatzlrely Dealing With Previous Separnrions Eases the Teminagon Recognizing the Resurgence of Symptoms as a Way of L>eah with the Me~ningsof TgmimCion Allowing For Fudher Contoet After Temimtion Dealing With the Need for Further Treatment 10 Variations and Adiuncts Rme-Limited PsychoU"zer~@E- TL) Fnmity and Othgr Pa&ers in lfie Treatment Group logical Treatments (Ised in ambination Wifi Psyehotherdpy Physical Examinaticms 11 Analogic Summaries Nurhr~ngan Unfamdiar Pl~rzt Beeling an Onion Sotw'ng rhe Grime i7f a Mystew Sloly fiseemiq a Trge in a Dense Forest PlqOnga Chess Game (Revisited) PART I11 Appendices 1 A Reminder Checklist for the Therapist for SE Txeatrnent Arrangements 2 A Sample Report of a Pretreatment Diagnostic Evaluatiant Mieh Led to Time-Limited Psychotherapy 3 An Anticipatory Socialization Interview for Psychotherapy 4 An Example of the Core Conflictual Relationship Theme Method: Its Scoring and Research Supports 199 STEPS IN SCORING THE 66RT 2m GUIDES Xi"6R SWRING WISHES, NEEDS, AND INTEmaPaS TOWARD THE OBjEm; W 203 GUIDES FOR SCORING THE CQNSEQUENCES FRQM THE aR FROM THE SELF 205 SCORI~I~ENSIW OF THEME COMPONEMTS 206 GUIDES FOR SCORING THE PATXEW'S EXPERIENCE OF THE: REMTIQNSHIP 207 NOTATIQHS FOR SCORING THE RE 208 Mr. B.N, $eggion 3, 209 DXSCVSSXON OF THE SCORING QF MR. B.N. BY FOUR INDEPENDENT JUXES 220 CCR 7" Ifi"ctorg!sheets 22 1 Summary of CCA "I" Resear& 225 RELIABEIW 2 2s CoMSESTENCY OF THE CCRT OVER TIME 226 CONSISTENCY OF THE GCRT FOR RELATIONSHIPS TO PARLmS VERSUS RELATIONSHIPS TO THE THEMPEST 227 COr;rSIs.nENCY OF CCRT BASED ON V SESSIONS VERSUS BASED ON NhRMmVES RWUESTEI) BY AN INTERVIEWER OUTSIDE OF PSVCWOTNEMPY 227 COMPARISONS OF THE CCRT METHOD WITH OmER MEASURES OF THE TMMSFERENCE PATTERN 228 5 Rating Scales for Supportive-Expressive Psychoanalytically Oriented Psychotherapy AN IWRODUCTION TO RATING SUPWRTIVE-EXPRES~IVE PSYCHQTMZMPY 231 m TIHG SC&E$ FOR THE MAIN DISTlMCTIVE QUALITIES OF' 23.2 MTING SCALES FOR SUPmRITIVENESs 233 THE~~PIST")SWA VS OF' FACIEITA TING HELPING A:PEi 233 THEMPXST> WAY"S OF FACILITA TfNG HELPING &LIANCE: WPE 2 234 ri?n TlNG SCALES mRUNDERSl;.rNDlNG 235 RATING SCALES FOR THRMPIST~ADEQUACY" OF RES~NDINGIN TERMS OF ExpREssrvB AIMS 2.36 MTING $CUE FOR THE THEMPIST)S SKILL 238 1UTING SCALE FOR DEGREE OF' HELP zj8 THE HELPING REU TIQNSHIP QUESl.rcMAI&E 239 References This page intentionally left blank Foreword Psychotherapy, generally speaking, has been shown to be effec- tive. Most people who seek help for heterogeneous arrays of rippling compulsions, paralyzing obsessions, de- pression, anxieties, and bodily aberrations without organic cause--are indeed helped by the psychotherapeutic encounter. The goals of these treatments have now extended beyond their original aim (which was the cure of recognized nosological entities, perhaps even diseases, such as obsessive-compulsive neurosis or hysteria), to personality or character problems, and even beyond those to "optimizing" social and interpersonal effectiveness. Regardless of the patient's condition, whether disease or plight, psychotherapy has shown itself to be helpful, as several comprehensive reviews have documented (e.g., Lu- borsky, Singer, and Luborsky 1975; Bergin and Lambert 1978; Smith, Glass, and Miller 1980). In spite of the demonstrated general superiority of psycho- therapy over no treatment, formidable problems for evaluation remain. They include the heterogeneity of conditions for which people seek relief, the array of psychotherapeutic meth- ods claiming effectiveness, and the multitude of therapists with their own theoretical persuasions. All of these factors demand more precise and specific answers to the question of what therapy, administered by what therapist, is effective for which patients with what conditions. Tne technology of psychother- apy, unlike, for example, that of physical medicine, is "soft." It depends on words. Yet the orchestration of the techniques requires deftness, subtlely, and integrity in the same measure Foreword as that needed by the skilled musician. As Hamlet forthrightly reminded the meddling Rosencrantz and Guildenstern, "you would pluck out the heart of my mystery, you would sound me from my lowest note to the top of my compass; and there is much music, excellent voice in this little organ, yet you cannot make it speak.
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