品川心療内科（港南口）

診療は「気」を感じている

だからたとえばネット診療はうまく行かないのだろうと思う

にじみ出る何かを感じているので

それを言葉にすることも難しい

精神分析-5

無意識

精神分析と他の心理学とを区別している第一のものはなんといっても、無意識の概念である。

他の心理学で無意識の概念を使用しているなら、それはフロイトから学んだもので、たとえばユングはその中で最も有名なものだろう。

ユングはフロイトの無意識の概念を継承し、しかも２つの重要な付加的業績がある。

一つは集合的無意識、一つは神秘主義とスピリチャリズムである。

フロイトは個人の意識の無意識を論じたのに対して、ユングは集合的無意識を論じた。

集合的無意識はアルケータイプ・イメージから成り立っている。すべての文化共通のシンボルの体系である。

ユングの場合、神経症は、無意識の内容から過剰に

切り離されたことによって生じる。

また夢分析はアルケータイプの意味を告げている。

ユングは神秘的でありスピリチャルであるが、それは初期の精神分析が無視した要素であって、現代の精神分析は瞑想や東洋宗教と関連させつつ、再研究しつつある。

アドラーはユングと並ぶもう一人のフロイトの継承者である。フロイトは抑圧を中心とした精神内界システムを考え、その一部として、無意識を構想した。

しかしアドラーは人間は自分について実際知っていると思っている以上に、知っているのだと信じていた。

実存分析でもやはり無意識に関心を寄せる。精神分析と同様に考えて、人間は精神内界で無意識の葛藤を経験し、意識から排除された部分があり、それが行動、思考、感情に影響を与えていると論じている。

実存主義者にとってそれは、死や孤独や無意味のような基本的実存的恐怖に対する不安である。その不安に侵食されることから、我々人間を守っているのが、無意識界に排除するというシステムである。

ゲシュタルト療法もまた精神分析から発展したものである。しかし急進的な一派であり、精神分析理論の多くを無視して、非常に構造的で能動的な治療技法を発展させた。

こうした大きな違いにもかかわらず、Fritz Perlsは「無意識を意識へ」という技法が治療的意味を持つと考えていた。

同様に、Morenoのサイコ・ドラマは問題のある対人関係場面を再演することによって、患者が抱いたけれども抑圧してしまった感情を確認し表現することを援助する。

Alvin Mahrerの 体験的心理療法　 Experiential Psychotherapy　では、精神分析から大きく異なっているが、母性的無意識は個人にとってユニークであり、母性的無意識は深い潜在的人生である。

最後に、家族療法の幾つかの流派では、お互いの関係において各メンバーが特別な役割りを無意識に演じると考えることで問題を解決しようとしている。

ーーーーー
一面では脊髄反射は無意識であり、腱反射は集合的無意識であるとも言えるだろう。

精神分析-4　

基礎となる臨床的考え方

自由連想

精神分析的治療の開始は「なんぶも心に浮かぶことを話してて下さい」というのが典型的である。

他の治療とは異なり、精神分析では、思考、夢、白昼夢、空想まで、なんでも治療に取り入れる。

意識によって編集されていない、そのままの思考を表現することが、精神内科医で何が起こっているかについて、より豊かな素材を提供してくれる。

症状を通して何が表現されているのかを知るためには、編集されていない、元のままの思考や感情を知ることが役に立つ。

自由連想はまた患者が自分自身について知ることに役立つ。

治療的傾聴

フロイトが勧めたのは、患者が何を言っても、「均等に漂うような注意」を維持することである。

分析はなにか特定の話題について限定するのではなく、コミュニケーションのあらゆるレベルのことを一度に聴く。

患者が表面の言葉で何を言っているか、その時どんな感情がこもっていたのか、そのとき治療者側の反応はどうのようなものであったか、すべてを均等の注意で捉える。

このように聴くことが精神分析的方法の基礎であり、それによって患者のすべての発信するレベルの情報をとらえることができる。

２つ目の治療的傾聴は分析家が患者のパターンを理解し始めた時に起こる。そのパターンは転移の形をとっており、意味と症状をつなぐものである。

治療的反応

解釈は伝統的な精神分析での基本的な反応である。

患者の中心テーマの理解を共有することであり、しばしば転移の一側面である。

解釈は患者が葛藤を解決することを助ける。その葛藤のゆえに患者は問題行動を起こしたり、症状を呈しているのであるから、分析家は患者が葛藤に取り組む準備ができたと判断とた時には解釈が与えられる。

夢の解釈は精神分析では特別な地位を占めている。「夢解釈は無意識理解の王道である」。フロイトは、夢の表面的な意味を分析し解釈することで、深い潜在的な内容に至ることができると考えた。

夢の言語を理解する方法はこの文章の次の部分で探求する。

共感は治療反応の一つの形であり、20世紀後半から大きな注目を集めている。共感的反応は患者の感情状態に波長を合わせ、感情的に理解していることを伝えることである。

治療者の共感と治療結果との関係が研究されている。

治療同盟

治療同盟または作業同盟は、患者と治療者との間のパートナーシップである。

治療において協力する。

Greenson(1967)は作業同盟と転移の違いを明確にし、治療にあたっての同盟の重要性を強調した。

最近の研究では、肯定的援助的同盟が治療要因の一つであり、良い結果をもたらす精神療法のに一貫して伴っていることが示されている。

他のシステム

精神分析は多様な精神療法の祖父であり、同時に現在生きている子孫をも指している。

他のシステムや理論(特にユングやアドラー)はフロイトが生きている頃にすでに枝分かれした流派である。

他にもその後に枝分かれしたものもあり、力動的精神療法のように「分析的傘」の下で発展したものもある。その中にはCarl Rogersのように、本質的な違いを強調される場合もある。

本質はなお精神分析であるが、各種理論には多くの違いがあり、それはフロイトの時代からすでにあった。

その中には、古典的精神分析、自我心理学ego psychology、対人関係学派interpersonal psychoanalysis、対象関係論object relations、自己心理学self psychologyなどが含まれる。

精神分析自体一つの理論であるが、他の理論に基礎を提供しているものでもあり、それは3つの基本的考え方である。

無意識、転移、過去の体験が現在の人格や症状を形成している、という3点であり、これを含むならば、分析的または力動的精神療法といえるだろう。

転移

転移はフロイトの考え方の中でも最重要のものである。

人生最初期の重要な対人関係で体験した感情を、現在の対人関係にも感じてしまうことを転移という。

人生最初期の経験が、新しい対人関係や状況に対するときの患者の態度の原型を形成している。

過去からの「テンプレート」によって現在を形成しているのである。

現在ならば「テンプレート」で、昔ならば「鋳型」と喩えたところだろう。

さらに現代では脳科学の言葉で表現したほうが分かりやすいかもしれない。人生最初期の段階で最初の対人関係を経験しているうちに、白紙の脳に、新しい回路が刻まれる。その後、さまざまに修正されることはあるものの、最初に刻まれた脳回路は一番の古層に保存されているだろう。

どの人も、自分の持って生まれた傾向と人生の初期の体験から得られた教訓の2つを組み合わせながら、自分なりの行動様式をつくり上げる。特に性的行動をフロイトは問題にした。このプロセスは鋳型またはテンプレートのようなもので、人生を通じて繰り返される。

過去と現在の状況が新しい自分を作り、それがまた新しい環境を体験し、新しい自分を作るという運動が続く。このあたりは簡単な数式ですっきり書ける。

その最初には生得的な性格特性と人生最初の体験があるわけだ。

精神分析では、転移の分析が治療の基本になる。

治療者に対する患者の転移は重要である。治療者に対する転移を分析することにより、どのような力が働いているのか、記憶や期待といった「脳内の出来事」と「外部現実」とをどのように区別しているかを知ることができる。

記憶や期待のような「脳内の出来事」と「外部現実」をきちんと区別できることが、relity testing 現実検討能力である。現実吟味能力（現実検討能力）とは、『外部世界にある事象』と『内面世界にある表象（心的内容やイメージ）』を区別する自我の機能である。

転移は過去から持ち越した鋳型であって、過去に反復されている行動や思考によって知ることができる。

患者は自分は昔反抗的だったと語るわけではなく、権威者に対して批判的だったと語るわけでもない。その代わりに、診察室で医師に対して反抗的に批判的に振る舞うのである。

転移を調べるには、臨床場面で中心葛藤関係課題Core Conflictual Relationship Theme (CCRT)を利用する。この文章の後半で、さらに説明し、妥当性の検証もする。

逆転移は治療者が患者に対して、過去の「鋳型」「テンプレート」で感じ、考え、行動することである。

転移と対になるもので、それは治療者が自分で解決しなければならない問題である。

患者の感情や非言語的コミュニケーションに対して治療者がどう反応したかを見れば、逆転移のあり方が評価できる。

東京新聞社説
<一審無罪の小沢一郎民主党元代表を検察官役の指定弁護士が控訴するのは疑問だ。そもそも検察が起訴を断念した事件だ。一審無罪なら、その判断を尊重するよう検察審査会制 度の改正を求めたい。 

新しい検察審制度で、小沢元代表が強制起訴されたのは、市民が「白か黒かを法廷で決着させたい」という結果だった。政治資金規正法違反の罪に問われたものの、一審判決は「 故意や共謀は認められない」と判断している。 

つまり、「白」という決着はすでについているわけだ。検察が起訴する場合でも、一審が無罪なら、基本的に控訴すべきではないという考え方が法曹界にある。国家権力が強大な 捜査権限をフルに用いて、有罪を証明できないならば、それ以上の権力行使は抑制するべきだという思想からだ。 

とくに小沢元代表の場合は、特捜検察が一人の政治家を長期間にわたり追い回し、起訴できなかった異様な事件である。ゼネコンからの巨額な闇献金を疑ったためだが、不発に終 わった。見立て捜査そのものに政治的意図があったと勘繰られてもやむを得ない。 

小沢元代表はこの三年間、政治活動が実質的に制約を受けている。首相の座の可能性もあったことを考えると、本人ばかりでなく、選挙で支持した有権者の期待も踏みにじられた のと同然だ。 

新制度は従来、検察だけが独占していた起訴権限を市民にも広げる意味があり、評価する。だが、新制度ゆえに未整備な部分もある。検察官役の指定弁護士に一任される控訴判断 はその典型例だ。検察でさえ、控訴は高検や最高検の上級庁と協議する。 

指定弁護士の独断で、小沢元代表をいつまでも刑事被告人の扱いにしてよいのか。「看過できない事実誤認」を理由とするが、検察審に提出された検察の捜査報告書などは虚偽の 事実が記載されたものだ。どんな具体的な材料で一審判決を覆そうというのか。 

むしろ、「白か黒か」を判定した一審判決を尊重し、それを歯止めとする明文規定を設けるべきだ。最高裁も二月に、控訴審は一審の事実認定によほどの不合理がない限り、一審 を尊重すべきだとする判断を示している。むろん被告が一審有罪の場合は、控訴するのは当然の権利だ。 

検察による不起訴、強制起訴による裁判で無罪なのに、「黒」だと際限なく後追いを続ける制度には手直しが急務である。

ーーーーーーーーーー
知人から紹介された文章

精神分析-2

基本となる理論

無意識

精神活動は意識と無意識に分けられると考えるのが精神分析の基本的理論の一つである。

無意識の心の領域は我々が自分では意識できない部分である。

無意識には感情、認知、記憶が含まれ、それらは患者の気持ちや行動に影響する。

フロイトの独自な貢献は、無意識の概念を使ってどのように精神世界を理解したらよいかを発見したこと、そして精神医学的な問題をどのように解決したらよいかを発見したことにある。

無意識の概念が初めて提案された当時から、それが科学的であるのかどうかについては、疑問が出されていた。

しかし最近の神経科学の発見によれば、我々が意識していない精神的なプロセスが心理と行動に影響を与えていると言われている。

神経科学の現状で言えば、むしろ、無意識的なプロセスについては科学の領域で解決しやすい問題であるし、進化論的にも理解しやすい問題である。むしろ、自意識の発生の方が、現状の科学の領域を超える難問である可能性があると指摘されている。

しかし普段生活している我々としては自意識は自明のものであり、無意識がむしろ、体験外のものであるという逆の事情になっている。

実験動物が作れないという難問も横たわっている。

精神力動

我々の目的は単に現象を記述して分類することではない。精神内界のいろいろな力が作用した結果としてもたらされていると認識することである。

我々は精神現象について力動的な考え方を獲得しようとしているのである。

精神内界についての力学的見方はエネルギー論とか水力学モデルとか呼ばれるように、フロイトが生きた1900年当時に優勢だった物理学モデルに立脚している。

たとえば、惑星の運行で引力と遠心力が複合して軌道を決定するように、人間の精神内界でも類似の「力学」が考えられるのではないかというのが発想である。

科学的ではないという批判としては、精神内界の「力」「エネルギー」というものが単なる比喩に過ぎず、実体が明らかではないということもある。

しかし科学が未発達の段階では、惑星の引力とか遠心力とかも「見えない力」であり、存在を証明するのも難しいことであったと思う。

その点から言えば、エネルギーがあるのだけれども、せき止める力が作用しており、しかしその抑止力が弱くなったときには、エネルギーが噴出し、といったような力学的モデルになる。

一時は量子力学的モデルなども言われたし、ホログラフィックモデルとか、色々あったものだが、最近ではもちろん、比喩として使うならば、コンピュータの比喩が分かりやすい。

ハードの障害、ソフトのバグ、ROM、RAMなどメモリーの種類、通信コードのエラーなどを使えばかなり比喩としては分かりやすいのだろうと思う。

精神力動は、精神の諸力がお互いに精神内界で作用し合うことである。

精神内界葛藤という考え方は精神力動の初歩的な例である。

精神内界での葛藤という用語は、自己の内部で対立する認知や感情が押し合い引き合いしている状態である。その一部または大部分は我々には意識できないものである。

意識できないものを扱うので大変微妙な話なのだが、単に思い込みが強くて、声の大きい人が断定的に何かを言っている場合もあり、そのようなことも、この業界の胡散臭さのひとつの原因となっているのだろうと推定される。

精神内界の葛藤の結果、問題行動が生じたり、症状を呈したりする。

たとえば、ある患者は妻への愛を確信していて、それを表明もしている、妻を傷つけることは決してしないと言っている、しかし婚姻外の交渉を持つ。彼の感情は自分が意識的に抱いている信念とは葛藤状態にあり、この場合は感情を行動化したということになる。

また例えば、患者は月曜日が来るごとに頭痛に悩まされる。仕事に行かなければならないという気持ちと、行くのが怖いという気持ちの葛藤の表現として頭痛があると考えられる。

日常用語でも、困難を抱えている場合、「頭が痛い」と慣用的に表現する。

精神力動的精神療法

精神分析の伝統に即した精神療法を精神力動的精神療法と呼んでいる。

精神力動的精神療法では精神分析の中核的原則は保持しているが、メタサイコロジーは使用せず、心の構造についての公式の理論も使用しない。

メタサイコロジー的仮説は「根本ではなく、全体構造の頂上である。そして理論全体になんらダメージを受けることなく、取り替えて、捨ててしまうことができる」とフロイト自身でさえ結論している。

力動的精神療法は精神分析を基礎として、それほど長期間を要さず、それほど複雑ではない事例に対応する必要から生まれて発展したものである。

精神分析では典型的には週に3回から5回、カウチに横になるのだが、力動的精神療法では週に1回又は2回、普通の診察室で行われる。

Supportive-expressive (SE) psychotherapyは現代的な形の力動的治療であり、臨床・研究両分野の方法論と一致したものになっている。

防衛

防衛という用語は、精神分析理論の力動的立場の初歩的表現である。

防衛機制は、無意識の不安や精神の危険を予感した場合に自動的に生じる反応である。

一般的な防衛の例としては、回避や否認がある。

どちらも、患者としては耐えることのできない思考や感情を何とかしなければいけない時に、「回り道」をすることで対応するものである。

有効な防衛は健康な精神には不可欠のもので、防衛があることによって、苦痛で圧倒的な困難になる可能性のある感情を、なんとか制御できるようになる。

しかしながら、防衛はしばしば現実生活では不適応も起こす。防衛機制によって現実を曖昧に認識したり、歪めて認識したりする傾向がある。

たとえば、試験勉強をしないでずっとインターネットにへばりついている学生の場合、回避の防衛機制を使っている。学期末の宿題のページを開くのが強烈な不安なので、それを和らげようとしている。他の防衛機制についてもこの文章の次節で論じる。

第二章　精神分析学

概観

「どうも腑に落ちないな」

我々が暮らしていて心を澄ませていると、そう感じることがよくある。

一見したところ立派そうな人がどうして子供を虐待するのだろう？

彼女はここ一年間素晴らしい結婚式を夢に描いていたのに、いざ実際に結婚式を迎えて、どうしてすてきなものにしようとしないのだろう？

素晴らしい隣人に恵まれ、素晴らしい学校で学び、良い家族に囲まれて育ち、人生に意欲が無いとは何ということだろう？

そして驚くことだが、「泥棒にも三分の道理」とことわざにも言われているのはどうしたことだろう。

100年以上前、ジークムント・フロイトは、我々の目に見える、表面に現れた人生というものは、我々の精神生活全体のほんの表面に過ぎないのだと主張した。

人間の精神生活の大部分は無意識のレベルで起こっていることである。

症状や問題行動を理解するには、無意識のレベルを理解しなければならないのである。

ストップウォッチで測れる時間、ものさしで測れる長さ、言葉で語られる意味、他人にも見える客観的行動、それらはほんの表面でしかない。その奥に深い精神世界がある。その理解なくして、症状も問題行動も理解はできない。

うつの症状カタログの中で何個が揃っていて、持続は何ヶ月でした、強迫症状としての鍵の確認は1ヶ月前は2時間かかって、現在は1時間です、それで何を理解しているのだろうか。

精神分析は治療システムであり、同時に、人間理解の方法である。そして今も活発に発見を与え論争を巻き起こしている。

精神分析的思考は日常生活の言葉にも入り込み(たとえば「フロイト的言い間違えだったよ」などと言う)、我々の思考に深く影響を与え続けている。

冒頭にあげた問いかけにあなたならどう答えるだろうか？

現在虐待している人間は虐待された過去があったのだろうかと疑うだろうか？

(意識からは消去されている人生早期の体験が反復されている。)

結婚式をショーアップしようとしない女性は、とても直面できないような、複雑な感情があるのではないかとあなたは感じなかっただろうか？

(意識的な感情体験にならないように防衛されている内面の葛藤。)

恵まれているが意欲のない学生は、目に見える以上の問題を抱えているのではないかとあなたは考えなかっただろうか？

(内的感情体験を覆い隠し、それを直接に感じることを妨げて防衛している表面的な幸せのストーリー。)

精神分析的思考は20世紀を通じて進展を続けた。その結果、古典的精神分析と現代的精神分析のふたつのアプローチが併存している。

精神療法は途方もなく多種多様に存在するのだが、その中で精神力動的精神療法は精神分析学のもっとも直系の子孫である。

Rangell(1963)によれば、広く実践されている精神療法の大部分は精神分析理論や技法を基礎としている。

精神分析は多様な分野に影響を与え、子供の発達理論、哲学、フェミニズムにまで及ぶ。

フロイトの説に反対し自分の説を主張しているような、ものを深く考える人や治療家にも、いまも霊感を与え続けている。

フロイトの説を拒否しても、改造しても、受け入れても、いずれにしてもフロイトの遺産とともに我々のいまはあるのだ。

この文章の目的は精神分析を少しだけ深く理解することで、特に現在でも強力な影響力を持つ精神分析的概念について解説したい。

フロイト自身の考え方は生涯にわたって変化進展を続けたし、それはいまでも進展し続けている。

精神分析が誕生した当時からすでに、反論もあり、変更もあった。

時間と研究によってふるい分けられて、ある部分は尊重され、ある部分は価値のないものとされた。

精神分析的思考がどのように役に立つかについては、臨床面で、また多様な分野での経験によって、エビデンスが蓄積されている。

この文章のゴールとしては、

・精神分析的考え方の中核を提示する

・精神分析的考え方がどのようにして発展してきたか示す

・精神分析的用語と原理の神秘性を取り除く

・精神分析的治療法を少しだけ説明する

・精神力動的思考の様々な応用を提示する

・精神分析的に方向づけられた治療の研究エビデンスを検証する

・精神療法で精神力動的思考法がどのように応用されるのか、例を上げて説明する

という予定である。

基本の考え方

人間の体の機能について考える時、機能を裏打ちしている構造があるはずだということで、解剖学や組織学のトレーニングを受けたことだろうと思う。

さらには顕微鏡でも見えないような生化学的な基礎を学び、生物学的な物の見方を学んだと思う。

しかし肉眼解剖学も、細胞生物学も、生化学も、我々の精神の謎を解き明かしてはくれない。

人間の全体が驚異の産物であるが、なかでも精神活動こそがその頂点である。

書物を理解するときに、書物を分解して、重さを測り、長さを測り、紙の成分とインクの成分を分析して、何が分かるだろう。書物という物体については分かるだろうが、何が書かれてあるのか、何が書かれていないのかについては、物理学でも化学でも知ることができない。意味について、物理、化学、生物学は教えない。

 

精神分析は人間の行動を内的体験の探求から解明しようというものである。

(その反対極が行動主義心理学といえるだろう。)

また、精神分析的理解の臨床的応用によって心理的問題を解決しようとするものである。

(その誤った応用は新興諸宗教に見られるだろう。)

したがって、中心原理は、理論的考え方でありも治療方法でもあることになる。

PSYCHOANALYSIS

Ellen B. Luborsky, Maureen O’Reilly—Landy, and Jacob A. Arlow

“It doesn’t add up.”

How could a seemingly nice person abuse a child? Why would someone not show up at her own wedding, one she'd planned for a year? How could a child from a great neighborhood with fine schools and an intact family never develop any ambition?

The next time you wonder, give credit Where credit is due. Over one hundred years ago, Sigmund Freud pronounced that the surface, or manifest, level of life is but the topsoil of mental activity. Much of it happens at an unconscious level. Symptoms and problem behavior begin to make sense when the deeper levels are understood.

Psychoanalysis, a system of treatment as well as a way to understand human behavior, has given rise to discoveries and controversies that are actively with us today. It has seeped into the language (“Was that a Freudian slip?”) and made an impact on our thinking.

Consider your reaction to the questions raised at the beginning of the chapter. Did you wonder Whether the abuser had himself been abused? (Repetition of an early experience not consciously remembered.) Did you suspect that the woman who never showed up at her wedding had mixed feelings she couldn't face? (Inner conflict, with warded off emotional experience.) Did you think that the student without ambition had more issues than meet the eye? (The surface story Functioning as a cover for, or defense against, inner emotional experience.)

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Psychoanalytic thinking has evolved over the last century, so that classical and modern psychoanalytic approaches now coexist. It has spawned different forms of psychotherapy, with psychodynamic psychotherapy being its most direct descendant. According to Rangell (1963), most of the widely practiced forms of psychotherapy are based on some element of psychoanalytic theory or technique.

Psychoanalysis has affected fields that range from child development to philosophy to feminist theory. It has inspired thinkers and therapists who disagree With Freud’s premises to come up with methods of their　own. Whether because it is rejected, adapted, or accepted, Freud’s legacy is still with us.

The purpose of this chapter is to better understand psychoanalysis, particularly those concepts that have had staying power. Freud’s own concepts evolved over the course of his lifetime, and they continue to do so. Controversy and change have accompanied psychoanalysis since it began. The tests of time and of research have highlighted some ideas and discredited others. Both the clinical and the empirical evidence For the usefulness of psychoanalytic thinking will be explored.

 

The goals of this chapter are 

To present the central psychoanalytic concepts

To examine the ways in which those concepts have evolved

To demystify the language and principles of psychoanalysis

To look at the treatment methods that have emerged from a psychoanalytic perspective 

To consider different applications of psychodynamic ideas 

To examine research evidence for psychoanalytically oriented treatment 

To give examples of how psychodynamic ideas can be used in psychotherapy

Basic Concepts

You have been trained to find an anatomical basis for the functions of the organism and their disorders, to explain them chemically and view them biologically. But no portion of your interest has been directed to the psychical life, in which, after all, the achievement of this marvelously complex organism reaches its peak. (Freud, 1916, p. 20)

Psychoanalysis seeks to understand human behavior through an investigation of inner experience, and to treat psychological problems through a clinical application of that understanding. Consequently, the central tenets include both theoretical concepts and clinical methods.

Basic Theoretical Concepts

The Unconscious

The division of the psychical into what is conscious and what is unconscious is the fundamental premise of psychoanalysis. (Freud, 1923, p. 15)

The unconscious consists of states of mind that are outside awareness. They include both emotional and cognitive processes, along with forms of memory that affect the patient’s reactions and behavior. Although the concept of the unconscious mind predates psychoanalysis, Freud’s unique contribution was to discover how the concept could be used to understand and inform the treatment of psychological problems.

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The scientific status of the unconscious has been in question since the concept was proposed. Recent discoveries of neuroscience offer some support for the influence of mental processes that are outside conscious awareness.

Psychodynamics

Our purpose is not merely to describe and classify the phenomena, but to conceive of them as brought about by the play of forces in the mind. . . . We are endeavoring to attain a dynamic concept of mental phenomena. (Freud, 1917, p. 60)

Psychodynamics is the “play [that is, the interplay] of forces of the mind.” The concept of inner conflict is a prime example of psychodynamics at work. The term inner or intrapsychic conflict refers to conflict between parts of the self that hold opposing perceptions or emotions, one or more of which is out of awareness. This may result either in problematic behavior or in symptoms. For example, a patient may express the conviction that he loves his wife and would never do anything to hurt her, while having affairs outside of the marriage. He may be acting out feelings that conflict with his consciously held beliefs. Or a patient may get a headache whenever Monday comes. The symptom may express a conflict between the part of her that knows she must go back to work and the part that dreads doing so.

Symptoms in psychodynamic theory are often seen as an expression of inner conflict. Whereas in the medical or diagnostic model a symptom is a sign of a disorder, here a symptom is a clue, expressed through the language of behavior, to the patient’s core conflicts. Decoding its meaning in the course of treatment allows the feelings once expressed through the symptom to be expressed in less harmful ways. The symptom-context method is a clinical-research method that aids in that process.

 

Psychodynamic Psychotherapy.

Psychotherapies that follow in a psychoanalytic tradition are referred to as psychodynamic treatments. They retain the central dynamic principles of psychoanalysis but do not make use of the metapsychology, or formal theories of the structure of the mind. Even Freud came to the conclusion that metapsychological hypotheses are “not the bottom, but the top of the whole structure [of science] and they can be replaced and discarded without damaging it” (Freud, 1915b. p. 77).

Dynamic psychotherapy evolved from psychoanalysis to fill the need for a form of treatment that was not so lengthy and involved. Whereas psychoanalysis is typically conducted three to five times a week, with the patient lying down, dynamic psychotherapy usually takes place once or twice a week, with the patient sitting up. Supportive-expressive (SE) psychotherapy is a current form of dynamic treatment that incorporates clinical-research methods.

 

Defenses

The term defense”. . . is the earliest representative of the dynamic standpoint in psychoanalytic theory. (Freud, A., 1966, p. 42)

Defense mechanims are automatic forms of response to situations that arouse unconscious fears or the anticipation of “psychic danger." Examples of common defenses include avoidance and denial. These both function as “ways around” situations that bring up thoughts or emotions that the patient cannot tolerate. Effective defenses are essential for healthy functioning because they render painful and potentially overwhelming feelings manageable. However, they often cause problems in real life, because they tend to obscure or distort reality. For example, a student who spends all of her time online instead of studying for exams may be using the defense

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of avoidance to counteract the intense anxiety she would feel if she opened up the semester’s untouched work. Other defenses will be discussed in the next sections of this chapter.

 

Transference.

Transference, Freud’s cornerstone concept, refers to the transfer of feelings originally experienced in an early relationship to other important people in a person’s present environment. They form a pattern that affects the patient’s attitudes toward new people and situations, shaping the present through a “template” from the past.

Each individual, through the combined operation of his innate disposition and the influences brought to bear on him during his early years, has acquired a specific method of his own in the conduct of his erotic life. This produces a stereotype plate [or template], or several such, which is constantly repeated . . . in the course of a person’s life. (Freud, 1912, pp. 99-100)

In psychoanalysis, the analysis of the transference is fundamental to the treatment. The patient’s transference to the analyst enables them both to see its operating force and to work on separating reality from memories and expectations. The transference contains patterns from the past that may he remembered through actions or through repetition of the past, rather than through recollection; . . . the patient does not say that he remembers that he used to he defiant and critical toward his parents’ authority; instead he behaves that way to the doctor” (Freud, 1914, p. 150). ,

Transference has been investigated through clinical research on the Core Conflictual Relationship Theme (CCRT) method. This research, which both clarifies and validates the concept, will be explored later in this chapter.

Countertransference refers to the therapists reactions to the patient. As the counterpart to the transference, it refers to the therapists reactions to a patient that may be linked to personal issues the therapist needs to resolve. Countertransference has been used recently to evaluate whether the therapist’s reactions may be responses to the patients emotions or to nonverbal communications from the patient.

 

Basic Clinical Concepts

 

Free Association.

 

“Say what comes to mind” is a typical beginning to any psychoanalytic treatment. Unlike other forms of treatment, psychoanalysis invites all thoughts, dreams, daydreams, and fantasies into the treatment. Psychoanalysts believe that the expression of unedited thoughts will bring richer material about the inner workings of the mind. The less edited the material, the more likely that it will contain clues to parts of the self that may previously have been expressed through symptoms. Free association also gives the patient a chance to hear himself.

 

Therapeutic Listening.

Freud recommended maintaining a state of “evenly hovering attention” to what the patient says. That means that the analyst does not seize on one topic or another but, rather, listens to all the levels of the communication at once. That includes what the patient is literally saying, What kinds of emotions she conveys, and the analyst’s reactions while listening. This form of listening is at the foundation of the analytic method, since it allows a full heating of the patient. A second kind of therapeutic listening occurs when the analyst develops a sense of the patients patterns——those that may form the transference as well as those that link symptoms with their meanings.

Therapeutic Responding. Interpretation is the fundamental form of responding in traditional psychoanalysis. It involves sharing an understanding of a central theme of the patient, often a facet of the transference. Interpretations are intended to help a patient

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come to terms with conflicts that may have been driving his behavior or symptoms, offered when the analyst senses that the patient is ready to grapple with them.

The interpretation of dreams has a special place in psychoanalytic treatment. “The interpretation of dreams is the royal road to a knowledge of the unconscious activities of the mind” (Freud, 1932, p. 608). Freud believed that the manifest content, or surface story, of dreams could be decoded to reach the deeper, latent content. Ways to understand the language of the dream will be explored in the next section.

 

Empathy as a form of therapeutic responding has received increasing attention since the second half of the twentieth century. Empathic responding means attuning to the patient’s feeling states and conveying a sense of emotional understanding. Research now links the therapist's empathy with the outcome of treatment. 

The Therapeutic Alliance.

 

The therapeutic or working alliance is the partnership between the patient and therapist forged around Working together in the treatment. Greenson (1967) clarified the difference between the working alliance and the transference and emphasized the importance of the alliance to the treatment. Current research confirms that a positive helping alliance is one of the Factors that is consistently associated with a good outcome in psychotherapy.

Other Systems

 

Psychoanalysis serves as both the grandfather and the current relative to many forms of psychotherapeutic practice. Some other systems and theorists (notably Jung and Adler) branched off from psychoanalysis during Freud’s lifetime. Others began as later adaptations and either remained under the “analytic umbrella,” as did dynamic psychotherapy, or highlighted an essential difference, as did Carl Rogers.

A number of distinct, but still essentially psychoanalytic, theories have emerged since Freud’s time. These include classical psychoanalysis, ego psychology, interpersonal psychoanalysis, object relations and other relational perspectives, and self-psychology. Although psychoanalysis as a system of thought comprises many theories, three basic ideas are common to all and provide a framework for comparison with other systems of psychology: the role of the unconscious, the phenomenon of transference, and the relevance of past experiences to present personality and symptoms.

The Unconscious Mind

 

The first central concept that distinguishes psychoanalysis from many other systems of psychology is a belief in the importance of the unconscious in understanding the human psyche. Other systems of psychology that acknowledge the significance of the human unconscious are, understandably, those developed by theorists who studied directly with Freud. Most notable among these is Carl Jung. Jung retained Freud’s belief in the unconscious but saw it as consisting of two important aspects. In addition to the type of personal unconscious that Freud described, Jungian analysts believe in a collective The collective unconscious is made up of archetypal images, or symbolic representations of universal themes of human existence that are present in all cultures, as opposed to the more personal Freudian unconscious. Similar to psychoanalysis, neurosis in Jungian analysis results when one is excessively cut off from the contents of the unconscious and the meaning of the archetypes, which can be understood through various methods, including dream analysis. Jung brought in aspects of mysticism and spirituality that were rejected or ignored by earlier psychoanalysts but which are now beginning to receive attention from modern psychoanalysts, particularly those with an interest in meditation and Eastern religions.

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Adler, another of Freud’s students, departed from the belief in the unconscious as part of an intrapsychic system based on repression of drives, but he continued to believe that people know more about themselves than they actually understand.

The Existentialists are also concerned with the unconscious. Like psychoanalysts, they believe that people experience internal unconscious conflicts and that these are excluded from conscious awareness but still exert an influence on behavior, thoughts, and feelings. For them, it is anxiety about basic existential fears such as death, isolation, and meaninglessness that is being defended against.

Gestalt therapy was also an outgrowth of psychoanalysis but departed from it in radical ways, not only in eschewing much of its basic theory, but also by developing very structured and active therapeutic techniques. Despite these substantial differences, Fritz Perls held on to a belief in the therapeutic value of bringing what is unconscious into consciousness. Similarly, Moreno’s Psychodrama, by enacting problematic interpersonal situations, helps a patient get in touch with and express feelings she may not have realized she had. Alvin Mahrer’s experiential psychotherapy also differs from psychoanalysis in a Wide variety of Ways. Mahrer regards unconscious material as unique to each individual and believes it represents one of many aspects of a deeper potential for experiencing life. Finally, certain schools of family therapy deal with the ways in which members unconsciously play out particular roles in relation to each other.

The “depth psychologies,” those that acknowledge that deeper underlying processes and experiences have significant effects on human behavior, contrast sharply with behavioral and cognitive approaches. Such therapies, which include behavior therapy, ration ai emotive behavior therapy (REBT), cognitive and cognitive-behavior therapy (CBT), and multimodal therapy, are all rooted in learning theory. In these systems, the undesired symptom, behavior, or thought is understood as having been learned and reinforced by environmental events. These models do not look for meaning beyond observed behavior or conscious experience, and behavioral observation and self-report are their primary methods of assessment.

Some therapies derived from these models have demonstrated effectiveness in treating problems such as phobias and other well-defined anxiety disorders, as Well as certain symptoms of major depression. Thus, they have made a valuable contribution to the alleviation of psychological suffering. However, many difficulties for which adults seek psychotherapy are not so readily delineated and categorized. A woman may seek psychological treatment, for example, because she is unable to maintain a close and satisfying relationship, or because she experiences a sense of malaise for which she has no explanation. Further, even with well-defined symptoms, when “treatment-resistant” cases occur, these systems offer no conceptual tools for looking beyond the observable to understand What might have gone Wrong.

The Transference

 

A second idea common to psychoanalytic therapies is the transference. Freud was the first to recognize the therapeutic value of transference phenomena, in which the patient comes to experience others, the analyst in particular, in ways that are colored by his early experiences with important people in his life. Countertransference, or the response of the analyst to the patient and his transference, is also utilized in various ways in psychoanalysis. Most contemporary psychoanalysts regard countertransference as useful clinical information about the patient, including the types of Feelings he might evoke in others. Attention to transference and countertransference reflects interest both in the unconscious and in the importance of childhood experiences and early relationships. Jungian analysts and contemporary psychoanalysts work actively with the transference

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and countertransference, reflecting a move within both orientations toward recognizing the mutual influence between patient and therapist.

Gestalt, Adlerian, and Client-centered (Rogerian) therapists have less confidence in the therapeutic value of transference. They place greater value on actively cultivating a positive relationship with the client by maintaining a stance that is visibly empathic, supportive and non-judgmental and attempting to bypass any negative transference phenomena. Being empathic and non-judgmental are also highly valued by psychoanalysts, but they remain open to the expression of both positive and negative feelings about the therapist and attempt to understand and interpret either. They believe that understand» ing these feelings is important if deep and lasting therapeutic change is to occur.

In REBT, the therapist attempts to eradicate transference phenomena at the outset by demonstrating that the client’s Feelings are based on irrational, maladaptive wishes. Behaviorally and cognitively oriented therapists attempt to enhance the working alliance, but transference is not part of their theories. Their more active stance, in which homework assignments are routinely given and explicit instructions are provided about how to change thoughts and behavior, establishes the therapist as an authority figure, a role that is utilized to encourage compliance.

 

The Role of Childhood Experiences

 

A third characteristic shared by psychoanalytically oriented clinicians is a belief that childhood experiences influence personality development, current relationships, and emotional vulnerabilities. Many contemporary psychoanalysts incorporate research findings demonstrating the long-term impact of the quality of a child’s early attachment, childhood trauma, early experiences of loss, and other related areas into their thinking about personality development. Any system for which transference is an important concept is necessarily one that recognizes this past-present relationship. Jungian analysts work actively with transference material and are similar to psychoanalysts in their view that aspects of early formative relationships affect the analytic relationship, affording the patient an opportunity to Work through these feelings and move beyond their negative impact.

Although Ellis does not use the term transference, he acknowledges that transferential thoughts and feelings toward the therapist might arise but regards them as little more than irrational beliefs. Rather than examine and attempt to understand them, he points out their unrealistic nature and applies his very systematic REBT procedure with the intention of eradicating them.

In psychodrama, early past experiences are thought to have an impact on one’s current situation, and these are explicitly role-played in an effort to rework and replace the psychologically harmful experiences with more positive ones. Rogerians and existentialists are concerned with the therapeutic relationship, but past experiences do not figure prominently in their thinking.

For systems greatly influenced by learning theory, such as cognitive, behavioral, and cognitive-behavioral therapies, as well as multimodal therapy, the past is significant only in terms of the direct antecedents to the dysfunctional behavior. This major difference from the analytic perspectives may limit the types of psychological problems that the systems that rely on learning theory are able to address.

 

Common Factors

 

Various approaches to psychotherapy differ in what they see as fundamental to the process. Dynamic psychotherapies differ from behavioral forms of treatment in their understanding of the origins of psychological problems, as well as in aspects of technique.

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Although the differences among forms of therapy are frequently highlighted in writings about treatment, they also share important fundamentals. Establishing a working alliance is important in all forms of treatment, whether it is made explicit, as in psychodynamic theory, or not. So is the frame, or structure, of the treatment and the establishment of treatment goals. The role of common factors will be further explored in the Evidence section of this chapter.

 

Precursors

 

Psychoanalysis, as originated by Sigmund Freud (1856-1939), represented an integration of the major European intellectual movements of his time. This was a period of unprecedented advance in the physical and biological sciences. The crucial issue of the day was Darwin’s theory of evolution. Originally, Freud had intended to pursue a career as a biological research scientist, and in keeping with this goal, he became affiliated with the Physiological Institute in Vienna, headed by Ernst Bruecke. Bruecke was a follower of Helmholtz and was part of the group of biologists who attempted to explain biological phenomena solely in terms of physics and chemistry. It is not surprising, therefore, that models borrowed from physics and chemistry, as well as the theory of evolution, recur regularly throughout Freud’s Writings, particularly in his early psychological works.

Freud came to psychoanalysis by Way of neurology. During his formative years, great strides were being made in neurophysiology and neuropathology. This was also the time when psychology separated from philosophy and began to emerge as an independent science. Freud was interested in both fields. He knew the works of the “association” school of psychologists (Herhart, von Humboldt, and Wundt), and he had been impressed by the Way Gustav Fechner applied concepts of physics to problems of psychological research.

In the mid-nineteenth century, there was great interest in states of split consciousness. The French neuropsychiatrists had taken the lead in studying conditions such as somnambulism, multiple personalities, fugue states, and hysteria. Hypnotism was one of the principal methods used in studying these conditions. The use of the couch, with the patient lying down, began with the practice of hypnosis. The leading Figures in this field of investigation were Jean Martin Charcot, Pierre Janet, Hippolyte Bernheim, and Ambrose August Liebault. Freud Worked with several of them and was particularly influenced by Charcot.

 

Beginnings

 

Freud made frequent revisions in his theories and practice as new and challenging findings came to his attention. In the section that follows, special emphasis will be placed on the links between Freud’s clinical findings and the consequent reformulations of his theories. These Writings serve as nodal points in the history of the evolution of his theories: Studies on Hysteria, The Intrpretation of Dreams, Three Essays on Sexuality, On Narcissism, the metapsychology papers, Beyond the Pleasure (the Dual Instinct Theory), and The Ego and the M (the Structural Theory).

Studies on Hysteria (1395)

The early history of psychoanalysis begins with hypnotism. Josef Breuer, a prominent Viennese physician, told Freud of his experience using hypnosis. When he placed the patient in a hypnotic trance and encouraged her to relate what was oppressing her mind

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at the moment, she would frequently tell of some highly emotional event in her life. awake, the patient was completely unaware of the “traumatic” event or of its connection with her disability, but after relating it under hypnosis, the patient was cured of her disability. The report made a deep impression on Freud, and it was partly in pursuit of the therapeutic potential of hypnosis that he undertook studies first with Charcot in Paris and later with Bernheirn and Liehault at'Nancy, France.

When Freud returned to Vienna, he used Breuer’s procedures on other patients and was able to confirm the validity of Breuefs findings. The two then established a Working relationship that culminated in Sturlzes on Freud and Breuer noted that recalling the traumatic event alone was not sufficient to effect a cure. The discharge of the appropriate amount of emotion was also necessary. Anna O., a patient whom Breuer cured in this way, referred to the treatment as “the talking cure.”

The task of treatment, they concluded, was to achieve catharsis of the undisch arged affect connected with the painful traumatic experience. The concept of a repressed trauma was fundamental in Freud’s conceptualization of hysteria, which led him, in an aphoristic Way, to say that hysterics suffer mainly from reminiscences.

Breuer and Freud differed on how the painful memories in hysteria had been rendered unconscious. Breuer’s explanation was a “physiological” one, in keeping with theories of psychoneuroses current at that time. In contrast, Freud favored a psychological theory. The traumatic events were "Forgotten or excluded from consciousness precisely because the individual sought to defend herself from the painful emotions that accompany recollection of repressed memories. That the mind tends to pursue pleasure and avoid pain became one of the basic principles of Freud’s subsequent psychological theory.

Breuer refused to continue this line of research, but Freud continued to Work independently. Meanwhile, Freud learned from his clinical experience that not all patients Could he hypnotized and that many others did not seem to go into a trance deep enough to produce significant results. He began using suggestion, by placing his hand on the patients’ foreheads and insisting that they attempt to recall the repressed traumatic event. This method was linked to an experiment he had witnessed while working with Bernheim. In his Autobiographical Study (1925, p. 8), Freud described the incident:

 

When the subject awoke from the state of somnambulism, he seemed to have lost all memory of what had happened While he was in that state, but Bernheim maintained that the memory was present all the same; and if he insisted upon the subject remembering, if he asseverated that the subject knew it all and had only to say it, and if at the same time he laid his hand on the subject’s forehead, then the forgotten memories began to return, hesitatingly at first, but eventually in a flood and with complete clarity.

 

Accordingly, Freud abandoned hypnosis in favor of a new technique of forced associations. However, Elisabeth von R, the first patient whom Freud treated by “Waking suggestion,” apparently rebuked Freud for interrupting her flow of thoughts. Freud took her response seriously, and the method of “free association” began to emerge.

 

Clinical Experience and Evolving Technique.

The responses of Freud’s patients to his procedures made for modification in his technique as Well as in his thinking. Not only did he attend to Elizabeth van R’s response to his “forced” questions, but he also began to notice that she actively refused certain questions. This observation prompted his thinking about resistance, or a force of “not wanting to know” in the patient. That furthered his emerging use of free association, where the task was to bring the resistances to the fore, rather than trying to circumvent them.

This technical innovation coincided with another interest that pervaded Freud’s thought at the time. He had found that two elements were characteristic of the forgotten

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traumatic events to which he had been able to trace the hysterical symptoms. In the first place, the incidents invariably proved to be sexual in nature. Second, in searching for the pathogenic situations in which the repression of sexuality had set in, Freud was carried further and further back into the patient’s life, reaching ultimately into the earliest years of childhood. Freud first concluded that the patients he observed had all been seduced by an older person. In his further investigation, Freud realized that this was not always true, and he began to develop his theory of childhood sexuality, eventually coming to believe in the importance of childhood fantasies about sexuality.

Following the same principle of learning from patients, dynamic therapists who work with the survivors of childhood sexual abuse have reopened the topic of abuse and its aftermath in patients’ lives (Davies 6: Frawley, 1994). Thus, in the century that has followed Freud, attention has returned to actual abuse, along with the possibilities of complex, interwoven symbolic material.

 

The Interpretation of Dreams (1900)

The second phase of Freud’s discoveries concerned a solution to the riddle of the dream, Dreams and symptoms, Freud came to realize, had a similar structure. He saw both as products of a compromise between two sets of conflicting forces in the mind between unconscious wishes and the repressive activity of the rest of the mind. In effecting this compromise, an inner censor disguised and distorted the representation of the unconscious wishes. This process makes dreams and symptoms seem unintelligible, but Freud’s descriptions of the mechanisms of representation in the dream gave way to the understanding of dreams and their symbols.

The Interpretation of Dreams was the book where Freud first described the Oedipus complex, an unconscious sexual desire in a child, especially a male child, for the parent of the opposite sex, usually accompanied by hostility to the parent of the same sex, as Well as guilt over this wish to vanquish that parent. The development of that theory coincided with Freud’s own self analysis. Although the Oedipus complex continues to have an important place in classical psychoanalytic theory, more recent approaches that emphasize early attachment rather than childhood sexuality do not give it the same credence.

 

The Structure of Mind. In the concluding chapter of The Interpretation of Dreams, Freud attempted to elaborate a theory of the human mind that would encompass dreaming, psychopathology, and normal functioning. The central principle of this theory is that mental life represents a fundamental conflict between the conscious and unconscious parts of the mind. The unconscious parts of the mind contain the biological, instinctual sexual drives, impulsively pressing for discharge. Opposed to these elements are forces that are either conscious or readily available to consciousness, functioning at a logical, realistic, and adaptive level.

 

Because the fundamental principle of this conceptualization of mental functioning concerned the depth or “layer.” of an idea in relation to consciousness, this theory was called the topographic theory. According to this theory, the mind could be divided into three systems: consciousness, resulting from perception of outer stimuli as well as inner mental functioning; the preconscious, consisting of those mental contents accessible to awareness once attention is directed toward them; and finally the unconscious, comprising the primitive, instinctual wishes.

The concepts developed in The Interpretation of Dream unconscious conflict, infantile sexuality, and the Oedipus cornplex—enabled Freud to attain new insights into the psychology of religion, art, character formation, mythology, and literature. These ideas were published in The Psychopathology of Everyday Life (1901), and Their

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Libido Theory. Freud conceived of mental activity as representative of two sets of drives: Libidinal drives seek gratification and are ultimately related to preservation of the species; these are opposed by the ego drive, which seeks to preserve the existence of the individual by curbing the biological drives, when necessary. The term refers to sexual energies, although they have different meanings and manifestations at different ages.

Freud proposed a developmental sequence of the libidinal drives. The oral phase extends from birth to about the middle of the second year. One of the earliest analysts, Karl Abraham (1924), observed that people whose oral needs were excessively frustrated turned out to be pessimists, whereas those whose oral desires had been gratified tended to be more optimistic. The oral phase is followed by the anal phase. A child may react to frustrations during that phase by becoming stubborn or contrary. Through formation the child may overcome the impulse to soil by becoming meticulously clean, excessively punctual, and quite parsimonious in handling possessions.

Somewhat later (ages 3 1/2 to 6), the child enters the phallic phase. In this stage, children become curious about sexual differences and the origin of life, and they may fashion their own answers to these important questions. They enjoy a sense of power and can idealize others. By this time, complex fantasies, including Oedipal fantasies, have begun to form in the n1ind of the child.

Today’s child may still come home from nursery school saying he wants to marry his teacher. Freud’s theories have allowed the culture to be relaxed about such statements, and the vast differences in the meaning of such feelings to a child and to an adult are better understood.

These early psychosexual phases are followed by a period of latency, from the age of 6 to the onset of puberty. Then, under the influence of the biological changes of puberty, a period of turbulence and readjustment sets in, and when development is healthy, this period culminates in the achievement of adequate mastery over drives, leading to adaptation, sexual and moral identity, and attachment to significant others.

 

On Narcissism (1914)

The next phase in the development of Freud’s concepts focused on his investigation into the psychology of the psychoses, group formation, and love—-for one’s self, one’s children, and significant others. He found that some individuals led lives dominated by the pursuit of self-esteem and grandiosity. These same factors seemed to operate in the relationship of an individual to the person with whom he or she was in love. The beloved was aggrandized and endowed with superlative qualities, and separation from the beloved was seen as a catastrophic blow to self-esteem. These observations on narcissism remain relevant to more recent attention to the narcissistic personality disorder.

 

The Ego and the Id (1923)

Having recognized that in the course of psychic conflict, conscience may operate at conscious and/or unconscious levels, and that even the methods by which the mind protects itself from anxiety may be unconscious, Freud reformulated his theory in terms of a structural organization of the mind. Mental functions were grouped according to the role they played in conflict. Freud named the three major subdivisions the ego, the id, and the superego.

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21ST-CENTURY PSYCHOTHERAPIES

Other men are lenses through which we read our own minds.

                                                 Ralph Waldo Emerson (1850)

 

Psychotherapy, as far as it leads to substantial bebavior change, appears to

achieve its effect through changes in gene expression at the neuronal level.

                                                            Eric Kandel(1996)

This book surveys a diverse set of effective psychotherapies. Each represents a vision of

the Human as well as a set of distinct treatment procedures for addressing the emotional

distress and the accompanying behavioral and cognitive problems that drive people to

seek he1p.  As one reviews the evolution of this textbook through nine editions and the

theories of personality development that underpin each of the therapeutic modalities

treated within it, it's evident that these modalities have an increasingly short half-life.

Entire schools of psychotherapy have undergone dramatic change, some more rapidly

than others---and some have virtually disappeared (e.g., Transactional Analysis,). The

editors of this book continue to showcase several therapies that have their origins in

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the early 20th century, but they do this because these earlier therapies have evolved to reflect changes in the science of developmental psychology and have continually improved their clinical effectiveness. Therapies of more recent vintage have been added, which, although built on strong historical foundations, would strike even psychotherapists of the 1960s and 1970s as novel if not strange. In any event, to understand where We are heading, We need to know where psychotherapy started and how it has changed. The following section addresses this matter.

Historical Foundations of Psychotherapy

From the origins of recorded history, humans have sought means to remedy the mental disorders that have afflicted them. Some of these remedies were (and continue to be) patently unscientific, if not ineffective, such as the ceremonial healing rituals found in shamanistic societies. Pre-Christian, temple-like asklepeia and other retreat centers of the eastern Mediterranean region, using religio-philosophical. lectures, ineditation, and simple rest, competed with secular medicine to assuage if not remedy psychological disorders. This latter stream of psycho-physiological treatment, in which Hippocrates Worked, was surprisingly scientific. Hellenist physicians, through their empirical studies, understood that the brain was not only the seat of knowledge and learning but also the source of depression, delirium, and madness. indeed, he Wrote, “Men ought to know that from nothing else but the brain come joys, delights, laughter and sports, and sorrows, griefs, despondency, and lamentations . . . and by the same organ We become mad and delirious, and fears and terrors assail us . . . all things We endure from the brain when it is not healthy” (5th c. B.C.E., quoted by Stanley Finger, 2001, p. 13). Hippocrates himself insisted that his students address illnesses by natural means. He repudiated the popular notion that such illnesses as seizures were divine” and should be treated by appealing to and placating gods. Although the Hippocratic tradition endured uninterruptedly to the time of his renowned disciple Galen, who lived six centuries later, psychotherapy in its present guise did not clearly emerge until the 18th century.

The Unconscious

The reader will find that the construct unconscious plays a salient role in certain chapters of this volume, especially those that have a psychodynamic character, but it was also a key construct in the psychotherapies that emerged in the 19th century. The scientific study of the unconscious is commonly thought to have started with the renowned polymath Gottfried Wilhelm Leibniz (1646-1716). Leibniz studied the role of subliminal perceptions in our daily life (and, incidentally, coined the term “dynamic” to describe the forces operative in unconscious mentation). His investigations of the unconscious were continued by Johann Friedrich Herbart (1776-1841), who attempted to mathematicize the dynamics describing the passage of memories to and from the conscious and the unconscious. Herbart suggested that ideas struggle with one another for access to consciousness as dissonant ideas repel one another and associated ideas help pull each other into consciousness (or drag each other down into unconsciousness). Leibniz and Herbart are examples of 17th- and 18th-century scientists who attributed significance to an understanding of the unconscious in their work (Whyte, 1960).

Mesmer and Schopenhauer. Two of the most influential and creative thinkers in the early 19th century were Franz Anton Mesmer (1734-1815) and Arthur Schopenhauer (1788—1860). Their impact can be seen in the psychiatric literature that evolved into the full-fledged systems of Pierre Janet, Sigmund Freud, Alfred Adler, and Carl Gustav Jung. Thomas Mann (a Nobel laureate in literature) stated that in reading Freud, he had

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an eerie feeling that he was actually reading Schopenhauer (1788-1860) translated into a later idiom (Ellenberger, 1970, p. 209).

Mesmer and his disciple the Marquis de Puységur, regarded as the pioneers of hypnotherapy, effectively discredited the exorcist tradition that had dominated preEnlightenment Europe (Leahey, 2000, pp. 216-218). That there were many quaint and unsubstantiated hypotheses in the Mesmerian system does not diminish the fact that the notion of rapport between therapist and patient, the influence of the unconscious in shaping behavior, the personal qualities of the therapist, spontaneous remission of disorders, hypnotic somnambulism, the selective function of unconscious memory, impatients’ confidence in treatment procedures, and other common factors in our current therapeutics armory can be traced back to this period in European history.

Three distinct streams of investigation into how the mind works emerged in the 19th century. The contributors to these three streams were (a) systematic, lab-bench empiricists, (b) philosophers of nature, and (c) clinician—researchers. A multitude of psychotherapies were spun out from these investigations.

Psychotherapy-related Science in the 19th Century

The Natural—Science Empiricists

Some of the greatest scientists of the 19th century, such as Gustav T. Fechner (18011887) and Herman von Helmholtz (1821-1894), conducted seminal research in the area of cognitive science. Fechner’s work tapped into and overlapped with the investigations of Herbart. Fechner began with the distinction between the theaters of the waking and sleeping states—and especially the dream state. That the unconscious existed as a realm of the mind was evident even to the untutored farm laborer. Anyone who had ever struggled to recall a rnemory—and succeeded——knew that he or she retained knowledge that Was not always readily accessible. This knowledge had to reside sornewhere. In the late 1850s, Fechner, in his psychophysics experiments, attempted to measure the intensity of psychic stimulation needed for ideas to cross the threshold from the unconscious to full awareness, as Well as the intensity of the resultant perception. Fechner’s studies reverberated throughout Europe, and the reader may unknowingly resonate to his findings not only in Freud’s writings (Freud quoted him in several of his works) and the chapters of this book but also in those of myriad other contemporary theorists and practitioners, most notably the Gestaltists and (Milton H.) Ericksonians.

Helmholtz, another experirnentaiist, “discovered the phenomenon of ‘unconscious inference’,” which he perceived as a kind of instantaneous and unconscious reconstruction of what our past taught us about the object” (Elienberger, 1970, p. 313). Wilhehn Griesinger, Joannes von Muller, and many other such experirnentalists and brain scientists dominated the academic scene of Vienna, Heidelberg, Leipzig, and other Germanlanguage universities and institutes, making many contributions that infused the work of later psychodynamicists.

The spirit and approach of these lah-based scientists resounded throughout Europe and in large part constituted what became known there as the somatzlker (organicist) tradition. Several of Freud’s mentors, such as Ernst Briicke (1819-1892) and Theodor Meynert (1833—1892), were organicists. Although the organicists Worked feverishly throughout the century to find solutions to psychiatric disorders, Emil Kraepelin on the cusp of the 20th century finally conceded defeat, admitting that 50 years of hard bench work had given medicine few tools for curing psychiatric disorders (Shorter, 1997, pp. 103, 328). He turned his attention to classifying diseases, meticulously describing

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them, schernatizing their course, and establishing benchmarks for prognosis. This provided an opportunity for the pxyc/aiker (those who were convinced that only a psychological approach to mental illness would prove effective) to gain prominence. The work of all the brass-instrument methodologists and empiricist dream scholars still pales in significance by comparison with the influence of the psycho-philosophical Writers of the first half of the 19th century.

The philosophers of nature had a much greater, long-term influence on the development of the psychotherapies described in the following chapters of this book than did laboratory-based scientists. These philosophers can be historically situated in the same school of thought that nurtured Schiller and Goethe. They were Romantics in the philosophical sense, firmly rooted in nature, beauty, homeland, sentiment, the life of the mind, and of course, the mind at its most enigmatic: the unconscious. Arthur Schopenhauer, Carl Gustav Cams, and Eduard von Hartmann were among the most notable of this group.

Carl Gustav Carus (1789—1869), though largely unread today, can justifiably be singled out in a hook on psychotherapy because he developed one of the most sophisticated schemas that exist for the unconscious (see Ellenberger, 1970, pp. 202-210). Catus speculated that there are several levels to the unconscious. When humans interact, all levels of the unconscious as well as the conscious interact. To extrapolate to the clinic, when patient and therapist are at work, the conscious of each speaks to the unconscious as well as to the conscious of the other. But further, the unconscious of each speaks to the conscious as well as the to unconscious of the other. Needless to emphasize, both are communicating with each other in paravocal, nonverbal, organic, and affective modes of which both participants are largely unaware. In this perspective, boil) the therapist and the patient engage, willfully or not, in transference and countertransference (see Dumont 81 Fitzpatrick, 2001). Nonlinear messages are systemically (often simultaneously) sent in all directions. What Carus taught us is that transference occurs at an unconscious level.

Before Carus, Schopenhauer (1819) published “The World as \Will and Idea.” This masterpiece of the Western canon, once it caught on, provided ideational grist for generations of psychological researchers who followed. It inspired those psychologists who were children of the Philosophy of Nature and had embraced (or resigned themselves to) nonhiological methods for curing the fashionable disorders of the day-—-even those disorders that today would he classified as (DSM) Axis I disorders. Schopenhauer’s book was in large part a treatise on human sexuality and the realm of the unconscious. His principal argument was that we are driven by blind, irrational forces of which we are largely unaware and that we know things that we are unaware that we know. His irrationalist and pansexual view of human behavior and mentation was deterministic and also pessimistic (see Ellenberger’s [1970] analysis, pp. 208—210). Schopenl1auer’s thoughts influenced the psychology of many later thinkers, not least Friedrich Nietzsche and Sigmund Freud.

The tracts of Schopenhauer and Carus set the epistemological stage for von Hartrnann’s and Nietzsche’s influential Writings on our tacit cognitions, which they believed drove the daily, unreflective behavior of people. In Nietzsche’s view, humans lie to themselves even more than they do to each other. What We consciously are thinking is “a more or less fantastic commentary on an unconscious, perhaps unknowablc, but felt text” (cited in Ellenbcrgcr, 1970, p. 273). He developed notions of selfideception, sublimation, repression, conscience, and neurotic guilt. Cynic par excellence Nietzsche averrecl that every complaint is an accusation and every

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admission of a behavioral fault or characterological flaw is a subterfuge to conceal more serious personal failures. In brief, he unmasked many of the defense mechanisms that humans employ to embellish their persona and self-image. Nietzsche, in his unsystematic and aphoristic Way, cast a long shadow over the personology and psychotherapies of the 20th century.

The C1inician——Researchers

In the nascent clinical psychology of the 19th century, a great number of gifted clinicians made discoveries and innovations in their clinical practice that had implications for psychotherapy generally and for the development of theories of personality as Well. Some were humble practitioners like the celebrated hypnotherapist Arnbroise Liébault, other great scholars like Moritz Benedikt (1835-1920), whose work in criminology, psychiatry, and neurology won the admiration of Jean-Martin Charcot. Benedikt developed the useful concept of seeking out and clinically purging “pathogenic secrets,” practice that Jung later made an essential element of his analytic psychotherapy. Theodore Flournoy, Josef Breuer, Auguste Forel, Eugen Bleuler, Paul Dubois (greatly admired by Raymond Corsini), Sigmund Freud, Pierre Ianet, Adolf Meyer, Carl Gustav Jung, and Alfred Adler all made signal contributions to the science of psychotherapy. Though many of their contributions have outlived their usefulness, the many offshoots of their findings and systems can be traced in clinical psychotherapy and in other psychological disciplines.

A corollary of the notion that psychotherapies are in constant evolution is the recognition that clinicians have often perpetuated the strategies and techniques they learned in their graduate professional programs, dated though they may have become, rather than learning and developing important new principles and procedures through their professional practice and diligent reading of the literature in their specialty. Remaining at a fixed stage of one’s continually evolving profession is not a desirable outcome of training, for, to paraphrase an aphorism from sport psychology, practice makes permanent but not necessarily perfect. Improving our performance of an outdated or largely flawed technique is not a clinical desideraturn.

Chapters 2 through 15 of this volume represent scientifically recognized advances over what preceded them. Like all current and major psychotherapies, they have all emerged to a greater or lesser degree from the historical matrix described above. Even the contemplative therapies described in chapter 13 have their roots not only in the ancient traditions of the Middle and Far East but also in those of the Near East and the asklepeia of Hellenic Greece.

THE IMPACT OF THE BIOLOGICAL SCIENCES

When patients1 learn new ideas, Whether true or false, whether in the clinic or in the course of daily life, concomitant alterations of the brain occur (see, e.g., LeDoux’s [Z002], Synaptic Self). Every encounter with our environment causes a change Within us and in our neural functioning. Moreover, education implies permanence. Once skills and ideas are truly learned and lodged in permanent storage, it is difficult if not

1 Throughout this chapter we have used the term patzkvzt, which etymologically implies suffering and characterizes most people who seek therapy. It is a derivative of a Latin verb that means to endure a painful situation. In the 8th edition of this book, Ray Corsini noted the disciplinespecific connotations of patient and client, the former for medical contexts and the latter for his private practice.

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impossible to unlearn them. Given the solution to a puzzle, taught the secret of cracking a safe, or having developed the skill of riding a bicycle, one cannot unlearn that knowledge. Neuronal decay and lesions can, of course, undo memory and occur to a certain extent in aging and, catastrophically, in strokes, illness, or violent accidents. The task of the therapist in most cases is to help the patient fashion alternatzbe and future memories, supported by newly learned motivational schem as.

Klaus Grawe (2007), in his important book Neuropsyc/vothempy: How the Neurosciences Inform Psyc/902‘/aempy, noted that “Psychotherapy, as far as it leads to substantial behavior change, appears to achieve its effect through changes in gene expression at the neuronal level” (p. 3, citing Kanclel, 1996, p. 711). Further embedding patients in their dysfunctional past by prodding them to ruminate about that past does not erase their painful memories nor their penchant for dwelling on these memories. Nor does it teach. them more adaptive patterns of behavior. Therapists teach patients how to avoid dysfunctional, harmful behavioral routines and maladaptive habits. Effective therapists also help their clients develop alternative skills (social, interpersonal, self-disciplinary, and technical) that will advance their well-being and that of others with whom they interact. The neurosciences have demonstrated that neuronal~ restructuring, Which occurs in all learning processes, enables the adaptive changes in affect, behavior, and mentation that are the core objectives of psychotherapy (ct. Dumont, 2009; 2010).

A neurological perspective on psychotherapy does not exclude attention to changing clients’ environment or introducing constructive environmental stimuli into their lives. On the contrary, even minor novelties in clients’ lifestyle can have enormous consequences in the way they perceive and experience themselves. We now know that effective therapists and their clients can optimize desirable outcomes by epigenetically triggering the expression of z'mmedz'ate~earZy genes (IEGs) through exposure to nurturant social events (Giintiirkiin, 2006). (Epigenetz'c5 refers to the expression of certain genes that results from their activation by specific but common environmental events.) Culture generally and one’s immediate family specifically function as genetic enablers. Such epigenetic effects can operate for better or for Worse, depending on the quality of the experiences. In brief, it is the complex bio-cultural matrix of the organic and the environmental that co-construct our way of being and our potential for growth (Baltes, Renter-Lorenz, Rosier, 2006).

ORGANICISTS AND DYNAMICISTS: CLASHING

STANDPOINTS

Readers will immediately recognize the potential for cultural confrontations in these propositions. However, our view is that confrontation is neither necessary not useful. The ancient animosity between the somatiker and the psyc/yiker, the psychopharrnacological organicists and psychodynarnicists, the behavioral geneticists and the cognitive-behaviorists can be resolved through a systemic integration of the many variables that are at play at any moment. Indeed, such integration is necessary. To ignore organic or environmental variables in one’s treatment of one’s clientele is to neglect essential aspects of the whole person, and to treat all affective disorders as if there were no organicity in the causal skein of variables that brought them about is . an ancient error.

One example of this error is ignoring patients’ medication histories. Kenneth Pope and Danny Wedding (2010) discuss the danger inherent in neglecting to monitor patients who are taking psychotropic medication. Patients need to be pharmacologically guided and their experiences between sessions closely monitored. Medicating patients

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for psychological purposes requires preset clinical objectives and conscientious ongoing assessment of progress. Grawe (2007) stated:

From a neuroscientific perspective, psychopharmacological therapy that is not coordinated with a simultaneous, targeted alteration of the person’s experiences cannot be justified. The widespread practice of prescribing psychoactive medication Without assuming responsibility for the patient’s concurrent experience is, from a neuroscientific view, equally irresponsible. . . . The use of pharmacotherapy al0ne——in the absence of the professional and competent structuring of the treated patient’s life eXperience——is not justifiable . . . (pp. 5-6)

Nurture is profoundly shaped by nature. Similarly, aspects of our nature (that is, our genetic inheritance) are epigenetically expressed for better or for worse by the kinds of experiences to which WC are subjected throughout life. This explains in part why, among identical twins, one can become severely diabetic while the other does not. In this perspective, therapists become responsible to some degree for both the natural and nurturant components of the patients’ lives that come under their purview.

Evolutionary Biology and Behavioral Genetics

plications for psychotherapy. Evolutionary psychology will likely further clarify many of the temperamental traits that therapists need to understand to be effective. Steven Pinker (2002) has extensively documented the principle that all humans share the same, unique nature. If we exclude anomalous genetic mutations, the normative stance of all clinicians treating a patient is that they are dealing with an organism struck from the same genetic template as themselves.

Evolutionary psychology is closely related to the field of behavioral genetics, another discipline that will have an impact on the therapeutic modalities that clinicians of the future will assuredly develop. This discipline will shine a focused light on the lawfulness that governs the human genome and the biopsychosoeial regularities that occur in the course of one’s life. There are more regularities, that is, universal behavioral traits, than We have traditionally imagined (see Brown, 1991). While accepting the parameters established by our genetic inheritance and the regularities our genes prescribe for our human interactions and life course, clinicians will still need to treat the idiosyncratic dysfunctions their patients reveal to them. Moreover, as suggested above, psychotherapy will involve monitoring the situational variables and events that can trigger the expression of latent genes. Finally, the related fields of molecular genetic analysis, cognitive neuropsychology, and social cognitive neuroscience, which are advancing at an impressive rate, will inevitably infiltrate our porous integrationist models of helping.

Demographics

In this 9th edition of Current Psyc/90trlvempz'es, a new chapter is dedicated to current approaches to multicultural psychotherapy, This initiative is not simply a reflection of the self-evident importance of cultural factors in counseling and psychotherapy that have been developing in recent decades. It is also a reflection. of the changing demographic character of the planet, the human tides that are swirling about the previously distant continents of the globe, the tightening communicational network of masses of people engaged in armed conflict, research, diplomacy, and higher education, and

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the internationalization of professional psychological counseling. Although chapters on jungian psychotherapy (Chapter 4), existential psychotherapy (Chapter 9), and, most notably, contemplative psychotherapies (Chapter 13) have dealt heretofore with the ethno~cultural variables implicated in the treatment of diverse ethnic populations, at new chapter (Chapter 15) will be dedicated exclusively to this approach.

The complexities involved in multicultural counseling are incomparably greater than those involved in conducting therapy in a homogeneous culture where each member of the therapeutic dyad springs from the same ethno-cultural background. Where the patient and the therapist are solidly grounded in different traditional cultures, it matters if the “authority” figure is a member, say, of a minority, nondominant culture or the dominant, majority culture. In marital counseling, the difficulties multiply like fractals if the couple seeking help is biracial. In this case, the matrix of interactive variables becomes even more complex if the therapist/ counselor unknowingly identifies with one spouse rather than the other. Gender by culture permutations add another layer of systemic interactions. And of course it is not enough to simply acknowledge one’s differentness. Counselors are never fully aware of how different they are from the clients sitting across from or beside them for the simple reason that they are never fully conscious of the dynamics driving their own reactions to the client’s socially conditioned sensitivities. Much of therapists’ mentation operates beyond awareness, for their own cognitive and affective structures are intenneshed in the invisible, bottomless depths of their unconscious.

Cantonese speakers counseling Cantonese speakers in Hong Kong face a different set of parameters and challenges than Hispanic counselors in San Diego counseling other Hispanics. The philosophical and socio-economic differences that characterize men'1~ bers of the same society will determine the suitability of nonindigenous psychotherapies that are most congenial to both of them. But within homogeneous non-Caucasian populations, there is the same constellation of contingencies that confront Euro-American peoples. Iob stresses, finances, physical illness, personal history, family dynamics, personological variables of genetic and environmental origin, even the Weather will all affect what happens between a therapist and a client.

Language and Metaphor

Language, behavioral mannerisms, local and national poetry, metaphor, and myth are the instruments that shape the structures of our mind (see, for example, Lakoff 8: Johnson [1980] in Memp/901'; We Live By). Popular metaphors permeate all aspects of human thought. They ultimately shape a nation’s culture and collective personality. Those who are not familiar with these elements of their clients’ culture will find it difficult to enter the labyrinthine recesses where their ancestral and self-made daemons (some benevolent, some hurtful) resicle.

All therapists have clinical stories they can tell of mistakes they have made by the innocent use of a metaphor, a careless juxtaposing of questions, a refusal of a courtesy, or insensitivity to a taboo of their client’s culture. Painfully, their former friends and patients have left, never to return, with hardly a of explanation. For this reason, it has often been proposed that psychotherapies need to be incligenized. Rather than exporting Euro~Arnerican psychotherapies, say, to China, some would encourage Chinese healers to develop psychotherapies that reflect their philosophies, values, social objectives, and religious convictions. Yang (1997, 1999), for example, has suggested that Chinese counselors can more easily help resolve the paradoxes and dilemmas that characterize Chinese village, family, and personal life than non-Chinese can. Likewise, Hoshmand (2005 , p. 3) avers that “indigenous culture provides native ways of knowing what is salient and congruent with the local ethos and what are credible ways of addressing human prohlems,” a view supported by Marsella and Yarnada (2000). Similarly,

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Cross and Markus (1999) note that “the articulation of a truly universal understanding of human nature and personality . . . requires the development of theories of behavior in the indigenous psychologies of Asian, Latin American, African, and other non-Western societies” (p. 381). ~ The complex issues that we have alluded to here will be more fully addressed in

Chapter 15.

Division 12 (1995) of the American Psychological Association (APA) established a Task Force on Promotion and Dissemination of Psychological Procedures to grapple with the issues of empirically based treatments (EBTs), Since then there has been a flood of research conducted to demonstrate the scientific validity of those therapies their partisans espouse. As in earlier editions of Current Psyc/oot/oempies, the contributors to this book have wrestled with this issue. There are a number of serious fault lines in the terrain defining this debate, and although they have all been addressed by the professions serving the mental health needs of society, they still constitute threats to clinical credibility.

Psychotherapy: An Art or a Science

Patients typically work in session with one therapist for 50 minutes a Week but are exposed for the rest of the Week to innumerable contingencies outside the clinic that can confound their fine-tuned plans and firrnest resolve. Many of these contingencies are unforeseen and beyond their control. Paul Meehl (1978) called these random events context-dependent ytoc/aastologicals (pp. 812-814); they are a tangle of variables internal and external to the person that intertwine with job stresses, financial concerns, troubled children, angry spouses or in-laws, difficult colleagues, bad weather, life-threatening illness, dubious insurance claims, and the forgotten baggage of personal history and past defeats. Each patient has a unique set of such variables, but to make the situation even more complicated, they are often afflicted by a number of distinct disorders. This comorbidity complicates the categorization of disordered patients for purposes of validating therapy for them (Bcutler 8c Baker, 1998). For many practitioners and onlookers, the science of prognosticating outcomes in psychotherapy inspires as much confidence as predictions of stock market fluctuations. There is simply too much. opacity in the universe of variables, known and unknown, to make confident prognoses.

spontaneity and Intuition: “Throw-Ins”

Readers of the chapters of this book will be faced with clients who present complex puzzles to them, each client manifesting varying degrees of anxiety, coping skills, and emotional stability—and often with no clear idea what their treatment will consist of nor how effective this expensive service likely will be. Long before clinical interns enter that arena, they will need to have made some multilayerecl existential choices: Whether (or not) to become artisanal therapists, manuahhased “craftsmen,” or complex humanistic variants between these two extremes. Yalom (1980) Wrote about a cooking course he once took with an Armenian chef. She could not speak English, not could Yalom or other students speak Armenian. The students learned by watching, like so many Inuit children. Besides noting the main ingredients, Yalorn observed that as the pots and skillets were from counter to stove, a variety of spices were tossed in—a pinch of this and a pinch of that. “I am convinced,” he Wrote, “those surreptitious thr0w~ins made all the difference” (p, 3). He likened this process to psychotherapy. Often unknown to therapists, it’s their unscripted “throw-ins” that can make all the difference.

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manual

Spontaneous, unplanned throw-ins are hardly a basis for a science of psychotherapy. Doing psychotherapy in this manner makes it more like a craft, or at its pinnacle——as Yalom and Josselson do it—-an art. Even repeatedly demonstrating that one can improve client well-being and achieve therapeutic ohjectives by a manualizecl series of interventions does not explain how the variables have caused the outcome. Intensive research has been conducted in the last decade precisely to identify the mechanisms that are bringing about change. Although ambitious programs of process research, as distinguished from outcome research, are being conducted (see, e.g., Norcross 8c Goldfried, 2005), these causal links nature are not yet fully understood. Such understanding will only surface when We have a mature-neuroscience that can describe

the mechanisms involved. This problem is obviated for those who are only seeking

manualized approaches to therapy, that is, sets of sequential, algorithrnized steps for proceeding through phases of therapy (see Prochaska, N orcross, 8: DiClen1ente, 1995, for one cogent model).

There are several practical advantages to rnanualized psychotherapy. Engineering therapy in the guise of an architecture of stages or building blocks makes sense pedagogically. One proceeds from the known to the unknown and untried in a methodical, stepwise fashion, clearly specifying layered objectives and mobilizing the personal, social, and institutional 1“tlSOl/JICES that are so useful—and so often necessary. These processes through which the patient can be guided are amenable to various configurations. The chapters of this book (2 through 15) have been structured in such a way that the enterprising student can design a manual for each using the elements as they are presented.

obstacle

The sheer number of potent client and personological variables that must be considered when computing the outcome variance of a procedure dwarfs the influence of the technique. Citing numerous studies, Michael Mahoney wrote in 1991 “the person of the therapist is at least eight times more influential than his or her theoretical orientation and/ or use of specific therapeutic techniques” (p. 346). Norcross and Beutler (2008)

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stated that there are “tens of thousands of potential permutations and combinations of patient, therapist, treatment, and setting variables that could contribute” to improving treatment decisions (p. 491). They noted the earlier studies of Beutler and colleagues in which the latter conducted various analyses of these multitudinous variables with a sample of depressed patients. They reduced “tens of thousands” to a manageable number, trusting that the loss of specificity in their constructs would not overshadow the utility of their generic approach. This is analogous to the task undertaken by Allport and Qdbert (1936) and several generations of trait psychologists who followed them, who reduced 18,000 personality descriptors to a handful of core personality factors using the factor analytic techniques developed largely by Raymond B. Cattell.

The irntnensity of the task dawns on us when we consider the hundreds of other DSM disorders that call for varied treatments on the one hand and Meehl’s innumerable random events on the other. The complex and changing context of our patients’ daily lives is like a headwind that keeps pushing us back toward Yal0m’s kitchen and the critical importance of “throw-ins.”

The pursuit of what works is more important to pragmatic species like /some sapiem than the pursuit of why it works. This is especially true of psychotherapy, which is an applied and very practical science. Like wave and particle theories in the physics of light, art and science in psychotherapy are not incompatible paradigms. Both are valid, and elements of both appear in every clinical session. As unanticipated material comes to light, all clinicians to one degree or another rely on intuitive inspiration and creative imagination in deciding what to do next in therapy.

Some therapies, such as behavioral and cognitive therapies, are more amenable to manualization than others such as existential psychotherapy but ought not to be preferred simply for that reason. On the other hand, the manualization of therapies must not be caricatured simply as a cookbook approach to treating disorders. The variables and the random events that continually pop up in a patient’s life and complicate therapists’ best-thought-out plans require adjustment and compromise. Therapeutic judgment and creativity are always called into play. Pursuing the mirage of a blueprint that unfolds seamlessly from start to finish entails a loss of therapists’ time and effectiveness and drains patients’ emotional and financial resources. There is room in evidence-based therapies and tnanualizecl therapies for the poetry, spirituality, spontaneity, sentiment, free Will, even the mystery and romance of human. self-discovery and growth that both patients and humanistically inclined therapists crave. There should be no tension between getting better and feeling better. In fact, like butter in the batter, affect and reason are as inseparable here as elsewhere.

Although pastoral counseling and faith~based therapeutic procedures are still widely practiced in North America, and indeed globally, secular, science-based approaches to treating mental disorders have become normative. As psychotherapy has gained recognition as a health discipline, a growing chorus of voices (of both patients and mental health services professionals) has clamorecl for insurance programs to reimburse mental health costs. The establishment of managed health care (MHC) is a business issue and perhaps of little interest to students who Wish to commit their careers to helping people, but the reality is that students will need to ensure that they can run a solvent enterprise after they graduate, even if it is a humble independent practice. Like it or not, therapists

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are quickly drawn into a Web of institutional requirements that will secure not only the safety of the public they serve but their own livelihood as well.

The industrialization of all health professions, whether it be counseling, social Work, psychiatry, clinical psychology, neuropsychology, school psychology, or psychometrics has “been the linchpin of the development and use of empirically based clinical practice guidelines” (Hayes, 1998, p. 27). Readers may recoil from these institutional realities, but they are well advised to generate their personal therapeutic models during their studies and training such that they meet the demands of the accreditation, licensure, insurance, and medical organizations that will facilitate the growth and solvency of their practice.

Epilogue to This Chapter

In the previous edition of this book, Ray Corsini (2008) wrote,

I believe that if one is to go into the fields of counseling and psychotherapy, then the best theory and methodology to use must be one’s own. The reader will not be either successful or happy using :1 method not suited to her or his own personality. Truly successful therapists adopt or develop a theory and methodology congruent with their own personality . . . In reading these accounts, in addition to attempting to determine which school of psychotherapy seems most sensible, the reader should also attempt to find one that fits his or her philosophy of life, one whose theoretical underpinnings seem most valid, and one with 21 method of operation that appears most appealing in use. (p. 13)

A final value of this book lies in the greater self-unclerstanoling that may be gained by close reading. This book about psychotberapies may be psychotberapeutic for the reader. Close reading vertically (chapter by chapter) and then horizontally (section by section) may well lead to personal growth as well as to better understanding of current psychotherapies.

These counsels from a great therapist and scholar are a fitting conclusion to this chapter.

Valedictory

Some readers of previous editions of this book will note that this is the first time that Ray Corsini has not boon the sole author of this introductory chapter. Ray died November 8, 2008, in Honolulu at the age of 94. He left those of us who survive him hcrcft of one of the most creative, loyal, challenging, and inspiring colleagues We’ve had the privilege of knowing and Working with. Danny Wedding, Ray’s co-editor of Psyc/vat/verapzes, and all those, including me, who have had the privilege of working with Ray over the years, bid him a fond farewell and Wish him Well in this journey.

表１．FTDの神経病理学的診断基準（The Lund and Manchester Group, 1994 による）

１．前頭葉変性型　Frontal Lobe Degeneration Type

肉眼的変化：前頭葉と前方部側頭葉の両側対称的な軽い萎縮があり、脳室は前方部が拡大する。線条体、扁桃体や海馬に通常肉眼的萎縮はないが、時に激しく侵される例もある。

顕微鏡変化の分布：変化は前頭葉穹窿部皮質、時に眼窩皮質にみられ、又しばしば側頭葉皮質の前３分の１、帯状回

の前方部、稀に後部に認められる。上側頭回は明瞭に免れる。頭頂葉皮質が侵されるのは少数の患者でしかも軽い。

稀ながら進行した例ではより強く侵される。明瞭な常同型行動のある患者では、新皮質が侵されることは少なく、大抵は線条体、扁桃体、海馬に病変をもつ。これらはおそらく１つの亜型を表わす。

顕微鏡的特徴、灰白質：微小空胞形成と軽度ないし中等度のアストログリオーシスが主にI-III層にみられ、時にこれ

らの一方または他方の変化が優勢のこともある。II-III層に神経細胞の萎縮・脱落があり、一方V層では軽く、細胞

の脱落よりも萎縮が目立つ。時に２，３の異栄養性の神経突起がある。Pick小体、腫脹神経細胞、またはLewy 小体

はない。tauやubiquitinの免疫組織化学で何ら特別な特徴を検出できない。患者の中には黒質のメラニン色素細胞の軽度ないし中等度の脱落が見られる者もある。

白質：アストログリオーシスは中等度ないし軽度で皮質下のU線維に認められる。深部白質には穏和なアストログリ

オーシスがあり、時に髄鞘の狭小化と消失をともなっている。その分布は灰白質の変化と関係している。時に虚血に

よる白質の菲薄化もみられる。

　この分類（Table 1）はFTD（後にFTLD）の病理学的病型分類の基本をなすものであるが、研究が進んだ現在では、後述の如くこの中に多数の疾患が含まれることが明らかになっている。Snowden, Neary & Mann（1996）は全体を包括する臨床病理学的疾患群を意味する概念としてFrontotemporal Lobar Degeneration（FTLD）を用い、最初に侵される脳の領域の相違により、現れる臨床症状群の特徴に基づき３臨床型に分類し、FTDをその中の１型とし、他に非流暢性失語症と語義認知症を区別した。更にFTDを（a）脱抑制型（b）無欲型（c）常同型の３亜型に分けた（表２）。

２．Pick型　Pick-Type

肉眼変化：前頭葉変性型と同じであるが、一般により強く、より限局性である。左右非対称と線条体萎縮がよくみら

れる。顕微鏡変化の分布：肉眼的分布と符合して、前頭葉変性型と同じである。顕微鏡的特徴、灰白質と白質：前頭葉変性型と同じであるが、皮質の全層が強く侵される。腫脹神経細胞とPick小体が出る。これらは銀陽性で、tauおよびubiquitinに免疫反応性である。白質は前頭葉変性型より強く侵される。アストロサイトーシスが強い患者で腫脹神経細胞や封入体を持たないものはさしあたり含まれる。

 

３．運動ニューロン病型 Motor Neuron Disease Type

肉眼的変化：通常は余り重篤ではないが、前頭葉変性型と同じである。

顕微鏡変化の分布と灰白質と白質の顕微鏡的特徴：前頭葉変性型と同じである。脊髄の運動神経の変性があり、腰髄

と仙髄より頚髄と胸髄が強く侵される。前角では外側の細胞柱より内側の細胞柱でより細胞脱落がめだつ。運動

ニューロンの他、前頭葉と側頭葉皮質のII層神経細胞、海馬歯状回細胞などの運動系外にubiquitin陽性で、銀やtauには反応しない封入体がみられる。多くの患者で黒質の細胞脱落が顕著である。中には舌下神経核の変性を呈するものもある。

除外診断の特徴： Aβ蛋白質の抗体で老人斑、び漫性アミロイド沈着、およびアミロイド血管症が、また抗tau抗体

や抗ubiquitin抗体で神経原線維塊、neuropil threads  それぞれが年齢相応以上に多数あること。またプリオン蛋白質の沈着が抗プリオン抗体で証明されることを挙げている。（訳者注釈：記載はないが、Lewy小体が年齢相応以上に認められるものも除外されるであろう）

Preface

Do not cast me off in old age; when my strength fails, do 

not forsake me, Psalms 71:9 

The diagnosis of dementia or even the possibility of such a 

diagnosis is often greeted with fear and trepidation by those 

affected, The ensuing fears of losing one’s mind and capabilities

and of being abandoned or ‘put away’ in an institution are 

contemplated as fates worse than death. The disease stealthily  encroaches in some individuals, robbing them of insight 

into their illness before they can truly appreciate what has 

happened. Others notice the changes building month to 

month and year to year but resign themselves to the process. 

Still others fight the changes or those around them who insist 

that they cut back on the activities that once meant independence

and integrity but now carry the risk of disaster. 

In its early stages, dementia is a disease that unifies 

patients, caregivers, and clinicians in a necessary alliance as 

patients try to cope with changes in cognition and function, 

caregivers attempt to adapt to these changes, and clinicians 

seek to provide both diagnosis and treatment for a disorder 

that is often incurable. The pitfalls in this alliance are clear: 

patients wrestle with fear and confusion that may sabotage

their cooperation, caregivers struggle to overcome significant

grief and exhaustion, and clinicians must remain engaged

despite a tendency to develop a fatalistic; complacency. Many 

of these factors are amplified as dementia progresses into 

moderate and severe stages, ultimately culminating in a 

terminal state. Patients become robbed of those intellectual

and functional abilities that made them unique individuals,

while their Caregivers can be overwhelmed with the drain of 

caregiving-a burden that, in turn, increases their own

likelihood of dying by nearly 50%. Clinicians must deal with 

the myriad problems associated with dementia, including delirium,  apathy, depression, agitation, and psychosis, while still 

struggling to retain their ability to see and to respond to the 

humanity of each patient. 

Those clinicians who read and use this book will find sufficient

information teaching them about nearly every facet of 

dementia---its forms, pathways, pitfalls, and treatments. The 

book is designed to be a practical guide that can be brought 

into the clinic when one is evaluating and treating patients. 

l have endeavored to provide case vignettes and clinical tips 

to help clinicians move beyond a simple hook knowledge of

dementia and to hone their practical skills in assessment and

treatment. I urge all clinicians, however, to integrate their own 

clinical styles into whatever techniques I suggest. Furthermore, 

they must understand that the rapid pace of research into 

dementia and its treatments may affect some of the information

in this book, especially that relating to medication selection

and dosing in Alzheimer disease. 

With this in mind, the core theme underlying this book is to 

look for the human being behind the dementia. In practical 

terms, a clinician who masters every facet of dementia may be 

knowledgeable but not necessarily Wise or caring. Every individual

with dementia is more than a diseased brain; he or she is 

also an ailing human who is surrounded by grieving caregivers 

with good hearts but limited amount of time and patience. 

A busy and harried clinician can easily lose sight of these factors 

when he or she is Working with demented individuals who can 

no longer express their own needs and wishes and who now are 

engaging in troubling behavioral problems. 

Despite the efforts I have expended on this text, my sincerest

hope is that the ongoing work of researchers and clinicians  throughout the world will render this book obsolete by 

discovering definitive methods for the early diagnosis and 

treatment of Alzheimer disease. and other forms of dementia. 

In fact, since the publication of the first edition of this book, 

there have been major strides in this direction, including the 

potential revolution of amyloid-targeted neuroimaging and 

anti-amyloid therapies for Alzheimer disease. All of these 

new developments are detailed in the text, along with 

updates for other dementia types. The very title has even 

been changed to focus on the pre-eminet role of Alzheimer 

disease in both research and clinical work. I have also added 

a chapter on Mild Cognitive Impairment given the growing 

body of research on its relevance as 21 common prodromal 

state of Alzheimer disease. I hope that this newly revised 

work continues to serve as an invaluable guide and resource 

for all clinicians caring for individuals with dementia.

All physicians encounter patients they   find difficult to manage and treat. Such patients engender myriad feelings in us,  including aversion, anger, fear, guilt, frustration, and anxiety. They may be noncompliant  

with recommended treatment,  challenging to their physicians'  approaches to their care, or resistant to forming an effective alliance with their doctors. Physicians' negative responses to such patients can offer important clinical data that can help health care professionals take better eare of difficult-to-treat patients.  Failing to consider and acknowledge negative responses to patients may lead physicians to  deliver suboptimal health care and may have a negative impact upon their enjoyment of this profession.

What can surgeons do when they experience these powerfully negative feelings? Ideally, they frustration, and anxiety. They may be noncompli-

should use their feelings to help them take better ant with  recommended treatment, challenging to care of the patient. However, sometimes physicians their physicians’ approaches to their care, or react out such feelings in maladaptive ways. Some sistant to forming an  effective alliance with their potentially maladaptive initial responses to the doctors. 

There are several reasons why physicians help health care professionals take better care of may act in a maladaptive fashion. The patient– difficult-to-treat patients. Failing to consider and physician relationship can be influenced by fac- acknowledge negative responses to patients may tors about which both the patient and physician lead physicians to deliver suboptimal health care are unaware. Empathy, when  accompanied by patience and tolerance, can lead to insight into the patient’s negative behavior and enable the physician to develop a better partnership with the patient.2 Failing to exhibit empathy can occur in the presence of “counter-transference.”

Counter-transference and counter-reaction

Counter-transference refers to the develop- ment, in the physician, of positive or negative feelings toward the patient based on issues in the physician’s own life. For example, if a physi- cian is somewhat emotionally needy, he or she may become overly involved with a dependent patient, leading the physician to provide the patient with undue access to the physician (for example, giving out e-mail or cell phone num- bers). If the physician has an overly demanding parent, he or she may overreact with aggression and hostility toward a patient who shares the negative characteristics of that parent.

“Counter-reaction” needs to be differentiated from counter-transference, as this is usually a common or normal response to the patient’s emotions or behaviors. For example, when the patient becomes hostile toward the doctor, the doctor may wish to withdraw, or may feel anger in response. The physician has to try to figure out how to better respond to the patient’s feelings and responses, without personalizing them. This is easier said than done, as physicians, like their patients, are only human, and are subject to their own feelings and those of others toward them.

Characteristics of difficult patients

In his insightful article in the New England Journal of Medicine, titled “Taking Care of the Hateful Patient,” James E. Groves, MD, describes difficult patients as those who “kindle aversion, fear, despair or even downright malice in their doctors.”3 In trying to understand the nature of this situation, Dr. Groves classifies “hateful pa- tients” into the following categories: “dependent clingers,” “entitled demanders,” “help-rejecting complainers,” and “self-destructive deniers.”3 In placing the difficult patient into one of these categories, it is easier for a health care profes- sional to see their patient’s psychopathology more objectively. Once the surgeon conceptualizes the

patient’s pathology, coming up with a clinical ap- proach to deal with the patient’s difficult behavior fits more into the medical model of treating illness and symptoms.

Maladaptive responses to the difficult patient

• Ignoring phone calls

• Telling the patient to go to another doctor

• Being accusatory

• Getting angry

• Blaming the patient

• Telling the patient there is nothing wrong with him or her

• Telling the patient there is nothing more to be done for him or her

• Overmedicating the patient to silence him or her

• Dismissing the patient as a “malingerer”

• Handing the patient a “sign out against medical advice” form