Intensive Short-Term Dynamic: Selected Papers of Habib Davanloo, M.D. [1 ed.] 0471497045, 9780471497042

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INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY

INTENSIVE SHORT-TERM DYNAMIC PSYCHOTHERAPY SELECTED PAPERS OF HABIB DAVANLOO, MD

Habib Davanloo D epartm ent o f Psychiatry M ontreal G eneral H ospital

JOHN WILEY & SONS, LTD C h ich ester • N ew York • W einh eim ■ B risban e • Sin g ap ore • Toronto

Copyright © 2000 by John Wiley & Sons Ltd, Baffins Lane, Chichester, West Sussex P 0 1 9 lU D , England National 01243 779777 International (+44) 1243 779777 e-mail (for orders and customer service enquiries): [email protected] Visit our Home Page on http: //www.wiley.co.uk or http: //W W W .wiley.com All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, scanning or otherwise, except under the terms of the Copyright, Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency, Ltd, 90 Tottenham Court Road, London W IP OLP, UK, w ithout the permission in writing of the Publisher. Other Wiley Editorial Offices John Wiley & Sons, Inc., 605 Third Avenue, New York, NY 10158-0012, USA WILEY-VCH GmbH, Pappelallee 3, D-69469 Weinheim, Germany Jacaranda Wiley Ltd, 33 Park Road, Milton, Q ueensland 4064, Australia John Wiley & Sons (Asia) Pte Ltd, 2 Clem enti Loop #02-01, Jin Xing Distripark, Singapore 129809 John Wiley & Sons (Canada) Ltd, 22 Worcester Road, Rexdale, O ntario M9W I L l, Canada

British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0-471 49704-5 Typeset by Dorwyn Ltd, Rowlands Castle, Hants

Contents

1. In ten siv e Short-Term D y n am ic Psych oth erapy: Sp ectru m of P sy ch on eu rotic D isord ers

1

2. In ten siv e Short-Term D yn am ic Psych oth erapy: Technique of Partial and M a jo r U n lock in g o f the U n con scio u s w ith a H ighly R esistant Patient— Part I. Partial U n lock in g o f the U n con sciou s

37

3. In ten siv e Short-Term D y n am ic P sych oth erap y: M ajo r U n lockin g o f th e U n con scio u s— Part II. T h e C ourse of the Trial T h erap y after Partial U n lock in g

63

4. M a n a g em en t o f Tactical D efen ses in Inten sive Short-Term D yn am ic P sychotherapy, Part I: O verview , Tactical D efenses o f C ov er W ords and In d irect S p eech

111

5. M a n a g em en t o f Tactical D efen ses in Inten sive Short-Term D ynam ic P sych oth erapy, Part II: Sp ectru m o f Tactical D efenses

135

6. In ten siv e Short-Term D yn am ic P sych oth erap y— C en tral D yn am ic S eq u en ce: P h ase o f Pressure

183

7. In ten siv e Short-Term D y n am ic P sych oth erap y— C en tral D ynam ic S eq u en ce: P h ase o f C h allen g e

209

8. In ten siv e Short-Term D yn am ic P sych oth erap y— C en tral D ynam ic S e q u en ce: H ea d -o n C ollision w ith R esistan ce

235

Intensive Short-Term Dynamic Psychotherapy: Spectrum of Psychoneurotic Disorders HABIB DAVANLOO McGill University, Department o f Psychiatry, Montreal General Hospital, Montreal, Canada

In this article the author first describes the spectrum of patients that can successfully be treated w ith his technique of Intensive Short-Term Dynamic Psychotherapy and then he describes the application of the technique in the treatm ent of patients w ho are highly responsive with a single psychotherapeutic focus. There is an in-depth analysis of the process of a patient w ho was treated in a single interview.

Introduction D u rin g th e p ast 30 years, I h ave d ev elop ed a m eth od of In ten sive Short-Term D yn am ic P sy ch oth erap y w ith extraord inary pow er, capable o f resolvin g th e core n eu ro tic stru ctu re o f th e m ost resistan t lo n g stan d in g psy ch o n eu rotic distu rbances. In the d ev elo p m en t o f this tech n iq u e, I h ave used au diovisual record in g for teach in g an d research pu rposes. T h e w o rk o f th e early sixties prim arily focused on the p atien ts w h o are resp on sive w ith a single p sy ch o th erap eu tic focus. T h e w ork of the latter p art of the sixties and sev en ties prim arily focu sed on p atients su fferin g from severe p h obic an d ob sessio n al d isord ers and th o se high ly resistant su fferin g from life­ lo n g ch aracter n eu rosis. T his system atic w ork resulted in the d iscovery o f the tech n iq u e o f u n lo ck in g o f th e u ncon sciou s b y th e author, w h ich provides a unique op p o rtu n ity for b o th th e th erap ist and the p atien t to h ave a d irect view of the p sy ch o p ath olog ical d y n am ic forces resp on sible for the p atien t's sym ptom and ch aracter d istu rbances. I w as able to d em on strate th at the direct access to the u n con sciou s is possible, in a single in terv iew w ith ev ery resistan t p atien t and that the d eg ree of th e u n lock in g o f th e u ncon sciou s is exactly in p ro p ortion to the d egree th at th e p a tie n t h as d irectly exp erien ced th e tran sferen ce feelings. The clinical d ata clearly d em on strated th e in terrelatio n b etw een th e rise in the tran sferen ce feelin gs, ch aracter resistan ce and u n con sciou s th erap eu tic alliance.

2

Intensive Short-Term Dynamic Psychotherapy

T h e system atic w ork of the early eighties w as concern ed w ith the application o f m y technique w ith patients suffering from depressive, functional, som atization and panic disorders. This w ork clearly d em onstrated that the technique is highly effective in the treatm ent o f the w hole spectrum o f psychoneurotic disturbances. T h en I concern ed m yself w ith the application of the tech niqu e to patients w ith fragile character structure. T h ere I have b een able to dem onstrate that the tech n iq u e can be applied ev en w ith patients w ith severe fragile character structure. T h e w ork of the eighties and the early part of the n in eties resulted in a great deal of refinem en t in the technical in terv en tion s in Intensive Short-Term D ynam ic Psychotherapy, as w ell as in the d ev elop m en t of a very high ly pow erful m ethod of Psychoanalysis w h ich has the pow er to brin g m ultidim ensional structural character ch ang es in the extrem ely resistant patient w ith the m ost com plex path ogen ic u nconsciou s (w hich w ill b e the con cern of a series o f publications to follow ). T h e truth of this statem en t has b een dem onstrated unequivocally, it has b een presen ted at a large n um ber of audiovisual sym posia, courses and training program s to professional au dien ces in b o th N orth A m erica and Europe. T h e first few series of articles will b e con cern ed w ith m y tech niqu e of Inten sive Short-Term D ynam ic P sychotherapy and its application to tw o m ajor spectrum s o f patients that can be treated successfully w ith the technique: (a) Spectrum of psychoneurotic disturbances (b) Spectrum of patients with fragile character structure.

Spectrum of Psychoneurotic Disorders B ased on the chnical research d ata, patients o n this spectru m can be classified in to five m ajor groups.

Highly Responsive Circumscribed Problem Single Psychotherapeutic Focus

Highly Resistant Character Neurosis Diffuse Symptoms and Character Disturbances Highly Complicated Core Pathology

h/loderately Resistant Diffuse Psychoneurotic Disturbances Presence of Character Pathology Multifoci Core Neurotic Structure

Extremely Resistant Diffuse Symptoms and Major Character Disturbances Extremely Complex Core Pathology

(1) Extreme left on the spectrum T h ese patien ts are high ly resp on sive to p sy ch o th erap eu tic in terv en tion . T h ey m ight su ffer from m ild obsessional n eu rosis of recen t o n set, or mild phobic

Spectrum o f Psychoneurotic Disorders

3

disorder, or o th er form s o f n eu rotic disorder. T h e m ain featu res of all p atients on th e extrem e left of th e sp ectru m can b e su m m arized as follow s: * H igh resp on siven ess C ircu m scribed problem s Sin gle p sy ch o th erap eu tic focus * Very m ild d eg ree of resistance * A bsen ce o f u ncon sciou s m urd erou s rage

(2) Mid-left side on the spectrum T h e second m ajo r grou p are p atients w ith a m od erate d egree of resistance. Briefly, th e m ain featu res of this grou p can b e su m m arized as follow s; * M o d erate d eg ree o f resistance * D iffuse sym p tom distu rbances * P resen ce o f som e d eg ree o f characterological distu rbance * P re se n c e o f u n c o n s cio u s v io len t rage an d g u ilt- an d g rief-la d en u n con sciou s feelin gs tow ard early figure(s), e.g., parent(s), sibling(s), etc in th eir life orbit * M u ltifoci core n eu rotic stru ctu re

(3) Mid-spectrum T h e third m ajo r g rou p , w h ich w e m ay call m id -sp ectrum cases, are patients w h o su ffer from ch aracter n eu rosis. T h ey d em on strate: * M o d erate to h igh d eg ree o f resistance * S u ffer from d iffu se sym ptom and ch aracter distu rbances * P re se n c e o f u n c o n s cio u s m u rd ero u s rag e, g u ilt- an d g rie f-la d e n u n con sciou s feelin gs in relation to early figure(s), e.g. parent(s), sibling(s), etc in th eir life orbit F u sion o f sexuahty and m u rd erou s rage * P resen ce o f m asoch istic ch aracter traits * C om p licated core p ath olo g y

(4) Mid-right side on the spectrum P atien ts in this g rou p are m ore com plex and m ore resistant. T h ey su ffer from lo n g sta n d in g p sy ch o n eu ro tic d istu rbances. T h ey d em on strate: * H igh resistan ce * L ife-lon g ch a ra cter n eu rosis * D iffu se sy m p tom and ch aracter d istu rb ances * H ig h ly com p licated core p ath olo g y * P resen ce o f a n u n co n scio u s prim itive m u rd erou s rage, guilt- and grief­ la d en feelin gs tow ard b o th paren ts an d oth ers in th eir early life orbit— "T h e P erp etrator o f th e U n con scio u s" (D avanloo) * U n reso lv ed oed ip al an d sexualized feelings, w h en p resen t, are d eep ly fused w ith th e p rim itive m u rd erou s rage

4

Intensive Short-Term Dynamic Psychotherapy

(5) Extreme right side on the spectrum T h ese are patients w ith the m ost com plex character rieurosis, highly syntonic character resistance. T h ey dem onstrate: * Extrem e resistance * D iffuse sym ptom and character disturbances * P resence of a punitive superego pathology, high degree of m asochistic character traits * H ighly com plicated core pathology * H ighly prim itive unconsciou s torturous m urderous rage and intense guilt and grief, m ultidim ensional in relation to early figure(s), e.g., parent(s), sibling(s), etc * U nresolved oed ipal and sexualized feelings, w h en presen t, are deeply fused w ith the prim itive m urd erou s rage o f the unconscious. T h e profile of patients on the right side of the spectrum , based on the research data, d em onstrates w ith no exception: (a)

The presence of trauma, abandonm ent and/or series of traumatic experiences in the very early phase of life. (b) The presence of a highly painful feeling in relation to the trauma and abandonment, (c) The presence of an unconscious murderous rage or primitive murderous rage or even primitive torturous murderous rage in relation to parents, siblings and other figures in their early life orbit. (d) The presence of intense guilt- and grief-laden unconscious feelings. (e) They demonstrate a high to an extremely high degree of resistance. (f) The presence of resistance against emotional closeness. (g) The presence of a masochistic com ponent in their character.

Based on this data, I in trod u ced a con cep t w hich I called "T h e Perpetrator of the U n con scious."

Spectrum of Patients with Fragile Character Structure T h e second spectru m , as 1 have already in dicated, are those su fferin g from fragile ch aracter structure. If w e place these p atients w ith in a spectru m w e m ight consid er three m ajor groups: patients w ith mild and m od erate d egree of fragility, and those w ith severely fragile ch aracter structure. Patients w ith severe fragility can n o t w ithstand the im pact of their u ncon sciou s during the first interview , that is, d uring the trial therapy. T h ese patients do n ot h ave the capacity to experience and tolerate anxiety and painfu l feelings, and th ey h ave life-long access to a spectrum of prim itive d efen ses such as tem p er tantru m s, explosive discharge of affect, poor im pulse control, p ro jection , p ro jectiv e id entification and double projective id entification. T h ese p atients easily becom e flooded w ith a high degree o f anxiety and a m ajor disruption o f their cogn itive and p ercep tu al fun ctions w ith h allu cin atory experien ces. T h ey easily becom e ligh t-h ead ed , exp erien ce the p h en om en a of "d riftin g ," d row siness and dissociation. 1 h ave d em on strated that the w hole sp ectru m o f p atients w ith fragile ch aracter stru ctu re can be treated successfully w ith m y tech niq u e, and the cou rse o f therapy has a num ber of phases. Briefly, in the first p h ase the task of the

Spectrum o f Psychoneurotic Disorders

5

th erap ist is to b rin g a b o u t su fficient u n con sciou s stru ctu ral ch an g es to en ab le the p atien t to w ith stan d th e im p act o f his/her u nconsciou s. As a result o f such stru ctu ral ch an g es, th e d isch arge p attern o f th e an xiety shifts from cogn itive and p ercep tu al fu n ctio n s to an xiety in the form o f ten sio n in the striated m uscles. W h en the th erap ist has accom p lish ed this task and h as b ro u g h t abou t su fficient cogn itive and p sy ch ic in teg ratio n , th e n h e can proceed w ith the tech n iq u e of rep eated , first p artial th e n m ajo r u n lock in g of the u nconsciou s. T h e tech niq u e of b rin g in g a b o u t stru ctu ral ch an g es w ith fragile p atients will be the focus o f a series of articles in the futu re. It has alread y b een p resen ted in m any sym posia and cou rses, b o th in N orth A m erica and Europe; but, briefly the research data d em o n strates th e p resen ce o f an extrem ely high d egree of prim itive m urderou s rage w ith in the u ncon sciou s.

Intensive Short-Term Dynamic Psychotherapy with Highly Responsive Patient T h e rest o f this article will focus on the ap p lication of the tech n iq u e in patients w h o are h ig h ly resp on sive and so-called "m o tiv ated ." T h e cou rse of th e initial in terv iew o f a p atien t w h o w as treated in a single session w ill be an alyzed in d ep th .

The Case of the Salesman and His Sister-in-law At th e tim e o f the in itial in terv iew h e w as a 26-year-old m arried m an. As wiU b e seen , h e is exceed in g ly resp on sive and in the early stages is w illing to talk freely and m ean in g fu lly ab o u t d ifficult and p ainfu l su bjects. H e goes into a v ery mild d eg ree o f resistan ce com p arativ ely late in the interview , and as a result the th erap ist is able to co m p lete a larg e p art o f the in qu iry b efore an y su stained d yn am ic in tera ctio n b egin s. W h en this d oes h ap p en , som e o f the in terv en tion s m ak in g up th e C en tral D yn am ic S e q u en ce are used, th o u g h co n tin u in g to altern a te w ith th e p h ase o f in q u iry th ro u g h o u t th e interview .

Initial Exploration, Psychiatric Inquiry In the follow in g passage th e th erap ist op ens w ith the stan d ard q u estion about th e n atu re o f th e p a tien t's p resen tin g com plaint. H e learn s th at this is an ob sessio n al sym p tom , and h e sets ab ou t in q u irin g into its severity, th e ex ten t to w h ich th e p a tie n t's life is affected and w h eth er th ere are an y o th er difficulties. T h is is p art o f th e p sy ch iatric in q u iry an d the p sy ch o diagn ostic fu n ctio n o f th e trial therapy, the aim o f w h ich is to assign the p a tien t at o n ce to his co rrect p osition on the sp ectru m o f sev erity of p sy ch o n eu ro tic d istu rbances, w h ich obviou sly has im p o rta n ce in d eterm in in g th e road m ap to the u ncon sciou s. At o n e end o f the sp ectru m h e m ay b e a basically h ealth y y o u n g m an su fferin g from a m ild ob sessio nal sym p tom w ith a v ery m ild d eg ree o f resistan ce; in th e m iddle h e m ay b e a severely o b sessio n al ch aracter w ith a v ery h ig h d egree of resistan ce; w hile at

6

Intensive Short-Term Dynamic Psychotherapy

the oth er end his w hole life m ay be affected or even crippled by rituals and other obsessive-com pu lsive p h en om en a w ith a m ajor degree of resistance. In fact, it rapidly becom es clear that h e suffers from only a single type of sym ptom , that this is relatively m ild, and that although it pervades his life it does n ot seriously affect his functioning.

Initial Contact TH: C ould you tell m e ivhat seem s to be the problem that you are facing? FT: Well, the main thing is this repeating of, like checking my w ork and everything — alm ost like an obsession with it. I will take figures an d transfer them from one sheet to the sheet that I am w orking on, and 1 go back and recheck them; and even then I am still checking and rechecking, and 1 get alm ost like a phobia— that 1 have done it wrong. Yet I knoio that I have done it right. I have been doing this w ork fo r m any years now, and even checking it I can see that 1 have done it right. But it ju st seem s to nag, like at the back o f my head, that I have done it wrong. Som etim es after I have done som ething and 1 think back afterw ards and think— did I do that right? Som etim es it bothers me so much I go back and check it again. O ther times I can say, "No, 1 have done it right," an d try to forget about it. TH: You get these intruding, nagging thoughts if you have done it r ig h t . . . FT: Yes, and I go back an d check it over an d over. TH: C ould you g iv e m e a specific exam ple? This seem ingly in n o cen t question is on e of the standard m oves tow ard exerting pressure. In response to it som e patients im m ediately b ecom e alarm ed and go into resistance, already sensin g that they are going to b e asked to b e specific about m ore difficult areas as w ell; but, as wiU b e seen, it takes m uch m ore than such a mild d egree of pressure to alarm this particular patient. T h e indicator from the b eg in n in g is that the unconsciou s is in a fluid state. T h e therapist therefore continues w ith a straightforw ard question to clarify the psychiatric picture. FT:

For exam ple, w e have a statem ent in our office w e send out every month, and there is like a correction routine that loe have. 1 do it, but 1 have these flagging thoughts that it is not right, and I have to repeat it over an d over. 1 know the code num ber an d the inform ation laid out on the sheet, an d I know it is correct; but I have to check and recheck with no end. The thing is, noiv w hile I am doing my w ork I look at fig u res an d 1 transfer figu res fro m one place to another, an d I w orry w hether 1 have done them correct or not. >\s I told you, I go back an d check them, an d check, an d still I check back; an d I end up checking . . . an d rechecking, you know — still I have these doubts, and I get like a fu n n y feelin g in m y legs an d like in m y head a kind o f fu z z y feelin g — like alm ost like my nerves, every one o f my nerves are ju st sort o f on edge. TH: Is this only in you r jo b — this need to check an d recheck? FT: No, like I will g o into the carport at hom e and take out a bag o f chips, read all the stu ff on it— alm ost like I have to rem em ber exactly ivhat it says on that bag o f chips, you know, how m any ounces, lohich com pany, m ade by such an d such, checking . .. well, I alw ays check. Then read it over again, m em orizing lohat it

Spcctrum o f Psychimeurotic Disorders

TH : PT:

TH : PT:

TH : PT: TH : PT:

1

says on the bag o f chips. A n d this is not only with potato chips— labels at hom e on other packages, everythin g— street signs— keeping my m ind occupied. So there is this nagging doubt if w hat you have don e is right, an d there is a constant need to keep y ou r m ind occupicd. Even w hen I leave m y jo b a couple o f hours later I ju st sit there an d start w orry in g about w hat I have don e at loork, even though 1 know I have done it right, w hich becom es very painful. T hese in truding thoughts an d you r need to check an d recheck, is it interfering w ith y ou r job? I have got that alm ost— lack o f self-confidence, sort of; an d I ju st sit there. I keep thinkin g abou t it, an d people w ill talk to me and it w ill seem that they are not there— 1 am so busy concen tratin g on these other things. Hm. H m m . D oes it interfere w ith y ou r personal life? O h yeah. M y m ind still is there, an d my ivife is talking to m e an d 1 have to concentrate, you know, as if m y m ind is still on m y job, on those figures. A re there an y other areas that you have difficulties? Putting the lights o ff in my car at night. Like I w ill get hom e an d autom atically put it in "park," turn the lights o ff turn the key off, get out, lock the door and close it. A nd now I have to check and rechcck, trying to convince m y self that they are o ff 1 g o in, an d I have the thought that the lights are on.— "Look, it is autom atic, you do it, s o ." I know I turned the lights off, but then I have to g o and check them . But again the thoughts an d the doubts. A nd I say to m yself— "Aw, I checked it," y o u know, 1 say I checked them, an d I say to m yself convince m yself that the lights are o ff A nd som etim es 1 am successful.

T h e th erap ist n ow asks ab ou t the d uration of this sym ptom . T his q u estion serves to place the p a tie n t on a n o th er sp ectru m , n am ely th at o f chronicity. It will th e n lead to the q u estion of w h eth er the on set can be traced to a particu lar m om en t, or at least a p articu lar period in the p atien t's life. W h en this is possible, th e ev alu ator m ust alw ays th in k in term s of search in g for a p recip itatin g factor, of w h ich th e p atien t m ay or m ay n o t b e aw are. Su ch factors are usually o f great d yn am ic sign ifican ce, so th at the therap ist's q u estion about d u ration is preparin g the w ay for m ov in g b ey o n d the pu rely psychiatric inqu iry in to the exploration of th e p sy ch o d y n am ics. At this stage o f th e interview , the p atient is sh ow in g no resistan ce. In an sw erin g th e q u estion about the d u ration h e reveals n o t o n ly the tim e of on set b ut also the p recip itatin g factor, o f w h ich he is w ell aw are. (It is w orth m en tion in g h ere th a t th e a m b ig u o u s term "s is te r -in -la w "— a p e rso n w h o fig u res so p ro m in en tly as th e clinical m aterial u nfold s— clearly refers to his w ife's sister rath er th a n to his b ro th e r's w ife.) TH: H oio long is it that you fin d y ou rself in this state? PT: A bout a y ea r or so— but very bad fo r the last few months. TH : Is it g ettin g w orse? PT: Right. It started out— I was m arried fo r about a year (the patient has been m arried 3 years) and got involved in a sort o f an affair with my sister-in-law that lasted fo r a m onth and a h a l f . . . a couple o f months. A nd 1 started to have guilt feelin gs about it. So I broke it o ff and told my wife about it. She loas upset but she

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Intensive Short-Term Dynamic Psychotherapy

forgave me and said, "Well, it happened"— sort o f thing. "Forget about it. Look, it is done. It is over. Forget about it. You have done it. You can't undo it"— sort o f thing. "You can't go hack and say I didn't do it." Well, really 1 did not forget about it. The m em ory o f it sort o f kept com ing back into my mind, and you know, without trying to think about it I would he doing my work and they would sort o f come back. 1 w ould start thinking about my sister-in-law and I would feel worse. I would feel guilty again, alm ost as if I was recommitting the act, sort o f thing. So ivhat I started doing, really, was reading street signs, forcing my s e l f . . . like . . . when I was doing my work to really concentrate on it— to keep these other, these thoughts o f my sister-in-law out o f my head. The thing is, over t h e . . . this went on fo r 6, 8 months, and 1 sort o f succeeded in forgetting about it. Then it started . . . I thought everything was all well, and then it started com ing back again so 1 started forcing even more so. 1 just seem to have transferred it from one problem to another. T he above passage show s one of the m ain features of patients w ho are responsive, w ith a single psy ch oth erap eutic focus; nam ely h ere how clearly and lucidly he talks about his sym ptom , the on set of his sym ptom , the m echanism of displacem ent; and later on h e talks about tran sferring it from one problem to another. T h e above in form ation also poses an im portant question. Since his wife forgave him , it w ould seem that the episode should have b een forgotten. Instead, he has n ot only con tin u ed to feel v ery guilty but has developed a neurotic sym ptom . T h e therapist know s that the reason is likely to b e that the episod e has reactivated guilt-laden feelings b elon g in g to the past, the figures in his early life; b u t in no w ay d oes he im pose this idea u p on the patient; but he uses it to guide his exploration w h ich starts w ith a sim ple question, TH: C ould w e look into this incidence? PT: 1 had m y affair— /call it m y affair— with m y sister-in-laiv and after a m onth and a h a lf I fe lt guilty, 1 cut it o ff an d 1 told m y wife, all at about the sam e time. TH: H ow did the relationship develop? PT: She and h er husband and their three children were living on the East Coast and w ere m oving to the W est an d they had a stop-over here. She an d the three kids stayed with m y m other-in-law w hile her husband w ent to the West Coast to get a house, or m ake arran gem en ts fo r a h o u s e . . . an d my w ife an d 1 ivent over there. Well, you know how it is w ith relatives . . . you haven't seen a relative fo r a while . . . you give a kiss . . . sort o f hello, how are you sort o f thing. W hen I gave her a kiss, I don't know, I fe lt as though there was m ore to the kiss than ju st "hello." TH: On w hose part? PT: Uh, on m y part, on her part, like the loay she kissed me, I fe lt that there was more than "hello." TH: H oio old is she? PT: 2 years older than m y wife. TH: So w hat happened? PT: Well, w e started doing . . . it started w orking up to the fact that she used to com e over to our place after they had eaten their supper, an d my w ife an d I had eaten our supper, and she sort o f com e over to m y loife an d som etim es my w ife w ould go out into the garden an d I w ould kiss my sister-in-law an d feel her, an d she ivould do the same.

Spectrum o f Psychoneurotic Disorders

9

TH : H mm. PT:

Well, I never had intercourse w ith her, ju st m ore or less playing around . . .

T h e th erap ist n ow b egin s search in g for fu rth er p recip itatin g factors. The p atien t d oes n o t d em o n strate a n y resistan ce, and it is im p o rtan t to n o te th at h e is ah ead o f th e th erap ist and sp o n tan eou sly an sw ers the question ab ou t sex, w hich h ad b e e n im plied b u t n o t d irectly asked. T h e ab sen ce of an y obvious factors is clearly sign ifican t b u t d eep en s th e m ystery. TH: PT: TH: PT: TH: PT: TH : PT:

TH: PT: TH:

This started a y ear after xjour m arriage. Hoiv was you r relationship with your w ife du rin g that year? A lw ays happy. O ur sexual relationship fin e. A ny problem s? T here w ere no problem s. C ould you tell m e m ore about y ou r sister-in-law ? She used to com e here an d at ev ery opportunity w e w ould end up kissing and feelin g each other, an d it gradu ally led on. Led on? Yeah. A t the tim e I ivas g ettin g m y car painted, an d so I asked her to g iv e me a lift in her car to g o an d g et the car. So loe stopped on the w ay back and fo oled around. Like I said, I never had intercourse; but loe m essed around. D id you have the desire? Oh yes. We never really had the chance, the opportunity, enough time, really, to, to have intercourse. But the thought luas there.

This is the seco n d poin t at w h ich the therap ist has exerted a very m ild d egree o f pressu re. W h a t h e h as d o n e h ere is to u n d erlin e the im pulse. H ow ever, the p atien t is w ell aw are o f this. PT: Oh yes, definitely. TH: A nd how did you fe e l tow ard the thoughts? PT: E r . . . at the tim e I fe lt it was g oin g to he great. N oio I fe e l differently. N ow th e th erap ist exerts som e pressu re TH:

You w ere not decisive about it? W anting an d not w anting?

T h is co m m u n icatio n n eed s con sid erable analysis. First of all, it tran sfers the p a tie n t's in d ecisio n from a p u re sy m p tom atic situ ation— w h eth er or n o t h e had ch eck ed the figu res or the car ligh ts— to an em otion ally ch arged situation. Secon d , it d escribes th e p atien t as in d ecisiv e, w h ich is en tirely accu rate on th e o n e hand b u t w h ich the p atien t will n ot like on the other. H e m ight first exp erien ce irritation and th e n su p p ress it, w h ich will in crease the tension. But, d eep er th an this, the th erap ist is by im p licatio n m ak in g a co n n ectio n b etw een the sym p tom of in d ecisiv en ess w ith the basic gu ilt-lad en conflict. As h e is d oin g this on ly by im p lication and n o t ov ertly th e ev alu ator is co m m u n icatin g w ith the p atien t's u n con sciou s as w ell as his con scious. H e thu s con v eys the h id d en m essage th at he u n d erstan d s m ore ab ou t w h at is h a p p en in g th an the p atient w ould w ish him to know , w h ich is in ten d ed to h eig h ten th e ten sio n further. But this com m u nication d oes n o t p ro d u ce an y resistance.

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Intensive Short-Term Dynamic Psychotherapi/

PT:

Yes.

Pressure, the First Challenge, the Search for Resistance The therapist has a fairly com plete know ledge of recent precipitating events, about w hich the patient has b een w illing to talk quite freely. But the therapist has n o t yet id entified the anxieties th at have given these ev en ts pathological significance. W hatever these anxieties are, they m ust be in an area that has n ot yet been touched on. An im portant feature o f this technique o f trial therapy can be described as follows. The therapist w elcom es the resistance and h e know s that the resistance can be reliably overcom e and that the very act of overcom ing it has far-reaching beneficial effect. It is an actual therapeu tic tool to help break into the patient's unconscious. W h en , as here, the p atient is responsive to the prelim inary inquiry, the next stage therefore consists of searching for resistance. In accordance w ith this, the therapist asks a question w hich, w ithou t the p atien t know ing it, was d estined to lead into the core of his neurotic structure. This exploration w as based on extensive clinical experience, w hich consisted of the follow ing repeated observations: w h en m ale patients w ere asked to describe the body o f their current sexual partners, m any had great difficulties and becam e resistant. T h e problem often seem ed to cen ter around describing the breasts as w ell as oth er parts of the body, and the reason is the u nconsciou s con n ection b etw een the p atien t's current sexuality and the patien t's feelin g for his m oth er or oth er figure in his early life orbit. N ow w e retu rn to the interview . TH: PT:

Hoiv ivould you describe you r sister-in-law in terms o f physical appearance? Physically she is a very attractive girl, very well built.

The therapist asks the p atient to be m ore explicit. TH : Hm hmm. In w hat zuay? The p atient n ow sh ow s the b eg in n in g of a v ery m ild d egree of resistance by using a series of tactical d efen ses. It is im p ortant to n ote that n on e of these d efenses are m ajor d efen ses. It is essen tial to rapidly id entify these tactical d efenses and to know how to h andle them . In the follow ing passage, the d efensive w ords and phrases w h ich m ark th e b egin n in g o f a m ild d egree of resistance are pu t in quotation m arks to draw atten tion to them . T h e patient already show s his reluctance to an sw er the q u estion by h esitating; h e puts in the w ord "w ell" to m ake his statem en t m ore in d irect, an d he uses paraphrases to avoid the explicit w ord "breasts." PT:

E r . . . “Well" she is very pretty, she has a "big ch est" . . . The rest o f her body is nice.

This gives som e rise in tran sferen ce feelin g, and his resistance becom es som ew hat m ore intensified w ith the use of tw o fu rth er tactical d efen ses, nam ely v agueness and obsessional ru m in ation s, w h ich are design ed to avoid a direct experience of feeling. We have the first in d ication of a rise in tran sferen ce feeling. In the follow ing sen ten ce the w ords "I thin k" m akes the statem en t hypothetical; "I d o n 't kn o w " largely nullifies his true feeling; and "so rt o f" m akes the w ord "attracted " w eak and ind efinite. T h ese are all tactical d efen ses.

Spcclnim o f Psyckm curotic Disorders

PT:

11

Yeah. "1 think" that is w h a t . . . "I don't k n o w " . . . I have alw ays been "sort of" attracted to that.

T h e th erap ist n otes all this but h e, on ce m ore, m akes the p atien t's statem en t explicit and co n tin u es his exploration. TH : PT: TH : PT TH : PT: TH : PT TH : PT:

TH : PT:

TH : PT:

TH :

W ould you say that that loas the part that attracted you the most? Yeah. Right. ' I see. Htn hmm. D uring this period that you w ere necking an d petting, that was the part that you loere very m uch . . . Yes. Right. C ould you tell m e hozv you en ded you r relationship xoith you r sister-in-laio? Was it y ou r decision? Yes. It w as m y decision. Was it a sudden decision? Yes. A nd w hat ivas h er reaction? Very su rprised — really. W hat happen ed was that I told her that I cou ld n ’t go on an y more, an d I fe lt the nerves in m y legs, the fu z z y feelin g in my head, like all m y nerves w ere sort o f tense. M y legs w ere tioinging, ju st before deciding to tell her. I w as in a separate w orld, en closed in a bubble. I could hear you talk but it loas as if you w ere fa r away. I told h er this luas w rong . . . I can't g o on, sort o f thing. I g u ess the w eeken d that I told her m y w ife an d m yself w ere g oin g up to visit frien d s, g oin g out fo r a w edding, out o f tow n; so w e w ent up, an d so that sort o f put her out . . . sort o f out o f sight, but not out o f mind. I was still rem em bering it, really, you k n o w It really bothered me; and I gu ess w e cam e back, an d she stayed an oth er w eek or two. A nd then they l o e n t . . . she luent out to live on the W est Coast. A nd then I told m y w ife . . . W liat fo rced you to talk about it to y ou r wife? B ecause I fe lt so g u ilty abou t it. I knew I had done wrong. And, you know, I ju st had those feelin g s in m y head an d in m y nerves, an d I ju st fig u red that by telling h er that that w ould, you know, clear everythin g u p . . . m y nerves. 1 wouldn't get that fu z z y feelin g in m y head, or an ythin g else. You thought h er being understan ding w ould resolve the problem . . . . W hat happen ed then? I started, you knmu, to think o f her, to think back about the tim e kissing in the kitchen, fe e lin g her body, stu ff like this. A nd 1 think partially w hat it w as— / tried so hard to put it out o f m y m ind that it w ould keep com ing back in rather than . . . C ou ld w e look to those thoughts that w ere com ing back to you r m ind after you term inated w ith her?

It is im p o rta n t to n o te th at in the follow ing passage th e p atien t sh ow s no resista n ce an d is b e in g a b so lu tely explicit ab ou t sexu al in cid e n ts w ith his sister-in-law , w h ereas h e had sh o w n som e resistance again st d escribin g h er body. PT:

O h . . . inciden ts w hen w e w ere together. 1 think about on e tim e w hen m y wife w as out in the garden, an d she was in . . . w here she ivas staying at m y in-laws, it is an old house. They don't have hot water, so they don't have a shower, so she

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Intensive Short-Term Dynamic Psychotherapy

was taking a show er at our place. So, anyway, my wife was outside and I said "Can I com e in?" She said "Yes:" So 1 opened the door, 1 walked in, and opened the curtain. She was standing there naked, so I look at her atid said, "Do you want to see me?" She said, "Yes." So I exposed myself: Stuff like this. TH: So you had these flashbacks to that incident? PT: Yeah. There were a few other episodes like that. There was a time, alm ost the sam e thing. She was in the sh o io e r :. ,u h . . . in the bath . . . and the sam e sort o f thing. . . . A nother tim e com ing back from baseball w e went back to my place, our place, m y ivife, m yself and my sister-in-law — and 1 drove a frien d o f m ine home. She cam e ivith us 'cause she was sort o f frien dly with the gu y anyiuay; and w e cam e back and stopped o ff an d started necking, petting . . . she did fellatio on me . . . then I took her home. A nother tim e w e were starting fo r a party. We had to pick up soft drinks, and we w ent som ew here else an d she did fellatio again, and I felt her . . . uh . . . 1 fe lt her breasts . . . uh. . . . These w ere the recurring thoughts that w ere com ing after I stopped the relationship.

Challenge Alternating with Exploration In th is in te rv ie w w h ic h is w ith a p a tie n t fro m th e e x tre m e le ft o f th e sp e ctru m o f p sy c h o n e u ro tic d iso rd e rs, e x p lo ra tio n , p re ssu re an d c h a lle n g e p ro ce e d in a cy cle, so th a t th e re is n o c le a rc u t p o in t at w h ic h th e p h a se o f c h a lle n g e b eg in s. H o w ev er, th e fo llo w in g p a ssa g e c o n ta in s a s e c o n d m ild d e g re e o f ch a lle n g e :

TH: PT: TH: PT: TH:

In these incidents, then, you w ere intim ately involved with each other? Right. Yeah. But you say you did not have an opportunity fo r intercourse. Yeah. There was not enough time. H oio could that be? O bviously if you had time fo r fellatio and playing with her breasts you could have had tim e fo r intercourse.

T h is m ild d e g re e o f c h a lle n g e p ro d u c e s so m e re sista n ce in th e fo rm of v a g u e n e ss as is sh o w n b y th e w o rd s in q u o ta tio n m a rk s, all o f w h ic h are tactica l d e fe n se s to avo id m a k in g a d ire c t sta te m e n t.

PT:

"I g u ess." Yeah. "I g u ess. " really i f . . . we "probably" could have.

At th is p o in t, it w o u ld o b v io u sly b e p o ssib le to in te rp re t th e d e fe n siv e m o v es. For ex am p le, to b rin g to th e p a tie n t's a tte n tio n th a t h e w a s b e c o m in g v a g u e in o rd e r to av o id o p e n ly a c k n o w le d g in g h is a n x ie tie s a b o u t h a v in g in te rc o u rse . T h is in m y view , w o u ld m o v e th e p ro c e ss to in te lle c tu a liz a tio n . T h e p re s e n t te c h n iq u e aim s to cre a te g re a te r te n sio n b y ta k in g th e p o sitio n o f a d v e rsa ry a g a in st th e p a rt o f th e p a tie n t id e n tifie d w ith his d e fe n se s. T h e v a g u e n e s s is th e re fo re c h a lle n g e d . M a n y p a tie n ts w o u ld th e n e m p lo y a series o f o th e r d e fe n s e s, e a c h o f w h ic h w o u ld b e ch a lle n g e d in tu rn . B u t th is h ig h ly re sp o n s iv e p a tie n t r e sp o n d s im m ed ia tely , w h ic h is th e c h a ra cte ristic o f all p a tie n ts o n th e e x tre m e le ft o f th e sp e ctru m . N o w w e re tu rn to th e in terv iew .

TH:

When you say “probably," is it or isn't it? A nd you already have said that you entertained the thoughts.

Spectrum o f Psychoneurotic Disorders

PT:

13

I f w e had tim e to do that, obviously w e could have had tim e to . . . yeah. There was. You're right. I was w orried about g oin g too far. It was a sort o f w anting an d not w anting.

N ow, th e th erap ist resu m es his exploration. TH : PT:

TH : PT:

TH : PT: TH : PT: TH : PT:

TH: PT: TH :

PT:

TH :

So these in tru ding thoughts involved her being naked, the intim ate relations. Were they pleasureable? Oh, at first, yeah . . . w ere pleasant. But after they kept com ing back an d back and back then they becam e disturbing, an d I fe lt guilty. I think it started to m ake me fe e l g u ilty again alm ost as if I w as recom m iting the act. There w as a con flictin g situation. A nd this w ent on fo r how long? This w ent on fo r a w hile . . . a fe w m onths, I guess. A nd then gradu ally I sort o f h a lf fo rg o t about it. A n d it didn't bother m e so much fo r a lohile. Then it started to com e back an d the thoughts loould start com in g again ; an d I think that is w hen I started w ith . . . like reading, an d all the doubts, an d checking an d rechecking . . . like reading a neiuspaper an d reading the sam e thing over and over. I g o back a n d read it, an d I g o back an d read it again — the sam e article. Then I m oved to this checkin g an d rechecking. M y concentration is not good ivhen I am in the office. In the office there are six o f us. But you know, som etim es you g et on e person talkin g to y ou — but you r m ind is not there. I fin d I can't concentrate. Your m ind wanders. Yeah. I hear them. G oin g back to y ou r sister-in-law , do you see her? Well, they are . . . She is living w ith her fa m ily on the West Coast. O nce in a w hile she com es dow n, to visit, w ith her husband an d children. H m hm m . A nd som etim es w hen they fir s t com e dow n . . . I don't w ant to g o over there. 1 don't w ant to see h er sort o f thing. But once I get over there it is fine. I ju st sort o f say "hello" an d . . . D oes h er husban d knoiv about this? As fa r as I know, no. A fter you stopped seein g her, you kept havin g thoughts about her. M y question is this, do you g et these in tru din g thoughts about you r sister-in-law at the present time? Som etim es. It is som etim es, an d it doesn't bother m e as much. R eally less. O ccasionally, w hen I am m akin g love w ith m y w ife she com es to my m ind, but im m ediately I put h er out. So the thoughts abou t y ou r sister-in-law are much less. But these obsessive thoughts, these doubts, this checking an d rechecking, they have taken over.

N ow the p ro cess m ov es to th e follow in g p iece of in sigh t, w h ich co n tain s four co m p o n e n ts: (1) h is o b sessio n al sym p tom s express his n eed to b e p u n ish ed , w h ich (2) h e h as h ad to take in to his ow n h an d s, b ecau se (3) his w ife w as too u n d ersta n d in g , an d . . . (4) did n o t p u n ish him herself. O n ce m ore th e p atien t d em o n stra tes his extraord in ary d eg ree o f resp on siven ess. T h e th erap ist only m en tio n s co m p o n e n t (3), b u t th e p atien t im m ed iately resp o n d s w ith co m p o n en t

14

Intensive Short-Term Dynamic Psi/chotherapi/

(4), thus enabling the therapist to add com ponent (1) and (2) quite naturally, in the form o f a first interpretation. It is im portant to n ote that so far in the presen t interview there have been only two m om ents of a m ild degree of ch allenge, and so far the transference has not need ed to b e m entioned at all. It is im portant to em phasize that m y research w ith a large series of patients has show n, w ithout any question, that brin gin g out the n eed for self-punishm ent and self-defeat is an essential part of the therapy of m any patients, particularly those w ho— in contrast to the p resen t patient— suffer from severe character neurosis and are located w ithin the right side of the spectrum . T h ere I have introduced the con cep t of the p erpetrator of the u nconscious, w hich will be discussed in greater leng th in future publications. But this in no w ay applies to the patient on the extrem e left of the spectrum . N ow w e take up the interview just before the point w h ere w e left off. . . . this checking and rechecking thei/ have taken over. You said your loife was very understanding. PT: M ore understanding than I fig u red she w ould be. I d o n ’t knoio. I wonder, myself. . . . M aybe she didn't g iv e me, you know, really . . . give m e shit sort o f thing rather than . . . TH: You w anted her to punish you. But you are, yourself, doing a good job. W hat you are doing, really, is punishing you rself PT: Right. 1 think so, basically. TH: You are punishing y ou rself because o f these guilt feelin gs that you have talked about. A nd the w ay in w hich you do it is by doubting you rself by torturing y ou rself by being obsessed w ith these statem ents, by checking an d rechecking, this obsessive type o f thinking— which on the surface is linked with your sister-in-law and your wife. PT: Yeah. Right. TH:

O n ce m ore the therapist resum es his exploration TH: PT: TH: PT: TH: PT: TH: PT:

H oio long have you been m arried? 3 years. H ow old is you r wife? She is 24. A nd you have been m arried for 5 years. Yeah. A ny children? She w ants children. A nd m y idea loas that it is better that w e wait.

In view of w hat em erges later, this com m u nication is h ig h ly significant. TH: PT:

H ow about after the incident w ith you r sister-in-law ? She still talks about having children. But I said to her that 1 w ant to see if I can get w hatever is w rong with us, or w hatever thoughts, or I w ant to try to get that cleared up before 1 take on the responsibility o f having children, really. TH:. C ould loc look to the loay you met you r ivife and decided to get m arried? PT: Well, 1 met her on the com m uter train. 1 had seen her for a while, but I hadn't talked to her. O ne day 1 ended up s ittin g . . . like they have bench seats, and ended

Spcctriim o f Psydumeurotic Disorders

15

up sittin g beside her. We started talking, an d I asked her if she w anted to g o out an d have a drink. She said, w ell she w as engaged. So I said, “okay— if you change y ou r m ind." Then after that I w ould m eet her every night sort o f thing. She w ou ld save a seat fo r me, an d I w ould sit an d talk with her. A nd fin ally I con vin ced h er to g o and have a drink together. Then I . . . on e night I said, “Wlwt are you doin g Friday night," or som ething; an d she m entioned, well, you know, she wasn't d oin g anything. So I asked her if she w anted to g o out. She said "Well, 1 don't know abou t g oin g out, hut com e over to m y p la ce." So I w ent over there. H er parents w ere out, an d xoe started necking: and then w e had intercourse, and she broke o ff her engagem ent an d I w ent out with her fo r about a year— an d then lue g ot m arried. O n e of the im portant features o f this technique is that it reveals, w ith utm ost clarity, certain ever recurring pattern s that lie behind h u m an neurotic suffering. This enables a therapist to direct the process tow ard significant areas w ith the help of m inim al clues. In the presen t interview the therapist perceives a further occurrence o f a triangular relation created by the patient in w hich it w as the patient w h o cam e o ff best. In the in cid ent w ith his sister-in-law he both caused h er to betray her h usban d and m ad e his w ife jealou s, w hile in his w inn in g his w ife he com peted successfully w ith an o th er m an. M ost patients on the extrem e left of the spectrum show a high d egree of fluidity o f their u nconscious, and the u nconscious therapeutic alliance eith er is in operation or easily com es into operation. In this patient, the u nconsciou s therapeu tic alliance indicates that the patient has a need to create such situations because of unresolved feelings about som e previous triangular situations. N ow the question is this, is he trying to perpetuate a situation in w hich he w as the w inner, or to und o a situation in w hich he w as the loser? Obviously, the therapist d oes n o t know ; b u t h e decides to underline the triangular relation im m ediately. TH; So in a sen se you m anaged to take h er aw ay from her fiance. PT: Yeah. TH : A nd that sh e preferred you. PT Yes. TH : So in a sense, he lost her, then, to you. T h e th erap eu tic allian ce h as m ad e an o th er com m u n ication . T h e p atien t had em p h asized th at h is sister-in-law w as "very w ell built . . . a big ch est." N ow the q u estio n is this; h ow ab ou t his w ife? T h e th erap ist foUows th e p ath , b reak in g in w ith th e q u estion ; TH : PT: TH: PT: TH : PT: TH: PT: TH : PT:

H ow w ou ld you describe y ou r w ife in term s o f body build an d otherw ise? She is a nice looking girl. A verage build, not big. H m hmm. Uh . . . gee, really . . . I f y ou com pare h er to y ou r sister-in-law , how w ould you describe . . . W e l l . . . m y sister-in -law is built a lot bigger. Hm hm m . But there are things about her that attract you. Yeah. H er breasts. Yeah “1 think" that is it. A nd y ou r wife? A nd m y luife is not nearly as big.

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Intensive Short-Term Dynamic Psychotherapy

TH: H ow w ould you say it is? PT: She, "I g u ess," "you could say" she is a sm all-breasted woman. T h e p atient has becom e u neasy by this su bject and still is trying to m aintain his vagueness. An effective w ay of dealing w ith m any defenses is sim ply to draw attention to them , w hich com m u nicates to the p atient's u nconscious that the therapist know s only too well that som ething anxiety-laden is b ein g defended. This the therapist does, and th en he m akes an oth er com m unication, pu tting into w ords the possibility that b en eath the surface the patient is dissatisfied w ith the size of his w ife's breasts. TH: PT: TH: PT: TH : PT:

You say, I "could say. " Is your w ife a sort o f flat-chested type? Er . . . yes . . . tow ard t h a t . . . m ore than big. W hat else about you r sister-in-law attracted you, besides her large breasts? N othing else. She is attractive, the sam e as my wife. I f you think about it, besides her body w hat else was there about her that attracted you as well? "I think" I know lohat "you have in m in d " . . . that she loas m arried . ..

A lthough this is a m ajor piece of collaboration on the part o f the therapeutic alliance, it is shU h ed ged w ith tactical d efenses. At a later stage o f the interview , w h en resistance is at a m inim um , the p atien t will respond to questions from the therapist w ith m uch m ore sp o n tan eou s insight. But at this stage h e em ploys some tactical d efenses. T h e therap ist's n ext in terv en tio n illustrates v ery clearly a fu n d am en tal principle o f this tech niqu e; nam ely, w h ere a resp on se con tain s a m ixture of com m u nication and resistance, no m atter h ow g en u in e the com m u nication, the e lem en t o f resistan ce m ust still b e ch alle n g ed . T h is p articu lar d efen se is challenged. TH :

That she belonged to som eone else. H er husband is on the West Coast, and she is preferring you to her husband. A nd you a m inute ago told me that you r w ife ivas engaged an d you fin a lly m anaged to convince her to drop her fian cee fo r you. So w hat is there that I have in my m ind?

T h e p atient respond s to this ch allen g e w ith ou t defen siveness. PT:

Wow

Further Inquiry and Part of the Developmental History Sin ce the p atient has resp on d ed so positively, the therapist resu m es further exploration. H is aim is to assess b o th the quality of the m arriage, th e sexual relation, an d the d egree to w h ich the affair w ith th e sister-in-law h as th reatened it. All o f the in form ation is reassuring, in d icatin g th at th e p atient is an em otionally h ealth y you n g m an, w ith a good close relation sh ip , su fferin g from a single obsessional sym ptom — a sym ptom n eu rosis rath er th an a ch aracter neurosis. T he p atient in d icated that the sexual relation sh ip has b een good since th e b eg in n in g of the m arriage. For a few m onths, w h en the sister-in-law w as in the picture, there w as a decline; but at th e p resen t tim e it is v ery satisfactory. D u rin g intercou rse

Spectrum o f Psychoneurotic Disorders

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w ith his w ife h e m ay g et flashbacks o f his sister-in-law , m ain ly h er face, w h ich he is able to p u t o u t o f his m ind ; it d oes n o t in terfere w ith his erection , and h e has n ev er had an in cid e n t w h ile h av in g sex w ith his w ife of im agin in g h e w as h avin g sex w ith his sister-in-law . T h e th erap ist n ow fills in fu rth er d etail about the history o f the p atien t's relation s w ith girls, still ch eck in g on w h eth er there is an y d istu rb an ce or any fu rth er ev id en ce for recu rren t p ath olo gical p attern s. T h e in form atio n is typical of th e d ev elo p m en t o f a h ealth y yo u n g m an in N orth A m erican culture, and the w h ole pictu re is en tirely reassuring. H ere, for the sake o f brevity, this part of the exploration is su m m arized. Q u estio n ed ab ou t his m o th e r's attitu d e about his d atin g and sexual issu es, h e said, "S h e n ev er said w atch you rself or a n y th in g .. . . Sh e w as v ery u n d erstan d in g and alw ays figu red th at I know ." E xplorah on w as m ade on th e issue of sex ed u cation , and he said th at o n e o f th e teach ers co n d u cted sex ed u cation classes after sch ool w ith p a re n ts ' p erm issio n . H e in d ic a te s th at h e had an o p e n sy stem of co m m u n icatio n w ith his parents. PT.

1 asked h er how the baby urns . . . how it loas fo rm ed in the stom ach, I rem em ber askin g her about stu ff I was interested because 1 zvanted to fin d out certain things.

H is relation w ith girls b efore th e m arriage w as explored. H e had th ree relation sh ip s w ith n o in d icatio n o f an y problem . H e had m an y close friend s and w as in v olv ed in h ock ey and baseball. After h e finished h igh sch ool h e w en t to w ork, an d his w o rk record is good. N o previous psychiatric history. All o f his sy m p tom atolog y started after the in cid en t w ith his sister-in-law .

Developmental History T h e th erap ist n ow em barks on explorin g the p atien t's fam ily b ack grou nd . TH: You are fro m w here? PT: 1 w as born in Toronto an d later the fa m ily m oved fu rth er East. B oth p aren ts are living. H e has o n e b roth er 7 years y o u n g er th an the patient. H is father, an in d u strial ch em ist, is 58 and his m oth er is 50, a h ou sew ife.

Dynamic Exploration of the Patient's Early Life H av in g o b tain ed this in fo rm atio n , the therapist explores the d yn am ic aspect of th e p a tie n t's early life. TH : PT:

W hat is y ou r earliest m em ory o f life, as fa r back as you can rem em ber? O ne is o f g oin g to . . . firs t startin g school. That is w hen I w as six. That alw ays seem s to com e to m y m in d because 1 didn't w ant to g o to school until a fe w frien d s cam e over, like, a couplc o f frien ds. O ne o f them had an older brother, an d h e w as sort o f g oin g w ith us to g o to school. So once they cam e over it didn't bother me. I w ent o ff alon e to school. TH : This m em ory is arou n d the ag e o f . . . PT: I thin k six.

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Intensive Short-Term Dynamic Psychotherapy

TH: Were you closer to your fath er or to your mother? PT: M y mother, because w henever I had any problem or anything I always went to m y mother— because she was alw ays there, whereas my fath er was at work. So 1 don't know w hether that was . . . I guess . . . well, it was love, too. But it was m ore or less that she was there all the time, w hereas my fa th er was not th e r e . . . he ivould leave early in the m orning and get hom e at night. TH: W hat are your earliest m em ories o f your father? The sort o f things you did together? PT: I rem ember he alw ays took us on vacation. W henever he was on vacation from w ork we ahuays w ent som ew here. A nd it was alw ays fun. TH: D id your fa th er show interest in you when you loere grow ing up? PT: N ot in the younger years. In the younger years he was m ostly at work. TH: H oio ivould you describe you r fa th er as a person and . . . ? PT: Fair, fairly s t r ic t . . . well, used to be. 1 think he is m ellow ing notu with getting older. Good to be around. TH: Noiu? PT: Yeah. TH: You said he was strict. PT: Yeah. H e was, but he w asn ’t an authoritarian type. Just if you were supposed to do something, do it, get it done. Don't mess around. I f you have hom eivork to do, do that. I f you have chores to do, do them . . . you knoiv? Then once you have done that, w hatever free tim e you have is yours. H e had pretty high standards. I f you've g ot to do som ething, do it right sort o f the thing, you knoio? D uring the week I w ould com e hom e from , let's say, high school or whatever, and I kneio I Itad to pick up the mail. This and this. Okay, once 1 did that then you coidd, you knoiv, go out an d see your frien ds, w hatever But, you know, do w hatever has to be done first. TH: I see. H oio about you r mother? PT: M y mother? . . . I got alon g great loith my m other Uh. . . . She was m ore o f a disciplinarian than my fa th er was. TH: She loas more? PT: Yeah. Like she w ould . . . like, because, ivell I have got a younger brother and having a youn ger brother I had argum ents with him , an d battles, and . . . TH: H oio much youn ger is he? PT: H e is seven years younger. H e is now 19. TH: H e is now 19? PT: Yeah. She w ould g et upset w ith us an d pick up, like, a fly sw atter and give us a sm ack with it and tell us, you know, stop w hatever you are doing or on e o f you get out— one in one room an d one in another, or, you know. This w as much m ore so than my fa th e r W hereas h e w ould com e home, you know — my m other w ould say, well w hat they did today. TH: Was there a lot o f fig h tin g betw een you an d you r brother? PT: Yeah. T h e d a ta se e m s to su g g e st th a t th e m a jo r so u rce o f te n s io n fo r th e p a tie n t in th e fam ily w as h is y o u n g e r b ro th e r. T h e q u e s tio n fo r th e th e ra p ist: is a clo se early re la tio n w ith th e m o th e r d isru p te d b y th e b irth o f h is y o u n g e r b ro th e r? T h e th e ra p ist see k s fu rth e r e v id e n c e , a n d as h a s a lre a d y b e e n m e n tio n e d se v e ra l tim es,

Spectrum o f Psychoneurotic Disorders

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th is p a tie n t h a s s h o w n a m a rk e d la c k o f re sis ta n c e th r o u g h o u t th e in te rv ie w ; a n d w h e n h e h a s b e c o m e re s is ta n t h e h a s re s p o n d e d q u ick ly to m in im a l ch a lle n g e . It is c le a r th a t th is m in im a l c h a lle n g e h a s stiU b e e n e n o u g h to k e e p h im n o n re s is ta n t; h is th e r a p e u tic a llia n c e n o w p ro d u c e s a p ie c e o f s p o n ta n e o u s in sig h t.

TH :

W hat w as y ou r relationship with y ou r m other like in the early years before you r brother w as born? PT: Far back in the very early phase I had a close relationship, an d much m ore so than w ith m y fa th e r because he w ent to w ork an d he was m ostly away, an d being, four, fiv e an d six, you are at hom e all the time. So naturally you relate m ore to you r m other than y ou r father, really. N ow w hat com es to m y m ind also is you asked abou t my earliest m emory. This was at age 6, an d I really had a fe a r o f going to school. TH : You had fe a r to g o to school then? PT: W as it fea r? I don't know, m aybe I ju s t w anted to stay loith my mother. T h e th e ra p is t d e c id e s n o t to p u rs u e th is fo r th e tim e b e in g . H e is w e ll a w a re o f th e th e m e o f tr ia n g u la r re la tio n s h ip s in th e p a tie n t's c u r r e n t h isto ry , a n d h e n e e d s to e sta b lish w h ic h o f th e e a rlie r tria n g le s , th e tria n g le in v o lv in g h is fa th e r o r th e o n e w ith h is b ro th e r, w as th e m o re im p o rta n t. H e d e c id e s to e x p lo re th e fo r m e r tr ia n g le first.

Dynamic Exploration. The Triangle Involving the Patient, His Mother and His Father TH : A n d y ou r relationship w ith y ou r fa th er then? PT: (pause) I don't really remember. TH : D id you fe e l close to y ou r fath er? D id you look forw ard to his com ing hom e? PT: M y m em ories o f the early years are m ostly when w e used to g o on vacation, and som etim es m y g ran d m oth er an d grandfather. TH : Then w hen y ou r fa th er w as around, ivhat was you r relationship with you r m other like then? PT: 1 think I w as still w ith m y m other m ore than really w ith m y father. TH : W hat was the relationship betw een y ou r parents like? PT: As fa r as I can rem em ber they alw ays got along fin e . . . uh. . . . A few years ago they had a fa llin g out, an d this was w hen I w as 16 or 17. TH : So arou n d a g e 16 then there w ere problem s betw een you r parents? PT: Yeah. They started to have argum ents. TH : W e can g et to that in a m inute. W hat w as the sexual life o f you r parents like? W hat w ere y ou r thoughts abou t y ou r parents' sexual life? T h e p a tie n t re s p o n d s w ith a m ix tu re o f th e ra p e u tic a llia n c e a n d th e ta ctica l d e fe n s e o f ru m in a tio n . O n c e m o re , w h e n th e r e is s u c h a m ix tu re it is th e d e fe n s iv e a s p e c t th a t m u s t b e c h a lle n g e d a n d th e c h a lle n g e m u st b e k e p t u p so lo n g as a s ig n ific a n t d e g r e e o f re s is ta n c e is p re s e n t. T h e fo llo w in g p a s sa g e v e ry cle a rly illu s tra te s th is p ro c e s s , w h ic h e n d s re la tiv e ly q u ic k ly w ith th is p a tie n t, a n d th e re is e m e r g e n c e o f a n im p o r ta n t p ie c e o f in sig h t.

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PT:

I w ould really say no idea. I don't know fo r som e reason. I never really pictured them as having sex together fo r som e reason. 1 don't know why. TH: So your m em ory collapses on you. You say you never really pictured them as having sex, but obviously they m ust have, because after all there you a r e . . . and

PT: A nd there is my brother. TH: Then obviously there was a w ish on your part that you w ould not think o f sex in terms o f your parents. T h e p atient responds w ith rum ination. PT: TH: PT: TH: PT: TH: PT: TH:

PT:

TH: PT:

TH: PT: TH: PT:

It m ight have been. 1 can't really . . . it is . . . I was thinking back to then, and it is hard to say. But that doesn't help us. We need to look at you r thoughts. It seem s 1 didn't want to recognize the fa ct that m aybe I was jealou s o f my fath er in a way. From w here does the idea o f being jealou s o f you r fa th er come? I don't know. It suddenly cam e to my m ind if I didn't picture them having sex, you know, m aybe I w anted m y m other like fo r me. H m hmm. H ave you had these thoughts? N ot really before. It cam e to m y m ind now that I am talking to you. So fa r the picture is that you have a very close relationship loith your mother, and y ou r fa th er is only som ebody w ho is w orking hard day an d night and he is not very much in the picture. A nd even du rin g vacation when he was around or other tim es you m aintained a close relationship with you r mother. At least this is the picture until you r brother was born. But when I was around 16 or 17 I saw more o f my father. By then I sort o f had an interest in goin g ou t— H e used to talk about g oin g to the tavern and playing shuffleboard and stu ff like that. So that sort o f interested me. I w anted to see, you know, exactly w hat it was so I asked him if I could an d he said yes. So when I first went, o f course, he let me have one or two beers; an d that was it. H e didn't want to get me drun k an d take m e hom e to m y m other or som ething. We used to go out together. Then he sort o f sw itched jobs so I was gettin g a ride home, a ride into w ork with him, an d a ride back so 1 was more with him m ore than before. So, around this tim e you developed a much closer relationship with you r father. But did y ou r feelin g s about you r m other at that tim e change? No. I have alw ays been close to m y mother. Still I am now. Uh . . . M y fath er started to drin k a little too much an d w ouldn't show up fo r supper, and stu ff like that. Finally, i v e l l o n e tim e my m other sort o f l o e l l . . . she never told him but she m entioned to m e that she was thinking o f taking off, goin g back to England . . . w hile her fa th er w as still alive. At the tim e I ju st thought to m yself it is ju s t an ger tow ard m y father, that it zoas ju st like a threat, really, sort o f an expression o f ju st pure frustration. That ivas the first tim e that you r m other talked to you about you r father? Yeah. That luas the first time. P rior to that? No. She never talked behind m y fa th er that I remember. That w as the first time, an d anyw ay that's been patched up. So my fa th er cut dow n on his drinking.

Spectrum o f Psychoneurotic Disorders

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W h a t em erg ed w as th a t h is fa th e r d ra n k som e beer, b u t n ev er to excess. It w as o n ly w h e n th e p a tie n t w as ab o u t 16 th a t his d rin k in g in creased an d b ecam e a so u rce o f con flict. T h e n th e focus o f th e session is on the relatio n sh ip b etw een h is p a ren ts, an d th e p a tie n t in d icated th a t as far as h e can rem em b er th e y h ad a v ery goo d rela tio n sh ip . H is p ositiv e feelin g s for his fath e r in th e v ery early years relate to v acation s. T h e n th e sessio n focu ses on th e p a tie n t's feelin gs at th e age o f 16. TH : I f w e g o back to the ag e o f 16, hoio did you fe e l when you r m other w as talking to you about leav in g y ou r fath er? H ow d id you fe e l about that? PT: Uh . . . it didn't bother me, really. It didn't bother me, really, ’cause, ju st the w ay they got alon g other than w hen he w ent out on, like he didn't do it every . . . TH : You m ean you didn't have an y feelin g s either w ay tow ard you r mother, talking to y ou about h er bitterness an d w anting to leave you r father? PT: Uh . . . I w orried, I w ondered, you know, w hat I'd do and. I'd stay w ith my m other or stay w ith m y father. TH : A n d w hat w ere y ou r thoughts an d ideas— to stay with which one? PT: Uh . . . I think I w as m ore inclin ed to stay here, to stay in C anada loith m y father. M y brother, w ell he ivouldn't have much choice— he w as only eight at that time. TH : But this doesn't fit. You had a close relation w ith you r m other— then you r brother an d y ou r m other w ould have en ded up to g o together. PT: Well, all m y frien d s w ere here. As I g ot older I was m ore draw n to m y fa th er than m y mother. Im p o rta n t m aterial has em erg ed in the above passage, and the th erap ist's co n clu sio n is th a t th e trian g le in v olv in g the fath er d oes n o t relate to the p atien t's co re p roblem . T h e n the p rocess o f th e in terv iew m ov es to the o th er triangle.

Dynamic Exploration: The Triangle Involving the Mother and the Brother, Leading to Resistance TH : PT:

W hat do you rem em ber abou t w hen y ou r brother w as born? You w ere then seven. I rem em ber w ritin g notes to m y mother. She was in the h o s p ita l. . . I think that she w as in the hospital fo r a week. I am not sure. TH : D o you rem em ber w hen she w as pregnant? PT: I saw h er pregnant, an d I rem em ber I thought it w ould be great, you know, to h ave a baby brother. TH : H ow d id you feel? T h e focu s is o n th e p a tien t's feelings. It sh ou ld be n o ted th at b eh in d th e d en ial th e d y n am ic force of th e th erap eu tic allian ce is in operation . PT:

I fe lt okay, except that h e g o t a lot o f attention.

T h e th erap ist asks for a sp ecific exam ple. TH:

Can you g iv e m e a specific exam ple o f how he got special attention ?

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Intensive Short-Term Dynamic Psi/chotherapy

PT:

Well, when 1 luas 10 or 1 1 1 used to have chores. I w ould have to do . . . like go fo r bread, to get things. I rem em ber I used to have to get w ood fo r the fire. 1 used to have to do a lot o f things, but he didn't have to do any o f these things. Even she w ould get after me to do things like shovelling, cleaning. TH: I see. You were glad to have a baby brother, but at the sam e time this baby brother is getting a lot o f attention from you r mother. PT: Right. Again focusing on feelings. TH: Could we look to your feelin g s about that? At this point, there em erges a com m u nication of the type w h en both resistance and the dynam ic force of the unconsciou s therapeu tic alliance are both in operation. This takes the form o f a negative statem ent, unconsciously im plying a positive one. H ere the statem en t "I n ev er had tem p er tantru m s" (w ho said an ything about tem p er tantru m s?) im plies th at he w an ted to h ave them . This com m u nication from the therap eu tic alliance indicates: (1) that there w as indeed hostility against the brother, (2) th at it did arise from jealousy, (3) that h ere lies the core of the patien t's neu rotic problem , and therefore (4) th at w h en th e patient show s resistance against exam in ing this area, th en h ere is the poin t at w hich the h ead -on collision m ust b e b rou g h t into play. The therapist is acutely aw are that this leaves a crucial question still u nan sw ered — w h ere d oes the sister-in-law fit in? PT:

W hat I rem em ber is that I n ever had tem per tantrum s. W hat I rem em ber is a fe w years later w hen h e w an ted to tag alon g loith m e I didn't w ant him with me. TH: But you said there w ere fig h ts betw een you an d you r brother. PT: O ver anything. I gu ess there w as so much o f an age difference. H e used to want to fo llo io m e around, an d I didn't w ant that. H e was too young. TH: You mean that was the factor? PT: Yeah, yeah. TH: W as that the factor, or w as it that he had becom e the fav ou rite o f you r mother? Was there any favou ritism ? T h e p atient b eg in s w ith a d en ial and th e n , on ce m ore, th e th erap eu tic alliance com es into operation. T h e therap ist reinforces this and th e p atien t im m ediately goes into rationalization and ru m in ation . At this poin t the h ead -o n collision begins. PT: TH: PT: TH: PT:

No. No favouritism . No, 1 think 1 used to think there was. You used to think? Yeah. C ould w e look at that? I guess because he was the youngest, sort-of-thing. So I guess I used to think that he got m ore or really he d id n ’t. B u t . . .

Spectrum o f Psi/choneurotic Disorders

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Head-On Collision with the Resistance: Further Rise in Transference Feeling TH :

PT: TH : PT: TH :

PT: TH : PT: TH :

PT: TH : PT: TH : PT: TH : PT: TH : PT:

I w onder if y ou notice that w hen loc w ant to talk about you r relationship with y ou r brother— the fig h ts, y ou r relationship w ith y ou r mother, that are obviously very im portan t fo r us to understand— you have becom e vague an d rum inate an d rationalize aw ay, because he was the youngest, because this an d that. For instance, you said that you had to do all the chores an d he didn't. You were the on ly child, then y ou r brother com es along. A nd you m ust have a lot o f feelin gs that ive have to understand. Yeah. Right. But I really know . . . But . . . this loay by ru m in ating an d rationalizing w e are not g oin g to un derstan d w here the core o f you r problem lies. I don't really kn ow w hether 1 had that feelin g or not, you know. It is . . . N ow you are qu estion in g w hether you even had that feelin g. But w here did the idea com e fro m a m om ent ago w hen you said you fe lt that you r brother was g ettin g a lot o f attention an d you ivere forced to do a lot o f dirty chores? Yeah. 1 gu ess really I did. You see . . . Yeah. Right. I see lohat you mean. The only w ay that w e can u nderstand the problem is to look to y ou r m em ories rather than to ration alize things. So obviously there w as a feelin g in you that y o u r brother had d isru pted the close relationship you had with you r mother, the relationship w here there w as no com petition— you an d y ou r m other together and y ou r fa th er busy. Uh hm m . N oiv w hat are y ou r m em ories about y ou r brother gettin g more? Uh . . . g ee . . . (p a u s e ) . . . g ettin g m ore . . . It h ad to do w ith the atten tion o f y ou r m other Yeah . . . it alw ays, like to m e I gu ess it seem ed that he used to be able to stay up later than I d id at his age, you know. N ot to do chores. Your m other w as m ore lenient with him an d m ore strict with you? A nd your brother had a heavenly deal? I gu ess you cou ld say that, yes. That he w as the fa v o u rite o f y ou r m other? That he becam e the star? Yeah . . . okay.

N o w , th e th e r a p is t c h a lle n g e s th e p a tie n t's p a s siv e c o m p lia n c e , w h ic h is a ta c tica l d e fe n s e to p r e v e n t h im fro m e x p e rie n c in g h is tru e fe e lin g s.

TH :

W hy do you say, "Yes . . . okay"? Is it, or isn't it?

T actical d e fe n s e o f ru m in a tio n .

PT:

Yes. I g u ess h e w as then, but. . . . W e are looking at it then . . . okay . . . favou rite? . . . fav ou rite? H e w as the fa v o u rite because he was the youngest.

T actical d e fe n s e o f " b e c a u s e " u se d to a v o id fe e lin g w h ic h is ch a lle n g e d .

TH :

Let's not g et to "because."

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Intensive Short-Term Dynamic Psychotherapy

C hallenge to the tactical d efen se of vagueness PT: TH:

Yeah. Right. I guess so. I guess he was. W hy "guess so"? Was he or wasn't he?

Return to tactical d efen se of rum ination PT: It could. I don't know whether, you know . . . she intentionally did it. TH: There again you are m oving to "because"— rationalizing. PT: Okay. Yeah. Then to me, then, yes. H e was the favou rite at that time— the way I saw it then. TH: A nd you w ere after him to fight, an d you were seven years old. Vagueness again PT: Possibly right. TH: Again, "possibly"? T h ere is fu rth er rise in th e tran sferen ce and concom itan tly w e see a rise in the unconscious therapeu tic alliance w h ich ackn ow led ges the resistance openly. PT:

I don't w ant to answ er the question directly.

This com m u nication has tran sferen ce im plications. The process focuses on the tran sferen ce and this is the first tim e th at this has b een m en tion ed . T h en the process m aintains its focus on the d efen ses an d fu rth er the focus is on the und erlying feelings, n ot on ly about the b ro th er b u t about the m oth er as w ell. T h en the focus is on the an g er tow ards b o th o f them . TH: N ow let us look at y ou r relationship here with me. You prefer to hang things in the m iddle o f nowhere, okay? Look at it. W hen you are describing your relationship ivith your brother, w ith you r mother, you cannot com m it you rself to what really was there, okay? In all— "guess," "perhaps," an d "maybe." You give me a picture that you r brother becam e the fav ou rite o f you r m other and that your m other replaced you with you r baby brother, then you m ove to rationalize. You becom e vague. A nd obviously you w anted to pick a fight, an d you were older and stronger, an d to get at him — ivho had replaced you in relation to you r mother. A nd obviously, also you have feelin gs about you r mother, ivho replaced you like that. A nd not only that, is g iv in g all the attention to you r brother and the dirty chores to you. PT: Yes. 1 loould say yes. Right. I resented it. TH : W hen in a fig h t he was obviously the loser to you. PT: W e l l . . . uh . . . There w as m ore arguing than fighting. P hysically I hit him once or twice. TH: So you had the upper hand. PT: Oh, yes. Definitely. TH: Hm hmm. In term s o f you r mother, w hat was her feelin g? That there w ere two o f you instead o f one? W ould you say that you lost that privileged, num ber one position in relation to y ou r m other? PT: W e l l . . . I lost it. TH: A nd how do you fe e l about it? She has you r brother, an d all the attention goes to him . ..

Spectrum o f Psycho7teurotic Disorders

25

T h en th e focu s is o n th e p a tien t's sm ile an d th e n on the p atien t's tran sferen ce feeling. TH : . . . You are sm iling. H ow do you fe e l right now w hen I . . . ? PT: The thing is . . . back . . . you know . . . I don't, can't really rem em ber w hat I thought back then. TH: I am not su re if it is that, that you don't rem em ber— or som ehow you w ant to leave it in the m iddle o f nowhere. PT: Possibly. B u t . . . like 1 said, 1 don't rem em ber how I thought. TH : L et m e qu estion you abou t on e thing . . . PT: H m hmm. F u rth er C h allen g e to th e Tactical D efen se TH : PT: TH: PT TH : PT: TH :

I f you look here w ith me, you often say "possibly," "perhaps," "guess so" rather than look at things. D o you see w hat 1 m ean? Yeah. I see w hat you mean. That you say, “possibly," "guess so," an d so forth. Is it like this w ith everybody else? No. It is here only? M aybe it is, I don't know . . . 'cause I j u s t . . . A nd how do you fe e l about m e qu estion in g you an d . . .

T h e p atien t d eclares th a t h e h as feelin gs b u t in a v agu e and evasive way. PT:

I gu ess . . . N ot "1 gu ess "— that is part o f it. I feel, you know, fe e l “kind o f fu n n y " talkin g about— you know — "everything." TH : H ow do you fe e l w hen 1 con stan tly keep you on the issue rather than to . . .

The p a tie n t's th erap eu tic allian ce n ow o p en ly ackn ow led ges his d efen siv e m an eu v ers an d h is ap p reciatio n of w h at th e th erap ist is tryin g to do, at the sam e tim e m ak in g clear th a t h e did n o t exp ect exp loration into the p ainfu l issues of the past. PT: TH : PT:

Let m e o ff the hook . . . yeah. I don't know. The thing is . . . You are sm iling. I know w hat I am doing. I am trying to avoid the direct question. I didn't want to g e t . . . 1 didn't know, like, you w ou ld g o back into m y problem s or back to my parents an d a ll this.

T h e th erap ist n ow applies o n e of th e im p o rtan t co m p o n en ts o f the h ead -o n collision. TH :

Okay. You said that you are tryin g to avoid. N ow let's look at it. O bviously you h ave a problem a n d this problem is a source o f m isery an d suffering fo r you. PT: Hm hm m . Right. TH : A n d you have, on y ou r ow n will, com e to fin d an ansiver to you r problem — with the h elp o f each other to g et to the bottom o f y ou r problem , to get to the core o f y ou r problem s. This is y ou r goal. Right? P T Right. Yeah.

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Intensive Short-Term Dynamic Psijchotherapy

TH: N ow if here you are going to avoid, then obviously you are not going to reach your goal, that you have set fo r you rself In other words, it becomes useless to you — an d there will he self defeat in it, isn't that? PT: Yeah. TH: N ow my question is this, why should you on your oion will com e here and see if we can get to the bottom o f you r problem yet at the sam e tim e another part o f you w ants to defeat the purpose, the goal, and the aim you here set fo r yourself— because if you are going to avoid to face ivith many o f these com plicated feelings then obviously we are not goin g to get anyiohere. PT: We l l . . . I didn't realize that we'd have to go back, you know, all that far. I figured we'd ju st go back to where it started. F or th e tim e b e in g th e th e ra p ist d e c id e s th a t th is h e a d -o n co llisio n a n d th e re su ltin g o p e n a c k n o w le d g e m e n t b y th e p a tie n t o f h is d e fe n s iv e p o sitio n are su fficie n t. H e re su m e s h is ex p lo ra tio n a b o u t th e m o th er.

Exploration of the Relationship with the Mother, Resistance and Challenge TH: N ow could you tell me m ore about you r mother, you know . . . then . . . the loay you rem em ber her. H er physical appearance, h e r . . . C h a lle n g e to th e re sista n ce h a s g iv e n rise to tr a n sfe re n c e fee lin g s a n d fu rth e r m o b iliz a tio n o f th e th e ra p e u tic a llia n c e to su c h a d e g re e th a t th is q u e stio n re su lts in m a jo r co m m u n ic a tio n .

PT: E r She's nice looking. She's sm all— sm all build. She looks like my wife. TH: Hm hmm. PT: A bout the sam e height, sam e weight. TH: I am talking about lohen you w ere a child— your m em ories o f her body an d her build. R e tu rn o f re sista n ce , th e d e fe n s e o f e v a s iv e n e ss a n d c h a lle n g e

PT: Uh . . . not really an ything to speak o f . . . nothing in particular. TH: You mean you don't have any m em ory o f you r m other as a child? PT: I rem em ber . . . TH: Wlmt do you remember? PT: She ivas there sort o f . . . C h a lle n g e to ta ctica l d e fe n s e o f e v a siv e n e ss

TH: I knoiv she was there, but w hat do you remember? PT: I don't really, you know, in particular, nothing. TH: Huh? PT: In particular, nothing. A lw ays she loas good and loving, taking really good care o f me. TH: Hm hmm. PT: You know . . . I used to have problem s in school. TH: Again you avoided m y question. We w ere focu sin g on her physical appearance. Again you avoided to tell me about her physical appearance when you were a child.

Spcctrum o f Psychoncurotic Disorders

27

P re v io u s h e a d -o n c o llisio n a n d c h a lle n g e to th e d e fe n s e o f e v a s iv e n e s s n o w p ro d u c e s a m a jo r c o m m u n ic a tio n fro m th e th e ra p e u tic a llia n c e w^hich clea rly th ro w s lig h t o n w h e r e th e siste r-in -la w fits in.

O ne thing I do rem em ber is. . . . I prohabli/ . . . not probably— sorry, I do remem ber, is that I alivays thought that she was sm all in the chest as com pared to oth er m others. That is one thing that I can rem em ber . . . I rem em ber that. I rem em ber . . . w ell . . . I used to look at others, my frien ds' m others, an d think they are fa irly big. A nd I used to w on der why, sort o f wonder, w hy m y m other isn't, you knozv. A t that tim e I didn't realize, you know, probably different people are different sizes sort-of-thing. I gu ess I sort o f had it fix ed that all m others should sort o f be the sam e size. TH : So, you w ere com parin g the breasts o f you r m other w ith the breasts o f your frien d s' m others— that they had large-breasted m others an d you had a sm all­ breasted m other PT: Yes. But som e o f the oth er m others had smaller, too. TH : I see. H ow old w ere you then ? PT: Seven, eight, nine . . . TH : Then these relate to the early years? PT:

T h e th e ra p is t n o w first m a k e s a c o n n e c tio n b e tw e e n th e p a st a n d th e p re s e n t th e n a sk s a c ru c ia l q u e s tio n a b o u t th e p a st. O n c e m o re , th e th e ra p e u tic a llia n c e m a k e s a n o th e r h ig h ly s ig n ific a n t c o m m u n ic a tio n , g iv in g e v e n fu rth e r p o in t to th e c o n n e c tio n w ith th e c u r r e n t p ro b le m .

TH : PT:

TH :

PT:

TH : PT: TH : PT: TH : PT:

You said that y ou r w ife looks like y ou r m other H ave you thought o f it that way? O yeah. I h av e seen it. W e ll. . . people have said, people that don't know m y w ife an d m y m other that w ill have asked if she was her daughter sort-of-thing. They are qu ite sim ilar Your m em ory indicates, then, that you w ere very conscious o f the breasts o f your m other; a n d you said this ivas arou n d the age o f eight o r nine. But how did you becom e aivare o f the size? (pause). 1 rem em ber one time, I don't rem em ber how old I ivas, she was, 1 guess she loas in the bath or gettin g dried an d my fa th er had to g o to the bathroom an d h e ivent in, an d I rem em ber she ivas standing sideioays an d I saw h er She was in the bathroom , but w here w ere you standing? T here loas like a hallw ay, an d I ivas ju st standing in the hallw ay; an d as the door open ed 1 h ap pen ed to look up an d I saw her breasts. 1 don't know how old 1 was. You are say in g you "happened" to look up? O nly later you becam e curious? N ot so m uch abou t my m other hut about other women. I f you com pared your m other's breasts w ith other w om en's breasts, obviously you w ere curious. You thought, "W hy have I g ot a m other w ith sm all breasts?" 1 n ever tried to peek into h er room.

A g a in th e n e g a tiv e s ta te m e n t im p ly in g p o sitiv e , w h ic h is a fu n c tio n o f th e th e r a p e u tic a llia n c e to w h ic h th e th e ra p is t im m e d ia te ly d ra w s a tte n tio n .

TH :

1 didn't say that! In that m em ory, did y ou r fa th er g o into the bathroom ?

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PT:

I heard the door open and looked up. It was a fraction, it was ju st fo r a fraction o f a second, and then the door closed.

T h e th e ra p ist n o w exp licitly m a k es th e lin k w ith th e sister-in-law .

TH: Still you prefer not to declare that you w ere actively interested. A nd obviously w hat took place between you and you r sister-in-law, in that episode you were an active p a rticip a n t. . . T h e p ro cess n o w re tu rn s to th e tria n g le in v o lv in g th e p a tie n t, h is m o th e r an d h is b ro th e r a n d th e issu e o f h id d e n re s e n tm e n t a g a in st th e b ro th er, a n d th e p a tie n t g iv es e v id e n c e th a t h e is w o rk in g o n this.

PT: R esentm ent? (quietly) mm . . . g ee . . . I d o n 't. . . TH: Som ething that you alw ays have difficulty about. Do you have difficulty about the issue o f resentm ent? PT: (pause) M aybe I don't loant to a d m it . . . T h is a d m issio n th a t h e d o e s n o t w a n t to a d m it is e n o u g h fo r th e th e ra p ist to sen se an o p p o rtu n ity to b rin g th e p a tie n t's n e g a tiv e tr a n sfe re n c e fe e lin g in to th e o p en .

TH:

N ow le t’s look at another issue. H ere during this tim e that w e have been together goin g over these com plicated issues, was there any tim e that you felt resentful tow ard me? PT: A fe io times, yes. TH: A nd I sense it, too. PT: Yes . . . sure . . . you can sense it, when I don't answ er you. I g o all around the issue. The issue is resentm ent. N ot that I dislike you, it is just, maybe, you know, I... T h e p a tie n t h a s o p e n ly a c k n o w le d g e d n e g a tiv e

f e e lin g

in

th e

tr a n s fe r e n c e .

h is d e fe n s e a g a in s t u n d e rly in g

A lth o u g h

th is is a v e r y

im p o r ta n t

c o m m u n ic a tio n , h e h a s still e n d e d b y d e n y in g th e tru e im p a ct. As alw a y s, it is th e e le m e n t o f r e s is ta n c e th a t m u s t b e b r o u g h t in to th e o p e n . T h e th e ra p is t im m e d ia te ly p o in ts o u t th e d en ial.

TH:

Right aivay, also, you are reassuring m e about liking an d disliking. Im m ediately you said, "not that I dislike you."

T h e th e ra p ist n o w g iv es a n in te rp re ta tio n o f th e re s ista n c e , re s e n tm e n t o f liim in tru d in g n o w b e tw e e n th e p a tie n t a n d h is m o th e r w ith th e b r o th e r 's in tru s io n in th e p ast.

TH:

PT:

So obviously ivhat w e have seen here in relation to m e is that you resent my getting into you r personal, intim ate life, an d that you resent m y gettin g into you r intim ate relationship with y ou r m other— the sam e w ay that you loere angry that you r brother got betw een you an d you r mother. In term s o f your father, he was too busy— either at w ork or in the tavern, so he loasn't a threat. Yeah . . . right.

TH: A nd the w ay you are dealin g with you r negative feelings is ice skatin g around the. . .

Spectrum o f Psijchoneurotic Disorders

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PT: TH :

Yeah. Right. B eating arou n d the bush. B eating arou n d the bush an d becom ing vague an d nonspecific. That is the w ay you are han d lin g y ou r negative feelin g s here. PT: Yeah. Okay. TH: So that is w hen I said . . . PT: Yeah, "get to the point."

Recapitulation O n e of th e im p o rtan t featu res of this tech n iq u e is th e w ay in w h ich the p rocess p ro ceed s in a spiral: exp loration , resistan ce, ch allen g e to the resistan ce, rise in tra n s fe r e n c e , fu rth e r re s ista n c e , in te rv e n tio n aim ed at w e a k e n in g tran sferen ce resistan ce, retu rn to exp loration and so on. B u t th e read er should keep in m ind th a t this p rocess, b o th q u an titativ ely and qualitatively, is extrem ely d ifferen t w ith p atien ts o n th e extrem e left o f the sp ectru m com p ared to tho se w ho are h ig h ly resistan t on the rig h t side of th e spectru m . L o o k in g b a ck ov er th e m id p h ase o f this interview , w e can see the follow ing: (1) The therapist began to explore the triangular relation involving the brother. This led to; (2) The patient going into som e resistance, em ploying rum ination; (3) The therapist begins with the head-on collision with the resistance which leads to; (4) The patient's admission of his defense, that he does not w ant to answer the question directly; (5) The therapist first draws attention to the transference com ponent in this and then continues his challenge; (6) The patient admits the underlying feeling of resentm ent towards his mother; (7) The therapist presses the patient for further feelings at which point the patient gives an involuntary smile and the therapist presses for further feelings; (8) The patient at first m anages to avoid answ ering this question and later gets no further than saying he feels "kind of funny talking about the past”; (9) The therapist applies head-on collision to bring further rise in transference feelings and further mobilization of the therapeutic alliance; (10) The head-on collision has the desired effect, and the focus is on the m other's body; (11) Im portant m aterial about the m oth er's small breasts and the large breasts of the sister-in-law; (12) The therapist then returns to the early triangular relation to bring up that the patient felt resentm ent towards his brother; (13) Then the focus is on the transference with the question w hether the patient at any time felt resentm ent towards the therapist; (14) Now, for the first time, the patient admits the transference feelings; (15) His resistance has been sufficiently w eakened and he makes his own interpretation of the defense and his underlying feeling in the transference, nam ely that w hen he started "beating around the bush" it m eant that he was feeling resentm ent; defense against underlying feelings in the transference; (16) The therapist gives further interpretation, spelling out the issue of resentm ent at the therapist intruding betw een the patient and his m other and linking it w ith that tow ards his brother; (17) N ow the therapist and the patient are able to collaborate actively in elucidating the links betw een the current pathogenic situations and the buried feelings about the past. There is no need for any further m ention of either resistance or transference.

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Uncovering of the Core Neurosis T h e p ro cess n o w re tu rn s to th e p a tie n t's feelin g s in th e o rig in a l tria n g u la r situ atio n , a n d ev e n tu a lly th is b rin g s th e fo llo w in g :

PT: I fe lt like punching him. TH: W hat was your feelin g fo r your mother? PT: I resented it. I kept it in. 1 did not talk about it. But in the past tiuo or three years 1 have talked about it. TH: Do you rem em ber exactly when? PT: Som eiohere around the, around 3 years. Som ehow 1 started to mention to h e r .. . I m entioned to her that I thought he didn't do stu ff he didn't have . . . lo e ll. . . w e l l . . . as, as rough a life as I had. I had m ore responsibilities. 1 also had to take care o f him. 1 rem em ber m y parents w ould g o bowling, an d I had to stay hom e to take care o f him. TH: So you have been talking about your resentment. PT: A nd she agrees with me. She agrees that in som e ways she was unfair. TH: This talking to your m other about preferring your brother, loas it before you got m arried or after? PT: 1 t h i n k . . . no, definitely it zoas after I got married. It w as then that these things cam e out. TH: Then a part o f you m ust have been really angry at your m other an d w anted to g et at your mother, w anted to punish you r mother, w ho preferred your brother to you and replaced you w ith y ou r brother. PT: Yeah. It is clear TH: The question is, luhere the an ger is directed. Is it displaced onto som eone else? PT: You mean m y wife? T h e p a tie n t re sp o n d s b y first re a c h in g a fre sh m e m o r y a n d th e n b y g iv in g his o w n in te rp re ta tio n a n d , as w e se e , h is p re v io u s d e fe n s e s (v a g u e n e ss , ru m in a tio n , a v o id a n c e a n d in te lle ctu a liz a tio n ) a re n o t fu n c tio n in g .

TH: W hat do you think? PT: N ow that I look at i t . . . it m ust be that, you know, w ithout really planning it subconsciously. I remember, you knoio, I told you about m y fe a r o f going to school. N oio 1 rem em ber I had trouble in G rade 2, and that luas w hen 1 w as eight. A nd that zvas the year m y brother ivas born. TH: Hm hmm. PT: That was the only teacher I didn't like . . . the one I had in G rade 2 . . . the only teacher, really, that I didn't g et along ivith . . . that teacher . . . I didn't like her at all. TH: Hm hmm. W hat are you r thoughts? PT: W hen I think about it now, 1 had been an gry ivith my m other; an d luhen I think o f it I must have taken m y an ger out on the teacher rather than on m y mother. In th is p h a se o f an in te rv ie w , w h e n th e re sis ta n c e h a s b e e n d isso lv e d , it is p o ssib le to su rv e y e v e ry fa ce t o f th e p a tie n t's n e u ro sis — all o f th e ra m ifica tio n s o f e v e n ts a n d o f fam ily re la tio n sh ip s th a t h a v e le d to re p re ss e d fe e lin g s. W ith a ca se as sim p le as th is, w h ic h is a re p re s e n ta tiv e o f th e ca s e s o n th e e x tre m e le ft o f th e sp e ctru m , it is p o ssib le to re a c h all o f th e im p o rta n t fe e lin g s w ith in a sin g le

Spectrum o f Psychoneurotic Disorders

31

in te rv ie w . W ith m o re c o m p le x p a tie n ts (th o s e w h o a re h ig h ly re sista n t) th e th e r a p is t c a n a c h ie v e s im ila r r e s u lts a n d h a v e d ir e c t a c c e s s to th e p s y c h o p a th o lo g ic a l d y n a m ic fo rce s re s p o n s ib le fo r th e ir sy m p to m a n d c h a r a c te r d is tu rb a n c e s w ith in a sin g le in te rv ie w , w h ic h is u su a lly o f lo n g e r d u ra tio n . In th e fin a l p h a s e o f th is in te rv ie w , th e fo llo w in g issu e s a re c o v e re d : (1) lin k b e tw e e n th e m o th e r, th e te a c h e r a n d th e w ife; (2) th e w a y in w h ic h re la tio n w ith th e siste r-in -la w e x p re sse d n o t o n ly lo v e, b u t also h o stih ty ; (3) fe e lin g s fo r h is m o th e r, th e is su e o f th e w o m e n 's b re a s ts; (4) th e lin k b e tw e e n

th e th e h is th e

p r e s e n t a n d th e p a st; (5) th e p a tie n t's n e e d to b e th e v ic to r in tria n g u la r situ a tio n s a n d its lin k w ith th e fa c t th a t h e w as th e lo se r in th e p a st; (6) se lf p u n is h m e n t e x p re sse d in th e p a tie n t's c o m p u ls iv e sy m p to m . As w ill b e s e e n in th e fo llo w in g p a ss a g e , th e p a tie n t lis te n s in te n tly a n d a p p re cia tiv e ly , fo llo w in g e v e r y th in g th e th e ra p is t sa y s a n d c r e a tiv e ly p u ttin g it in to h is o w n w o rd s.

TH :

O bviously this is very im portant to look at, this m echanism o f displacing your an ger at y ou r m other fir s t onto you r teacher, an d then onto you r wife. It obviously involves y ou r sister-in-law as w ell— this tendency to take it out an other people. O bviously it involves not only anger— it involves other feelin gs as well. N ow g oin g back to y ou r wife, as w e have established, both you r m other and y ou r w ife have the sam e name. They are both M rs. ________. A nd as you described so clearly, they are also very sim ilar physically. So you r w ife was a con ven ien t person to displace all these n egatii’c feelin g s fo r you r m other onto, to punish h er fo r lohat y ou r m other did. PT: Som ebody I could sort o f take it out on. TH: So y ou r m other w as unfaithful to you, an d you m anaged to be unfaithful to her. PT: To m y wife. W ow . . . it is not m y zoife's fau lt. TH : But also, obviously, there is you r sister-in-law , w ho becam e the target as well. A n d if w e look at it carefully, one can say that you r crim e w as not so much again st y o u r wife. In a direct w ay you did som ething to you r wife, an d to you r sister-in-law ; you w ere pu n ishin g y ou r wife, but really the reason w hy you felt that w ay w as p rim arily because you fe lt that you w ere doing som e punishm ent o f y ou r mother. That w as m uch m ore serious. You see, the root o f it com es from way, loay back an d involves y ou r m ixed feelin g s fo r you r brother as well. PT: I fe lt v ery bad fo r m y sister-in-law , as well. H er husband aiuay stru gglin g to fin d TH : PT TH:

PT: TH :

PT: TH : PT

a house. H ow old is h er husband? 28. A n d you w ere h ighly attracted to her breasts. A nd in a sen se you w an ted to take over his wife. A t the sam e tim e there w as a m ajor conflict w ithin y o u rself You en tertain ed the thought o f h avin g intercourse an d goin g fu rth er . . . I w as really postp on in g it. A n d if w e g o fa r back to the early years an d look at the triangle o f youlyour m other/an d y o u r brother, y o u r m other w as unfaithful to you an d you r brother took y ou r m other aw ay fro m you. Yeah, I see w hat you m ean. But do you thin k som ethin g repeated itself Yeah.

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Intensive Short-Term Dynamic Psi/chotherapi/

TH: You, your mother, your brother and the issue o f a sm all-breasted vs. large­ breasted woman. PT: Som ething ivas taken aioay from m e so 1 was trying to get back by taking som ething aw ay from som ebody else, without realizing it. TH: But if you look at it, there have alw ays been these attached women. There was your brother, and w e know you had 7 or 8 years o f devoted attention from your mother. PT: Right, fu st to m yself TH: You had the exclusive relationship with your mother. PT: Right. TH: Then w e saio the w ay you m et you r wife, w ho was engaged to another man— and you m anaged in som e w ay that she dropped the other man and preferred you. Then w e see your sister-in-law , who is married. H er husband was struggling to fin d a house, and she is preferring you to her husband; and the affair PT: Yes. I see the forbidden fruits. TH: So you see, there are all these triangles all the time. PT: Hm hmm. TH: D id this idea o f forbidden fr u it occur to you then? PT: I w ould say yes, it did. TH: In an y event, ivhat w e see is— noio you are punishing y ou rself you r obsessional sym ptom atology, you r doubts, obsessional thoughts about the lights o f the car, checking and rechecking, an d the agony. PT: Like m y m ind ju st scattered all over TH: A nd zohat you said ivas very interesting because you expected that she loould have punished you. PT: N ow I am doing my oivn punishm ent. TH: You are punishing y ou rself much harder, and you are paying a very high price. O bviously there are a lot o f m ixed feelings, a lot o f m ixed feelin gs in relation to you r mother, you r brother, you r father, that you m ight w ant to exam ine and put into perspective. We have already brought into the open m any o f these issues. But if you try to fo rce these thoughts, these ideas and feelin gs out o f your mind, as you have been doing, then you w ill continue to punish you rself the obsessional thoughts. PT: N ow I see w hy you w ant m e to an sioer straight. Very good. You can pick out stu ff like that, whereas, 1 see it, if I ju st beat around the bush you can't. You can't, you can't, pick out— uh— the relationship. A nd I think that one o f the bad things that I have done, too, is that 1 have loaited so long to come. T h e re re m a in s o n e im p o rta n t issu e th a t d o e s n o t a p p e a r in th e in te rv ie w w h ic h h as n o t b e e n tra n scrib e d . W h y w a s it a t th a t p a rtic u la r p o in t, a fte r a y e a r o f m a rria g e , th a t th e se e v e n ts o c c u rre d ? C learly , th e re a so n h a d to d o w ith th e fact th a t it w as a ro u n d th a t tim e th a t th e p a tie n t's w ife b e g a n ra isin g th e q u e s tio n o f h a v in g ch ild re n . H e w as a m b iv a le n t a b o u t it. T h e w ife 's w a n tin g to h a v e ch ild re n w as th r e a te n in g h im w ith th e re p e titio n o f th e o rig in a l tra u m a o f th e b irth o f h is y o u n g e r bro th er. It w as th e n th a t his e a rlie r fe e lin g s w e re re a c tiv a te d , so th a t h e se t a b o u t c re a tin g a tria n g u la r situ a tio n in w h ic h h e w as th e v ic to r ra th e r th a n th e loser.

Spectrum o f Psychoneurotic Disorders

33

A n o th er q u estion had to do w ith th e issue of sm all breasts vs. large breasts, an ev er recu rrin g issu e in m an y o f ou r patients. We m ay n ote th at it w as the sister-in -law 's larg e b reasts th at particu larly attracted him . W h y th erefore did he m arry a w o m a n w ith sm all b reasts? In his b ack grou n d , h e asked h im self w h y his m o th er d id n o t h ave large breasts like the m oth ers o f the o th er children. H ere w e can say th at his orig in al attraction w as to his m o th e r's sm all breasts, and th at he tu rn ed again st her, feelin g th at o th er w om en w ere m ore attractive w h en she b etray ed him w ith his y o u n g er b ro th e r This w ould acco u n t for his ch oice of partner, b o th in his m arriag e an d in his affair.

Technique of IS-TDP zvith Patients on the Extreme Left of the Spectrum T h e trial th erap y w ith this grou p o f p atients should result in at least som e of the follow ing , an d th e C ase o f the Salesm an is m ore or less a rep resen tativ e. (1)

(2)

(3)

(4)

(5)

Self-exam ination and high responsiveness to inquiry. This patient showed this throughout the interview, and the evidence hardly needs to be spelled out: (a) he was able to clearly describe the developm ent of his obsessional sym ptom s; (b) he's speaking fully and honestly about his guilt-laden relation with his sister-in-law; (c) his open acknow ledgem ent of his own resistance "I don't want to answ er the question directly." A positive response to the therapist's intervenhons. The pahent him self made the link betw een the defense "going all around the issue" and the underlying feeling of "resentm ent." The therapist made the link betw een him self and the brother over the issue of intrusion into the relation with the mother. E xp erien ce and ack n ow led g em ent of tran sferen ce feelings and the mobilization of the therapeutic alliance. W hen the patient finally admitted that there had been occasions in the interview when he had experienced resentm ent toward the therapist and that he had used the defense of "going all around the issue under discussion." M anifestation of the therapeutic alliance, w hich has already been elaborated on in the text of the interview. Dissolution of resistance and access to the core neurosis. With the rise in the transference and mobilization of the therapeutic alliance, the therapist was more able to interpret the whole of the patient's pathology and make all of the links with the current situation. O n several occasions the patient actively gave his ow n interpretation, for example the recent link betw een his m other and his w ife, and in his early years the link betw een his m other and the teacher Reconstruction of the core neurosis and acquainting him with it in a m eaningful way.

Conclusion I h ave d escribed tw o sp ectru m s o f p atien ts w h o can b e su ccessfu lly treated w ith m y tech n iq u e o f In ten siv e Short-Term D yn am ic P sychotherapy. T h e first sp ectru m con sisted o f five m ajor grou ps of patients; on the extrem e left highly resp on sive an d o n th e extrem e rig h t extrem ely resistant. T h en I described the ap p lication of m y tech n iq u e to fragile ch aracter stru ctu re and v ery briefly in d icated th a t the tech n iq u e n eed s certain m odifications. T h en th e m ajo r focus of

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Intensive Short-Term Dynamic Psychotherapy

th e a rticle w as o n th e an aly sis o f th e in itia l in te rv ie w o f a p a tie n t o n th e ex trem e le ft o f th e sp ectru m . N o w w e ca n b riefly su m m a riz e th e m a jo r fe a tu re s o f th e m a jo rity o f p a tie n ts o n th e ex trem e le ft o f th e sp e ctru m as follo w s; (1) (2) (3) (4) (5) (6) (7)

(8)

They have the ability to respond to inquiry in a very meaningful way. They show clear fluidity in their unconscious and as a result the unlocking of the unconscious technically does not apply to this group of patients. There is a virtual absence of unconscious murderous rage and intense guilt­ laden feelings in relation to early figures in their life orbit. As a result, a punitive superego pathology is not present. The nature of the resistance is very much different. The duration of the com prehensive initial interview is 1 hour to 1 hour and a half. With this technique, the course of the therapy is anywhere betw een one and five psychotherapy sessions, each of 1 hour duration. With the above patient, the therapy consisted of a single psychotherapy session. The second session took the format of outcome evaluation. M y extensive experience, in both North America and Europe, in university clinics and in private practice, indicates that indeed the num ber of patients who are responsive ("m otivated") with circumscribed problems and a single psychotherapeutic focus are definitely very few. The large m ajority of patients are those who are highly resistant with a highly com plex pathogenic unconscious, suffering from life-long character neurosis and those who suffer from fragile character structure. These patients are the m ajor focus of this technique.

References Davanloo, H. (1975). Proceedings of the First International Symposium and Workshop on Short-Term Dynamic Psychotherapy. M ontreal, Canada. March. Davanloo, H. (1976). Proceedings of the Second International Symposium and Workshop on Short-Term Dynamic Psychotherapy, M ontreal, Canada. M arch-April. Davanloo, H. (1977). Proceedings of the Third International Congress on Short-Term Dynamic Psychotherapy, Century Plaza, Los Angeles, California. November. Davanloo, H. (1978). Basic Principles and Techniques in Short-Term Dynamic Psychotherapy. (New York: Spectrum). Davanloo, H. (1979). Technique of short-term dynam ic psychotherapy. Psychiatric Clinics of North America, (1). Davanloo, H. (1980). Short-Term Dynamic Psychotherapy (New York; Jason Aronson). Davanloo, H. (1980). Audiovisual Course on Intensive Short-Term Dynamic Psychotherapy presented at the 133rd Annual M eeting of the American Psychiatric Association, San Francisco, California. May. D avanloo, H. (1981). Audiovisual Sym posium on In tensive Short-Term D ynam ic Psychotherapy sponsored by the New Jersey Institute for Short-Term D ynam ic Psychotherapy. Paramus, New Jersey. April. Davanloo, H. (1981). Audiovisual Course on Intensive Short-Term Dynamic Psychotherapy presented at the 134th Annua! M eeting of the American Psychiatric Association, New Orleans, Louisiana. May. Davanloo, H. (1984). Short-term dynam ic psychotherapy. In Kaplan H, Sadock B. (Eds), Comprehensive Textbook o f Psychiatry 4th ed.. Chap. 29.11, (Baltimore, M D; William & Wilkins). Davanloo, H. (1986). Intensive short-term psychotherapy with highly resistant patients. 1. Handling resistance. International Journal o f Short-Term Psychotherapy, 1(2) 107-133.

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Davanloo, H. (1986). Intensive short-term dynam ic psychotherapy with highly resistant patients. II The course of an interview after the initial breakthrough. International Journal o f Short-Term Psychotherapy, 1(4), 239-255. Davanloo, H. (19W). Unlocking the Unconscious (Chichester, England: John Wiley & Sons). D avanloo, H. (1990). Proceedings of the Sixth European Audiovisual Immersion Course on Intensive Short-Term D ynam ic Psychotherapy sponsored by the Swiss Institute for Intensive Short-Term D ynam ic Psychotherapy. Geneva, Sw itzerland. June. Davanloo, H. (1993). Proceedings of the Eleventh Sum m er Institute on Intensive Short-Term D ynam ic Psychotherapy in the Treatment of Fragile Character Structure. Killington, Vermont. July. Davanloo, H. (1993). Proceedings of European Audiovisual Immersion Course on Intensive Short-Term D ynam ic P sych oth erap y: Fragile C haracter Structu re. Bad Ragaz, Sw itzerland. December.

Intensive Short-Term Dynamic Psychotherapy: Technique of Partial and Major Unlocking of the Unconscious with a Highly Resistant Patient— Part I. Partial Unlocking of the Unconscious HABIB DAVANLOO McGill University, Department o f Psychiatry, Mojitreal General Hospital, Montreal, Canada

Introduction T h is is p art o n e of a tw o -p a rt article co n cern ed w itli th e tech n iq u e of both partial and m a jo r u n lo ck in g of the u n con sciou s in a single in terv iew in the treatm en t o f a certain kind o f p atien t su fferin g from ep isod ic d ep ression , oth er p sy ch o n eu ro tic d istu rb an ces and m ajo r ch aracter pathology. In m an y of these p a tie n ts th e ir ch a ra cte ro lo g ica l d efen se s are sy n ton ic. I h av e alread y both p resen ted an d p u blish ed th e d iscovery o f the tech n iq u e of u n lockin g o f the u n co n scio u s an d h av e d em o n strated th at this provides a u niqu e o p p ortu n ity for b o th th e th era p ist an d th e p a tie n t to h ave a d irect view o f th e p sy ch o p ath ological d yn am ic forces resp on sible for the p a tie n t's sym ptom and ch aracter distu rbances. Further, I h ave d em o n stra ted th at th e d eg ree of th e u n lock in g o f the u n con sciou s is p recisely in p ro p o rtio n to the d eg ree th at th e p atien t is ex p erien cin g the tran sferen ce feelin g. I h av e alread y ou tlin ed the d yn am ic seq u en ces used in trial th e ra p y c o n sistin g o f a se ries o f a sp ecific ty p e o f in te rv e n tio n w ith its co rresp o n d in g resp on se. F u rth er system atic research in the eighties and th e early n in eties h as resu lted in b o th refin e m en t in th e tech n ical in terv en tio n s in In ten sive Short-Term D y n am ic P sy ch oth erap y as w ell as the d ev elo p m en t o f a high ly p o w erfu l m eth o d o f p sy ch o an aly sis w h ich will b e the co n cern o f a series of p u blication s to follow.

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Intensive Short-Term Dynamic Psychotherapy

This tw o-part article prim arily is con cern ed w ith the technique of Intensive Short-Term D ynam ic Psychotherapy.

Spectrum of the Technique of Unlocking of the Unconscious Based on the analysis of the clinical research data, there are four m ajor techniques o f unlocking: (1) Partial unlocking of the unconscious. (2) M ajor unlocking of the unconscious. (3) Extended major unlocking of the unconscious. (4) Extended, multiple major unlocking of the unconscious.

This tw o-part article con cern s itself w ith partial and m ajo r urUocking of the unconscious. T h e technique o f extended m ajor u nlocking as w ell as extended m ultiple m ajor u nlocking do n ot con cern them selves w ith the standard technique. They have already b een presented in a n um ber of audiovisual sym posia and courses and will appear in future publications.

Dynamic Sequence in the Process of Unlocking of the Unconscious U pdated analysis o f our clinical research data requires certain m odification and refin em en t of the central d ynam ic sequ en ce, w hich will b e the con cern o f this paper. T h e w hole process is divided into a series of phases:

Phase 1: Inquiry (a)

Exploring the patient's difficulties: initial ability to respond.

Phase 2: Pressure (a) Pressure, leading to resistance in the form of a series of defenses. (b) Rapid identification of the patient's character defenses. (c) Clarification and challenge to the defenses, leading to rising transference and increased resistance which gradually acquires transference quality. (d) Psychodiagnostic function; this is of extrem e im portance particularly in patients that do not respond to inquiry and the therapist in the initial contact encounters with the patient's character resistance, as well as in patients who com e into the interview in the state of resistance in the transference.

Phase 3: Challenge: Making the Patient Acquainted with his Character Defenses (a)

Challenging the resistance com bined with the conveyed lack of respect for them. (b) Challenge directed toward the therapeutic alliance. (c) Systematic attempt to make the patient acquainted with the resistance that has paralyzed his functioning.

Partial Unlocking o f the Unconscious (d) Special form of partial head-on collision with the transference resistance with special reference to resistance against em otional closeness in the transference with the aim of speeding up the process of making the patient acquainted w ith the character defenses that have paralyzed his functioning. (e) Crystallization of the character resistance in the transference; rise in the transference; mobilization of the therapeutic alliance. (f) To turn the patient against his resistance; the patient must clearly see that his resistance that has paralyzed his functioning is being challenged.

Phase 4: Transference Resistance (a) (b) (c) (d) (e) (f)

M ounting the challenge to the transference resistance. H ead-on collision with the transference resistance. To intensify the rise in the transference feelings. To bring the patient face to face with the self-destructiveness of his resistance. M obilization of the therapeutic alliance against the resistance. To loosen the patient's psychic system and make possible a partial unlocking of the unconscious.

Phase 5: Direct Access to the Unconscious: Partial Unlocking of the Unconscious (a) (b)

Crystallization of the resistance and high rise in the transference feelings. Intrapsychic crisis; to create a state of high tension betw een the resistance and the therapeutic alliance in the transference. (c) To maximize the inner tension betw een the unconscious therapeutic alliance and the resistance. (d) M obilization of the unconscious therapeutic alliance. (e) Breakthrough of the com plex transference feeling; the triggering m echanism for the partial unlocking of the unconscious. (f) Direct view of the psychopathological dynam ic forces responsible for the patient's sym ptom and character disturbances.

Central Dynamic Sequence P h a s e 5 : D ir e c t A c c e s s to t h e U n c o n s c io u s : M a jo r U n lo c k in g o f t h e U n c o n s c io u s (a)

In terlo ck in g ch ain of h ead -o n collision w ith the ch aracter d efenses crystallized in the transference. (b) To m ount a direct and system atic challenge to all the forces m aintaining selfd estructiveness and the m ajor resistance of repression. (c) Intensification of the rise in the transference feeling. (d) High mobilization of the unconscious therapeutic alliance. (e) Direct experience of the transference feeling; the triggering m echanism . (f) M ajor unlocking with the passage of the m urderous rage in the transference, em ergence of sadness. (g) Passage of the guilt-laden unconscious feeling. (h) The unconscious now transfers the murdered body of the therapist to the genetic figure. (i) Direct view of the psychopathological dynam ic forces responsible for the patient's sym ptom and character disturbances.

39

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Intensive Short-Term Dynamic Psychotherapy

Central Dynamic Sequence Phase 5: Direct Access to the Unconscious: Extended Major Unlocking of the Unconscious (a) (b) (c) (d) (e) (f) (g) (h) (i) (j)

(k) (1) (m) (n)

Interlocking chain of head-on collision with resistance in the transference with the aim: To mount a direct challenge to all the forces m aintaining self-destructiveness. Systematic weakening of the major resistance of repression and all the tactical defenses entrenched in the major resistance. A very high rise in the transference feeling. Optimum mobilization of the unconscious therapeutic alliance. Direct experience of transference feeling; the triggering mechanism. Extended major unlocking with the passage and experience of the primitive m urderous rage in the transference with its psychophysiological components. Instant em ergence of the sadness, patient attentively looking at the murdered damaged body of the therapist. The unconscious now transfers the murdered body of the therapist to the murdered body of the genetic figure. It is important to note that the murdered body of the therapist appears exactly as the murdered body of the mother, father or brother— in terms of color of hair, eyes— in every respect. The patient is seeing, for example, the dead body of the mother with blond hair and blue eyes. The dead body of the therapist is not there anymore. W hen the unconscious makes the transfer, instantly there is a major breakthrough of intense guilt-laden feelings. The duration of the passage of the guilt with all its psychophysiological com ponents is on average 8-12 minutes in the first extended major unlocking. Passage of the grief-laden unconscious feeling. Direct view of the psychopathological dynam ic forces.

Phase 6: Systematic Analysis of the Transference L ead in g to the resolu tion o f th e resid u al resistan ce; and is extrem ely im p o rta n t in p a tie n ts su fferin g from p an ic, so m atizatio n , fu n ctio n a l and depressive disorders.

Phase 7. Dynamic Exploration into the Unconscious (a) (b) (c) (d)

Unconscious therapeutic alliance is in com m and of the process and; Spontaneously introduces traumatic events and incidences with; Repeated breakthrough of guilt and grief-laden unconscious feelings. ConsolidaHon, recapitulation and psychotherapeutic plan.

As I h ave alread y stated, n ot all the th erap ies proceed in exactly this sequence. T h e p h ases tend to overlap and proceed in a spiral rath er than in a straight line. For those interested in lea rn in g the tech niq u e, the d yn am ic sequ en ce can be seen as a framev^ork w h ich the therap ist can use as a guide, con stan tly w orkin g from one phase to another. We should keep in m ind th at the em phasis on the d ifferen t types of in terv en tion s d ep en d s on a n u m b er of variables. For exam ple, the phase of inqu iry is alw ays possible in p atients on the extrem e left on the spectru m of psy ch oneu rotic disorders. T h e best exam ple is the case o f the Salesm an. A nother

Partial Unlocking o f the Unconscious

41

o n e is the C ase o f H en ry IV M an . B oth of th em , w ith great clarity, resp on d ed to the p h a se o f inquiry. B u t p atien ts on the right side of the sp ectru m , particularly th o se w ith sy n ton ic ch a ra cter resistan ce, are n ot able to resp on d to the p h ase of inquiry. T h e th e ra p ist im m ed iately en co u n ters w ith the sy n to n ic ch aracter d efen se s th e m in u te the in terv iew starts. In th e first p art o f this tw o -p a rt article th e early ph ase of trial therap y of a p atien t o n the m id -righ t side of th e sp ectru m of p sy ch o n eu rotic disorders w ill be an alyzed to h ig h lig h t the tech n iq u e and the process of partial u n lockin g of the u n con sciou s.

The Case of the Strangler At the tim e of the trial th erap y he w as in his forties. T h e th erap ist starts w ith th e p h ase o f inquiry.

Phase o f Inquiry T h e th erap ist d oes n o t kn ow an y th in g ab ou t the p atient and starts the session by ask in g th e p atien t "W h a t are the difficu lties that you w an t to get h elp for?" T h e resp o n se to th e in q u iry is v ery lim ited. H e in d icates th at h e and his w ife h ave b een in cou p le th era p y for th e past year, b u t the th erap y w as n o t h elp in g. H e w as told by the th erap ist th a t "M y problem s are d eep ly rooted in the p reverbal p h ase of my d ev elo p m en t; w h ich n eed s y ears of in d ivid ual treatm en t," and the plan w as for the co u p le th erap ist to carry th e in d ivid ual treatm en t of his w ife and that he sh ou ld seek trea tm en t for him self.

Phase of Pressure H e has b e e n m arried for 20 years, b u t th e problem s in his m arriage d ate b ack to th e 7 m o n th s th ey k n ew each o th er p rior to the m arriage. H e in d icated that the m arriag e h as d eteriorated o v er the years. T h en th e session focu sed on his d ifficu lties, and he said th at o n e o f his m ajo r problem s is that "I act like a ch ild ," "I b eco m e p a ra ly z ed ;" b u t h e can n o t give a specific exam ple. It b eco m es im m ed iately clear that the p h ase of in q u iry is n ot possible. H e is n o t able to resp on d to th e q u estion re a specific exam ple of the problem s in his m arriag e, u ses v ag u e g en eralizatio n s; an d the th erap ist im m ed iately in trod u ces pressu re, ask in g for som e specific in cid en ts, to w h ich the p atien t declares "it is d ifficu lt." As a resu lt of this pressu re to the resistan ce th ere is m obilization o f som e d eg ree o f an x iety an d th e th erap ist focu ses on the p atien t's feelings.

Further Pressure by Focusing on his Feelings As w e w ill see, th e p rocess im m ed iately m oves to the p h ase of rapid id en tificatio n , clarification and som e d eg ree o f ch allen g e to the p a tie n t's ch aracter d efen ses, an d to th e p sy ch o d iag n ostic ph ase.

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Intensive Short-Term Dynamic Psychotherapy

TH: H ow do you fe e l right noiu here? PT: N ot too bad, uh I'm, I'm having difficulty thinking clearly so I'm a b i t . . . I guess I'm a bit ah, a bit nervous. TH: 1 say hoio do you fe e l right now? You say you guess. PT: (sm all laugh) I feel nervous. TH: You feel nervous. Then w hy you say "guess?" PT: It's a w ay I have o f speaking, I think I say that a lot. TH: You mean that you are not definite a b o u t . . .

Challenge to the Tactical Defenses PT: Yeah, that's part o f the problem , 1 seem to . . . I d o n 't. . . TH: You see again you say "I seem to." PT: I often don't know what it is that I w ant, how I feel. TH : Noiv let's to look to this here with me. M y question loas how do you feel right noiv and you say you are nervous really. PT: Hm hmm. TH: But you have to say "it seems'' that you are nervous, as if you are n o t . . . PT: H mm. TH: H mm ? PT: That's, that's certainly w hat com es out all right. TH: Hm hm, that you are alw ays indefinite, or is here xoith me? PT: Am 1 alw ays indefinite? (low voice) TH: You knoio what 1 mean by indefinite? That you say "perhaps, guess." PT: Yeah, 1 see what you mean.

The Phase of Pressure and Challenge to the Resistance As w e saw, the therapist im m ed iately is focu sing on the patien t's tactical d efenses, such as "p erh ap s," "g u e ss," b ein g in d efin ite, "I th in k," and m aking the patient acquainted w ith these d efen ses to w h ich the p atient responded positively, "Yeah, I see w hat you m ean ." T his ch allen g e to the tactical d efen se m obilizes anxiety w h ich is the ind icator of fu rth er rise in the tran sferen ce feeling. T h ere is further ch alleng e to the p atien t's ch aracter d efen ses, w h ich gives fu rth er rise to transference feeling and crystallization of the p atien t's ch aracter d efen ses in the transference. It is im p o rtan t to n ote that alm ost alw ays the p h ase o f pressure, as w e saw in the above passage, m ay con tain passing m om en ts of ch allen g e, but system atic challenge is n ot to b eg in u ntil resistan ce has b een tangibly crystallized b etw een the therapist and the patient. T h en , n ot only m ust the resistance be challenged, b u t the p atien t's atten tion m ust be d raw n to it and its n atu re clarified for him . This will h ave the m axim um effect w h en the p atient can n o t avoid recognizing it. N ow w e return to the interview . TH: That you c a n n o t . . . PT: Yeah I, I think I do qualify. TH: You see "I think I . . ." PT: I do qualify yeah, I . . .

Partial Unlocking o f the Unconscious

TH : PT: TH: PT: TH: PT TH: PT: TH: PT: TH :

TH : PT: TH : PT: TH :

43

But there is "think"; it m eans that in a sense still you are not definite. I'm not sure o f things . . . (m um bling) I f you are an xiou s right now w hy “it seem s" or "I think"? Either you are nervous or you are not nervous. I have a hard tim e identififing that. You m ean you are nervous an d you have difficulti/ to identify you're nervous? Yeah. Then w hy you say you arc nervous? B ecause lohen you ask m e about it then I perhaps becom e m ore aw are o f it. A gain you becom e indefinite. I don't knoiv the ansiver to that. N oio you say you don 7 have an anszoer to that, hm m . Noiu, what is it like lohen you're nervous? (Pause) N ow you notice you also avoid me? Yes I'm, I'm w ithdraw ing. You're w ithdraw ing? Yes. I h ave . . . I don't fe e l com fortable. I said how do you physically experien ce you r nervousness?

As w e see, th ere is fu rth er crystallization of th e p atien t's ch aracter d efen ses in the tran sferen ce. PT:

I fe e l defensive, I f e e l . . .

Exploring the Physiological Concomitant of the Anxiety H e in d icates th a t h e is p ersp irin g and th at he feels cold in his shou lders. This exp loration o f th e an x iety is o f great im p o rtan ce, and th e th erap ist p u ts the q u estio n v ery specifically, "H ow d o you physically exp erien ce this n erv o u sn ess?" E xp loration in to th e p h y siolog ical and psy ch ological con com itan ts o f anxiety in d icates th at ov erall, the p sy ch o logical co n co m itan t of an xiety exceeds the p h ysiolo gical co n co m ita n t, w h ich is an in d icator that his cap acity to tolerate u n co n scio u s an xiety is at a h ig h level; and th e therapist kn ow s, b ased on the research d ata, th a t this h as im p o rtan t p sy ch o d iagn ostic im plications.

Challenge to the Resistance As h e co n sta n tly avoid s ey e con tact w ith th e therap ist, this is b ro u g h t to his atte n tio n an d the p ro cess co n tin u es w ith fu rth er ch allen g e to th e resistan ce, w h ich n ow h as d efin itely acqu ired a tran sferen ce quality an d the th erap ist b eg in s to m ake him a cq u ain ted w ith the resistan ce again st em otio n al clo sen ess in the tran sferen ce, w h ich is syn ton ic. TH : PT

You see you use words. I said how do you physically experience this nervousness? O ne, you say you have som e perspiration . . . Yeah.

44

Intensive Short-Term Dynamic Psychotherapy

TH:

. . . and then the other one you say you feel cold in your shoulders and so forth and som e tightness in your chest. W hat else do you experience w hile you are nervous? A nd your eyes are on the carpet. 1 mean you are . . . PT: I'm trying to concentrate, an d I ’m having difficulty. TH: Is it that, or is it that there is a need in you to avoid me? PT: I don't know.

Psychodiagnostic Function In this initial contact, the therapist first in trodu ced pressure w hich gave rise to transference feeling and anxiety in the tran sferen ce. This led to resistance in the form of a series of d efen ses as w ell as resistance against em otional closeness, and finally there was crystallization of the resistance in the tran sferen ce. Throughout this process, the therapist m onitors: — rise in transference — rise in anxiety — crystallization of the resistance in the transference. T he therapist's task is to d eterm in e the discharge p attern of the unconscious anxiety as soon as he introd u ces the pressure. H ere, th e therapist introduced the pressure. T h ere w as a rise in the tran sferen ce, anxiety w h ich w as in the form of tension in the m uscles of the hands, the su pin ator and p ronator of the forearm s, and anxiety in the form of tension in the intercostal m uscles. T he nonverbal cues w ere: w ith a high pressure pressing his thum bs against each other; clen ch in g his hands togeth er w ith high pressure; and a d eep sigh. All this indicates: (1) (2)

(3)

Discharge pattern of anxiety is exclusively in the form of tension in the striated muscles. No discharge pattern of anxiety in the form of disruption of cognitive and perceptual function (which is the characteristic of patients with fragile character structure). Rise in the transference gives rise to unconscious anxiety, which then results in intensification of the resistance in the transference.

O n the basis o f this, the therapist con clu d es that the p atient suffers from character neurosis and can w ithstand the im pact o f his u ncon sciou s in a single interview . W ith this in m ind , still the therapist w ants to further evaluate and reconfirm his decision. Now the therapist m oves to ch allen g e the resistance against em otional closeness in the tran sferen ce, w hich leads to fu rth er rise in the tran sferen ce feelin g and further rise in anxiety in the form of ten sio n in the striated m uscles, w hich further indicates that there is no trace o f fragility and he can use the standard technique of rapid and direct access to the u nconsciou s.

Further Challenge to the Resistance in the Transference System atically M aking the Patient A cquainted w ith his R esistan ce TH: Again you m ove to the '7 don't know." M oving to the helpless position. H ow do you feel when you look to niy eyes?

Rirtial UitUKkiu^f o f the Uuconsciom

45

PT:

I don't know.

TH:

H m hm m . So "I don't k n o w ” is an other sy>tew like "/ so," ''perhaps, " huh? Yeah. Noco this is an oth er fo r w a t of the . . . huh? (Pause) Do you notice that you are very much detached from we? Yes' W hat? \V7iy? A nd there is som e kin d o f a icall hetu'een you an d we. H m hmm. A voiding m y eyes, a iv id in g me, hm m . C ouhi we look i>ito that? Could we look into that . . . to the fact that you w ant to avoid me.

PT: TH: TH: PT TH: PT TH: PT: TH:

Further Challenge and Crystallization of Character Defenses in the Transference M ak in g th e P atient A cquainted w itli his C haracter D efenses TH: PT TH: PT: TH: PT: TH: PT: TH: PT TH: PT: TH: PT TH: PT: TH: PT: TH: PT: TH : PT: TH: PT:

To the fact tJwt you avoid m y ei/es, an d that you d o n ’t -want to be involved here in a sense. Hm. D etachm ent, w ithdraw al, hm m ? Can you help tne to az'oid that? I w ant that. Yeah, but you see you wo'ce again to a positioii that is helpless, taking a helpless position with me. H m hm m , hm hmm. A nd nodding your head an d sayin g "hm h m w " doesn't do anything. (lau ghs) I don't know iclmt else to do. A nd nozc you smile. Yeah. R eally you fe lt your sm iling? D id i fe e l m y . . . You sm iled. I said did you really feel like sm iling or . . . Yeah. . . . this is a cover-u p o f som ething? the sm ile? Hm hmm. W hat hm hm m ? 1 don't kn ow w hat hm hmm. (laughs) You see again your eyes are som ew here else. Well I find it h ard to concentrate if you ask me a direct question. W hat do you m ean by difficulty to concentrate? I mean -what is that? W ell you ask m e a direct question. H m hm m . A nd in try in g to ansiver it 1 fin d t h a t . . . it very difficult to think if I ’m looking directly at you.

46

Intensive Short-Term Dynamic Psijchothcrapij

It is im portant to note that the rapid rise in the transference has rapidly crystallized the p atient's character resistance in the transference. The therapist now applies one of his m ost pow erful technical interven tion s, the technique of the interlocking chain of h ead -on collision w ith the transference resistance, w ith the goal of a rapid partial unlocking of the unconscious.

The "Technique of Interlocking Chain of Head-on Collision with the Patient's Character Resistance Heavily Crystallized in the Transference" (Davanloo) T h e interlocking ch ain of h ead -on collision is alw ays used w ithin the setting of resistance in the transference. In the follow ing passage the therapist challenges four com ponents o f the h ead -o n collision: * * *

*

Pointing out the natu re o f the resistance; E m phasizing the problem s that h e h as in his m arriage; C om m u n icatin g the m asochistic com p o n en t of his ch aracter and the self­ d estru ctiv e e lem en t o f th e re sista n ce, th e se lf-d efea tin g an d selfsabotaging aspect of the resistance; B ringing into the focus his treatm en t w ith Dr. X, w h ich w as a failure, w hich is establishing a parallel b etw een his previous treatm en t and the tran sferen ce, the failure th a t m ight com e.

TH:

You are like this usually? . . . detached, noninvolved, taking a sort o f the passive, de t a c h e d . . . PT: 1 don't think o f m yself as . . . TH: But you see you rum inate "I don't think." I'm talking right nozv with me. Look at it, aren't you totally w alled o ff an d totally noninvolved? A nd this is very im portant w e look at it, because you say you have a set o f problems. So fa r we don't know anythin g about it except a piece o f it, that is you have a problem in you r m arriage, hm m ? an d that it has been goin g on fo r 20 years, okay. A nd you have been in treatm ent with Dr. X, hm m , an d the problem still is there I assume, otherw ise you w ouldn't be here. So that you have a problem which so fa r lue only know the m arriage part o f it, superficially okay? A nd has been goin g fo r 20 years, hmm ? PT: Hm hmm.

Continuation of Head-on Collision In the follow ing passage the therap ist con tin u es w ith th e tech n iq u e of in terlockin g ch ain o f h ead -o n collision, w h ich consists of: *

E m phasizing the p atien t's will, that the p atien t is the prim e m over in seekin g help "a n d th at is you r ow n will to com e h ere," to w h ich the p a tie n t resp o n d ed "y e s." T h e n th e th e ra p ist m o v ed to a n o th er com p onent;

Partial Unlocking o f the U>iconscious

47

*

E m p h asizin g th e p artn ersh ip b etw een the p atient and the therapist, "th at w ith the h elp o f each other." T h en the therap ist m oved to an oth er elem en t;

*

T h e th erap eu tic task, em p h asizin g the therap eu tic goal "to see w h at is the core o f y o u r difficu lties."

TH: A nd I assu m e now that you have com e here— this is you r w ill to com e here or that Dr. X thinks this is the best fo r you? PT: N o i t ' s . . . TH: This is your own will? PT: Yes. TH: This is. huh? PT: Yes. TH : A n d this is y ou r own w ill to com e here, hm m . That w ith the help o f each other loe can fir s t understand y ou r difficulties an d hopefully w e can get to the engine o f y ou r difficulties. PT: H m hmm. TH : To see w hat is the core o f y ou r difficulties that creates all these disturbances that you have, w hich w e know a little bit, only m arriage okay? PT: Hmm.

Continuation of Head-on Collision In th e follow in g p assage, th e th erap ist con tin u es the in terlockin g ch ain of h ea d -o n collision con sistin g of: * *

* *

* *

TH :

A d d ressin g th e n atu re o f th e resistance; E m p h a siz in g th e re s ista n c e a g a in st em o tio n a l clo se n e ss in the tra n sferen ce, an d h e im m ed iately m oved to the follow ing com p o n en t: B rin g in g in to focus th e co n seq u en ces "if you keep this w all," and this is im m ed iately follow ed by a n o th er elem en t: T h e d estru ctiv e asp ect o f th e resistan ce; the self-d efeatin g and selfsab o tag in g co m p o n e n t an d th e failure "d o o m ed to fail." T h is follow s: D e activ atin g th e tran sferen ce and b rin g in g the p atien t in to th e reality o f th e p rocess "a t som e p o in t tod ay w e say goo d bye," "You go you r w ay and I go m y w ay," "a n d 1 tell to m y self I did m y b est;" th en h e im m ed iately m ov ed to: U n d o in g th e o m n ip o te n ce an d k eep in g the resp on sibility w ith the p a tien t, w h ich is im m ed iately follow ed by addressing: "T h e p erp etra to r o f th e u n co n scio u s" (D avanloo) "p e rp etu a te w h atev er m isery you h av e," reem p h asizin g the m asoch istic co m p o n e n t of his character. N ow if you take a detached position w ith me, an d if you take a noninvolved position w ith me, an d if you erect a ivall— you kncao w hat I m ean by wall? by distancin g, by pu ttin g a barrier betw een y ou rself an d me, avoidin g m e an d not loan tin g m e to g et to kn ow y ou — then this process is doom ed to fail. In a sen se if

48

Intensive Short-Term Dynamic Psychotherapy

you keep this wall, this distancing, this barrier, and not loanting me to get to your intim ate thoughts, your intim ate feelings, then this process is doom ed to fail. So then at som e point today loe say goodbye to each other and you go your way and I go m y way. PT: Hmm. TH: A nd I tell to m y self O kay I did my best to understand this man's problem; I failed. But then you go and perpetuate w hatever m isery you have. PT: Hm hmm.

Continuation of Head-on Collision In the follow ing passage he addresses various elem ents of the interlocking chain of h ead -o n collision: * * *

the perpetrator of the unconsciou s; the punitive superego "g oin g to perpetuate your suffering" and then; Puts pressure on the u nconsciou s therapeu tic alliance "W h y do you w ant to do th at?", to w hich the p atient respon ded "I d on 't," and then he; R eem phasizes the self-d estru ctive elem en t of the resistance, challenging th e self-d efea tin g and self-sab o tag in g asp ect of the resistan ce and reem phasizes that "it is h ere w ith m e."

TH: PT: TH: PT: TH: PT: TH: PT: TH:

H ow old are you ? 46. 46. So still you have a long w ay ahead o f you. Hmm. W hy you w ant then to go on and perpetuate the suffering? Until w hat? (laughs) N ow your sm ile is s t i l l . . . N o I don't fe e l like sm iling. Then you are g oin g to perpetuate y ou r suffering until you r grave. Noiu why do you w ant to do that? PT: 1 don't. TH: But im m ediately som e im portant aspect is here. 1 have a feelin g that you have a need to sabotage, you have a need to defeat, that you are a self-defeating and selfsabotaging man. That there is a need in you to defeat an d sabotage. O f course you have lived with y ou rself fo r 46 years, you knoiv it better than I. Are you the type o f the person w ho sabotages his potentiality, sabotages and becom es a victim of situations and so forth? Are you the type o f the person w ho constantly fin d s h im self into defeating and sabotaging? Because it is here loith m e hmm? PT: Hmm.

Now, the therapist im m ed iately retu rn s to the com p o n en t of the against em otional closen ess and follow s it w ith an o th er co m p o n en t of nam ely the con seq u en ces, d riving h om e the m essage th at if the patient in a state of resistance the goal in th erap y wiU n o t b e ach iev ed , "T h is doom ed to fail."

resistance the chain, con tin u es process is

Partial Unlocking o f the Unconscious

TH : PT:

B ecause if this process o f you m ain tain ing a wall, not w an tin g m e to get to your intim ate thoughts an d intim ate feelin g s continues, this process is doom ed to fail, H m hmm.

In th e fo llo w in g p a ssa g e, th e h e a d -o n co lh sio n co m p o n e n t o f th e in terlo ck in g ch ain to an oth er: * * *

* TH :

PT: TH : PT:

49

co n tin u e s from

one

In d irect ch a llen g e to th e d efian ce; D eactiv atin g th e tran sferen ce; E stab lish in g p arallel b etw een tran sferen ce and o th er relations "20 years of m arriag e," "you yo u rself say p aralyzed ," "th is process w ill be paralyzed like th e o th e r "; U n d o in g th e o m n ip o te n ce , "th e re is n o th in g on e can do." So if this is y ou r w ill that you w ant to fail, then there is nothing one can do about it. So you have had 20 years o f m arriage that you refer to . . . in a sense has been crippled. You y o u rself say paralyzed. H mm. So this process w ill be paralyzed like the other H m hmm.

Continuation of Head-on Collision In th e fo llo w in g p a ssa g e, o n e c o m p o n e n t o f th e h e a d -o n co llisio n is in terlock ed w ith a n o th er co m p o n en t: * * * *

* TH :

P ressu re to th e u n con sciou s th erap eu tic alliance "w h y you w an t to do th a t," and th e n ; E m p h asizin g th at h e is the prim e m ov er in seekin g h elp "co m e on you r o w n w ill," w h ich th e n follow s; C h a llen g in g th e self-d efeatin g, self-sab otagin g and self-d estru ctive aspect o f th e resistan ce "a t the sam e tim e set the stage to sabotage it;" E m p h asizin g th e con seq u en ces, em p h asizin g that if his will is to sabotage th e n h e h as to su ffer the con seq u en ces; D e activ atin g the u n con sciou s d efen se m ech an ism of defian ce; D e activ atin g th e tran sferen ce. So w hy do you w ant to do that? To com e on you r own w ill but at the sam e tim e set the stage to sabotage it. I f that is y ou r will, to sabotage it, then there is n oth in g an ybody can do about it.

PT: H m hmm. TH : W hy do you w an t to do that? PT: H m hm m . T h e th erap ist th ro u g h o u t the p rocess is p u ttin g p ressu re on th e u n con sciou s th erap eu tic allian ce to g et it m obilized again st the forces o f the resistan ce. TH :

"Hm hm m " is not enough, let's to see w hat arc w e g oin g to do about it.

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Intensive Short-Term Dynamic Psychotherapy

H ere, the therapist em phasizes another com porient o f the h ead -on collision, pressure on the resistance and the unconscious therapeu tic alliance, rhetorical question to the therapeutic alliance.

Major Aim of Head-on Collision As w e will see, this h ead -on collision results in the partial u nlocking of the unconscious. Pressure and then challenge to the p atient's character resistance brought about a rise in the tran sferen ce, and rapidly we saw the crystallization of the p atient's character d efenses in the transference. The therapist had determ ined that the patient has the capacity to w ithstand the im pact of his unconscious as rapidly as possible. T h en he introd u ced one of his m ost pow erful technical interventions, nam ely the in terlockin g ch ain of h ead -on collision w ith the aim: (a) To mount a direct challenge to all the forces maintaining self-destructiveness, his self-defeating and self-sabotaging pattern and masochistic com ponent of his character; (b) To intensify the rise in the transference feeling; (c) To loosen up the patient's psychic system in such a way as to make the unconscious more accessible; (d) To mobilize the therapeutic alliance against the resistance; to tilt the balance between the two forces in favor of the therapeutic alliance; (e) To bring the patient face-to-face with his self-destructiveness. Such communication as "misery," "we say goodbye," "your will to sabotage" and "doom ed to fail" both shocks him out of the syntonic part of his resistance and challenges his therapeutic alliance to make a supreme effort; (f) To create a state of high tension betw een resistance and therapeutic alliance in the transference.

The First Partial Breakthrough into the Unconscious Gradually, d uring the last p art of the h ead -o n collision, the p atient becom es increasingly sad; and the in d icator is that an initial b reakth rou g h into the unconsciou s is im m inent. It is im p o rtan t to n ote th at w h en a therapist applies the tech niqu e of in terlockin g ch ain o f h ea d -o n collision w ith th e crystallized character resistance in the tran sferen ce, w h ich aim s at the first b reakth rou g h into the unconsciou s, he m ust carefully m on itor the signaling system that indicates that som e b rea k th ro u g h is im m in en t. T h e m ost im p o rtan t are n o n v erb al cues ind icating drop in tension in the striated m uscles and the em erg en ce of sadness. W h en a b reak throu g h into the u ncon sciou s takes place, be it partial or m ajor, it is alw ays associated w ith a m ajor d rop in the u ncon sciou s an xiety and tension. At this poin t in the interview , th e therapist observes this p h en o m en o n and know s that the b reakth rou g h is im m inent. H e is aw are th at the unconsciou s therapeu tic alliance is m obilized against the resistan ce, b u t at the sam e tim e he is weU aw are that resistan ce rem ains in operation ; and for the m om en t h e focuses on the patien t's sadness, b u t at the sam e tim e m ain tain s ch allen g e to the resistance. N ow w e retu rn to the interview . TH : I fe e l also that there are certain feelin gs w ithin you— 1 feel, I don't know 1 might be wrong. That from you r eyes I have a feelin g that you have a certain feelin g ivithin y ou rself which you are very heavily controlling.

Partial Unlocking o f the Unconscious

51

PT:

No, I fe e l very sad.

TH:

You fe e l v ery sad. A nd there also you don't w ant to have the fu ll im pact o f you r sadness.

In th e follow ing passage, h e rem ain s sad and tearfu l, and the therapist fu rth er lin ks this w ith his p roblem w ith in tim acy and clo sen ess "y o u 're terrified of clo sen ess w ith m e." PT: TH: PT: TH : PT: TH :

TH : PT: TH : PT

That's right (barely audible) You don't loant to share w ith m e the fu ll im pact o f you r sadness, which is another side o f a paralyzed man. W hy? (exhalation) A n d still you are tryin g to hold in this sadness an d the tears that you have in y ou r eyes. W hy? W hy don't you w ant to have the fu ll im pact o f it? 1 don't knoiv, I'm afraid. Let's to see w hy you don't w ant to. It's not the fear, it has to do w ith the issue, as I said, o f closeness an d intim acy, an d the barrier that I talked of.You're terrified o f closeness w ith me. (Pause) A n d look, again you are trying to hold in this sadness an d tears . . . not to have the fu ll im pact o f y ou r feelin g s, why? W hat com es to m e is that I don't know you. So then, in a sense, I am a stran g er Yeah.

A fter th e kind o f in itial b rea k th ro u g h th at w e see, th e p atien t is u sually in an altered in n e r state. H is w h o le p sy ch ic system h as b een lo osen ed and the b alan ce b e tw e e n th e o p p o sin g forces w ith in him has b een tilted in favor of the th erap eu tic alliance. T h is m an ifests itself as an in creased resp on siven ess, w h ich m ay be o b serv ed in a n u m b er o f d ifferen t w ays su ch as w h en h e says "w h at com es to my m ind is th at I d o n 't k n ow y o u ." B u t at the sam e tim e the th erap ist kn ow s that the resistan ce is still in o p eratio n an d th erefo re he ad h eres to th e cen tral p rincip le of the tech n iq u e, th a t w h en th ese tw o forces are in op eration th e m ost im p o rtan t task is to m a in tain ch allen g e to the resistan ce w ith fu rth er pressu re to the u n con sciou s th erap eu tic alliance. H ere, the th erap ist m oves to fu rth er h ead -o n coUiding w ith the resista n ce again st em o tio n al clo sen ess in the tran sferen ce, ad d ressin g the c o n s e q u e n c e s o f m a in ta in in g th is resista n ce , an d th e n m o v es to a n o th e r co m p o n e n t w h ich h as to do w ith d eactiv atin g the tran sferen ce— "w h at can 1 do? 1 h ave to ad m it to failu re." T h en h e in trod u ces pressu re to the u n con sciou s th erap eu tic allian ce. T h is results in fu rth er m obilizah on o f the u n con sciou s th erap eu tic allian ce, an d he d eclares "I d o n 't w an t to do th at."

Further Head-on Collision with Resistance: Emphasizing the Resistance Against Emotional Closeness TH: A n d that is luhat I am talkin g about. You don't ivant this stran ger to g et into y ou r in tim ate thoughts an d feelin g s. You don't w ant m e to get into you r life. A n d that is w hat I call the barrier an d the wall.

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Intensive Short-Term Dynamic Psychotherapy

PT: Hm. TH: But up to the tim e you d o n ’t want me to get into your life, to your intim ate thoughts, into your intim ate feelings, then what I'm saying is this process is doom ed to fail. But if this is your will then it means you have to carry this to you r grave. I don't knoiv w hat has happened in your life that you are so terrified o f this closeness, an d as you put it, you referred to a “stranger" to get into your private life. A nd you are putting a harrier between you rself and me as a stranger. A nd w hat I'm saying is up to the tim e w e have this barrier w e are doom ed to fail. O ur goodbye w ould be a sad goodbye. You know w hat I mean by sad goodbye? That I say okay 1 did the best but he is goin g to carry his crippled life. But what can I do? I have to adm it to failure. But fo r you it is a different story; you have to perpetuate your sufferittg to your grave. W hy do you w ant to do that? PT: I don't loant to do that. TH: But this loould be. (Pause) TH: Your previous treatm ent has been a failure, 20 years' m arriage has been . . . so luhy do you w ant to do that? PT: I d o n ’t.' TH: Then le t’s to see w hat are you g oin g to do about the barrier between you and me. In the above passage the therapist con tin u es w ith fu rth er h ead -o n collision w ith the patien t's resistance in the tran sferen ce. H e heavily em phasizes the resistance against em otional closen ess and its con seq u en ces, and on ce m ore he brings the patient face to face w ith th e self-destru ctiveness o f the resistance; challenges the self-d efeatin g and self-sabotaging com p o n en t o f the resistance in the transference. H e m akes com m u n ication such as "w e are doom ed to fail," "our goodbye w ould be a sad g ood bye," p u tting fu rth er pressure on the u nconscious therapeu tic alliance.

Breakthrough of Major Wave of Painful Feeling T h ere is fu rth er m obilization o f the u ncon sciou s th erap eu tic alliance against the resistance, and there is fu rth er passage o f a m ajor w ave of painful feeling. The patient is h ig h ly choked up, w ith freq u en t d eep inhalations. N ow the therapist's task is to ease off the break th rou g h of this m ajo r w ave of painfu l feelin g and at the sam e tim e to search for the com m u n ication from the u n con sciou s therapeu tic alliance for the signal of the d irect access in to the unconsciou s. TH:

Because these tears and sadness m ust com e from someivhere, I don't know from where. PT: It comes. TH: Hm hm m PT: A t times w hen I f e e l . . . (sigh) . . . that I ju st c a n ' t . . . I'm only h a lf a person. (choked voice) TH: Right noio you are fig h tin g a m ajor w ave o f painful feelin g that you have. Even there you avoid my eyes. PT: (deep exhalation— pause) PT: I ju st don't know hoiv to describe it, it's a . . .

Partial Unlocking o f the Unconscious

53

TH:

I'm talking abou t this w ave o f pain fu l feelin g that even is interfering w ith you r talking. W hy you are hold in g onto it? W hy don't you w ant to fu lly experience y ou r pain fu l feelin g ? PT: I don't kn ow w hat else to do w ith it. TH : W hy don't you w ant to have the fu ll im pact o f it, to experience the whole? (Pause) TH: A gain y ou r eyes avoid me. PT: (sniffling) I fe e l it com es in w aves a n d then som etim es, then it, then it subsides, it goes back doiun again. As I h av e in d icated b efo re, after the kind of initial b reakth rou g h th at w e see in this p atien t, h e is d efin itely in an altered in n er state. T h ere is d efin ite ev id en ce that his w h o le p sy ch ic system has b een lo osen ed and th e b alan ce b etw een the o p p o sin g forces has m arked ly tilted in favor of the therap eu tic alliance. B u t if any resistan ce still is in o p era tio n , tech n ically on e shou ld m ove to ch allen g e or even h e a d -o n collid e w ith th e resistan ce. W ith this in m ind, the therap ist applies a com p o site form of h ea d -o n collision , em p h asizin g the th erap eu tic task; h ead -o n collision w ith resistan ce again st em otio n al closeness; em p h asizin g the parallel b etw een self-d efeatin g and self-sab otagin g p attern in the tran sferen ce and in o th er relation s, and co n tin u es to fu rth er em p h asize the th erap eu tic task, the p atien t's goal, th e n p u ts fu rth er pressu re on the u n con sciou s th erap eu tic alliance.

Further Head-on Collision TH :

I'm su g g estin g obviously it m ust have to do w ith me. Because you don't w ant me fu lly into y ou r life. I'm referrin g to y ou r private thoughts, private intim ate thoughts, intim ate feelin g s, the distancing, an d as you put it the stranger. W hy shou ld you let a stran ger to get into y ou r intim ate thoughts an d feelin gs, why shou ld you ? This is w hat you are sayin g in a sense. A nd I w ould assu m e you m ust have a trem endous problem w ith closeness an d intim acy unless it is only specifically w ith me. E ither you m ust have this problem with every relationship in y ou r p erson al life or w hat, or m ust he exclusively with me. This problem about intim acy, closeness, an d letting m e to g et to you r intim ate life an d intim ate thoughts, in tim ate feelin g s, m ust be in other relationships as well. A nd it's very im portan t fo r you to idetitify, hm m ? Is this the case, that you have a problem in

that way? PT: That I distan ce m yself? TH : Intim acy, closeness an d . .. PT: I'm . . . I try not to. TH : But I'm say in g do you have? P T I, I a h . . . TH : You see it's v ery im portant fo r us because w e are here . . . PT TH :

PT:

Yes. . . . w ith the help o f each other to u nderstand you r difficulties an d get to the core o f y ou r difficulties. A n d it's very im portant w e step by step exam in e this process. U nless you w ant to carry the crippled life. N o, I don't, I don't w ant to do that.

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Intensive Short-Term Dynamic Psyclwthcrainj

Further Breakthrough of Painful Feelings Patient is sobbing so intensely that it interferes w ith his talking. TH: So then ivc have a major jo b here, to exam ine them. Because you said that these tears and sadness that you had here had to do with something. PT: Well they, they have to do loith . . . no I don't want it to go on. (voice breaks) T h ere is further m obilization of the unconsciou s therapeu tic alliance against the resistance, and the therapist know s that the balance b etw een the tw o has tilted strongly in favor of the therapeu tic alliance. T h e therapist is well aw are that the u nconscious therapeu tic alliance has n ot yet introduced the dynam ic events of his very early life that have had such a negative im pact on his character. H e continues em phasizing w hy should h e sen ten ce him self to suffering, w hy should he continue to punish him self, ad d ressing the p erpetrator of the u nconscious, his need to go from the frying pan into fire, "W h y is there a n eed in you to continue your suffering?", addressing the punitive su perego, the guilt and pu nishm ent. H e further addresses the unconsciou s "W h at have you d on e?", "W h y is there a need in you to con tin ue a paralyzed life?"; and the p atient in a painful state repeatedly declares that h e does n ot w ant to con tin u e w ith his suffering. N ow w e go back to the interview . PT: TH: PT: TH: PT: TH: PT: TH:

PT: TH: PT:

(w eeping) It's the way you say it, that I act as though 1 w ant them to g o on, but I don't, (crying) I don't. A nd yet 1 can form . . . because . . . Hmm? I can feel m yself pulling back from it because I know I can live . . . You can live a crippled life, no question about it. But som etim es that seem s safer. But my question is luhy? (sob) W hy do I have to? W hy do you have to sentence y ou rself to a paralyzed crippled life? W hat have you done that you are sentencing you rself to this crippled, paralyzed life? W hat have you done? I don't know. W hy is there a need in you to continue a paralyzed life? (sniffling) W e ll. . . (Passage o f painful feelin g con tin ues.)

Direct Access to the Unconscious W aves o f Very Painful Feeling TH: From w here do you think they come? PT: I think they com e from m y childhood, I think they com e from . . . at least they m ight be from b e in g . . . It com es to my m ind as a child being left. In a painful state he talked abou t his fath er w h o w en t to the Secon d World War in Europe. The p atient w as 1 y ear old. H e com es w ith the m em ory of a picture w hen he w as 1 year old w hich w as taken b efo re his father left. In the pictu re are he, his brother, m oth er and father.

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55

TH: A n d w ho is in that picture? You . . . PT: M y mother, m y brother, an d I. TH : You, y ou r m other an d y ou r brother. A nd you r father? The fo u r o f you? PT: H m hmm. TH : In the fron t. W ho is next to y ou r father? PT: M y brother is next to m y father. I'm next to my mother. M y brother is 4 years older. In a v ery sad an d p ainfu l state h e talked abou t the b reakd ow n o f the n u clear fam ily an d p ain fu lly said "m y m oth er also left." Sh e w en t to an o th er city; and he an d h is b ro th er, w ith a n u m b er o f o th er ch ild re n , w ere placed w ith his gran d m oth er, B la n ch e, an d w ith his aunts. T h en h e com es w ith a n o th er m em ory w ith a w av e o f v ery p ainfu l feelin g and said that o n ce in a w hile h e w ould be taken by o n e o f h is a u n ts to th e city w h ere his m oth er w as, for a visit; b u t h e had alw ays th o u g h t th a t his m oth er cam e to visit him .

Dynamic Exploration TH : The w ish ivas that she had com e to see you. PT: H m m . TH : But then the reality was t h a t . . . PT: A nd then I w as also . . . TH : So then y ou m ust have a lot o f feelin g about that as well. PT: Yes, I fe e l a great sadness that I never knew my m other . . . TH : That you never kn ew . . . PT: 1 n ever kn ew h er at all, an d . . . TH : As if she h ad d ied in y ou r life w hen you w ere a year old. PT: Hm m . TH : That she d ied that early in y ou r life. PT: She never . . . but n either o f m y parents ah . . . TH : Tm talkin g abou t y ou r mother. Is that the idea that she died in y ou r life in the very early . . . In a sen se this is w hat you describe. PT Yes. TH : P sychologically as if she disappeared in you r life. PT: H m m . TH : A n d then y ou r father, also you lost him in the early phase to the war, hm m . PT TH : PT:

Yes. D id you see him w hile he was in the war? No. '

Exploring the Patient's Feeling H e rem ain s so m e w h a t sad an d for the m o m en t th ere is n o passage of painfu l feelin g , an d n o w th e th era p ist asks the p atien t, "H ow do you feel?" TH : H ow do y ou fe e l right now? PT: I fe e l tired, but I don't fe e l as nervous. You see, I don't fe e l as cold.

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Intensive Short-Term Dynamic Psychotherapy

TH: PT: TH: PT: TH: PT:

Hm hmm. A hit drained. You feel drained you said? Yeah. In lohat sense drained? It's like being stretched or . . .

Th en he said "a song goes through m y m ind, it is 'B e n ot afraid'." This triggers off a breakthrough of an oth er m ajor w ave of painful feeling, w ith heavy crying. TH:

But you see the w ave o f painful feelin g com es and then you try to put the shutter. I think this is a m ajor problem. PT: (sniffling) You mean because I hold it in? TH: Because you don't w ant to have the fu ll im pact o f these w aves o f the feelings that you have. PT: (deep heavin g breaths) TH: Because s o m e h o w . . . PT: (d eep breathing) TH: . . . you have this constant need to control, hmm, and maintain a paralyzed position, hmm. PT: Yeah, I'm afraid o f it. T he above passage clearly dem onstrates that for the tim e being, the pow erful dynam ic force o f the u nconscious therapeu tic alliance is in com m and and has introduced, at least, the very center o f the patien t's m ajor traum atic experiences. At the sam e tim e the therapist is w ell aw are th at in this Wnd of partial breakthrough into the unconscious the retu rn o f the resistance is unavoidable. The therapist, for the tim e being, is w aiting for the passage of the w aves of painful feeling so that he can m ove to the ph ase of analysis of the tran sferen ce and consolidation, and then to the p h ase of in qu iry; d ev elo p m en tal h istory, a ltern atin g w ith d ynam ic exploration until he m eets the resistance again. T h en the process is ready for the technique of m ajor u nlocking of the u nconscious. N ow w e retu rn to the interview. TH:

PT: TH: PT: TH: PT: TH: PT: TH: PT: TH:

You lost your fa th er to w ar at the very early phase o f you r life, hmm. Then also you lost you r mother. In a psychological sense they died in you r life. W hat I said is m aybe it is the engine or m aybe it is the force behind the fa ct that you don't loant me to get to your intim ate thoughts an d feelings, in a sense when I said about the issue o f intim acy an d closeness, hmm. In looking back m y experience is that all intim ate relationships have been ah, have been a disaster. The only reason the m arriage has survived . . . You mean is death? Sorry? Like death, they died. They died, (sad voice) Hmm? Yes. (w hispers) They died. Is som ething like that isn't it? I never thought o f that,(low voice) As if you r m other died inyour life in the very early phase, hmm.

Partial Unlocking o f the Unconscious

PT:

57

H m hm m .

TH : A nd then y ou r fa th e r died in the sense that he luas taken to the war, hmm.

The Issue of Resistance against Emotional Closeness As w e saw in th e ab ov e p assage, the therap ist m ade an in terp retation w h ich linked th e resistan ce again st em otio n al clo sen ess in the tran sferen ce w ith his fath er w h o w en t to th e w ar and his m oth er w h o d u m p ed him , and drives h om e in sig h t in to on e o f th e d y n am ic forces w h ich is respon sible for su ch a resistance. It is also im p o rta n t to n o te that h e clearly m akes com m u n ication referrin g to the d eath "T h e y d ied in y o u r life," to w h ich the p atient resp on d s w ith extraordinary clarity an d says "a ll in tim a te relation sh ip s h ave b een a disaster," and th en he says "I n ev er th o u g h t o f th at."

Most Recent Precipitating Event which has Created a Major Disequilibrium T h e p a tie n t n ow m akes an im p o rta n t com m u n ication w h ich clearly ou tlin es the m o st recen t p recip itatin g ev en t, th e possibility of th e b reak d ow n of the m arriag e w h ich m ig h t d isru p t the close relation sh ip w ith his tw o child ren. The th erap ist had com m u n ica ted to him "y ou r m oth er died in you r life," "you r father d ied in th e se n se." N ow th e p atien t sp o n tan eou sly talked abou t his m arriage w h ich m ig h t en d in disaster, and in a very sad and tearfu l state he talked ab ou t the p ressu re d u rin g the p ast year, the b reak in g p o in t in his m arriage. T h en in a painful state h e m en tio n ed th at this m igh t cau se a b reakd ow n o f his relation sh ip w ith his d a u g h ter and his so n , and the fact th at cou p le th erap y had n o t b ro u g h t any ch an g es. H e fu rth er says that all o f his relation sh ip s h ave en d ed in disaster. A n y th era p ist train ed in the trad itional p sy ch o an alytic m od el m igh t h ere m ake an in terp re ta tio n in v o lv in g the tw o triangu lar situ ations; he, his fath er and m other, and h e, his d a u g h ter and son. B ut in this tech n iq u e this w ould be co n sid ered a m a jo r tech n ical error. T h e th erap ist kn ow s th at th e im p o rtan t task ah ead is th e m a jo r resistan ce again st the m urd erou s rage an d in ten se guilt-laden u n co n scio u s feelin g in relation to m oth er and/or father and so forth. N ow the th erap ist retu rn s to th e system atic analysis o f the transference and the p h ase of co n so lid a tio n , follow ed b y th e p h ase of in q u iry and d ev elo p m en tal history.

Developmental History T h e p a tie n t w as b o rn in ea stern C anad a. T h en sh ortly the fam ily m oved to the m id w est. T h e re w e re m a jo r p ro b lem s in his p a re n ts' m arriag e. A fter th e b reak d o w n o f th e n u clea r fam ily, h e and his b ro th e r lived w ith his g ran d m o th er (B lan ch e), tw o a u n ts and an u ncle. T h ere w ere seven o th er ch ild ren . T h ey lived in a p oo r sectio n o f th e city. T h e n he talked abou t his Aunt E lizabeth , w h o w as kind. H e h as a m em o ry o f this a u n t tellin g him th at he w as a v ery sad child and n ev er sm iled. S h e w as th e o n e w h o d ressed h im up and w ou ld take him to visit his m o th er in th e city w h ere sh e w as living.

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Phase of Inquiry N ow the therapist returns to the phase of inquiry and explores the patient's difficulties. H e suffers: (1)

Disturbances in the interpersonal relationships with both men and women. He emphasizes that in his interpersonal relationships he finds himself "paralyzed” and has a fear of being abandoned. This is with both men and women. (2) Major problem with intimacy and closeness with both men and women, much more pronounced with women. (3) Chronic state o f anxiety. (4) Somatization disorder such as pain in his neck, stiffness in his neck, frequent headaches and at times generalized stiffness. (5) Functional bowel disorder, occasional looseness of the bowels with diarrhea. (6) Sexual problem, a decline in sexual desire. During the sexual relationship with his wife he has to resort to the mental image of another woman in order to be able to have intercourse and describes it as a totally mechanical act. This has been throughout the 20 years of marriage. (7) Problem in his marriage. He describes a m ajor problem and refers to it as being paralyzed in relation to his wife. He describes her as being highly critical, demanding, criticizes everything that he does, and further points out that she becomes explosive and at times physically violent. The way he handles himself is by either taking a passive, detached, compliant position, trying to do everything according to her wishes, or by moving to a silent defiant position which angers her. O n a num ber of occasions he has had explosive discharge of affect, which makes the relationship worse. (8) Episodes o f clinical depression. He has suffered from a num ber of clinical depressions, a few of them were before the marriage, and each of them followed a breakdown of a relationship with a woman. Since his m arriage he has had a num ber of clinical depressions, most of them in the recent years when the marriage has been on the verge of breakdow n and there has been the threat of losing his children. (9) Character disturbances. Either he becom es an extremely passive, compliant, silent and detached person or he may move to the opposite and become defiant. M asochistic character traits are evident. As we see, now during the inquiry he dem onstrates a high degree of responsiveness and clarity.

T h e therapist know s that th e m ajor resistance is ah ead , th at he is w orking w ith a person w ho has b een bad ly traum atized in the very early p h ase o f his life and w h o suffers from characterological depression w ith a m asochishc com p onent in his character. T h e therapist m oves to d yn am ic exploration altern atin g it w ith inquiry until he has the op p ortu n ity to m eet the m ajor resistance.

Dynamic Exploration into the Marriage H e n ev er felt close to his w ife, w hich d ates b ack to the year that th ey dated each other. "I m arried h er k n ow in g that th ere w as d etach m en t, n on in v olv em en t and a total absen ce of em otion al closen ess." It is im p o rtan t to n ote that his com m u nication is very m ean in g fu l and he talks abou t "d etach m en t," "ab sen ce of em oh on al closeness," w hich w as n ot the case in the b eg in n in g o f the interview . T h en he talked about his h o n ey m o o n and refers to it as h avin g been an unp leasant experience "w h en w e m ade love th at n igh t I m ade love b ecau se that is w hat one does on o n e's w ed d ing n igh t," and ad ded "It w as ph ysical," "I m ade love and w ent through all the m otions b u t I did n ot feel an y . .."

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T h e n h e in d icates th a t w h en h e m akes love it is u n d er the pressu re of his w ife, and th a t th e o n ly w ay h e can h ave sex is to resort to th e m en tal im age of an oth er w om an . In recen t y ears h e actively brings the m en tal im age of an o th er w om an n am ed L in d a w h ile h a v in g sex w ith his w ife. W h en asked to describe the physical b uild o f L in d a h e b eco m es m ore and m ore anxiou s and th ere is a retu rn of the resistan ce in th e tra n sferen ce, and the process m oves to the ph ase of system atic ch allen g e and p ressu re to th e resistan ce. B u t this tim e the th erap ist's task is a system atic w ea k en in g of the m a jo r resistan ce, w h ich is the resistance against the m u rd erou s rage an d the guilt o f the u ncon sciou s. This system atic w ork then results in a m a jo r u n lo ck in g of th e u ncon sciou s, w h ich will be an alyzed in d ep th in Part II o f this tw o -p a rt article.

Summary and Conclusion T h e article d escribed the cen tral d yn am ic seq u en ce in the process of partial, m ajo r and exten d ed m ajo r u n lock in g of the u ncon sciou s. It is im p o rtan t to recap itu late and su m m arize so m e o f the m ain tech n ical in terv en tio n s in the p rocess of partial u n lo ck in g o f th e u n con sciou s w ith this patient: (1)

(2) (3)

(4)

The central dynam ic sequence in the process of partial unlocking of the unconscious was described in a num ber of the phases: (a) The phase of inquiry: exploring the patient's difficulties, with rapid identification of the patient's character defenses. (b) Pressure leading to the resistance, rise in the transference, increased resistance and psychodiagnosis. (c) Challenge to the resistance, system atic attem pt to make the patient acquainted with the resistance that has paralyzed his functioning, and crystallization o f the character resistance in the transference. (d) Transference resistance; head -on collision w ith the tran sferen ce resistance to loosen the patient's psychic system ; m obilization of the therapeutic alliance against the resistance. (e) Breakthrough of the com plex transference feelings; the triggering m echanism for the direct access to the unconscious and direct view of the psychopathological dynam ic forces responsible for the patient's sym ptom and character disturbances. (f) System atic analysis of the transference. (g) D ynam ic exploration into the unconscious and psychotherapeutic planning. The interview started with the phase of inquiry, w hich was not possible. The therapist introduced pressure to the resistance of vague generalization, asking the patient for a specific example. This led to some rise in the transference and anxiety in the transference, and the therapist introduced further pressure by focusing on his feelings, which led to resistance in the form of a num ber of tactical defenses. Then, as we saw, there was a gradual transition from pressure to challenge to the patient's tactical defenses. There was gradual crystallization of resistance in the transference, and the therapist not only challenged the patient's character defenses but system atically made him acquainted w ith them. From the psychodiagnostic point of view, the therapist concluded that the patient suffers from character neurosis and decided that a rapid breakthrough into the unconscious is the procedure of choice.

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Intensive Short-Term Dynamic Psychotherapy (5)

Now the therapist's technical intervention consisted of an interlocking chain of head-on collision with the patient's character resistance crystallized in the transference. (6) This pow erful form of head-on collision resulted in the first partial breakthrough into the unconscious and major waves of painful feeling with the mobilization of the unconscious therapeutic alliance and direct view of the psychopathological dynamic forces: the center of the patient's very early trauma, namely of being abandoned by both parents at the age of one. Then the process entered: (7) The phase of analysis of the transference and consolidation. Then the process returned to the phase of inquiry into the patient's areas of disturbances; the patient was quite responsive and every area of disturbance was explored. (8) The therapist was well aware that in a patient with such a complex psychopathology the major resistance, which consists of the major repressive mechanism, is in full operation in spite of the partial breakthrough into the unconscious and mobilization of the unconscious therapeutic alliance. (9) In search of the return of the resistance, he made a dynamic exploration into the marriage and his sexual life. W hat em erged was that the only way he could have intercourse with his wife was by bringing the mental image of a woman named Linda. In exploring the body of Linda there was mobilization of a major resistance in the transference. Now the therapist moves to bring about major unlocking of the unconscious and the weakening of the major resistance. The rest of the interview will be the subject of Part II of this twopart article.

References Davanloo, H. (1976). Audiovisual Symposium on Short-Term Dynamic Psychotherapy, Tenth World Congress of Psychotherapy, Paris. France. July. Davanloo, H. (1977). Proceedings of the Third International Congress on Short-Term Djmamic Psychotherapy, Century Plaza, Los Angeles, California. November. Davanloo, H. (1983). Proceedings of the First Sum m er Institute on Intensive Short-Term Dynamic Psychotherapy. W intergreen, Virginia. July. Davanloo, H. (1984). Short-Term Dynamic Psychotherapy. In Kaplan H, Sadock B (Eds), Comprehensive Textbook of Psychiatry, 4th ed., chap. 29.11. (Baltimore, MD., Williams & Wilkins). Davanloo, H. (1984). Proceedings of the Audiovisual Immersion Course on Intensive ShortTerm Dynamic Psychotherapy, sponsored by the San Diego Institute for Short-Term Dynamic Psychotherapy, San Diego, California. May. Davanloo, H. (1986). Proceedings of the Second European Audiovisual Symposium and Workshop on Intensive Short-Term Dynamic Psychotherapy, sponsored by the Swiss Institute for Intensive Short-Term Dynamic Psychotherapy. Bad Ragaz, Switzerland. June. D avanloo, H. (1986). Audiovisual Sym posium on Intensive Short-Term D ynam ic Psychotherapy, presented at the Annual M eeting of the Royal College of Psychiatrists of England. Southam pton, England. July. Davanloo, H. (1987). Unconscious therapeutic alliance. In Buirski P (Ed), Frontiers o f Dynamic Psychotherapy, Chapter 5, 64-88. (New York: Mazel and Brunner). Davanloo, H. (1987). Proceedings of the Fifth Sum m er Audiovisual Immersion Course on Intensive Short-Term Dynamic Psychotherapy. Killington, Vermont. August. Davanloo, H. (1987). Proceedings of the Audiovisual Symposium on Intensive Short-Term Dynamic Psychotherapy, sponsored by the New Jersey Institute for Short-Term Dynamic Psychotherapy. Paramus, New Jersey. September. Davanloo, H. (1987). Proceedings of the Audiovisual Sym posium on Intensive Short-Term Dynamic Psychotherapy, sponsored by the Rochester Institute for Short-Term Dynamic Psychotherapy. Rochester, New York. October.

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D avanloo, H. (1988). Central dynam ic sequence in the unlocking of the unconscious and com prehensive trial therapy. Part I. M ajor unlocking. International journal of Short-Term Psychotherapy, 4(1), 1-33. D avanloo, H. (1988). Central dynam ic sequence in the m ajor unlocking of the unconscious and com prehensive trial therapy. Part II. The course of trial therapy after the initial breakthrough. International Journal o f Short-Term Psychotherapy, 4(1), 3 5 ^ 6 . Davanloo, H. (1989). Proceedings of the Audiovisual Sym posium on Intensive Short-Term D ynam ic Psychotherapy, sponsored by the C enter for Teaching and Research of ShortTerm D ynam ic Psychotherapy, D epartm ent of Psychiatry, M ontreal General Hospital. M ontreal, Canada. M arch. D avanloo, H. (1990). Unlocking the Unconscious (Chichester, England: John Wiley & Sons). D avanloo, H. (1990). Proceedings of the Sixth European Audiovisual Im mersion Course on Intensive Short-Term D ynam ic Psychotherapy, sponsored by the Swiss Institute for Intensive Short-Term D ynam ic Psychotherapy. Geneva, Sw itzerland. June. Davanloo, H. (1993). Audiovisual Course on Intensive Short-Term Dynamic Psychotherapy, presented at the 146th Annual M eeting of the American Psychiatric Association, San Francisco, California. May. Davanloo, H. (1993). Proceedings of the Audiovisual Im mersion Course on the Technical and M etapsychological Roots of Intensive Short-Term Dynamic Psychotherapy. Bad Ragaz, Sw itzerland. December.

Intensive Short-Term Dynamic Psychotherapy Major Unlocking of the Unconscious— Part II. The Course of the Trial Therapy After Partial Unlocking HABIB DAVANLOO McGill University, Department o f Psychiatry, Montreal General Hospital, Montreal, Canada

In this tw o-part article the author presents his technique of partial and major unlocking of the unconscious in the trial therapy. The partial unlocking was described in Part 1. In this Part II, the central dynam ic sequence for the m ajor unlocking of the unconscious is described by com plete account of the interview which was used as an exam ple in Part I.

Recapitulation In Part I o f th e p re sen t article I d escribed the p h ases o f th e cen tral d yn am ic seq u en ce in th e p artial, m a jo r an d exten d ed m ajo r u n lockin g o f the u ncon sciou s. H ere, I w ill d escribe th e d y n am ic seq u en ce in m ajo r u n lockin g, w h ich can be su m m arized as follow s: * *

*

*

Inquiry, exploring the patient's difficulties; initial ability to respond. Pressure, leading to resistance in the form of a series of defenses; challenge to the defenses leading to a rise in transference and increased resistance; rapid identification of the patient's character defenses. C hallenge to resistance and m aking the patient acquainted with the defenses that have paralyzed his functioning and turning the patient against his resistance; crystallization of the character resistance in the transference; rise in the transference and m obilization of the therapeutic alliance. Transference resistance; m ounting the challenge to the transference resistance w ith special em phasis on head-on collision with transference resistance to bring the patient face to face with the self-destructiveness of his resistance, and to intensify the rise in the transference feeling; mobilization o f the therapeutic alliance against the resistance; to loosen the patient's psychic system to m ake the unlocking possible.

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Intensive Short-Term Dynamic Psychotherapy *

* *

Direct access to the unconscious; interlocking chain of head-on collision with the character defenses crystallized in the transference; systematic weakening of the major resistance of repression and all the tactical defenses entrenched in the major resistance; a high rise in the transference feelings; high mobilization of the unconscious therapeutic alliance; direct experience of the transference feelings; major unlocking with the passage of murderous rage in the transference, em ergence of sadness; passage of the guilt-laden unconscious feelings and grief-laden feelings; the unconscious transfers the murdered body of the therapist to the genetic figure; and a direct view of the psychopathological dynamic forces responsible for the patient's symptoms and character disturbances. Systematic analysis of the transference. Dynamic exploration into the unconscious; consolidation; recapitulation, and psychotherapeutic planning.

I indicated that th ese phases ten d to overlap and proceed in a spiral rather than in a straight line.

Case of the Strangler In Part I, I analyzed the process of the early phase of the trial therapy o f a m an in his forties w h ich can be sum m arized as follows: (1)

(2) (3)

(4)

(5)

(6)

(7) (8)

The interview started with the phase of inquiry, which was not possible. Then the therapist introduced pressure to the resistance of vague generalization, asking the patient for a specific example, to which the patient responded "it is difficult." There was further pressure, w hich mobilized some rise in the transference feelings and anxiety in the transference. Then the therapist introduced further pressure by focusing on his feelings, w hich led to resistance in the form of a num ber of tactical defenses. Then process entered into: Challenge to the resistance, which now has acquired a transference quality. Patient was systematically acquainted with his character defenses. Psychodiagnostically, the therapist had com e to the conclusion that the patient suffered from character neurosis, is highly resistant, and that rapid breakthrough into the unconscious was the procedure of choice. O n the basis of this, the therapist moved to a systematic challenge to the patient's character defenses with further crystallization of the character resistance in the transference and a further rise in the transference feelings. Then the process moved to the phase of transference resistance. Then: He applied his most powerful technique of interlocking chain of head-on collision with the aim: to m ount a direct challenge to all the forces maintaining self-destructiveness; to intensify the rise in the transference; to loosen up the patient's psychic system in such a way to make the unconscious more accessible; to mobilize the therapeutic alliance against the resistance; to create an intrapsychic crisis, which is a state of high tension betw een resistance and therapeutic alliance in the transference. Partial unlocking of the unconscious with the passage of m ajor waves of painful feelings and there was direct access to the center of the very early trauma, nam ely being abandoned by both parents at the age of one. Then the dynamic sequence moved to: The phase of analysis of the transference, and then: The therapist returned to the phase of inquiry into the patient's disturbances, to which the patient was highly responsive. The inquiry indicated that he

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suffered from diffuse sym ptom s and character disturbances. H e has suffered from life-long psychoneurotic disturbances, chronic anxiety, episodes of clinical d ep ression , m ajor d isturbances in in terp erson al relationships, som atization, pain in his neck, some functional disorders, m ajor marital problem s, characterological problem s and m asochistic character traits.

Further Exploration into the Marriage In ex p lo rin g h is m arriag e, the p a tie n t in d icated that h e m akes love w ith his w ife on ly w h e n sh e p u ts pressu re on him , and sp o n tan eou sly said that h e has to b rin g th e m en tal im age o f a n o th er w om an . In recen t years h e brings th e m ental im age o f a w o m a n n am ed Linda. At this p o in t of the interview , the p atien t is h igh ly resp on sive and highly collab orativ e an d th e u n con sciou s th erap eu tic alliance is clearly in com m an d of th e process. T h e lo n g p assage o f m ajo r w aves of painful feelin gs has com e to an en d b u t still h e is sad. T h e th erap ist kn ow s th at the resistance that so far has b een the focu s is n o t all o f th e story in a m an w h o has b een so badly ab an d o n ed in the v ery early p h a se o f his life, and th a t the m ajo r resistan ce, w h ich consists o f the p o w erfu l d efen se m ech a n ism of rep ression , m ust be in operation .

Search for the Resistance For th e tim e b ein g th e th erap ist co n tin u es the d yn am ic exp loration and follow s th e lead o f th e u n con sciou s th erap eu tic alliance, askin g the p atient to d escribe th e b o d y o f L in d a w h ile m o n ito rin g the p atien t's u n con sciou s responses. In exp lorin g th e b o d y o f L in d a th ere is m o u n tin g an xiety an d m obilization of resistan ce. In Part I I I w ill attem p t to an alyze th e rest of this in itial interview . We retu rn to th e in terv iew w h ere w e h ad left it at th e end of Part 1.

Return of the Resistance T h e th era p ist is p u ttin g pressu re on the p atien t to describe the b od y of Linda, and h e fin ally says th at sh e has b lu e eyes and sm all breasts. TH : PT: TH : PT:

H ow abou t the rest o f the body? H er eyes are blue. H ow abou t the rest o f the body noio? The rest o f the body. B road shoulders, uhh she's strong.

As w e see, resistan ce is b ein g m obilized. H e uses the tactical d efen se o f cov er w ord s "b ro a d sh o u ld ers," "s h e 's stron g ."

Challenge to the Resistance TH :

D o you notice, again, now that w e loant to focu s on the body o f Linda, now you are becom in g detached an d w ithdraiun, an d erecting a w all?

PT:

H m hm m .

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Head-on Collision with the Resistance T h e therapist progressively escalates the d egree of challenge and brings about a h ead -on collision w ith the tran sferen ce resistance, trying to m obilize the unconscious therapeu tic alliance against the resistance. In the follow ing passage, he introduces a com posite form of head-on-collision. * * * * * * * *

Puts pressure to the resistance: "Hm hmm is not enough;" Challenges the resistance against emotional closeness in the transference; Emphasizing the consequences of the resistance in the transference: Pressure, emphasizing the patient's will; Challenging the self-defeating, self-sabotaging, self-destructive aspect of the resistance in the transference, the masochistic com ponent of his character; Challenge to the defiance; Keeping the responsibility with the patient; Further pressure to unconscious therapeutic alliance.

TH:

"Hm hm m " is not enough. I f you w ant to g o that w ay then the barrier and the loall is here with me. In a sense you don't w ant me to get to you r intim ate thoughts an d feelin g ; and if you w ant to do that then this w ould be a crippled, paralyzed process. PT: N o I don't want. TH: Then let's to see what you are goin g to do about this first. Because from the beginning I have told you that if you loant to censor yourself, if you w ant to erect a w all between y ou rself and me, this process is doom ed to fa il an d you'll carry a crippled life to you r grave. N oio you have a right to do that if you w ant to do that. I f you w ant to keep you r paralyzed life, after all that is you r life and you have the right to do that. But the question is w hy you w ant to do that? PT: N o I don't w ant to do that, (very low voice) As w e see, in spite of the p a tie n t's d eclaration "N o I d o n 't w an t to do that" w ith a very low voice, the b alan ce b etw een resistan ce and th e therap eu tic alliance is in the d irection of in creasin g resistance. T h e therap ist is w ell aw are o f this and m oves to fu rth er crystallization and in ten sification of the resistance in the tran sferen ce. H e asks the p a tie n t to com p are th e body o f L in d a w ith th at of his wife. TH: I f you com pare her breasts with you r loife's breasts ivhat w ould he the difference? PT: I've never seen h er breasts. TH: In term s o f thought I mean, a picturing. I f you com pare hmm. PT: H er breasts are small. TH: Hmm? PT: H er breasts are small. TH: The breasts o f Linda are sm all. A nd you r ivife's breasts? PT: A re large. TH: Large. So com pared w ould be sm all breasts vis-a-vis large breasts. PT: A nd my w ife is very heavy an d Linda is slim. TH: H eavy where? PT: Big, she's . . .

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T h e n the p atien t says "m y w ife is fa t"— b u t Linda is very slim an d athletic. L in d a h as b lon d hair, sm all breasts and the pubic h air is dark. T h e therapist q u estio n s a b o u t th e rest o f th e body, b u t h e says that h e ca n n o t rem em b er and he ca n n o t d escribe th e rest of h er body. TH : PT:

W hat else cou ld you say abou t the body o f Linda? O hh . . . ohhh.

Escalating the Degree of Challenge TH : We have again a paralyzed . . . do you notice again you r m em ory collapses? PT: Yes. TH : Yes w hat! PT: Yes it collapses, I don't rem em ber it. TH : I m ean y ou say y ou are an engineer. PT: Yes. TH : A s an en g in eer you have a problem with you r m em ory? P T No. TH : Then hoio com e here y ou r m em ory w ith m e im m ediately collapses? Do you notice the position here? PT: H m hm m . TH : W hat "hm hm m ?" PT I f e e l .. . In so m e p atien ts, "I d o n 't rem em b er" can b e a tactical d efen se, b u t in this p atien t this d e fen se is w ell en tren ch e d w ith the m ajo r resistance. In the follow ing p assag e th e th erap ist m o u n ts the ch allen g e to th e resistan ce, w h ich results in a rise in the tra n sferen ce, rise in an xiety an d fu rth er crystallization of resistan ce in the tra n sferen ce. T h e im p o rta n t task is th at ev ery ch ara cte r d efen se w h ich is m o b iliz ed ra p id ly b e id e n tifie d a n d c h a lle n g e d w ith th e aim o f fu rth e r in ten sifica tio n o f th e rise in th e tran sferen ce. By d oing so, the p rocess rapidly m ov es to th e m a jo r resistan ce in the tran sferen ce, w h ich the therapist is lookin g forw ard to. We retu rn to the interview . TH : PT: TH :

H oldin g y ou r h an d like that. Do you notice? Yes I notice. But ad m ittin g that you are paralyzed doesn't help us. Look at it. M y question w as, w as there an y other w om an besides Linda? But now you m ove towards the collapse o f y ou r m em ory. (Pause) TH : So you h ave a need to actively censor yourself. A nd nodding y ou r head is not enough. PT: 1 don't fe e l that. TH: You see y o u r ru m in ation "I d o n ’t fe e l th at." You are actively doing it a n d then at the sam e tim e actively d en y in g that you do it. That is the portrait o f the

PT:

p aralyzed man. Hmm.

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TH: But nodding your head is not good enough. So let's to see what you are going to do about this need in you to censor you rself and take a crippled position. Your hand again is like that, eyes closed, h a lf opened. (Pause) And the paralyzed crippled position you take. PT: That's exactly the .. . TH: But that is not good enough. PT: It's very frustrating. It is im portant to note that d uring this process the therapist m ust m onitor and address the nonverbal signals, such as clen ch in g of the h ands, the rate o f deep sighing respiration and so forth. T h ey are the indicators for the rise in the transference and rise in u nconscious anxiety in the form of tension in the striated m uscles; a rise in the transference feelings an d the direct experience of the transference feelings is the goal tow ard w h ich the therapist is w orking. The patient has declared frustration. Frustration is a tactical defense against anger and, in m any patients, anger by itself, can b e a tactical d efen se against rage, and the rage can be a tactical d efen se against m urderous feelings. It is im portant to note that the patient declares "I feel frustration." H ere we see another tactical defense, the fact is that the patient is bypassing the transference "w ell, I'm frustrated." This again is a form of tactical d efen se that is w ell en tren ched w ith the m ajor resistance. Technically, the therapist m ust m aintain a system atic challenge to this tactical d efense and consider it as part of the m ajor resistance. In the follow ing passage the therapist m aintains system atic challenge and pressure to the resistance. TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH:

You mean it is fru stratin g here with me? Yeah you're aah . . . You are fru strated here with me? I don't know lohat to think. N o you are not an sw erin g the question, 1 say is this . . . 1 feel frustration. You feet fru strated with me. Is this w hat you say? I fe e l fru strated, that's w hat I'm saying. You fe e l fru strated at who? A gain you are crippled, to say you are fru strated . . . is a cu t-off sentence. "I feel frustrated" is a cu t-off sentence. Frustrated at who? I ' m ... A gain you're crippled, fru strated at who? Your hand again. I'm fru strated. Frustrated at w ho; First let's to establish at w ho are you frustrated. N ow your head goes there, you r hand goes there . . . (m akes grow ling sound) O rrrrrh . , . . . . an d then you m ove tow ard this crippled position. Frustrated at who? You said you are fru strated, fru strated at who? Do I have to be fru stra ted at som eone? Again you rum inate. Well I'm frustrated! Yeah but frustrated at who? I'm ju st fru strated, Tm not fru strated . . . At w ho arc you frustrated?

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N ow, h e m ov es to th e d efen se m ech an ism of denial and n eg ation and says "I am n o t fru strated at anybod y." PT: I'm m t fru stra ted at anybody. TH: A gain you take a crippled position, cu t-off position. You see a cu t-off position is exactly like Linda, has a head an d hair but the rest o f the body is cu t-off (Pause)

PT: TH: PT:

D o you notice how crippled you are? You say you are fru strated, but at the sam e tim e you don't loant to really spell out at w hom you are fru strated. Look to you r hand. N ow you are fidgetin g. H m hmm. 'Hm hmm'. (laughs)

TH: A dm ittin g you are crippled is not g oin g to solve an ythin g . . . N ow you are avoid in g m y eyes. PT: I . . . TH: A t w ho are you fru strated ? Let's fir s t establish that. You have a tendency to flig h t, you have a tendency to run aw ay from any issues. PT: Yes. In th e fo llo w in g p assage th ere is h ea d -o n collision w ith th e d efian ce, d e a c tiv a tio n o f th e tra n s fe re n c e , an d em p h a siz in g th e c o n se q u e n c e s o f m ain tain in g th e resistan ce in th e tran sferen ce. TH :

You have don e it 46 years o f y ou r life, an d if you w ant to do it you can do it an d g o to y ou r grave.

O ften , tactical d efen ses are strategic satellite d efen ses and are d ifferen t from so -called m ajo r d efen ses. B u t ou r research data in d icates th at tactical d efen ses can b e w ell en tren ch e d w ith th e m a jo r resistan ce an d should b e con sid ered as such. As w e see, the p ro cess is still a sy stem atic ch allen g e to this d efen se "D o I h av e to b e fru strated at so m e o n e," w h ich is totally av oid ing th e tran sferen ce. The ch allen g e in th e ab ov e p assage h as fu rth er in ten sified the rise in th e tran sferen ce, and the th e ra p ist m on itors it via u n con sciou s an xiety in the form of ten sio n in the striated m u scles. H e has d eep , sig h in g resp iration, the rate of w h ich has in creased and w h ich clearly in d icates to the th erap ist th at th e rise in the tran sferen ce feelin g s is in th e u p w ard position . It sh ou ld be em p h asized th at it w ould b e a m ajo r m istake for the th era p ist to explore the p atien t's feelings. T h at is w h at the resistan t p art o f th e p a tie n t w ou ld like. T h e therap ist w ell kn ow s that the n atu re and the d eg ree o f th e resistan ce and the com plexity of the p sy ch o p ath olog y are extrem ely d ifferen t from tho se of the C ase of the Salesm an , or of an y o th er p atien t w h o is p laced on th e extrem e left of the sp ectru m o f p sy ch o n eu ro tic disorders. We retu rn to th e in terv iew w h ere w e had left it. PT: N o I don't w an t to do it. TH : So let's to see a t w hom you are fru strated. (Pause) A gain you are terrified at lookin g at m y eyes an d declaring. PT:

(d eep sigh)

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TH: Again your sigh. Do you notice your hand? You are totally crippled to look at my eyes and tell me at w ho you are frustrated. Because frustration refers to som ething negative huh? PT: Yes. TH: But you are paralyzed to look to my eyes . . . L et’s establish at loho are you frustrated? PT: (m um bles) TH: A nd w e knoiv you r fa th er died in you r life in the very early years and your m other died in you r life in the very early years, and you w ant to relate to me as if I am dead as well. (Pause) N ow let’s to see at who you are frustrated. Noiv your hand is like this. PT: (laughs) Is there no place to put my hand? I ’m frustrated, frustrated. TH: Hm hmm. But you are paralyzed to declare at who you are frustrated. PT: Yes that’s right. Finally, in the follow ing passage he declares "1 am frustrated at you ." TH:

That is right is not enough. A dm itting you are crippled doesn't help. A nd that is another part o f you; you resort to the crippled, paralyzed position. Because you are totally crippled to declare w here the direction o f the frustration is. In a sense you don't w ant to declare that I am a part o f this system . That is w hy 1 say you w ant to dism iss me. PT: Hmm. TH: 'Hm h m m 'an d repeatedly an other part o f you is adm itting to a crippled position. Do you notice that in a sense you don't w ant to involve m e in this process. "1 am fru stra ted ." PT: I'm fru strated at you. T he question that w e m ight raise, w h y such a d efen se "D o I have to be frustrated at som eon e" should requ ire this d egree of ch allenge and pressure? As I have already in d icated , such a tactical d efen se is w ell en tren ch ed w ith the m ajor resistance, w hich is the resistance against th e experien ce of the unconsciou s m urderous rage and guilt. It is equally im p o rtan t to n ote that w h en such a resistance is tim ely id entified , ch allen g ed , pressu red and h ead -o n collided w ith, it functions in the service of m obilization o f tran sferen ce feelings as well as m obilization of the th erap eu tic alliance, w h ich is the goal tow ard w h ich the therapist is w orking.

Head-on Collision with Resistance In the follow ing passage, the therap ist applies his tech n iq u e of h ead -on collision: * * * *

Pointing out the nature of the resistance; Emphasizing the therapeutic task “to get to the engine or the core of your problem;" Emphasizing the partnership '"for you and 1 to see what are we going to do," "then the whole process of both of us w orking together;" Addressing the resistance against em otional closeness;

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Pointing out the self-d estru ctive co m p on en t of the resistance in the transference; Pointing out the consequences of the resistance in the transference "the process is doom ed to fail."

TH:

H ow do you experience’ this fru stration with me? So fa r w hat you say is that you are fru stra ted with me, but y ou r hand is clenching like that, you r body is im m obile an d you are taking a detached, paralyzed position. So let's see w hat are w e going to do about this crippled m an? It is very im portant fo r you an d m e to see what are w e g oin g to do about this crippled man. Becausc this d eta ch m en t. . . an d that is very im portant fo r you to look at it, unless you want to dism iss this as well. PT: (d eep sig h in g resp iration) TH : I f this p aralyzed position continues, if you m aintain this detached an d extrem ely p assive position, this process is doom ed to fa il an d these m echanism s are the ingredients o f the w all; an d if this continues the w hole process o f both o f us w orkin g together, tryin g to u nderstand you r difficulties, w hich w e have understood, but equally im portant to g et to the engine or the core o f the problem is doom ed to fa il. So the im portant issue for both o f us is ivhat are w e goin g to do ivith this m assive w all? A nd it is very im portant to identify this, you see, because a part o f you w ants to g iv e up your crippled life, okay. PT: Yes. TH : O kay? A part o f you w ants to g iv e up the crippled life but another part o f you w ants to p erp etu ate the crippled life. The other part that w ants to perpetuate the crippled life uses all kinds o f system s an d all kinds o f m echanism s. But this part that w ants to perpetu ate is using all these m echanism s. N ow the question for you an d 1 is lohat are lue g o in g to do with that part o f you w ho w ants you to remain crippled? PT Yeah. TH : It is very im portant to see ivhat are w e goin g to do w ith that part o f you that w ants to rem ain in a crippled paralyzed position? D o you follow me? PT: Yes, I understand. T h e m ain aim o f iiea d -o n collision at this poin t of the in terv iew is: (a) (b) (c) (d) (e) (f)

To bring the patient face-to-face with his self-destructiveness. To make him well acquainted with the nature of the resistance. Further rise in the transference feeling To m aintain the resistance crystallized in the transference. To mobilize the therapeutic alliance against the resistance. To create a state of high tension betw een resistance and therapeutic alliance in the transference; the two m ajor forces "a part of you wants to give up the crippled life" (therapeutic alliance), but "an oth er part of you w ants to perpetuate the crippled life" (punitive superego).

Anger in the Transference TH : PT TH :

You said you are an g ry w ith me? Yes. H ow do you ex perien ce y ou r an ger tow ards me? You are pressin g you r hand. We don't know how you physically experience you r an ger towards me. We knoiv how you ex perien ce an xiety hmm.

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PT: Hm hmm. TH: W hat is the way you physically experience you r anger in relation to me? Your head goes doion. A lm ost all patients w ith character neurosis can not differentiate betw een the physical experience of an ger and that o f anxiety, w hich is in the service of resistance. At this point, the task o f the therapist is to m aintain his challenge and pressure, and if necessary h ead -o n collision to the resistance against physical experience of the an ger in the tran sferen ce. T h e therapist puts pressure on the physical experience of the an ger and concom itantly challenges the resistance. Especially im portant, the therapist m ust see that the patient is w ell acquainted w ith the resistance that is b ein g ch alleng ed , and th at his com m unication is very specific. If w e look to the follow ing passage, the patients says "I have a hard time w ith anger," and the therap ist's respon se is "im m ed iately that part, th at paralyzed part com es up," ad d ressing the part of the p atient that has heavily identified w ith the resistance. It is also im portant that the therapist him self does n ot use tactical defenses. For exam ple, in the follow ing passage "You see I questioned you how do you experience you r an ger in relationship w ith m e" rather than to say to the patient "h o w do you experien ce you r anger." N ow w e retu rn to the interview . PT. Well I've . . . I have a hard tim e with anger. TH: You see again im m ediately that part, that paralyzed part com es up. You see? You have a side o f you that uses all kinds o f m echanism s to m aintain the paralyzed PT: I'm afraid o f losing m y tem per TH : Yeah but zue are looking to hmo you experience you r anger here with me. P T Physically? TH: Yeah. We know hoio you experience the anxiety, and it is im portant to see haiv you experience you r an ger in relationship with me. Hozv do you experience your an ger in relationship loith me? So fa r w e see a paralyzed . . . PT: I fe e l tense, I tense. TH: Yeah okay. You see I questioned you how do you experience you r anger in relationship with m e; you say you feel tense, but that is anxiety. P T Yeah. TH: But anxiety is not the an g er Do you folloiv that? PT: I'm not sure I see the difference. TH: You see I question you how do you experience you r anger in relationship with me? You say you feel tense. Tension is a part o f one's anxiety. W hen you are anxious there is a tightness in y ou r chest, that is tension. But that is not anger. W hat you describe is anxiety. Do you notice you r hand? W hat you describe is a)txiety. Do you notice your hand? P T Yeah. ' TH: W hat? W hat do you notice? PT: I'm I'm . . . TH: Clenching. PT: C lenching an d . . . but that's anxiety too. I d o n ' t . . TH: Tension. PT: Tensio)!.

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TH :

But m aybe there is an oth er feelin g underneath of this tension because you say you're an g ry hm m . PT: So they're both g on n a he there. TH : But obviou sly there m ust be som e link betw een the anger an d the anxiety. PT: Yes. TH :

PT:

But w e kn ow hoiv you experience the anxiety but w e don't know hmv you experience the anger. (Pause) You see when w e focus on you r an ger toioards me how p aralyzed you becom e? Yes I block it.

T h e p rocess d em o n strates system atic w eak en in g o f the rep ressive m echanism w h ich is the m ajo r resistan ce again st the m urd erou s rage and guilt. It is im p ortant to n o te th at o n e o f th e d efen se m ech an ism s that can easily com p licate the process, w h ich is o ften syn ton ic, is the m ech an ism of defian ce. For that reason it is im p o rta n t th at th e th erap ist m oves to the d eactiv ation of this d efen se. This can be d o n e by p o in tin g ou t to the p atien t "u n le ss you d o n 't w an t to do an y th in g about it," "m a y b e you r d ecision is to carry you r m isery the rest of you r life." This form of in terv en tio n at th e sam e tim e con tain s d eactiv ation of the tran sferen ce and k eep in g th e resp on sibility w ith the p atient. Now, w e retu rn to the interview .

Challenge, Pressure Combined with Repeated Partial Head-on Collision TH:

PT:

But that is the part, the side, the part that I said that a part o f you loants to perpetu ate this m iserable life. So then w e have to do som ething about it, unless you don't w ant to do som ethin g about it. N o I w ant to, uh a . . . I w ant to do som ething about it.

It is im p o rtan t to n ote that the therap ist rep eated ly pu ts pressu re on the p a tie n t's w ill, to the p a tie n t's th erap eu tic allian ce to m ake a su p rem e effort. TH : PT: TH : PT: TH : PT;

TH :

So do you see there is a part o f you that wants to sabotage the w hole process. (su p erego resistan ce) Yes, yeah I can see that. But a part o f you loants to say goodbye to the crippled life, (th erap eu tic alliance) Yes. So then w e h ave a m ajor problem ahead o f us. (em p h asizin g the p artn ersh ip ) Yes.

That part o f you that w ants to sabotage the w hole process, (d estru ctive asp ect of resistan ce in tran sferen ce) A nd the issue is this, w hat are you goin g to do about it? (q u estion to the u ncon sciou s therap eu tic alliance)

Further Challenge PT: TH:

I fin d it so hard to say how I experience . . . You see again the paralyzed part com es im m ediately to the fron t, you see?

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PT: (deep sighing) TH: Do you notice? PT: Yes. TH: Im m ediately crippled 7 don't knoio.' PT: Yes. TH: 46 years you have been on that boat. PT: I don't know hoio to . . .

Challenge, Pressure and Head-on Collision TH: A nd I assum e you w ant to say goodbye to it. PT: I do, but I don't know how. TH: Let's to see how you experience you r anger in relation to me. (pause) Let's to see how you experience your anger. Your hand is like that, you r leg you are keeping it tight. Do you notice the position o f you r hand? PT: It's . . . I'm protecting myself. TH: H m h m m . So let's to see how you're experiencing your anger. So fa r you're a cut­ o ff man. (pause) Let's to see hoiv you experience you r anger. M oving to the crippled position is not goin g to help us. 46 years you have done it anyway. Let's to see hozo you experience this anger. A gain you w ant to m ove toward this . . . (PT deeply sighing) . . . paralyzing poofff and so forth. Let's to see how you experience you r anger. PT: But that's hoiv I experience it. TH: A nd your head is doivn. U sing all kinds o f the m echanism s to avoid to see how you experience you r anger. There is a part o f you that w ants to perpetuate this crippled position, an d loe have to see lohat w e can do about that part. Unless you don't zoant to do som ething about it. PT: I w ant to do som ething about it. TH: The first issue is how do you experience you r anger. Noio, you are becom ing more sloio, looking puzzled; again fu rth er paralysis. PT: Hm hmm. TH: "Hm hm m" is not enough. You have lived this crippled life fo r 46 years; do you w ant to say goodbye to it or do you zvant to keep it? PT: I zvant to say goodbye to it. TH: Then let's to see hozo you experience you r anger in relation to me. N oio you m ove like this, (pause) Do you notice your body? Do you see you r body? PT: Hm hmm. TH: You zvant to m ove toioard that side, the paralyzed side. A nd zve are here together to deal zuith that paralyzed side; unless you don't zvant to. (Pause) So then obviously you zvant to carry this to you r grave. That is becom ing clear. PT: I don't! But I don't knozv zohat to do zoith it. TH: To do zvith zvhat? Hozo do you experience y ou r anger tozoards me, physically . . . We knoio zohen you are anxious, physically you have a certain zoay o f experiencing anxiety, but hozv do you e.xperience the an ger that you have inside you tozoards me? Do you see hozo terrified you are? PT: I am afraid . . . I am afraid o f being violent.

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In th e ab o v e p assage, the th erap ist m ain tain s the ch allen g e, pressu re and a rep eated com p o site form of h ea d -o n collision w hile carefu lly m on itorin g the sign alin g system ; th e n on v erb al cu es such as freq u en t deep sighs, clen ch in g o f b o th h an d s, etc. T h e p rocess clearly in d icates a stead y rise in tran sferen ce feelings. T h e sy ste m a tic w o rk o n w ea k e n in g th e m a jo r resistan ce o f rep ressio n is p ro gressin g and th e p a tien t n ow d eclares "I am afraid o f b ein g v iolen t," "it is so m eth in g totally irration al," "a loss of con trol." It is im p o rtan t to n ote th at the p rocess h as m oved from "fru stra tio n " to "v iolen ce" and w e h ave a clear indication o f th e m ob ilization o f th e u n con sciou s therap eu tic alliance again st the resistance. We retu rn to the interview . TH:

PT: TH :

PT TH: PT TH : PT: TH: PT TH :

PT: TH : PT: TH :

PT:

Violent. You m ean there is a volcano inside you?, a fireball inside you that you are afraid m ight com e out? This is w hat you are saying? You mean there is a fireball in sid e you t h a t . . . you are afraid that it m ight erupt. (d eep sigh in g) It is som ethin g totally irrational, a loss o f control. Losin g control? But how do you physically experience this? H ow internally do you ex perien ce this w ave that goes w ithin you? \Nc are talking about this violent rage, (pau se) A gain, you see, clenching. You arc protecting m e against your anger, isn't that? Yes. Hmm? Yes. Yes w hat? I'm protectin g m y self But obviously p rotectin g m e as locll. Because you r hand is like this. But I think o f it m ore as protecting m yself But still w e don't know how you experience this rage inside. Hoiv you're ex p erien cin g it inside? Wi’ are not talking about pu ttin g it out, w e are talking about how you're ex perien cin g it inside. Ju st stays up in the head. But still w e don't kn oic how you physically experience this rage. I fe e l tight, I fe e l it. But that is anxiety, that is not rage. A nd ivhat you experience is an xiety but u nderneath o f it is rage. You experience the anxiety but w e don't know how you experien ce the rage. Do you notice there is a link betw een anxiety an d rage? H m m , but they're not the same.

H e in d ica tes th a t h e has "a n aw fu l te m p e r" and th at he is afraid o f losin g co n tro l, "m ig h t b eco m e d estru ctiv e." T h e therap ist brin gs his atten tio n to the exp erien ce o f rage. T h e d eep sig h in g respiration has in creased , w h ich signals a fu rth er rise in the tra n sferen ce feelin gs. R eferrin g to his in n er rage h e says "I d o n 't feel a co n n e c tio n ." PT: TH : PT: TH :

I can't relate it to ah, to an experience. H ow do you physically experien ce it? It a ll sou n ds like anxiety, I m ean I fe lt a tightness in the chest an d ah . . . But you see tightness in the chest m eans anxiety in this muscle.

PT

Y eah

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TH: But anxiety and rage are two different things. Underneath the anxiety obviously is the rage, and as soon as the rage is m obilized you become anxious. So anxiety is a mechanism o f dealing with rage, detachm ent is a mechanism o f dealing with rage, holding the fis t like that is a mechanism o f dealing with rage, making y ou rself tight like that is a w ay o f dealing with the rage. But how do you experience the rage itself? For a m om ent, it is very im portant to sum m arize the process and discuss som e of the technical and m etapsychological issues re the w ay the unconscious functions: (1) (2) (3) (4) (5)

(6) (7)

(8)

(9)

There has been systematic challenge, pressure and repeated head-on collision with the patient's transference resistance, which gave: A steady rise and a direct experience of the complex transference feeling which was signalled by; Rise in anxiety in the form of tension in the striated muscles and its nonverbal cues; There is mobilization of the unconscious therapeutic alliance; The process indicates that the repressive mechanism is in the process of being weakened, which has been mobilizing a high degree of anxiety, again in the form of tension. His body is immobile and other nonverbal cues already m entioned; The unconscious murderous rage is close to breakthrough, which is a major source of mobilization of anxiety; Therapists working with this technique must have a good knowledge about the somatic or the psychophysiological pathway of unconscious anxiety in the form of tension in the striated muscles (will be discussed briefly at the end of this article); Therapists must have knowledge about the somatic pathway of the passage of the unconscious m urderous or unconscious primitive murderous rage. I have clearly dem onstrated in a large series of unlockings, that the passage of the murderous or primitive murderous rage has a definite somatic pathway, which has been presented in many symposia and courses; and I will briefly address it at the end of the article; As soon as the unconscious murderous rage is experienced in the transference the whole anxiety and tension drop, signaled by the nonverbal cues.

H ere it is im portant to very briefly su m m arize som e of the fun dam en tal principles of the w ay the u ncon sciou s functions; (a)

Actual experience and passage of the unconscious murderous rage in the transference is instantly associated with a drop of anxiety and tension, and em ergence of sadness is an indicator that the breakthrough of the guilt and grief-laden unconscious feelings is em inent. (b) Experience and the passage of the unconscious murderous rage in the transference, as 1 have indicated before, is instantly associated with sadness. The patient's attention is on the murdered body of the therapist and then his unconscious transfers the murdered body of the therapist to the genetic figure, namely father, m other or sibling. (c) As soon as this transfer takes place there is a breakthrough of intense major waves of guilt-laden uncon.scious feeling, which is then followed by a major passage of grief-laden unconscious feelings.

Principles (b) and (c) can be d em on strated w ith every extended m ajor unlocking of the u nconscious w ith ev ery highly resistant patient w ith com plex psychopathology. O n e of the m ain reasons has to do w ith the fact that the rise of

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and the d irect exp erien ce of tran sferen ce feelings is at its optim u m level and there is op tim u m m obilization o f th e u ncon sciou s therap eu tic alliance and the resistance has lost its pow er. T h is is w h at I have called m obilizarion of the "u n con sciou s therap eu tic allian ce; dream in g w hile awake," (D avanloo) w h ich has already b een p resen ted in m an y sym posia and courses and will appear in future series of articles. If w e go b a ck for a m o m en t to m ajo r u n lockin g, th ere is som e d egree of v ariatio n an d this d ep en d s on th e exten t o f the rise and direct exp erien ce o f the tran sferen ce feelin gs. I h ave alread y in d icated that the d egree and th e exten t of the b rea k th ro u g h in to th e u n con sciou s is exactly in p ro p ortion to th e d egree that th e p atie n t h as d irectly exp erien ced his tran sferen ce feelings. O n th at basis w e can say th at th e re is a sp ectru m o f m ajo r u n lockin g of the u ncon sciou s. N ow w e retu rn to th e in terv iew w ith this patient. T h e th erap ist m ain tain s ch allen g e to the resistan ce again st th e exp erien ce of his rage in the tran sferen ce, askin g h ow the p a tie n t e x p e rien ces th e rage. T h e sp ecificity of this q u e stio n is extrem ely im p o rtan t. T h e p a tie n t finaUy in d icates th at th ere is "so m eth in g rising" and the th erap ist follow s. TH: PT:

TH : PT:

TH : PT: TH : PT: TH: PT: TH : PT:

That fireball? Yeah, it's, risin g up inside, (referrin g to the som atic p ath w ay) (h and s are n o t clen ch ed , his totally b en t position b ecom es u p righ t and he says, "risin g up in sid e" referrin g to his abd om en and chest) W hat is the luay you are ex perien cin g it? Well, it's to, it's to . . . it's to explode, you know it's to shout, (the h an d is in the u p w ard p osition , his voice is loud, no ten sio n in the vocal chords, in d ica tin g th at the b rea k th ro u g h is taking place) Explode? It's to shou t a n d . . . There is a rage in you like that? Yes. That you w an ted to blast on m e? That there is a rage in you tow ard me? No, rage is too big a w ord fo r it. A n d I think that it is very im portant that w e exam ine this, unless you w ant to keep y ou r m isery the rest o f y ou r life. No. (d eep exh alation)

T h ere is d efin ite ev id en ce that the b reak th ro u g h has taken place. A nxiety and ten sio n h av e d ro p p ed . T h e th erap ist b ypasses th e tactical d efen se "N o , rage is too big a w ord for it." N ow th e th erap ist explores h ow it w ou ld h ave b e e n like if he had pu t his rage o u t (it is im p o rtan t to n ote that if this w as an exten d ed m ajor u n lo ck in g , w ith an op tim u m rise in the tran sferen ce feelin g and op tim u m m ob ilization o f th e u n co n scio u s th e ra p eu tic allian ce, d irect exp erien ce and p assage w ou ld h ave b e e n sp o n tan eou s). We retu rn to the interview .

Passage of the Murderous Rage in the Transference TH :

I f you lash out, how that w ou ld be like? In term s o f thought an d fan tasy. You kn ow the story o f Dr. Jekyll an d Mr. Hyde?

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PT

TH:

PT: TH:

TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH:

PT: TH: PT: TH:

Yes. (the atm osphere o f the interview is differerit, there is no tension and no anxiety) Now, i f . . . you know, that m onster comes out o f you, what you w ould be like? and that is very im portant fo r you to look at because that has m ade your life miserable, that has paralyzed you r life and why w ould you go to your grave in that way? I f that m onster com es out o f you, what that w ould be like? In terms of thought and fantasy. I w ould attack you directly, with my fists . .. Then there w ould be attack on me? (he is sitting in the upw ard position. At this m om ent, his tw o han ds are in the upw ard position, outstretched opposite to each other, and is dem onstrating to the therapist how he would strangle the therapist) Could you portray hoiv you w ould attack me? Throttle you around the neck . . . like that. You mean your hands? Right, right in . . . O ver where? C ould you portray it? Yeah. A round here? (referring to th e neck) Yes. So you w ould h o l d . . . put you r hands around my neck, your thum b w ould be on my. . . A nd choke. Uh huh, an d then choke me? Yeah. A nd then, how xoould you g o further? If you let this . . . go further. I w ould choke you and shake you until, until you stop moving. Yeah, but then hoio it w ould be like? in term s o f you r thoughts. M y fingers w ould be ju st pressing (referrin g to the therapist's neck) A nd push? Push and push and shake. A nd then? A nd then, release. But what happens? I mean fin a lly I am . . . You w ould fa ll to the ground. You mean that I w ould be g aspin g fo r air. No, you ivould be dead. I w ould be dead hmm. In the chair there or where? It wouldn't m atter w hether you're in the chair or fe ll to the ground. Yeah but in term s o f thought. I mean you r hand is on that an d then you arc pushing and pressing an d pressing an d then I die. C ould you portray the dead body o f m ine on the . . . W here? You w ould be . .. you ju st slum p back on the chair. On the chair an d the head back you mean? Yeah like that. A nd hozo about n/i/ eyes?

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PT: W ide open a n d staring. TH : S taring at w here? PT: Ju st starin g up. TH : The ceiling? PT: The ceiling. T h e p a tie n t is b eco m in g in creasin g ly sad. T h ere is no an xiety and ten sio n and the p a tie n t is in an altered in n er state. We co n tin u e the interview . TH: an d then my hand? PT: Ju st . . . lik e that. TH : L ike that. A nd then w hat do you do a fter that? A fter I am murdered? PT: I f I'm still an gry? I f I'm . . . if I ’m fu ll o f remorse? TH: N o I m ean luhat happens? N oio you have put your hands on m y neck an d then I... PT: I've killed you ; rem orse, guilt. I ivould . . . the rage w ould be gone. TH : R ag e is g o n e hut w hat other feelin g loould you have? I mean I'm back there and I am dead. PT I I . . . TH: W hat w ould y ou do? PT: I'm ju st totally stricken, I ivould ju st ah . . . (sighs) TH: But then w hat w ou ld you do a fter that? H ow w ould you fe e l at that m om ent? PT: D readful, I'd f e e l . . . TH: Wlnj? PT: For having killed you. TH : W hy? W hy w ou ld you have rem orse? PT: For having killed a hum an being. TH : A n d w hat do you do w ith m y dead body? PT: N othing, (sniffling) TH : I m ean lohat do you do w ith it? You mean you ivalk out or you . . . PT: I c a n ' t . . . I loou ld . . . I can picture a collapse, I picture not doing anything. TH: I m ean lohat do you do? I m ean you leave m e an d w alk out the door? T h e sad n ess is b eco m in g in ten sified , tears are in his eyes. PT: TH : PT:

N o I w ou ld g o an d fin d som eone. W ho? W hat com es to y ou r m ind? (h eav y sobbing) I picture g oin g out that door an d fin ding the fir s t person an d saying I've killed this man. TH : H m hm m . A nd hoio w ould you fe e l tow ard m y dead body?

Passage of Guilt-Laden Unconscious Feeling T h ere is a b rea k th ro u g h o f a m ajo r w ave of gu ilt-lad en u n con sciou s feelings, w ith h ea v y sobbin g. T h e g u ilt-lad en u ncon sciou s feelings com e in w aves and in v olv e the w h o le u p p er resp iratory area. T h e in terv iew con tin u es. TH :

H ow w ou ld you fe e l tow ards m y dead body?

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PT: (crying) 1 w ould be sorry. TH: Hmm. PT: I w ant to help bring you hack to life, (further breakthrough o f guilt and painful feeling) TH: You mean there are positive feelin gs as well? PT: (further breakthrough of guilt) TH: Hmm? PT: (further breakthroug h of guilt) TH: Positive feelings there also? PT: Yes. TH: A nd then m y burial w h a t . .. PT: Ohhhhh. TH : H ow that loould be like? PT: Ohhhhhh. TH: H m m? You loould be at m y burial? (B reakth rou gh of w aves of guilt-laden unconsciou s feeling). It is im p ortant to note that the u nconsciou s has not, as of yet, transferred the m urdered b od y o f the therapist to the dead b od y of the g en etic figure, w hich shortly as w e will see is the m o th er T h rou g h ou t th at passage, there wiU be m ajor w aves of painful feelings. Now, we retu rn to the interview . PT: TH: PT: TH: PT: TH:

I think I'd w ant to hide from it, but I'd be there. I'd be afraid. Afraid? O f who? O f those that loved you. (cries) Those? W ho love you an d seeing the person luho'd m urdered you. Because there is an elem ent o f death, m urder and death hmm. But who com es to you r mind, because the one w ho loved me loho w ould be m ostly affected by this, by m y death? In term s o f thoughts. PT: Children. TH: There w ould be children? PT: All those w ho'd be close to you, frien ds, most, m ostly fam ily. TH: W ho w ould be m ost hurt about this death? PT: Well a child. TH: Child. In a sense the one that they w ould be m ostly affected w ould b e . . . children

At this m om ent, there is an oth er m ajor w ave of guilt-laden painful feelings; and the unconscious therapeutic alliance clearly identifies the identity of the m urdered therapist, w hich is the dead mother. His voice is choked -u p and w h at em erges is the m urderous rage to strangle the m o th er T h e focus is on the m urderous rage tow ards "m y m other," m urderous rage to throttle h er n eck to death. PT: It is m y mother. TH: You say that, or that com es . . . PT: I can see it, it is m y mother. W hat we have seen so far in d icates m ajor w eak en in g of the resistance and m obilization of the u ncon sciou s therap eu tic alliance, w h ich is n ow in com m an d of the process.

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Analysis of the Transference N ow the th erap ist retu rn s im m ed iately to the p h ase o f analysis o f the tran sferen ce b efo re h e u n d ertakes the d y n am ic exploration. For the sake of brevity, so m e asp ect o f this part o f th e in terv iew is om itted , o th erw ise it rem ains verbatim . TH : It is very im portant w e exam in e it. PT: W ell I think . . . so afraid to shoiv it. TH : I know, hut you see that is w hat loe see. PT: I loould d ie m y self if I show ed it. TH : You see, you h ave developed a set o f m echanism s fo r 46 years to deal w ith these buried feelin g s, w ith this buried m urderous rage, the painful gu ilt feelin g s an d obviou sly other feelin g s. PT: Yes. (h e is sobbing) TH: N ot on ly the m urderous rage an d the gu ilt but also other feelin gs, the feelin g o f sadn ess an d the g r ie f about the loay life has gon e fo r you. PT: (co n tin u es cryin g) (w h isp erin g) TH : T here m ust be a trem endous painful feelin g in you, the pain o f being left by your parents . . . an d that there are a lot o f feelings that a big chu n k o f you r life has g on e in w aste an d m isery, hm m . PT: Yes. (w h isp erin g ) TH; S om ethin g has to explain w hy you are so terrified o f anger, hmm. O bviously, as w e see, there has been a m ajor seethin g rage that you could m urder her an d the g u ilt feelin g s abou t it, hut also the m ajor pain o f being dum ped by her and the w ay you have dealt loith this, the pain o f being abandoned, the seething rage and the gu ilt that m ade you a paralyzed man and that this was a defense m echanism again st all o f these feelin g s, hm m ? PT: (w h isp erin g ) / can see that, (con tin u es crying) TH : D o you folloiv me? D on't agree zvith w hat I say. H ere w e are fo r you to exam ine them . PT: I can see . . . (w h isp erin g) (he is v ery sad, w ith a low voice) TH : That this need in you to suffer, this need in you to perpetuate suffering and m isery, the need in you to destroy y ou r potentiality, all are m echanism s o f d ealin g w ith this pain, m urderous rage an d gu ilt which is w ithin you, that you w ou ld put y ou r hands over h er neck an d choke an d choke until she w ould be dead. D o you fo llo w me? PT Yes. TH : A n d that the w ay you dealt loith it is to becom e a paralyzed man, to lose you r au ton om y an d freed om as ivell as a m echanism o f dealing w ith that. But obviously, w e haven't so fa r touched y ou r feelin g s tow ards y ou r father, you r brother, an d obviously there are other fig u res in you r life such as you r aunt and y o u r gran d m oth er a s well. In the ab ov e p assag e, th e th erap ist d rives h o m e in sigh t in to the asp ects of the p s y ch o p a th o lo g ic a l d y n a m ic fo rces th a t are re sp o n sib le fo r th e p a tie n t's d istu rb a n c e s, h is m a so c h istic c h a ra c te r p a th o lo g y , th e "p e rp e tr a to r o f th e u n co n scio u s" (D av an loo ), w h ich m ay b e su m m arized as follow s:

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Intensive Short-Term Dynamic Psychotherapij (a) (b) (c) (d) (e) (f) (g)

Attachment and the bond: Abandonment and the severe trauma; The pain of the trauma; Murderous rage toward the mother by strangling her; Intense guilt-laden unconscious feelings and; Intense grief-laden unconscious feelings; the whole set of character defenses "you have developed a set of mechanisms for 46 years to deal with these buried feelings, with this buried murderous rage."

It is im portant to n ote that the therapist is clearly w^orking w ith v\rhat the process so far has covered and w^hat the unconsciou s therapeu tic alliance so far has introduced. At no poin t he m ad e a com m u nication that the patient m ay have rage tow ard his father, broth er and so forth; and this is an im portant aspect of the technique.

Major Communication from the Unconscious Therapeutic Alliance Murderous Rage towards the Brother N ow the pow erful dynam ic force of the unconscious therapeutic alliance spontaneously introduces the p atient's m urderous rage tow ard his brother. H e spontaneously talks about an in cid ent in w hich h e w as near to m urder (his brother). PT: TH: PT: TH: PT: TH: PT:

TH: PT: TH: PT: TH:

PT:

Sham e an d gu ilt and . . . all because . . . is I tried to hurt m y brother very much w hen I luas very young; throiuing scissors at him in a fit o f rage. Fit o f rage? Yeah. With your brother. 1 lost my tem per and . . . 1 mean there was an incident? I have stron g m em ory o f this, o f gettin g enraged w ith him. The last tim e 1 lost my tem per and fe lt the rage I had scissors in my hand and 1 picked them up and I threio them at him. H ow big loere the scissors? Big scissors. Oh one o f those okay. Hoiu did you throw it at him? W hat luas the incident? The incident uh I . .. he he got me angry, my brother an d I could alw ays get each other angry, very, very angry. Hm hmm. (the incident as he describes it is as follow s. The brother had bent down to put his overshoes on, and the patient threw the scissors lohich could have got on the brother's neck, as patient shoios it with his body m ovem ent, but the scissors went into the overshoes) A nd I could get him very angry, he could get m e very angry. I don't know what it was that he got me angry with, I was . . . all I knoio he loas holding a pair o f those overshoes that xve w ould put on an d I can rem em ber ju st scream ing in rage and throw ing them and having them, having them stick loith the knife into the shoe.

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TH : PT: TH :

Stick w ith the knife? N ot stick w ith the knife, the scissors. Scissors.

PT: TH: PT:

Into the, into the boot that he was holding. H ow ? You m ean the scissors . . . The scissors I threio them an d sss . . . they w ent right into the boot that he was holding. That had? You m ean that heavy? Yes. You m ean then i/ow loere really enraged. I was . . . y es I w as totally out, en raged . . . totally out o f control. A n d then the scissors w e n t . . . W ent right into t h e .. . these these rubber boots you know, w ent right into the boot. A n d then?

TH : PT TH : PT: TH : PT: TH : PT: TH : PT: TH: PT:

TH : PT: TH : PT: TH : PT: TH : PT TH : PT: TH : PT:

I don't kn ow ivhat happen ed im m ediately after but I rem em ber that being the last tim e; 1 said no more, that I'm g o in g to . . . I kn oio h u t . . . I don't knoio w hat happen ed right after. I don't have a recollection. Noiu if it had g o t on his neck w hat w ould have happened? O hhh . . . (d eep sigh) (T h e c o m m en t o f the th erap ist "if it had got on his neclc w h at w ould h av e h a p p e n e d "— at this m o m en t h e h as sh iv erin g w ith som e tremor. H e is v ery sad and tearful). I f that scissors had got like that on the neck w hat do you think w ould have happened? Ohh w ould h ave been aw ful. P icturing I mean. Picture him bleedin g a n d I picture m e j u s t . . . W hat part o f the neck w ould catch ? A h into the neck right there. L ike this? Yeah. So in a sen se ivould g o over the neck like that and then? Then I see m y s e l f . . . I w ou ld . . . then w e ju st dissolve, ju st, ju st be . . . the rage w ou ld be g o n e in in . . . I knoiv but w hat w ould happen to him? H e w ould die o r he w ould bleed very badly an d I w ould try to stop it. I . . . I . . .

I'd b e . . . TH : So then h e w ould be m urdered. PT: H e ivould be m urdered. TH : H m m ? PT: Yes. (d eep sig h in g w ith m ajo r w ave of p ainfu l feeling) TH : So then there is also this m urderous rage an d gu ilt tow ard you r brother. H is b ro th e r is 4 years old er th an the patient. In a painful state he says "H e w as the first b a b y and w as privileged to h ave a m oth er and a fath er u ntil th e age of four." It is im p o rtan t to n ote th at as he describes the in cid en t he is fully in touch

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w ith the m urderous rage the w ay he held the scissors, the way he threw the scissors, ar\d the w ay they w ould have gone into his b ro th e r's neck. A shivering m om ent indicated his reaction and his intense experience of the guilt and the w hole psychophysiological concom itant characteristic of the passage of the guilt. In the sum m ary of this article, I will briefly discuss m y research data on the im portance o f the actual experience of the passage of the m urderous rage, the in ten se g u ilt-lad en u n co n scio u s feelin gs an d th eir p sy ch o p h y sio logical com ponents in the here and now, and their relation to structural character changes.

Death and the Funeral of the Mother After the passage of the guilt-laden u nconscious feelings, the patient cam e w ith a m em ory of a picture w ith his broth er sm iling and "is happy w ith his m other." It is im portant to n ote that he refers to "h is m other," referring to the m other of the brother. T h en h e com es w ith a vivid m em ory of his broth er crying over "h er d eath ." T h en he spontaneou sly talked about th e death of his mother. She died at the age of 67, as a result of a m assive blood clot. T he therapist makes a d ynam ic exploration into the circum stances su rrou nding h er death. O n the w ay to attend h er funeral, h e shed tears. T h en the focus of the process is on the funeral. TH: Hoiv did she look like at the fu n eral . . . ivhen you looked at the dead body? (Patient is sad and tearful) PT: N ot m y mother. TH: W hat did she look like 1 mean? PT: The body, the body ivas hard, the fa c e was hard an d bitter. The fa ce was sharp and and, and uh . . . cold. TH: Hm hmm. PT: A nd 1 thought that's not m y mother. But I didn't feel, 1 didn't feel, 1 didn't cry. I didn't fe el that feelin g o f em otion until at the fu n eral the m om ent they closed the casket fo r the last time. TH: W hat was you r goodbye to her? W hat did you tell her at the last goodbye? PT: (heavy sobbing) /ju st said goodbye. (B reakth rou gh o f a m ajo r w ave of painfu l feeling.) PT: Iju . . . I ju st said goodbye, (very ch oked -u p voice) TH: But what did you say to her? PT: It was som ething very sim ple like goodbye . . . TH: You touched her an d said goodbye? PT: I did touch, (grasping h er hand) TH: So you touched the hand and said goodbye.

Two Hours with his Mother N ow, th e u n con sciou s th erap eu tic a llia n ce in tro d u ce s an in cid e n t w h ich intensifies the p atien t's painful feeling. In a v ery h igh ly ch arged , em otional state, he sobs. This is so in ten se th at it in terferes w ith his sp eech and h e says that h e only sp ent 2 hou rs in his life w ith his m other, and it w as som e m on th s prior to h er d eath. We retu rn to the interview .

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I said goodbye. (Pause) I think it's i m p o r t . . . the year ju st before, I had n o t . . . I didn't see m y mother, I hadn't know n her as a person at all, and literally that Iw ppened in the winter, I gu ess it was the fall, that ivas in January. A nd in October she w as in town, an d fo r the fir s t tim e she cam e to visit an d loe w ent out together fo r d in n er . . . ju s t fo r lunch, and spent 2 hours ju st talking. That's the first and the last tim e that's ever happened, (voice breaks) A nd I loas very grateful, (sobs) You mean that O ctober was the first an d the last time that you had together I g et pretty . . . (m ajo r w ave o f p ainfu l feelings) So you m ust have a lot o f m ixed feelin g s about life with you r m other Yeah. We never lived as a fam ily, even w hen w e . . . after the war. We alw ays lived w ith m y g ran d m oth er an d . . . aunts. But w here w as that? We are a r e s t . . . a little restaurant, zvent to a little restaurant. You an d y ou r mother. Ju st m y m oth er A n d you say this is the fir s t tim e that you . . . First tim e I ev er sat dow n an d w e talked about anything, an ythin g that ivas person al . . . or . . . an d even then it was a start, it was ju st a little . . . (loud sobs) (ch oked voice) I'd loved to have knoum her as a person. W hat? I'd h ave lov ed to h av e know n h er as a person an d not as a mother, not as that . . . sh e w as n ever p a r t . . . m y parents, n either o f them had ever been people to me. Even m y father, even now I can't reach him , not . . . I try an d it's im possible. Hm hm m . So then there is a lot o f m ixed buried feelin g w ithin you.

Further Dynamic Exploration H e fu rth er talked ab o u t h is m other, h e and h er alo n e to g eth er in th e little resta u ra n t w^hich h e refers to "a lucky ch a n ce ," "w e sp e n t a good 2 h ou rs tog eth er," an d th a t h is talk w ith his m o th er w as "a t a m u ch d eep er lev el th an I h ad ev er ex p erien ced b efo re." " S h e w as in good h ealth ." H e d id n 't see h e r ag ain after th a t; sh e d ied su d d enly. H e again talks ab ou t th eir tw o h ou rs together. "It w as sp ecial, I h u g g ed her." (b rea k th ro u g h o f a n o th er m a jo r w av e o f p ain fu l feelin g ) H e in d ica ted th a t it w as so m e th in g so d ifferen t th at had n ev er h a p p en ed b efo re. T h e n a few m o n th s later, his fa th e r telep h o n ed an d told h im th at sh e had died su d d en ly. T h e p a tie n t felt n u m b . H e th o u g h t of excuses, all o f th e reason s he cou ld n o t go to th e fu n eral. B u t fin ally h e w en t an d saw h er o n v iew the day of th e fu n eral. It w as d u rin g th e w inter, w ith h eav y sn ow an d th ey c o u ld n 't b u ry her. B u t th e n in th e sp rin g his fa th e r bu ried h er and th e p atie n t co u ld n 't go. In a sad state h e talked a b o u t his early y ears an d th e m em o ry of his au n t tak in g him to th e city w h ere h is m o th er lived , w h ile h e alw ays h ad the m em o ry th at his m o th er ca m e to visit h im . T h e realization o f this, th at sh e n ev er cam e to visit him m ob ilizes fu rth er w av es o f p a in fu l feelin gs. In his m em o ry his m o th er n ev er sh ow ed a n y em o tio n . T h e focu s is o n his g rief-lad en u n co n scio u s feelin g s, and h e in d icated th a t h e realizes th a t his feelin g s are d eep ly b u ried , "h a d b e e n bu ried an d c o n tro lled ."

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Further Analysis of the Transference After the passage of these w aves of painful feelings, on ce m ore the therapist m oves to the analysis o f the transference. First his rage, follow ed by m urderous rage, and finally the m urd er of the therapist b y strangulation. H ere, the therapist once again recapitulates on the w hole set o f u nconscious character d efenses that he had used in the transference and its link w ith the u nconscious anxiety, and its further link to the u nconscious m urderous rage. T h e therapist clearly and explicitly points out the w hole set of ch aracter defen ses in the transference. "T h ese are all a set of m echanism s you used in dealing w ith you r m urderous rage tow ards m e," and further points out that the m urderou s rage in the transference w as the m urderous rage tow ards the m other. T he therapist m aintains the focus on the m other and further indicates the traum a o f ab and onm en t, the m ajor pain of the traum a, the m urderous rage, guilt and grief-laden feelings and the w hole set of ch aracter defen ses th at he has d eveloped to d efend against aU these buried feelings. T h en the therapist focuses on his m ixed feelings in relation to his brother; the m urderous rage, guilt and grief and the w hole set of m echanism s he used to defen d against these buried feelings. T h e therapist, so far, on ly em phasizes the m oth er and the broth er and points out to the patient, "O f course w e h a v e n 't tou ched you r father yet." Patient's response indicates that h e is w ell in touch w ith the process. PT: Yes, I . . . I . . . I . . . it m akes sense. TH: Hmm? PT: It m akes sense to me. TH: N ow my question is this, do i/ou get depressed?

Exploring the Episodes of Depression A fter the first b reak th rou g h into the u ncon sciou s m u rd erou s rage and guilt, for the first tim e the m ajor d efen se m ech an ism respon sible for the depression, nam ely the in stan t rep ression of the m urd erou s rage, has b een w eakened to a m ajor extent; and it is im p o rtan t th at the therapist explores the episodes of depression and drives h om e fu rth er insight in to that m ech an ism . H e indicates that he suffered from episod es o f d epression. T h ey alw ays follow episodes of periods of m ajor conflict w ith his w ife, or w h en the m arriage is threaten ed to b reak up w hich m ight result in the b reak d ow n of the relationship w ith his tw o children. W h en d epressed , he says he is like "h a lf a p erson ," "close to a state o f paralysis." H e stays in bed, suffers from poor con cen tration , and his th ou gh ts b ecom e fatalistic and gloom y. In his y ou n g er years, b efore h e got m arried, h e had two m ajor episodes of d epression, each lasting a few w eeks and both of th em follow ed a breakd ow n of a relationship w ith a w om an. Suicide w as explored, and h e has never b een suicidal. T h en the th erap ist fu rth er explores his relation w ith his w ife.

Exploring his Relation with his Wife H e indicates that h e has no jo y in seein g her, fu m in g inside b u t silent, w ithdraw n and d etach ed outw ardly. T h en he talked about a recen t in cid ent. H e

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had picked up his w ife at the airp ort, had forced iiim self to show h er that h e had b een lo o k in g forw ard to h er retu rn . "I d id n 't h ave the jo y of seein g h er back ." H e fu rth er em p h asizes th at th ro u g h o u t his m arriag e he had learned to pu t up a facad e, to p re v en t h er from g ettin g angry, explosive, and critical. A fter they retu rn ed h o m e from th e airp ort that n igh t sh e w an ted him to m ake love to her, but h e co u ld n 't resp on d so sh e got an g ry w ith a bitin g tem per, criticizing him and p u ttin g h im d ow n . "S h e kn ow s m y w eakn esses." This w en t on until h e got angry and th e w ay h e h a n d led it w as b ecom in g totally d etach ed , w ith d raw n and silent. N ow , th e th erap ist m akes a link b etw een the tran sferen ce and his w ife. We retu rn to th e interview . PT: TH: PT: TH:

PT TH : PT: TH : PT TH: PT: TH:

I w as very an g ry zoith m y wife, but again I becam e loithdraiun, silent an d remote. So you loithdraiv then. I ivithdraiv into silence, I . . . I . . . I don't say anything. So silen ce is an oth er m echanism . Do you notice also silence w as with me?, was anoth er w ay o f dealin g w ith you r anger. W hen you w ere enraged w ith m e you took a silen t position. Yes, I . . . I think. You say that because I . . . N o, no, no you're right, you're right. You luould say som ething an d . . . then I g o t silent, detached . . . w ithdraw n. A n d then she is an g ry w ith you huh? Yes. A nd then w hat happens to you? A nd then, then it gets w orse, then I w ithdraw even fu rth er or I . . . So that m eans there is m ore an ger in you?

T h is m ig h t resu lt to fu rth er escalation an d sh e m igh t th reaten to term in ate the m arriage. T h e th era p ist k n ow s th at u n d ern e a th the an g er is m urd erou s rage. It is im p o rta n t to n o te th a t th e th erap ist ca n sim ply in terp ret this, b u t by d o in g so he is m ak in g a m a jo r m istake. As I em p h asized earlier, the p atien t m ust actually ex p erien ce, in the h ere and now , if h e has m u rd erou s rage tow ards his w ife, and m ost im p o rta n tly in terp reta tio n should com e from the u n con sciou s therap eu tic alliance. A gain w e see a m a jo r an d fu n d am en tal d ifferen ce b etw een the trad itional p sy ch o an aly tic system an d m y tech n iq u e. T h e th erap ist reem p h asizes th e set o f m ech an ism s that h e u ses again st his n eg ativ e feelin gs in relation to his w ife. "B u t this is im p o rtan t th at you exam in e som e o f th e se seq u en ces," em p h asizin g that th e m ore an g ry h e gets th e m ore silen t an d w ith d ra w n h e b eco m es, w h ich sets the stage for m ore an g er in his w ife w ith criticism ; sh e b eco m es m ore d em a n d in g and puts him fu rth er d o w n , th en he b eco m es m o re d eta ch ed , rem o te an d m ore silent. T h en h e p oin ts ou t th at his w ife b eco m es p h y sically v iolen t, atta ck in g him w ith h er fists on his h ead , w ith him p ro tectin g him self, h o ld in g his h an d s ov er his face; an d th e n sh e th reaten s to term in a te th e m arriag e. T h e n h e in d icates th at h e m oves in to a state o f paralysis and th e n d ep ressio n takes over. H e em p h asizes th e tw o asp ects of his w ife, one b ein g critical, d em a n d in g , explosive, etc.; b u t the p en d u lu m can shift to the oth er side w h ere sh e b eco m es d istan t, rem ote an d w an ts to b e left on h er ow n , and

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"none of us could feel h er p resence." T h en h e spontaneously said that there has b een m any incidents w h en he felt "so frustrated, w h ere I w anted to strike out." P I'

Again i t . . . i t . . . it w ould he . . . as I say it's happened several times. It would he that point o f her saying you know "You leave m e in silence and you gotta stop doing that. Do som ething! You can do som ething. You can do som ething, you can do som ething, you can do som ething." TH: A nd then she w ould he after you to do something. PT: To do som ething. "You gotta do som eth in g !" . . . and dem anding in a preaching voice.

Direct Experience of the Murderous Rage in Relation to his \^fe Throu gh ou t this passage, he is clearly experiencing an in ten se violent rage tow ards his wife. H e is sitting straight up, high ly charged, his hands are in the upw ard position, ou tstretch ed , opposite to each other, exactly the sam e w ay he was w h en he w anted to throttle the therapist. H e is experiencing his m urderous rage. N ow w e return to the interview . TH: I f you had let y ou rself go . . . PT: W hat w ould I do? TH: H ow the attack on her w ould have been ? With you r brother it was scissors on the neck, with me it loas the hand on the neck to throttle an d with your m other it was the hands on the neck and again to throttle. PT: Well I certainly can see the hands on the neck too; choke an d stop the, stop the talking and . . . (W ith his tw o h an d s h e is sh ow in g h ow he w ould m urder his w ife by strangling her.) TH: H ave you experienced it like this with you r wife? PT: N ot at the time. It w as ju st w hen you asked me w hat loould I do an d and . . . TH: W hat com es to you r m ind if you . . . PT: It's the throttling that w ould stop the, stop the talking. TH: H oio ivould you g o on her neck? PT: Again it zoould be in the bed an d I'd be on . . . TH: In bed. PT: She w ould be in the bed. TH: A nd then you are? PT: I'm, I'm over her an d throttling her saying "shut-up, shut-up, shut-up I don't w anna hear an y m ore." TH: Hoio ivould you do that? PT: A nd I w ould uh an d hit itup an d doion an d up an d doivn on the bed;shut-up, shut-up. (Inten se sadness; b reak th ro u g h of a m ajo r w ave of painfu l feeling) TH: Yeah hut hoio you r voice w ould be like i f . . . PT: I w ould be scream ing, (w eeping) T h e strangling of his w ife takes place in bed. T h e therap ist em ph asizes the sim ilarity of the passage of the m u rd erou s rage in the tran sferen ce to that w ith his

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m o th er and n ow to th at w ith his w ife. T h en the p atient says "Yeah, a v ery stron g h an d m o tio n ." N ow th e th erap ist m oves to som e analysis o f the process, reem p h asizes th e sim ilarity o f the w ay he experien ced th e m u rd erou s rage tow ard s th e th erap ist, his brother, his m oth er and n ow to th at w ith his w ife, and h e follow s it clearly. It is im p o rta n t to n o te th at th e forces of resistance to a m ajo r exten t h ave b een w eaken ed and the u n con sciou s therap eu tic allian ce has b een m obilized to a d egree th at it is in com m an d of the process. T h e therap ist con tin u es his dynam ic exp loration in to the p a tie n t's m arriage. H e explores the p atien t's sexual life and q u estio n s h im h ow his d eta ch m e n t, w ith d raw al and silence affects his sexual life and his erection . TH :

So then in a sense, y ou r relationship ivith your w ife is quite storm y an d as you, yourself, put it, you are paralyzed, you have to comply, you have to perform an d you have to do y ou r best by pu ttin g on a facade. But at the sam e tim e there is a m ajor volcano ivithin you. PT: Yes, it's qu ite right, it is. TH : Then she is like a pain on y ou r neck. PT: Like a pain in the neck. G et rid o f the pain in the neck. TH : You sm ile w hen I say she is a pain in the neck. PT: N o, 1 . . . w ell it w as the relationship to throttling her by the neck an d the pain in the neck. It is im p o rtan t to n o te th at this m an suffers from freq u en t episod es of pain in his n e ck and also th e m u rd er of his w ife, his b ro th er and his m oth er is at th e n eck le v el, w h ich d em o n stra te s th e m ech a n ism o f p ro jectiv e id e n tifica tio n and sym p tom form atio n . B u t at this m o m en t the therap ist co n cern s h im self w ith the in cid e n t at th e airp ort, w h ich th e u n con sciou s therap eu tic allian ce h as in trod u ced . T h e th erap ist raises th e q u estio n h ow he w ould have felt if h er p lane had crash ed ? T h is tech n ica l in terv en tio n , as w e will see, is im portant. TH : PT: TH: PT TH : PT: TH: PT: TH :

a crash and Now, if the pain in the neck, say f r o m ___t o ____ had . . .there luas y ou r w ife had died. Wlrat w ould have happened to you an d you r life? I'd fe e l free, fir s t o f all I w ould fe e l free, an d no . . . I've often thought o f it. You've had often thoughts that if she drops dead then you luould be . . . It w ou ld be a relief A fr e e man you mean. That's the fir s t thought, that, that is the initial .. . that's, that's . . . I think beyond that hut yes there is a sen se o f relief. R elief I f it w ould end. C ou ld w e look to y ou r thoughts. A gain w e are exam ining these thoughts.

P T Yeah. TH: W hat w ay sh e w ou ld die? PT: It doesn't seem to be specific, it doesn't seem to matter, 'cause I also think if she w ere to w alk ou t the door tom orrow an d say I'm leaving 1 w ould fe e l relieved. So TH :

its the g o in g away. So in a sen se she is such a pain in the neck that you look fo n v a rd to her death in a sense.

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PT: TH: PT: TH: PT: TH: PT:

(sighing) 1 don't knowwwio. But it's very im portant you exam ine your feelings. Yes, that's right, that's right. You have to face with the truth. Yes. You see, even if that truth is an ugly truth. 1 mean "trooth", you have to face with it. Yes, it is quite right.

In the above passage, w ith a great feeling of relief he talked about the death of his w ife; and the process clearly d em onstrates that the resistance is not present and that the unconsciou s therapeu tic alliance is in com m and, and the therapist em phasizes the ugly tru th that he has to face. Patient has already adm itted to active d eath w ishes for his w ife and the therapist m oves to the in cid ent that he w anted to strangle his w ife. T h e therapist attem pts to explore his feelings in relation to the m urder and the d eath of his w ife. TH: . . . and if she dies, and already you have described how you throttle her to death. W hat she w ould he like w hen you strangle her in the bed? You have strangled. PT: I strangle her an d I see her then at peace. In the follow ing passage, the therapist focuses on the dead body o f the w ife, and it is im portant to n ote that he sp on tan eou sly links it w ith th e portrait that he had already m ade o f the throttlin g and m u rd erin g of the therapist. Su d d en ly there is a m ajor passage of guilt-lad en u ncon sciou s feeling. His Feeling for his W ife TH: She's at peace. PT: A nd I'm at peace because she's at peace because she . . . TH: But hoiu does she look in bed? PT: H er eyes are closed and her hair is fram in g her head like an O phelia or som eone like that loho is lying dead an d is now peaceful. TH: A nd how do you portray her body in bed? PT: Ju st lying an d ah with her head on a pillow an d she's got long dark hair and just fram in g her fa ce and she's . . . an d and she's not saying anything anym ore, eyes are closed and her fa ce is in repose. I f I also see in my mind's eye her face all distorted as I pictured yours as eyeballs staring out an d tongue protruding and the violence o f having killed her that w ould be awful. TH: A nd how ivould you feel towards her? PT: A aah if . . . again . .. H aving killed her, if it's violent and an d the eyeballs are staring and so on and then the rage is gon e then, then again the rem orse because I care fo r her too. TH: You mean there are also positive feelin gs for her? PT: Yes I've got a lot o f positive feeling. (low voice) (Intense sad ness and the passage of w aves of painful feelings) TH: O ne o f the other issues is this, do you notice that as much as you have problem s with the negative you have problem s also zvith the positive? PT: Aw yes.

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It is im p o rta n t to n o te that w h ile p ortray in g the face of th e m urdered b od y of his w ife, h e sp o n tan eo u sly b ro u g h t th e portrait of th e m u rd ered b od y of the th erap ist "ey eb a lls starin g ou t an d ton gu e p ro tru d in g" (and after the passage of the m u rd erou s rage tow ard s the therapist, the m u rd ered body of the th erap ist w as tran sferred to th e m u rd ered b od y of the m other.) This form o f in terp retation u sually is m ad e b y th e p atien t after high m obilization of the u ncon sciou s th erap eu tic alliance. T h e p rocess n ow en ters to the ph ase of con solid atio n, and the therapist an aly ses the m ech an ism o f p ro jectiv e id entification and sym ptom form ation. H e fu rth er reem p h asizes th e m u rd erou s rage in the tran sferen ce, w h ich w as the m u rd erou s rage tow ard his m oth er and the gu ilt-laden u n con sciou s feelings and m u rd erou s rage tow ard his b ro th e r and the in ten se guilt-laden feelings; and b rin gs in to th e focu s th e m u rd erou s rage tow ard his w ife w ith in ten se guilt, as w ell as his p ositiv e feelings. T h e th erap ist is w ell aw are that the m ajo r resistance w as m obilized w h en he focu sed o n th e b od y o f L ind a, w hom he brings into the bed w h en he has in terco u rse w ith his w ife. T h e id en tity of L inda so far has b een a m ystery, b u t now the u n co n scio u s th era p eu tic allian ce m akes it absolutely dear.

Major Communication from the Unconscious Therapeutic Alliance A fter h e talked ab o u t his p ositiv e feelings for his w ife he sp o n tan eou sly talks ab ou t h is tw o ch ild ren , a d a u g h ter aged 18 and a son aged 16 and em p h asizes that his life cen ters a ro u n d his tw o ch ild ren. "All the passion that I d o n 't feel in the m arriag e I feel it w ith m y ch ild re n ." T h en he talked ab ou t his d au g h ter Isabel, sayin g th at "sh e is b rillian t." PT. TH : PT: TH : PT:

She is slim , blond, with blue eyes. Is blond? She is fa ir haired, it's honey blond, it is fair. O kay, she is blond. B lond a n d slim an d both p assion ate an d w orried an d fru strated about life an d ive talk a lot, uh, abou t all kinds o f things she shares ivith me, hoio she feels about things, an d h er troubles. So w e share a lot o f things. Uh blue-eyed, an d she

w orries a lot. TH : H ow is the physical expression o f affection like betiveen you an d you r daughter? PT: I h u g her a lot an d she hugs m e a lot. TH : Realty you fe e l open? PT: O hhhh yeah, oh yeah. TH : O h I see. PT: A nd y et I d o n ’t think she . . . she's physically em otional. TH : W hen you h u g h er an d hold her do you get flash es o f the past? PT: (d eep sigh ) U hhhh I think o u t . . . like it's certainly . . . TH : You see on e thing sign ifican t in y ou r past is the absence. PT: That's right, I m ean 1 think it's because o f the absence o f that connection that I fe e l so, so strongly. T here cam e a tim e last year lohen ive alm ost separated, my w ife an d I. A nd w hen it cam e to it, if the children hadn't been there I w as gone,

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TH: PT: TH: PT:

TH: PT: TH: PT: TH:

PT:

TH: TH: PT: TH: PT:

I wouldn't have stayed. But when it cam e to the actual night to go and I told the children I j u s t . . . j u s t . . . ( cri es) . . . ju st couldn't leave, So with Isabel you capture the past in a sense. A nd with my son, we're very close. I know, but we can g o to that as well. Yeah, yeah. Very close. Uh yeah but it's a . . . b ut I can see a very close link there, I couldn't leave them fo r one m inute (choked-up voice) (breakthrough of w aves of painful feelings) W hen you hold her or hug her you get the flashes o f . . . I . . . is that w hat it is? Like am I consciously . . . Is buried and repressed in you but unconsciously you m ust be feelin g . . . Yes. . . . the experiences that you wish you could have had in the past. You see what 1 mean? Because there is a m ajor gap in you about you r life in these early years you see. The craving fo r a tender affectionate relationship hm m with . . . Yeah, an d I thitik I crave that fro m m y wife, and I don't get it because she's not my m other an d she refuses to he a mother. A nd I think also that relates to in this other w om an Linda I w as m entioning, is that my . . I sense that my passion fo r her or m y sense o f w anting to be with her is because I sense the m othering and caring. She's a close friend. Yeah I'm talking about the affectionate. But w e keep with Isabel. Yeah. You say you r daughter reciprocrates and you are able to both exchange a tender affectionate feelin g fo r each other? Yes, yes.

In the above passage th e u ncon sciou s th erap eu tic alliance clearly identifies the w om an that he brings into bed d u rin g in tercou rse is his daughter, w h o is slim, blon d , w ith sm all breasts and b lu e eyes. T h e u ncon sciou s has in trodu ced two portraits: one is the portrait of Linda, the oth er is the portrait of his daughter, w hich are exactly identical. T he therap ist follow s the com m u nication and raises the question to the p atient if he had had a w ife like his daughter. TH:

PT: TH: PT: TH: PT: TH: PT: TH:

Look, if you carefully exam in e you r m ind hm m , if you had a luife like your daughter, how w ould you portrait that? Again w e are talking about som ething that is heavy but is again very im portant. H as it ever passed through you r m ind that if you had a w om an like Isabel? N o I think not. I know because you suppress it. You have a tendency to suppress. You knoio what I mean by suppress? Push it aside. But the most im portant fo r you is not to go to that. Yes. Very carefully exam in e even if it is painful because she's your daughter. Yes. But a part o f you m ight at times have flash es that if you had a wife, or a ivoman

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Yes.

TH:

Noiu has such a thing, like a flash , a split-second, at tim es has passed through y ou r m ind? PT: W ell not that thought. TH : W hat thought? N ow the unconscious therapeutic alliance b rin gs into the o p en his in cestu ou s feelin g s for his daughter. PT:

TH : PT: TH : PT: TH : PT: TH : PT: TH : PT TH : PT: TH : PT TH : PT: TH : PT: TH : PT: TH: PT: TH : PT: TH : PT: TH : PT: TH : PT: TH : PT: TH : PT: TH :

I kn ow that . . . w hat w hat . . . as she was becom ing a w om an I was certainly aw are o f how easy it m ust be som etim es fo r incest to occur. I w as certainly aw are o f a physical response to m y daughter. In a sen se you have som e incestuous thought about her. Yeah, yeah. W hat exactly y ou r incestuous thoughts arc? W ell I m ean I can fe e l a stirrin g o f m y body, my m y . . . I get an erection. You iv o u ld feel an erection? Oh yeah I w ould, I w ould, I iv o u ld feel it an d an d be aw are o f it an d . . . W hile sh e luas . . . W hile, w hile I w as . . . yeah w hile I was sitting an d talking with her on her bed or it cou ld be som e intim ate, intim ate situation. A gain these things are painful. Yeah, u h . . . But ou r jo b is to exam in e them carefully. The fla sh is as if w hat it w ould be like to m ake love to her. A n d you have also erection w ith it? Yeah. H m hm m , that she w ou ld be nude? N u de yes, or partly so. You have seen h er nude? I see her, I m ean even noio. H ow she looks, . . . her body? She's beautiful. I know but how w ould you describe? I describe h er as uh . . . She's blond in the h air B lond in the hair an d black in the pubic hair. H er g en ital is black. Yes black. Uh an d she's very slim. Slim. Yeah she's . . . A n d sm all. . . . she's not big at all. H m hm m . Uh an d you know h er breasts are ju s t small. Small. S m all breasts So then in actu ality y ou r dau ghter is slim , w ith sm all breasts, blond hair.

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PT: TH: PT: TH: PT: TH: PT:

Yes. D ark genitals. Hmm. A vd you have had passing thoughts about a sexual relationship loith . . . Yes. ' A nd that obviously is som ething that passes through you r m ind and you even have erection. Yeah, it has.

It is im portant to note that the unconscious tiierapeutic alliance has m ade two m ajor com m unications: that he has incestuous feelings, even erection, in relation to his daughter and that the w om an he brings into the bed during intercourse w ith his wife is his daughter, w hich clearly explains w hy w hen the therapist w as exploring the body of Linda the resistance w as m obilized. N ow we return to the interview. TH: A nd very im portant again you exam ine this, when you are m aking love to your w i f e . .. PT: Yes. TH: . . . and you bring another loom an . .. PT: Yeah. TH: . . . okay? W ho is that wom an that you bring into the bed? PT: m i l . ' . . TH: It's very im portant because the woman you described . . . PT: . . . is like my dau ghter But it's n o t . . . TH: But you see, look, you are here to exam ine rather than to repress these issues. PT: Yeah. TH: Okay, because the essence o f all these things is to fa ce with the truth . . . the ugly trooth, which is T-R-O-O-T-H. PT: Yeah. TH: Because the question is this, the one that you described w as blond, slim, small breasts and genital dark. PT: (m um bles) TH: A nd then w e know you g et this kind o f thought about the sex an d sexual feelin gs fo r your daughter. Noiv the question is this, zvho is the woman when you are m aking intercourse with you r wife? PT: (sighs) TH: I knozv as a fa th er it's very painful to declare this, but at the sam e tim e you are here to fa ce w ith the truth o f y o u r . . . PT: Well it's . . . TH: Because you are now 46 years, you have been running aw ay from fa cin g with your buried feelings. PT: Yes. TH: But it is tim e you exam ined them, fa ce with them, an d fa ce with the truth. Then you w ould be a fr e e man. Then you r relationship w ith you r daughter w ould also follow a different perspective rather than . .. PT: You sec, I haven't had the . . . I've never thought o f that before, (sighing) TH: I know, but that is exactly the w om an that you describe luhen you are m aking love. It is exactly you r daughter.

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PT:

But it ’s a lso a w om an I know so I . . . see I've n e v e r . . . I can say I've n ev er.. I'm not e i ’en aw are o f tryin g to think a thought o f my dau ghter w hen I've been in bed w ith m y wife. TH : I knoio, but the w om an you describe is exactly your daughter. PT: Yes, yes. TH: PT: TH : PT TH : PT TH : PT: TH : PT:

H ow do you fe e l when w e see a bridge . . . you see the m iddle o f the bridge is w iped out. Yeah. The bridge betw een the bedroom ; you are m aking love loith you r w ife an d then there is this slim blond . . . Yes. . . . p etite a n d then g en ital dark an d then the hair blond. Yeah. W hich is y ou r daughter. H ow do you feel lohen w e bring this to . . . C onsciousness? I can see. B ecause obviously there m ust he som ething tike that there. You y ou rself said you g et this w hen you sit w ith h er and so fo rth ; you have had such a feelin g. You see, I fe e l very close to her, but I don't w ant to affect her that way, an d I have been very distu rbed about this erection an d the incest feelin g, an d 1 fe e l positive that w e are able to exam in e som e o f this .. .

T h en h e talked a b o u t his co n cern that th ese feelings m ight affect his d au g h ter n egatively. H e h as a close relation sh ip w ith his son, w h o is taller th an h e, and e n jo y s h u g g in g an d h o ld in g him . (It is im p o rtan t to n ote that a few w eeks after the trial therapy, th e p a tie n t en tered in to treatm en t and p oin ted ou t th at his in cestu o u s feelin g s for his d a u g h ter h ave b een totally resolved, w h ich w as a great relief to him .)

Exploring his Relationship with his Father H is relatio n sh ip w ith his fath er w as explored. H e says th at h e w as n o t arou nd to h u g u ntil the p a tie n t w as seven , and after that he refu sed to h u g him and rem em b ers b ein g told th a t "fa th ers did n o t h u g sons." T h e therap ist p oin ts ou t "you n ev er h ad th e taste of a tend er, a ffection ate fath er-son relation sh ip ," "life has passed and th e a ffectio n a te fath er-son relation sh ip n ev er w as realized ." H e b eco m es m ore sad an d says th a t m ust be the reason "I feel so good to h u g m y son, it feels so good to h u g h im ," an d his son reciprocates.

Exploring his Current Family T h e th e ra p ist exp lores his cu rren t life orbit, w h ich cen ters arou n d his tw o ch ild ren. T h en h e talked ab ou t his fear if so m eth in g h ap p en s to them . T h e th erap ist exp lores h is reactio n and h e said "I w ould b eco m e paralyzed . . . it w ould b e a trem en d o u s blow ." Patient is sad and w ith a low voice said "W ou ld I rage or . . . cry," "Y eah I th in k I w ould find it ov erw h elm in g , th at loss." T h en h e ad d ed , "I w ould so b," " I w ou ld w o n d e r w h e th e r I w ou ld h ave a rage again st god ," "I w ould go in to sh ock ."

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Inquiry into the current fam ily dynam ics show s that there is a pow er struggle betw een m other and the children and indicates that the children handle it m uch better than he does, in particular his daughter. As the therapist m ust bring the initial interview to the end he m ust explore areas that so far have n ot b een covered.

Inquiry into his Previous Treatment T h e p atient indicates that the con join t therapy w as totally unsatisfactory. It m ainly focused on their system of in teraction and h ow to bring about a better w ay of in teractin g on a d ay-to-d ay basis. W hat em erges is that he had negative feelings tow ard the therapist, and the w ay h e dealt w ith it w as taking a passive-com pliant position w ith her. "At the tim e I ju st accepted it m eekly, saying 'W ell that seem s reason able', and so on ." And finally she, the therapist, decided that his problem dates back to the "p rev erb al stage of m y d ev elo p m en t," and she indicated to him that he need s long -term treatm ent. His w ife decided that she w anted to continue in individual treatm en t w ith the sam e therapist. T h e therapist for a m om en t brings the tran sferen ce to the focus. TH:

You see, in relationship w ith you r wife, as well as Dr. X., you m ould you rself and as you say it "I ju st accepted it meekly," an d you com plied and it is important . . . I luant to m ake sure t h a t . . . that has not been betw een you and me. PT: 1 see w hat you mean. No, it is not. TH: That you are doing it because you feel that this is im portant fo r you? PT: Yeah. It's i mp o r t a n t . . . It is very im portant an d I w ant to do everything that I can to overcom e m y difficulties.

Return to the Phase of Inquiry Exploration into the developmental, medical and social history T h e therapist begins by questioning, "W h ere w ere you b o rn ?" H e w as b orn in Eastern C anada, then the fam ily m oved tow ards the M idw est. As already indicated both of his parents left him w h en he w as one. H is father w as an en gin eer before the war. After he retu rned from the w ar h e w orked as a m an ager in an apartm ent building. H is earliest m em ory o f life is of b ein g left alone. In the early part of his life he lived w ith seven oth er children, his Aunt Elizabeth, tw o oth er aunts, his uncle, and g rand m other B lanche. H e com es w ith a m em ory th at every m orn in g he w as put out into the street along w ith oth er ch ildren b y his grandm other, as the uncle w anted to sleep. H e com es w ith an oth er m em ory as a little boy w ith a stick of wood and w anting to m ake a gun out of it. As a child h e w as shy, d etach ed , passive, never a fighter, and d id n 't like o th er children. T h en he talked about his grandm other B lanche, describes h er as b ein g highly controlling, d em an d in g, critical and punitive both physically and psychologically, often w ith a vicious bitin g ton gu e that m obilized fear. T h en he talked abou t Aunt Elizabeth, w ho w as kind, affectionate. He cam e w ith vivid m em ories of h er d ressing him up, taking him by bus to the city w here his m other was living. H e has m em ories of h er rocking him , as h e used to cry a lot. D uring the interview h e says "e v e n right n ow h ere I can h ear h er voice telling m e 'd o n 't be afraid, d on 't be afraid' " and indicates that is w hat actually he

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does w h en h e faces w ith a d ifficult situation at h om e, w h en things are falling apart, h e w h ispers to h im self an d rep eats to h im self "d o n 't be afraid, d o n 't be afraid." In talking a b o u t E lizabeth h e b eco m es sad, w ith tears in his eyes. T h en , in a sad state h e talks ab ou t his brother, in d icatin g th at in th e early years of his life h e had lo ok ed u p to him as a protector. C u rren tly h e has a d etach ed relation sh ip w ith h im and refers to him as a m an w ith a stron g h om op h obia. In talkin g ab o u t his clo sen ess w ith his brother, th ere is a w ave of sad n ess w ith tears in his eyes.

Further Dynamic Exploration It is im p o rta n t to n o te th a t th e u n co n scio u s th erap eu tic allian ce is in op eration . H e is sp o n ta n eo u s, an d v ery lucidly talks abou t aspects of his early life. In th e follow in g p assage, h e talks w ith a g reat deal o f feelin g abou t his b ro th e r as a p ro tecto r and its lin k to his son. PT. TH: PT: TH : PT: TH :

PT: TH :

I think that com es again fro m that feelin g that m y older brother was, was a protector. You know, w hen you talk about how you wish that you could have a physical closeness w ith y ou r brother you becom e sad with tears in you r eyes. Yeah. A nd w hen you talked about the physical closeness, hugging an d holding with y ou r son then also there w ere tears an d sadness. H ave you noticed that? Yes, definitely, I can see that. A nd im m ediately sadness an d tears come. This raises the question if there isn't som e connection betw een the two, that when you r sou hugs you an d holds you, an d h e is qu ite taller than you, you m ight have som e feelin g about you r brother that you looked up to as a protector, as you said. Yes, that's right. That a part o f you has m urderous feelin g s fo r him as we saw, but an other part o f you has p ositive . . .

In the follow in g p assag e the process ag ain m oves to his fath er and the m ajo r gap w ith in him ab o u t th e fath er-son relation sh ip , an d the p atien t resp on d ed "th e m ale co n n e ctio n too, y es." TH:

In a sen se there is a m ajor big vacuum luithin you fo r the fa th er-so n relationship that d ied by v irtu e o f the w ar or whatever, doesn't m ake a difference you see, and as you y o u rself said, you looked up to you r brother as a protector, an d lohen you talk about him in the early years you becom e sad an d tearful. But there also, that relationship en d ed up in an exchan ge o f rage as w e saw the scissors incident that you w ere near to m urder him. A nd noiv in you r current life you are recapturing these elem en ts in the relationship zoith y ou r son. But still you have m ajor m ixed feelin g s. PT: H m hm m . TH : B ecause w hen you talk about xjour brother, true a part o f you has had m urderous feelin g s, but at the sam e tim e w hat loe can see is a part o f you has a lot o f positive PT:

huh? Very positive.

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Further Exploration into his Early Life It is im portant to note, and this is alw ays the case in trial therapy w ith patients w ith com plex p sychopathology w ith m oderate to high degree of resistance as well as those w ho are extrem ely resistant, that the phase of inquiry and exploration into the d evelopm en tal history becom es possible after direct access to the unconscious has b een achieved and there is a m ajor w eakenin g in the forces of the resistance w ith a strong m obihzation o f the unconsciou s therapeu tic alliance. So far, the unconsciou s therapeu tic alliance has m ade clear the two aspects of his feelings tow ard his brother, the m urd erou s rage and guilt and his positive feeling as a protector. At the sam e tim e he has em phasized that his son is taller than he, and w h en they h u g each oth er patient said, "it feels so good ": and w hat w e see is the link b etw een his b roth er and his son, w hich later on becom es linked to his father to w h ich the p atient refers "m ale con n ection ." O ur kn ow led ge about the father is not clear. But it is im portant to n ote that it is not the function of the trial therapy to cover all areas, particularly in a patient w ith as com plex a p sych opath ology as this. This w ill be covered in the body of the treatm en t after a series of rep eated b reakthrou g hs into the unconsciou s take place. N ow the therapist explores w hat h e rem em bers about his father. "W h at h appen ed w h en your father cam e b ack from the w ar?" H e rem em bers getting dressed up and goin g to m eet th e train, but "1 d o n 't rem em ber m eetin g him , all I rem em ber is m eeting the train and all the soldiers lookin g out of the w indow ." H e does not rem em ber w hich train station it w as. H e rem em bers his Aunt Elizabeth b ein g w ith him , along w ith his brother. T h en he added "of course, I w ou ld n 't recognize him "; and he fu rth er added "b u t I d o n 't rem em ber." "D o you rem em ber the con tact w ith him ?" Patient answ ered "N o I d on 't. 1 d o n 't rem em ber it at all," and added "1 have no . . . totally blanked out." After the retu rn of the father, his m oth er retu rned and they m oved into the sam e house. T h e fam ily con figu ration consisted of the p atient, m other, father, brother, tw o aunts and g ran d m oth er Blanche. T h e situation becam e very difficult. T h en he talked about the con flictu al years w ith gran d m oth er B lan ch e, w ho was controlling, d om ineerin g and d em an d in g, w ith a vicious tem per, m anipu lahng one against the oth er; and the p atien t refers to him self as the gofer. "T h ere w as a battlegrou nd ." W ith bittern ess he talked abou t Blan ch e, w h o pu t him dow n , was critical of him . "D o n 't do this, d o n 't do that." N o m atter h ow h e did it "still she w ould pu t m e d ow n ," "S h e had a vicious bitin g ton gu e." H e con tin ues: "U h , you left the toaster on." T he therapist is w ell aw are th at th ere are m any aspects, or ch aracter traits, of his w ife that are sim ilar to those o f his gran d m oth er B lan ch e, and durin g the interview the patient b ecom es w ell aw are o f the sim ilarities. At the sam e tim e, the therapist kn ow s th at access to his u n con sciou s rep ressed buried feelings in relation to his gran d m oth er requires an oth er unlockin g and system atic w ork on an oth er m ajo r layer of resistance against the exp erien ce o f m urd erou s rage. As this is a trial therapy in the stand ard tech niq u e and the therapist has to accom plish the task of com p letin g the initial interview , he should avoid fu rth er unlockin g w hich would turn the trial therapy into the process of treatm en t. At this point the therapist sim ply m akes som e fu rth er exploration about his grandm other.

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Further Exploration of Grandmother Blanche The Pathogenic Situation TH :

But you see on e o f the m ajor problem s that you have which you loant to really start to look a t; intellectu alizin g is a process that doesn't help one's feelings. PT: I do a lot o f it yeah. TH : You see? You can intellectu alize okay y ou r fa th er had to g o to the w ar hut still you have the fe e lin g about it. N oiv y ou r gran dm other is critical, isdem anding, ev ery th in g has to be her w ay an d so forth. At one level you can intellectualize, but the oth er sid e is to look to the feelings. PT: Hmm. TH : That she is critical, she's dem anding, an d she is running . . . PT: Yeah . . . she's the head m aster . . . hm m , a m alignant headmaster. TH : On the on e han d y ou r m other . . . who, the w ay you describe, is like a dead person, you r fa th e r is in the w ar an d w hen he com es back he's not there neither. PT Yeah. TH : Then you are left into a situation . . . you r gran dm other also is critical, "Don't do this, don't do that, don't m ove this loay." You m ust have a lot o f feelin gs tow ards her. PT: They w ere anger, angry. TH: H m m . H ow did it express itself? PT: 1 don't thin k it did, I think again I didn't express it. TH : H m hm m . PT: I rem em ber m y brother expressin g it. It is im p o rta n t to n ote that the therapist, h ere, asks the p atien t h ow he expressed h is an g er; w h ile d u rin g th e m ajo r u n lockin g h e rep eated ly pressed for the p h ysical exp erien ce o f anger. T h e m ajor reason is obvious. H e has decid ed to term in a te th e in itial in terv iew an d th e process o f b rin gin g him in to u ch w ith his u n co n scio u s m u rd erou s rag e is the task for the first few p sy ch o th erap y sessions, w h ich is th e p h a se o f rep eated unlockin g. R etu rn to the interview . TH :

So y ou r brother luas m ore assertive, bouncing back, an d then you loere the co m p lia tit. . . PT: Yeah. The pattern, yes that's right. TH : So then you took a beaten position with your gran dm other as well. PT: Yeah. TH : The beaten position w ith h er as loell. As if in a sen se the law that you set fo r y o u rself w as set up fro m the very early years huh. O nce beaten alxoays the beaten hm m . O nce crippled the crippled. PT Hm. H is g ra n d m o th er d ied w h en he w as 24. H e avoided the fu n eral in spite of the en co u ra g em en t o f A unt E lizabeth. T h en sp o n tan eo u sly he talked ab ou t the sim ilarity b etw een B la n ch e an d his w ife. "T h e o n e th in g that stands out, as I am talking a b o u t m y gran d m oth er, is th e w ay m y w ife d em an d s w h ere th in gs m ust b e d o n e in a certain w ay, and uh, like m y grand m other, sh e com es d o w n an d says

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this plate is n ot put away." Patient w ith a high pitched voice and anger talks about his w ife "It is not put away," . . . "w h y isn 't . . . w hy aren 't people pu tting plates aw ay?" "W h y is the toaster in the m iddle of the cou nter?" T h en patient says "W h en 1 look at it, that is m y grandm other, no question about it." PT:

You mean there are patterns o f behavior o f your w ife that is sim ilar to the pattern

PT: Very, very close. TH: . . . o f you r grandm other and so forth? PT: Yeah, very close. TH: Wlwt you say is this, ivith your grandm other this had to be this way, that loay, you had the rage and the anger and wiped it out and tried to be a goody-goody hoy. PT: That is right, with anger; but that is w hat exactly I do with my wife. TH: Detached, com pliant, silent and so forth. PT: This is exactly. TH: You see, I don't know if you rem em ber when w e m et today an d I asked you about you r difficulties you said "I act like a c h ild " . . . PT: Yeah, that's right, that is the way I deal with my ivife. This is the time to m ake love, this is the tim e to do this, this is the time to do that. Then 1 freeze. Then I fu m e and I push it aside and g o paralyzed. TH: But we saw under the paralysis is the m urderous rage to throttle her to death. In the above passage: (a)

he clearly sees the similarity of the pattern of behavior of his wife to that of his grandm other; (b) once more the therapist drives home insight into the nature of the defenses that he has used in relation to his grandmother, and he responded that that is exactly what he does with his wife; (c) the significance of "I act like a child" becom es clear; (d) patient very clearly and explicitly indicates that "I fume" and the defense mechanisms that he uses "freeze", "go paralyzed"; (e) and the therapist points out that underneath the paralysis is murderous rage to throttle his wife to death.

The therapist h ere is im p lyin g that his rage tow ards his g ran d m oth er m ust have that m urd erou s quality; b u t as w e see, technically, h e leaves this for the first phase of the treatm en t, w hich consists o f rep eated m ajor unlockin g of the u nconscious.

Consolidation; Bringing the Interview to a Close At this point of the interview , as the therapist has d ecided to brin g the interview to an end , he usually recapitulates som e of the key p oin ts of the process; briefly sum m arizes w h at has b een b rou g h t to the focus; explores the p atient's feelings, particularly tran sferen ce feelings; ou thn es a gen eral fram e of the course of treatm en t, and finally asks the p atient if he is d eterm in ed to do so. R etu rn to the interview . TH: PT:

So, you see, you have a m ajor diffuse problem w ith life. Isn't that? Yes, indeed.

Major Unlocking o f the Unconscious: Part II

TH: PT: TH : PT: TH : PT: TH: PT TH:

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You have a problem in relationship with people, you have suffered from m any disturbances, such as anxiety, depression o fiv h ich you are w ell aware. Yes... T here are m any problem s; is not a neio problem , it is a problem that is a life-long problem . Yes, I see that. It is misery. There is a need in you to g o fro m one disastrous situation to another, w hich goes to the very early phase o f life . . . throughout you r life, hm? Hm hmm. But at the sam e time, obviously on on e side you have m ade som ething out o f this disastrous situation o f the past, you have becom e an engineer. Yes. Yes . . . but the oth er side is a disaster.

T h e th erap ist o n ce m ore recap itu lates on th e self-d estru ctive aspect o f his resistan ce and the m asoch istic co m p o n e n t in his character. PT:

PT: TH: PT: TH :

PT TH : PT: TH :

PT:

I f w e look to this pattern, w hat w c see . . . there is a m ajor problem which roots itself in the earliest phase o f y ou r life, an d you have a lot o f m ixed an d buried feelin g s in relation to m any o f these figures. H mm. There are a lot o f m ixed an d buried feelin g s that g o back to the first year o f you r life w hich h av e carried on up to now, huh, okay? Hm. I can see that. As w e have seen, there are m any other problem s: passivity, detachm ent, g oin g to silen ce or g oin g to defiance, becom ing detached, remote, depression, an d pain in the neck, huh? Yes. So there is this pattern that you have been carryin g all you r life, but you have not d on e an y th in g abou t it. That is an other issue . . . I . . . I ’ve n o t . . . yeah. B ecause you are intelligent, you are an engineer, an d you know that these m ajor d ifficu lties m ight even p erm eate an d negatively affect you r w ork . . . I don't know, they m ay not . . . anyiuay you have not don e an ythin g about it. You, yourself, have said that you are like "half-a-person"; but if you look at what w e have seen so far, you are g oin g fro m the fr y in g pan into the fire, fro m one disaster to another. Yeah, but I w ant to change. I don't luant to g o to my grave a crippled man.

T h e th erap ist o n ce m ore d rives h o m e in sigh t into aspects of the d yn am ic forces th a t are resp on sible for the p a tie n t's d istu rbances, his m asoch istic ch aracter path ology, the p erp etra to r of his u n con sciou s. TH :

PT

That there is a need in you to suffer, this need in you to perpetuate suffering and m isery, a n d a ll the m echanism s o f dealing w ith the pain, m urderous rage and guilt, w hich as w e saw ivas tow ard y ou r mother, and you r brother, an d also w e saw toioard y o u r wife. 'We haven't explored you r fa th er or y ou r gran dm other yet. Do you fo llo w me? Yes.

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TH: A nd the way you dealt with this dilem m a and the pathogenic situation has been to lose your autonom y, to give up your freedom . H ere the therapist is reem phasizing: The breakdown of the nuclear family, Abandonment and severe trauma, The pain of trauma. Unconscious murderous rage and guilt in relation to his mother, Murderous rage and guilt in relation to his brother and wife (diagram). RESISTANCE AGAINST EMOTIONAL CLOSENESS CHARACTER RESISTANCE

PAIN OF TRAUMA BOND, ATTACHMENT

Figure 1. (Davanloo) Psychopathological dynamic forces.

T h e focus is on the guilt an d p u n ish m en t, and the therap ist on ce m ore drives hom e fu rth er in sigh t betvs^een th e p ath og en ic situation of the past and his need to let him self be used and abused, self-defeat and self-sabotage. T h e respon se to these in terv en tion s are highly positive, and he fu rth er says th at h e w ants to do ev eryth in g to ch ange, "I w an t to ch an g e and w an t to do ev ery th in g th at I can to free m yself." N ow w e retu rn to the very last p art o f the interview . TH:

PT: TH: PT:

But do you think w hat we did today, w hich was touching the top o f the iceberg, to say, if you do it m ore system atically, this w otdd be o f help to you, to resolve all o f these m ixed buried feelin g s from the past? N ot only the top o f it, the whole, and to becom e a free man w ith y ou r ozon . , . I loant to be a fr e e man. I don't w ant to continue . . . You see, w hat I am looking at is this; w e have touched the top o f that iceberg but my question is this, do you ivant to do it m ore system atically . . . I loant it all cleaned up. It frightens me as well, but you know. I, I don't loanna stop nozv. 'Cause you are right. 1 can see the pattern g oin g on and on forev er and that's j u s t a m appalled that I haz’e gon e so long. I zoant to change. This session has been helpful in m aking that much m ore real, zohat has been building up and zvhat I haz’c started to see, an d I can see that there is a part o f me that doesn't want to solve it. A nd you luroe m ade it clear hozo . . . hozo deep and pervasive, I gu ess all those m echa)iism s that I use.

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T h e p a tien t's resp o n se to th e trial therap y is high ly positive and indicates d eterm in a tio n to w ork and liberate him self. T h en the therapist brings in the tran sferen ce b efo re h e term in ates. In the follow ing passage h e asks the patient h ow h e feels tow ard s him . TH: PT: TH : PT: TH : PT: TH : PT: TH : PT: TH : PT: TH: PT: TH : PT: TH : PT: TH : PT: TH: PT: TH :

PT TH :

PT: TH: PT:

H ow do you fe e l tow ard me? (lau ghs) H ow do I feci? Part o f you w an ted to do aw ay with me. Yes. W hat happen ed to that part? W e ll. . . I d o n ’t loanua do aw ay with you. (sm iles) W hat happened to that part? It is g otten out, I . . . It is not there an ym ore you m ean? Yes, that ivas qu ite an experien ce So then w hat is the feelin g ? Feeling. W ell I fe e l close, uh, but not very close. I fe e l very . . . Do you notice also you have difficulty about the issue o f positive as well? Yes. That has becom e very real today. As if you are terrified to verbalize positive feeling. Yeah, I can see that, an d today it has becom e very real to me. N ow that w e say goodbye to each other, is the net— if you put the positive negative, is the net p ositive or negative? It's positive. H mm. It's positive. This is com plian ce or . . . No. No. It is positive. This is really w hat I feel. It is hard but it is positive. Hmm . It has been painful, but at the sam e tim e it has been positive. But before w e say ou r goodbye anoth er thing about you is you underestim ate y o u r p oten tiality , becau se let's to fa c e w ith it, u n der ex trem e difficu lt circu m stan ces o f life you have m ade a profession fo r yourself, you have a family. Yes. A nd under very difficult circum stances o f this m eeting w ith each other w e got to som e o f the very fu n d am en tal issues, w hich is the beginn ing o f the road to the fu tu re. H m hm m . But you have a trem endous tendency to underestim ate you r potentiality. D o you folloiv m e? Yes, I can see that.

Recapitulation H ere it is im p o rtan t to recapitulate the m ain tech nical in terv en tio n s and the process o f th e in itial in terv iew — the trial therapy, w hich w as p resen ted in this tw opart article. T h e p rocess of the w h ole in terv iew can be su m m arized as follow s:

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Intensive Short-Term Dynamic Psychotherapy (1) The interview started with the phase of inquiry, which was not productive. (2) The therapist introduced pressure on the resistance of vague generalization, asking for a specific example. This led to a rise in the transference and anxiety. The therapist introduced further pressure by focusing on his feelings. This led to further resistance in the form of a series of defenses. The resistance was tangibly crystallized in the transference. There was a gradual transition from pressure to challenge. The result was crystallization of the patient's character defenses in the transference, and the therapist systematically challenged the patient's character defenses and concom itantly made the patient acquainted with them. (3) From the psychodiagnostic point of view the therapist's conclusion was a man in his forties suffering from character neurosis and decided that a rapid unlocking of the unconscious is the procedure of choice and decided on his technique of a two-stage unlocking: partial, followed by a major unlocking in a single interview. (4) As already indicated, the process started with the phase of pressure on the patient's resistance. As soon as there was evidence that the resistance to some degree had becom e crystallized in the transference, the therapist introduced challenge to the resistance w ith further crystallization of the patient's character defenses in the transference and at the same tim e system atically m ade the patient acquainted w ith his character defenses. (5) Then the therapist's technical intervention consisted of his most powerful technique of an interlocking chain of head-on collision with the patient's character resistance crystallized in the transference. (6) This resulted in a partial breakthrough into the unconscious and major waves of painful feelings with the mobilization of the unconscious therapeutic alliance and a direct view of the psychopathological dynamic forces; being abandoned by both parents at the age of one year. (7) This was follow ed by a phase of analysis of the transference and consolidation. (8) Then the process returned to the phase of inquiry, which indicated that he suffered from diffuse symptoms and character disturbances. Now the patient was exceedingly responsive. (9) The therapist in search of a return of resistance undertook a dynamic exploration into the patient's marriage. There em erged that the only way he could have intercourse with his wife was to bring the mental image of a woman named Linda. Under pressure the unconscious therapeutic alliance described her as blond, blue eyed, slim, with small breasts and dark genital. This was the last com m unication of the unconscious therapeutic alliance as a major resistance was mobilized in the transference in describing Linda's body. (10) The therapist introd uced challen ge and pressure to the transference resistance, resistance against em otional closeness which further intensified the resistance. (11) The therapist mounted the challenge, which was followed by his technique of repeated short-range interlocking chain of head-on collision to the transference resistance. This led to frustration in the transference, and the patient declared, "Well I'm frustrated." This tactical defense was considered well entrenched in the m ajor resistance, and there was considerable challenge and pressure. Then finally the patient declared, "I'm frustrated at you." (12) This led to anger in the transference, pressure to the physical experience of anger, with challenge and pressure, with repeated partial head-on collision aiming at a systematic w eakening of the m ajor resistance of repression w hich led to:

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(13) M ajor u nlockin g. The direct exp erien ce of a m urderous rage in the transference. T he im pulse to murder the therapist by strangulation, the em ergence of guilt-laden unconscious feelings and mobilization of the unconscious therapeutic alliance. (14) The unconscious transferred the murdered body of the therapist into the murdered body of his m other with the em ergence of intense waves of guilt­ laden unconscious feelings. Then the process entered: (15) The phase of a systematic analysis of the transference, followed by: (16) M ajor com m u nication from the unconscious therapeutic alliance. The in cid en t w hen he nearly m urdered his brother: direct exp erien ce of m urderous rage toward his brother with the breakthrough of intense waves of guilt. The process spontaneously moved to: (17) D eath and funeral of his m other with the passage of intense waves of painful feelings. He cam e with the incident of the only 2 hours he had with his mother. Then the process entered: (18) O nce more into the phase of systematic analysis of the transference and consolidation. Then the therapist made a dynam ic exploration into this marriage, which led to: (19) M ajor com m u n ication from the u ncon sciou s therapeutic alliance. His m urderous rage toward his wife, w hich led to: (20) Direct experience of m urderous rage toward his wife; the passage of waves of guilt-laden feelings and the em ergence of positive feelings for his wife. Then cam e: (21) Another m ajor com m unication from the unconscious therapeutic alliance w hich clearly identified that the woman he brings to bed during intercourse w ith his wife is his daughter. This led to: (22) A nother com m unication from the unconscious therapeutic alliance, his erection and incestuous feelings for his daughter. (23) As the initial interview is com ing to an end, the therapist explores the patient’s relationship with his father. There emerged an absence of a father-son relationship. In his early years he turned to his brother as a protector. Then the therapist m ade further dynam ic exploration into his early life, which clearly indicates that after the breakdow n of the nuclear family the patient lived with seven other children with his grandmother, a clearly pathogenic situation; and the therapist explored further. There emerged that she was both physically and psychologically abusive. He refers to her as a "m alignant headmaster." (24) By now both the patient and the therapist have a much better view of the perpetrator of the patient's unconscious, nam ely the original trauma, being abandoned by both parents, and the subsequent disastrous traum atic situation with his grandm other. Here the patient introduced the link betw een his wife and his grandm other, saying that much of his wife's behavior is similar to that of his grandm other. (25) Then em erged a very im portant relationship, his Aunt Elizabeth. The data clearly indicates that she was a kind, affectionate woman w ho was like a substitute m other to him. Then the interview entered: (26) The phase of recapitulation, consolidation and finally exploring the patient's transference feelings, which clearly indicated his will and determ ination to change the course of his life. Around the end of the interview he clearly declares "But 1 w ant to change. I d on't want to go to my grave a crippled m an." Emphatically, he said, "1 have got to change."

It is im p o rta n t to n ote th at after th e m a jo r u n lockin g of the u ncon sciou s the p atien t b eca m e exceed in g ly resp on sive anci com m u n icative. T h e process clearly in d icates th at th e pow^erful u n co n scio u s th erap eu tic allian ce h as had total com m an d o f th e process.

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Summary and Conclusion H ere it is im portant to recapitulate the m ain technical interventions and highlight som e o f the im portant technical and m etapsychological roots of my technique. (1) I em phasized that the technique can b e applied to the w hole spectrum of psychoneu rotic disturbances, no m atter the degree of resistance. I sum m arized the features o f patients on the extrem e left of the spectrum — highly m otivated, highly responsive, w ith a single psy ch oth erap eutic focus. 1 em phasized a total absence of an u nconscious m urd erou s rage in this group of patients and further indicated that the natu re of the resistance is very different than that of patients on the right of the spectrum . T h e cou rse of treatm en t o f on e patient, the Case of the Salesm an, was p resen ted to d em on strate the extrem e ease w ith w h ich one can achieve therapeutic results. (2) T h en I em phasized som e of the m ain characteristics of patients on the right side of the spectru m of p sy ch oneu rotic disorders and indicated that they suffer from life-long ch aracter neurosis, highly com plex core pathology, are highly resistant; and in all of these p atients there is the p resen ce of an unconscious m urderous rage or prim itive m urd erou s rage or a prim itive, m urderous, torturous rage and in ten se guilt- and grief-lad en unconsciou s feelings. (3) T h en I briefly discussed the application of m y tech niq u e to patients w ith severely fragile ch aracter stru ctu re, and pointed out: (a) they do not have the capacity to experience and tolerate anxiety. T h e discharge pattern o f anxiety is heavily in the form o f a m ajor disruption of the cognitive and perceptual functions; (b) T h ey have easy access to a spectru m of prim itive d efen ses, explosive d ischarge of affect, poor im pulse con trol, p rojection , p rojectiv e identification and d ouble p rojective id entification , the p h en om en a of drifting and dissociation; (c) T he unconsciou s m urd erou s rage is extrem ely prim itive; and (d) T h ere is no d ischarge p attern of u n con sciou s anxiety in the form of ten sion in th e striated m uscles. Briefly, unlockin g the u ncon sciou s w ithin 3 0 -4 5 m in u tes is contraindicated. M y cu rren t data clearly d em on strates that this tech niqu e can be applied to the w hole spectru m o f p atients w ith fragile ch aracter stru ctu re, and the course of therapy has a n u m ber of phases. T h e first ph ase aim s at b rin g in g abou t sufficient unconsciou s structural ch an g es to enable the p atien t to w ithstand the im pact of the u nconscious. In this research I have clearly d em on strated that as a result of such structural ch an g es, the d ischarge p attern of the u ncon sciou s an xiety shifts from cognitive and p ercep tu al fu n ctions to an xiety in the form of ten sion in the striated m uscles. T h en the process en ters the second ph ase con sistin g o f repeated u nlocking of the u nconsciou s an d the direct exp erien ce of the unconsciou s prim itive m urd erou s rage and guilt- and grief-lad en feelings. By the second and third phases, the u nconsciou s th erap eu tic alliance is at a very high level. I have called this the "optim u m u n con sciou s th erap eu tic allian ce, d ream in g w hile aw ake." In this p h ase th ere is rep eated b reak th ro u g h of a prim itive m urderous rage w ith guilt- and grief-lad en u n con sciou s feelings in relation to parents, sibh n g(s), an d o th e r early figu res. T h en th e p ro cess e n ters th e p h ase of

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m u ltid im en sion al stru ctu ral ch aracter ch ang es. It is im p o rtan t to n ote that this treatm en t is h ig h ly effectiv e in the treatm en t of this grou p of patien ts provided the th e ra p is t h as e x te n siv e k n o w le d g e of th e stru ctu re an d fu n c tio n o f th e u n con sciou s and is in tu n e w ith all the in tricacies o f the u n con sciou s universe. (4) T h en fou r m a jo r tech n iq u es of u n lockin g the u n con sciou s w ere p resen ted : p artial, m ajor, exten d ed m ajor and exten d ed m ultiple m ajo r unlocking. (5) T h en th e d y n am ic seq u en ces in the process of lu ilockin g the u ncon sciou s w ere d iscussed , and it w as in d icated that these ph ases tend to overlap and proceed in a spiral rath er th a n a straig ht lin e, that these d yn am ic sequ en ces can be seen as a fram ew o rk w h ich the th erap ist can used as a guide, con stan tly w orkin g from one ph ase to another. (6) It is im p o rta n t to n o te th at the p h ase of pressu re m ay con tain passing m o m en ts o f ch allen g e, but system atic ch allen g e should n ot b egin until the resistan ce h as b een tang ibly crystallized in the tran sferen ce. T h en n ot on ly m ust the resistan ce be ch allen g ed b u t the p atien t's atten tion m ust be draw n to it and its n atu re clarified for him . M akin g the p atient acqu ainted w ith his resistan ce is an essen tial p art o f th e early process. (7) C h a llen g e con sists o f callin g u p on , cou n terin g, or b lockin g the resistance in su ch a w ay to co n v ey an attitu d e of no resp ect for it. C hallen ge is a cen tral in te rv e n tio n in m y te c h n iq u e an d is fo re ig n to th e th e ra p ist train ed in p sy ch o an aly sis and trad itional d y n am ic psychotherapy. (8) It w as em p h asized th at the cou rse of an in terv iew d ep en d s to a great exten t on the rapid ity o f th e d ev elo p m en t of resistan ce and tran sferen ce feelings. W h ere th ese tw o factors are n o t d etectab le and are slow to develop , the therap ist m ust m ove to the p h ase o f pressu re in a search for resistance. (9) I em p h asize th at the tran sferen ce hold s a very im p o rtan t key position , and the th erap ist m u st w atch w ith u tm ost vigilan ce for in d ications th at the tran sferen ce is b eco m in g a m ajo r factor in th e in terv iew and should take n ote of it and act u pon it. It is im p o rtan t to k eep in m ind that pressu re from the therap ist leads to resista n ce in th e p a tie n t, resista n ce lead s to ch alle n g e from the th erap ist. C h allen g e leads to a rise in tran sferen ce feelin gs and in creased resistance. This lead s to fu rth e r c h a lle n g e by th e th era p ist. N ow th e resista n ce b eco m es crystallized in th e tra n sferen ce in the form of tran sferen ce resistan ce. T h en the th erap ist's in terv en tio n is h ea d -o n collision w ith the tran sferen ce resistan ce, and this ev en tu a lly lead s to the p a tie n t's d irect exp erien ce o f tran sferen ce feelings, m obilization of an u n co n scio u s th erap eu tic alliance, and direct access to the u ncon sciou s. (10) In the p ro cess o f d irect access to the u ncon sciou s I em p h asized the p h ase of in trap sy ch ic crisis: a state of ten sio n b etw een tw o m ajor forces, n am ely resistan ce and th era p eu tic allian ce. T h e act of ch allen g in g the d efen ses w ith the con v eyed lack o f resp ect for th em creates an extrem ely com plex state w ith in th e p atien t, on e in w h ich th e p a tie n t w ish es to both hold on to his d efen ses ev en m ore stron gly and also b eg in s to tu rn ag ain st them . H e b eco m es b o th an gry and d eep ly ap p reciativ e o f the th e ra p ist's relen tless d eterm in a tio n to help him . T his creates a ten sion b etw een th e resistan ce an d the th erap eu tic alliance. (11) T h e n I p resen ted the tech n iq u e o f h ea d -o n collision, w ith h eav y em p h asis on the tech n iq u e o f an in terlo ck in g ch ain o f h ead -o n collision w ith the p atien t's

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character resistance crystallized in the transference. I consider it on e of the most pow erful technical interventions. It has b een an integral part o f m y technique and has b een the by-product of a series of system atic research w ith the aim: (a) To block all the d efen ses m aintaining the force of resistance. (b) To m o u n t a d irect ch a lle n g e to all th e fo rces m ain tain in g self destructiveness. (c) To inten sify the rise in tran sferen ce feelings. (d) To m obilize the therapeu tic alliance against the resistance. (e) To create a state o f tension b etw een th e resistance and the therapeutic alliance. (f) To loosen the patien t's psychic system ; to change the situation from the d o m in a n ce o f th e resista n ce to th e d o m in a n ce of the u n co n scio u s therapeu tic alliance, w hich is the first b reakthrou gh, and finally a partial or m ajor unlockin g in w h ich there is m ajor m obilization o f the unconscious therapeu tic alliance. (12) Throu gh ou t this tw o-p art article I em phasize the triple factors: resistance, tra n sfe re n ce , an d u n co n scio u s th e ra p e u tic allian ce. T h e co n ce p t of the u nconscious therap eu tic alliance takes a very cen tral position through out the history o f the d ev elo p m en t of m y tech n iq u e, and the w ay I h ave described it is fund am entally d ifferen t from psychoanalysis or any oth er form of dynam ic psychotherapy. In all resistant patients, and in particular those on the right side of the spectru m w ho are highly resistant w ith com plex psychopathology, this dynam ic force is n ot in operation ; and the pow erful force of resistance has paralyzed all the paHent's m ajor functions. It is the p ow er of this tech niqu e via pressure, ch allenge, rise in the tran sferen ce, inten sification of resistance, further challenge to the resistance, a fu rth er rise in tran sferen ce feelings, crystallization of resistance in the tran sferen ce, h ead -on collision w ith tran sferen ce resistance, w hich h ave b een described in these tw o articles, w h ich m obilize the u nconscious therapeu tic alliance against the forces of resistance. This pow erfu l dynam ic force first em erges in the form of ten sion w ith th e resistance. T h en we see a d om inance of the therap eu tic alliance against the resistan ce, w hich show s itself in the form of the first break th rou g h , w hich d em on strates that the w hole psychic system has b een loosened and the b alan ce b etw een th ese tw o forces then m oves in the d irection of an increased th erap eu tic alliance. T h e d egree of unlockin g of the unconsciou s is exactly in proportion to the d egree that the patient has experienced tran sferen ce feelings and the m obilization o f an u nconsciou s therapeu tic alliance. In a partial unlockin g the u n con sciou s therap eu tic alliance is m obilized and has clear d om inan ce over the force of resistance. In exten d ed m ajor u n lockin g the m obilization of the u ncon sciou s therap eu tic alliance is at its optim u m level. The task of the therapist in the first few p sy ch o th erap y sessions is to brin g the unconsciou s therap eu tic alliance to the optim u m level. (13) O n e extrem ely im p o rta n t asp ect to em erg e from m y research is the interrelation b etw een the rise in the tran sferen ce, m obilization of the unconsciou s therapeu tic alliance, and resistan ce, w h ich 1 su m m arize very briefly: (a) In cases of partial m obilization o f th e u ncon sciou s th erap eu tic alliance, the patient has freq u en t d ream s w ith laten t and m an ifest con ten t. (b) In cases of m ajor u n lockin g and high d eg ree of m obilization of the

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u n con sciou s th erap eu tic allian ce, th ere is passage of m urd erou s rage in the tran sferen ce w ith th e passage o f guilt- and grief-laden feelings; an d finally the m u rd ered b od y o f the th erap ist is tran sferred to th e early figure. T h ese patien ts d ream often . T h e laten t and m an ifest co n ten ts of the dream s b eco m e closer, an d the d ream s are m u ch m ore vivid. (c) In th e ex ten d ed -m a jo r and m u ltip le-m ajor u nlockings, w^hich is the basis of m y m eth od of psy ch o analy sis, th ere is direct exp erien ce o f the prim itive m u rd erou s rag e in th e tran sferen ce; b u t in stan tly d u rin g the passage the u n con sciou s tran sfers th e th erap ist to the gen etic figure, w h ich is then follow ed b y p assage o f h ig h ly in ten sive gu ilt feelings, th en grief. T h ese p atien ts do n o t d ream . T h e u n con sciou s therap eu tic alliance is at optim u m level, an d th ey d ream w h ile aw ake. (This w h ole su bject will ap p ear in future publication s.) (14) A n oth er im p o rtan t asp ect o f the tech n iq u e is that the therapist m ust have exten siv e k n o w led g e o f th e p ath w ay of u n con sciou s an xiety in the form o f ten sion in th e striated m u scles w h ich starts from the m uscles in the h an ds and spreads to the forearm , arm , shoulder, in tercostal, b ack and legs. (15) Equally im p o rta n t is the so m atic p ath w ay o f the direct exp erien ce of the m u rd erou s or p rim itive m u rd erou s rage in th e tran sferen ce. 1 h ave established th at this p a th w a y starts w ith the pelvis, then low er and u p p er ab d om en , then ch est, th e n m ov es to th e h ead , shoulder, arm , forearm , and h an d, w h ich patients o ften refer to as a "fireb all" or "v o lcan o," "a bu ild u p of h eat m ov in g u pw ard." Finally, in th is b rie f ex p o se 1 w a n t to say th at I h av e u n eq u iv o cally d em o n strated that in all resistan t p atien ts w ith high ly com plex p sy ch o p ath ology a m u ltid im en sion al stru ctu ral ch aracter ch a n g e is easily possible, b u t it clearly d ep en d s o n th e p a tie n t's d irect exp erien ce of all the layers o f u ncon sciou s prim itive m u rd erou s rage and in ten se guilt feelings and ev en tu ally the exp erien ce of th e p ain o f the v ery early traum a. T h erap ies that focus prim arily on the e x p e rie n c e o f g rie f-la d e n u n c o n s cio u s fe e lin g s w ith o u t d ire ct an d actu al exp erien ce o f th e m u rd erou s rage and th e guilt do n o t brin g abou t stru ctu ral ch aracter ch an g e.

References D avanloo, H. (1976). Audiovisual Sym posium on Short-Term D ynam ic Psychotherapy, Tenth World Congress of Psychotherapy, Paris, France. July. Davanloo, H. (1977). Proceedings of the Third International Congress on Short-Term D ynam ic Psychotherapy, Century P laza, Los Angeles, California. November. D avanloo, H. (1978). Basic Principles and Technique in Short-Term Dynamic Psijchotherapij (New York: Spectrum ). D avanloo H. (1980). Short-Term Dynamic Psychotherapy (New York: Jason Aronson). D avanloo, H. (1983). Proceedings of the First Sum m er Institute on Intensive Short-Term D ynam ic Psychotherapy. W intergreen, Virginia. July. Davanloo, H. (1984). Short-Term D ynam ic Psychotherapy. In Kaplan H, Sadock B (Eds) Comprehensive Textbook o f Psychiatry 4th edn., chap. 29.11 (Baltim ore, MD: William & Wilkins). Davankio, H. (1984) Proceedings of the Audiovisual Imm ersion Course on Intensive ShortTerm D ynam ic Psychotherapy, sponsored by the San Diego Institute for Short-Term Dynam ic Psychotherapy, San Diego, California, May.

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Davanloo, H. (1986). Proceedings of the Second European Audiovisual Symposium and Workshop on Intensive Short-Term Dynamic Psychotherapy, sponsored by the Swiss Institute for Intensive Short-Term Dynamic Psychotherapy. Bad Ragaz, Switzerland. June. D avanloo, H. (1986). Audiovisual Sym posium on Intensive Short-Term Dynamic Psychotherapy, presented at the Annual Meeting of the Royal College of Psychiatrists of England. Southampton, England. July. Davanloo, H. (1987). Unconscious therapeutic alliance. In Buirski R (Ed), Frontiers o f Dynamic Psychotherapy Chapter 5 ,6 4 -8 8 (New York; Mazel and Brunner). Davanloo, H. (1987). Proceedings of the Fifth Sum m er Audiovisual Immersion Course on Intensive Short-Term Dynamic Psychotherapy. Killington, Vermont. August. Davanloo, H. (1987). Proceedings of the Audiovisual Symposium on Intensive Short-Term Dynamic Psychotherapy, sponsored by the Rochester Institute for Short-Term Dynamic Psychotherapy. Rochester, New York. October. Davanloo, H. (1988). The technique of unlocking the unconscious. Part I. International lournal o f Short-Term Psychotherapy, 3(2), 99-121. Davanloo, H. (1988). The technique of unlocking the unconscious. Part II. Partial unlocking of the unconscious. International Journal of Short-Term Psychotherapy, 3(2), 123-159. Davanloo, H. (1988). Central dynamic sequence in the unlocking of the unconscious and com prehensive trial therapy. Part I. M ajor unlocking. International journal of Short-Term Psychotherapy, 4(1), 1-33. Davanloo, H. (1988). Central dynamic sequence in the major unlocking of the unconscious and com prehensive trial therapy. Part II. The course of trial therapy after the initial breakthrough. International Journal o f Short-Term Psychotherapy, 4(1), 35-66. Davanloo, H. (1989), The technique of unlocking the unconscious in patients suffering from functional disorders. Part I. Restructuring ego's defenses. International journal o f ShortTerm Psychotherapy, 4(2), 93-116. Davanloo, H. (1989). The technique of unlocking the unconscious in patients suffering from functional disorders. Part II. Direct view of the dynamic unconscious. International journal of Short-Term Psychotherapy, 4(2), 117-148. Davanloo, H. (1990). Unlocking the Unconscious (Chichester, England: John Wiley & Sons). Davanloo, H. (1990). Proceedings of the Sixth European Audiovisual Immersion Course on Intensive Short-Term Dynamic Psychotherapy sponsored by the Swiss Institute for Intensive Short-Term Dynamic Psychotherapy. Geneva, Switzerland. June. Davanloo, H. (1993). Audiovisual Course on Intensive Short-Term Dynamic Psychotherapy, presented at the 146th Annual M eeting of the Association, San Francisco, California, May. Davanloo, H. (1993). Proceedings of the Eleventh Sum m er Institute on Intensive Short-Term Dynamic Psychotherapy in the Treatment of Fragile Character Structure. Killington, Vermont. July. Davanloo H. (1993). Proceedings of European Audiovisual Immersion Course on Intensive Short-Term D ynam ic Psychotherapy: Fragile C haracter Structure. Bad Ragaz, Switzerland. December. Davanloo, H. (1994). Proceedings of the Audiovisual Immersion Course on the Technical and M etapsychological Roots of Intensive Short-Term Dynamic Psychotherapy. Bad Ragaz, Switzerland. December.

Management of Tactical Defenses in Intensive Short-Term Dynamic Psychotherapy, Part I: Overview, Tactical Defenses of Cover Words and Indirect Speech HABIB DAVANLOO McGill University, Dqiarhnent of Psychiatry, Montreal General Hospital, Montreal, Cam da In this tw o-part article the author presents the m anagem ent of tactical defenses in his technique of intensive short-term dynam ic psychotherapy (IS-TDP) as well as in his method of psychoanalysis. He describes the spectrum of tactical defenses. Part I primarily focuses on the m anagem ent of the tactical defenses of cover words and indirect speech.

Introduction I h ave alread y b o th p resen ted an d pu blish ed th e discovery o f the tech n iq u e of "U n lo c k in g th e U n c o n sc io u s" an d h a v e d e m o n stra te d th a t th is p ro v id es o p p o rtu n ity for b o th th e th erap ist an d th e p atien t to h ave a d irect view of the p sy ch o p ath o lo g ical d y n am ic forces resp on sible for the p atien t's sym ptom and ch aracter d istu rb an ces. I h ave d escribed a pow^erful tech n iq u e o f in ten sive sh ort­ term d y n am ic p sy ch o th era p y (IS-TD P) as v^eU as the h igh ly pow^erful m eth od of p sy ch o an alysis. I h av e em p h asized th at the tech n iq u e can b e applied to the w h ole sp ectru m o f p sy ch o n eu ro tic d istu rb an ces as w ell as tho se w ith fragile ch aracter stru ctu re. Briefly, th e m a jo r featu res o f the patien ts on the extrem e left o f th e spectru m are: h ig h d eg ree o f resp o n siv en ess; single p sy ch o th erap eu tic focus; ab sen ce of the u n co n scio u s m u rd erou s rage; and the n atu re o f the resistan ce is v ery m uch d ifferen t th an th a t of p atien ts on th e right side of the spectru m . I h ave ou tlin ed so m e of the m ain ch aracteristics of h igh ly resistan t patients w ith in th e sp ectru m an d in d icated th at all th ese p atien ts d em o n strate a highly com plex core p ath olo g y and th e re is the p resen ce of m ajor traum a, the pain of the

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traum a and reactive m urderous rage or prim itive m urderous rage and intense guilt- and grief-laden u nconscious feelings. In all of these patients w e see the presence of the m ajor resistance. The "cen tral dynam ic sequ en ce" in the process of u nlocking the unconscious and the technique of han dlin g m ajor resistance have b een described. The dynam ic sequence consists of a series of phases: inquiry; pressure; challenge; transference resistance; direct access to the u nconscious; and system atic analysis of the transference. H ere I will sum m arize som e of the im portant features of the technique; (1) (2) (3) (4) (5)

(6)

(7)

(8)

Pressure leading to rise in the transference and to resistance in the form of a series of defenses. Challenging the resistance; heavy crystallization of the patient's character defenses in the transference; transference resistance. M ounting the challenge to the transference resistance; head-on collision with the transference resistance. Rapid breakdow n of the m ajor resistance and direct access to the unconscious. To loosen the patient's psychic system and to change the situation from the dom inance of the resistance to the dom inance of the unconscious therapeutic alliance, which is the first breakthrough into the unconscious. The m ost im pressive fact in this w hole transform ation is reorganization of the unconscious and optim ization of the unconscious therapeutic alliance. With direct and optimum experience of the transference feeling and optimum mobilization of the unconscious therapeutic alliance we see the passage of the m urderous rage or primitive murderous rage in the transference; the transfer of the murdered body of the therapist to the murdered body of the mother, father or brother, etc; with the instant passage of the intense guilt-laden unconscious feeling; in this whole process the patient is in direct relationship with his or her early biological figure. I have described a new concept of transference. In contrast to all other forms of psychoanalysis, here we don't have any traces of the transference neurosis.

It has b een em p h asized that in p atien ts su fferin g from p sych oneu rotic disorders, from the v ery early p h ase w e shou ld m ain tain pred o m in an tly our focus o n th e p rocess ra th er th an on th e stru ctu re o f th e psychic system . But in p atients su fferin g from fragile ch aracter stru ctu re, in th e early p h ase w e should m aintain ou r focu s on the stru ctu ral p ath o lo g y and th e n on th e process. I have fu rth er in d icated clearly th at the therap ists w h o w an t to w ork w ith this tech n iq u e m ust h ave a com p reh en siv e k n o w led g e ab ou t th e new m etapsychology o f the unconscious w h ich I h ave in tro d u ced ov er the cou rse of 30 years of system atic research. H aving given som e g en eral overview , n ow 1 w an t to focus on on e of the im p o rtan t featu res o f th is p o w erfu l tech n iq u e. R apid m ob ilization of the unconsciou s m obilizes w h at I call "tactical" d efen ses and this has b een presented in a large n u m b er of sym posia, cou rses and o th er pu blications. It is essential for the therapist to be absolutely fam iliar w ith th ese tactical d efen ses used by the patient in the service o f resistance so that h e can be ready w h en appropriate, to ch a llen g e each o n e th e m o m en t it ap p ears. T h ey sh ow an extraord in ary u niform ity across a w ide ran ge of patients.

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Defense and Resistance I h av e freely used th ese tw o term s w ith ou t explicitly m akin g clear th e relation b etw een them . T h ese can b e v ery easily d efin ed as follow s: (1) (2)

D efense is any m echanism used for the avoidance of the true feeling. Resistance is the use of such defenses in the therapeutic situation.

Continuum of Tactical and Major Defenses T h ese tw o categ ories o f d efen se form a con tin u u m , and an y attem p t to draw a sh arp d istin ctio n b etw een th em w ould on ly result in hair-splitting. In highly resistan t p atien ts, th o se w ith com plex p ath o g en ic u ncon sciou s, tactical d efen ses are asp ects of m a jo r d efen ses and th ey can be con sid ered the fron tlin e defen sive stru ctu re o f th e m a jo r resistan ce. W hile in patien ts w ith no m ajo r resistan ce, the resistan ce p red o m in an tly consists of a series o f tactical d efenses. For ex am p le, the case o f the "sister-in -la w ", a m an in his tw en ties, m arried, w h o su ffered from ob sessio n al n eu rosis from tlie extrem e left o f the spectru m of the resistan ce, w h en the th erap ist in qu ired ab ou t the physical ap p earan ce of his sister-in-law : TH : PT:

H oio w ould you describe y ou r sister-in-law in term s o f phi/sical appearance? P hysically she is a very attractive girl, very xoell built.

T h e th erap ist asks the p atien t to b e m ore explicit. TH :

H m hm m . In ivhat luay?

W h a t h a p p en s n ow is o f im m en se im p o rtan ce to an y o n e learn in g the tech n iq u e. T h e p a tien t sh ow ed his resistan ce by u sing a series of tactical defenses. T h ese are n o t m a jo r d efen ses su ch as rep ression , p ro jection , etc. N ev ertheless, th ey are alm ost u niversal an d a p p ea r ov er and over again in d ifferen t p atients o ften in a regu lar se q u en ce, as a resp on se to pressure from the therapist. It is essen tial b o th to b e able to recog n ize them im m ed iately and to know h ow to h an d le them . N ow le t's take a n o th er p atien t, this tim e from the m id-left of the sp ectru m o f the resistan ce. H e d escribed an in cid en t that he and his w ife had quarrelled a few days b efo re th e interview . T h e th erap ist q u estion ed him ab ou t his feelin g tow ard his w ife an d h e resp on d ed : PT:

"I m ust, " "maybe" I am feelin g r e s e n tfu l. . . I "must" be resentful.

By su ch d ev ices th e tru e exp erien ce o f the feelin g can be largely avoid ed. In in terv iew s w ith p atien ts, th ese kin d s of d ev ices are en co u n tered again and again — th e u se o f in d irect and h y p oth etical p h rases such as "m ay b e," "I th in k ," "I gu ess," "I su p p o se," "so rt o f" provid e as cov er w ords to avoid or w eaken an open d eclaration o f so m eth in g p ain fu l or an xiety -lad en , and w h en the therap ist puts pressu re and ch allen g es th ese d efen ses a stron ger w ord m ay ap p ear in their place,

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but the therapist should not necessarily be satisfied for such tactical defenses m ight be used to avoid the actual feelings. As I have already m en tion ed , tactical defen ses m ay be aspects of the m ajor defenses and in patients w ith m ajor resistance they can b e considered the fronthne defensive organization of the m ajor resistance. This can be illustrated by focusing on the very early part of the interview w ith a you n g m an in liis thirties. H e entered into the interview anxious, w hich had tran sferen ce im plication. T h e therapist exerts pressure tow ards his feeling: TH: Let's to sec how you feel about your com ing here and seeing me. PT: I fe lt nervous. TH: That is one, w hat else? PT: Uhh. H ere, anxiety is a d efen se against the underlying feeling and the therapist exerts further pressure "W h a t else do you feel besides anxiety?" This im m ediately gives rise to the p atien t's tran sferen ce feeling and m obilization of resistance. H e puts his head dow n and says; PT:

I don't know, I don't knoiv what my feelings are uhmm . . . other than feelin g nervous about it and the nervousness com es from . . .

N ow w e see m obilization of the tactical d efen se o f diversification, w hich is im m ed iately blocked w ith pressure to the u nd erlyin g feeling. TH: N ow you m ove to luhere the nervousness com es from . M y question is zvhat else do you experience besides nenw usness? N ow the p atient sp o n tan eou sly in trod u ces anger, b u t im m ediately also m oves to diversionary tactic "m y n eed to . . . " w h ich is im m ediately blocked and then there is m obilization of the tactical d efen se of retraction. PT:

U hm m m . . . I'm trying to think o f anger, anger over my need to . . .

PT:

Well I don't knoio if I'm an gry or not.

T h en he again d eclares an ger but w ith diversionary tactic. PT: TH: PT

Yes I'm angry, at m yself You say you are angry but then you m ove and say you are angry at you rself First let's to establish are you angry or aren't you angry, then second w e go to . . . Yes.

T h e therapist exerts pressu re on the actual experien ce of the an g er and he m oves to an o th er tactical d efen se "invisible fr o io n ." T h e th erap ist ch allen g es this "th at is a sen ten ce," and exerts pressu re to the actual exp erien ce o f anger. The patient then m oves to the tactical d efen se of passive-com pliance. T h en an oth er tactical d efen se em erg es, "/ don't kn oiv.” PT: TH:

W hat are w e g oin g to do about it? I don't knoiv. "I don't knozu" is another helpless position.

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T h is results in fu rth er in ten sification o f the resistance crystallized in the tran sferen ce w ith th e em erg en ce of defiance. PT:

You're askin g m e to g iv e you w ords that w ill satisfy you r question. I don't . . .

PT:

The an g er I'm experiencing nmv is tow ards you. I don't w anna talk about it anym ore.

W h at th e th erap ist h as d on e is exerting pressu re to the u n d erlyin g feelin g, the an ger, an d th is im m e d ia te ly m o b iliz ed a set o f tactical d efe n se s su ch as d iv ersion ary tactic, retraction , p assiv e-com p lian ce, v agu eness, ru m in ation etc. E ach o f th ese d efen ses w as im m ed iately ch allen g ed ; im m ed iate rise in the tran sferen ce feelin g; in ten sification and crystallization o f the fron t-lin e ch aracter d efen ses in the tran sferen ce. T h e th erap ist's pressure to the exp erien ce of an ger im m ed iately reactiv ates the u n co n scio u s d efen siv e organ ization again st the p atien t's u n co n scio u s m u rd erou s rage tow ards his sister, to a m uch h ig h er exten t tow ard s his m o th er an d to a lesser d eg ree tow ard s the fath er as w ell as in ten se guilt- and grief-lad en u n con sciou s feehngs as w ell as the very cen ter of his u n co n scio u s p sy ch o p ath olog ical d y n am ic forces: the attach m en t; the traum a; the p ain of th e trau m a; reactiv e m u rd erou s rage; and su bseq u ent traum as. T h e th erap ist m ust alw ays take into con sid eration th at the tw o categories of the d efen se , tactical and m ajor, form a con tin u u m . T h e con tin u u m can be illu strated b y a freq u en tly used d efen se o f "n ot rem em b erin g ." At o n e end, the p atien t m ay use th e tactical d efen se of p reten d in g th at he can n ot rem em b er so m eth in g o f w h ich he is fully aw are but w h ich he does n ot wish to adm it to the th erap ist; at th e o th er en d , he m ay g en u in ely be u naw are of so m eth in g held at bay b y th e m a jo r d efen se o f rep ression ; w hile in the m iddle are all grad ations of n ot w an tin g to ad m it so m eth in g to him self, w h ich in volves rep ression to a greater or lesser d egree. T h ese tw o articles d escribe, w ith clinical exam ples, the categories of the tactical d efen se s m ost co m m o n ly en co u n tered . T h e first article w ou ld address tw o m ajor categ ories o f co m m o n ly used tactical d efen ses, the tactical d efen se of cov er w ords and th e tactical d efen se o f in d irect sp eech . T h e second article w ould focus on the w ide ran g e o f o th er tactical d efen se s that the therap ist m igh t see in th e cou rse of th e w o rk w ith th eir patients.

The Tactical Defense of Cover Words Call defense in question Challenge defense in question T h is tactical d efen se is freq u en tly en cou n tered . T h e p atient uses a weaker, w atered -d o w n w ord for th e on e h e d o e sn 't w ish to say. O f all types o f tactical d efen se o f cov er w ord s, th o se exp ressing an g er and m u rd erou s rage are the m ost freq u en t. T h e follow in g are exam ples: "u p se t m e," "b o th ere d m e," "h u m iliated ," "em b a rra sse d ," "u n h a p p y ," "fru stra ted ," "a n n o y e d ," "irritated ," "ag g rav ated ," "co n fu sio n ," "u n co m fo rta b le," "d islik e" and "p issed off."

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Cover words

"

Intervention " 'I felt terrible' is ju st a sentence." "You are back again to the issue of 'em barrassed.' " "You are helpless to tell m e w hat your in n er experience w as." "D o you notice you are totally incapable of telling m e how you felt?" " 'E m barrassm en t' is ju st a w ord. It d oesn 't tell us how you felt." "W h a t is that? W h at is 'co n fu sion '?" "You use the w ord 'co n fu sio n ' for b ein g uncom fortable?" "N ow you m ove to 'co n fu sion .' Still w e d o n 't know how you experience you r anger."

T h e follow ing are a few exam ples to illustrate the tactical d efen se of cover words.

Masochistic Woman with Brutal Mother W h en she en tered in to treatm en t sh e w as 30 years old, divorced and suffered from m asochistic ch aracter pathology, episodes of depression, diffuse anxiety, and m ajor d istu rbances in in terp erson al relationships. PT:

I notice you are using the w ord "crippled" again . . . w ell she could w alk with a walker, but she was "handicapped."

H ere again the avoided w ord w as too explicit b ecau se it w ould face the patient w ith the reality of w h at had h ap p en ed to h er grandm other, and h er infinitely painful and gu ilt-lad en feelings abou t it.

Tactical Defense of Cover Words for Anger As already m en tion ed th ere are a w ide ran ge of tactical d efen ses used to avoid the expression of anger, rage, violen t rage and m urderou s rage; they can be classified into a n u m b er of broad categories. We should keep in m ind that in a large m ajority of p atients su ffering from ch aracter neurosis, particularly those on the right side of the spectru m of resistan ce, the an ger itself is a cover w ord to avoid the unconsciou s m u rd erou s rage and in ten se gu ilt-lad en u nconsciou s feeling. H ere we focus on the ran ge of tactical d efen se of cov er w ords used to avoid anger.

Describing Distress Rather than Anger "U p set," "ag itated ," are tactical d efen ses against anger. T h is is one o f the com m on est tactical d efen ses en cou n tered in the therap eu tic situ ation for avoiding the exp erien ce of anger. If u n d ern e a th th e an g er th ere is v iolen t rage or m urderous rage, the person w h o is a n gry avoids by con v ertin g it into an appeal for sym pathy.

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The Case of the Hyperventilating Woman At th e tim e o f th e in terv iew sh e w as in h er tw en ties, suffered from chron ic anxiety, con flict in h er m arriag e, con flict w ith m em b ers o f h er fam ily and frequ en t attacks o f h y p erv en tilation . PT:

. . . an d then I had a conversation with m y sister which "bothered" m e a lot, and then fo r the next fe io hours I hyperven tilated quite badly.

PT:

Yes, it "upset" m e quite a bit.

In th e seco n d in terv iew sh e d escribed h er h u sb an d 's n eglect: PT:

He'd com e hom e fro m school at 3 o'clock. We'd have su pper together an d then he w ou ld have to g o out again. TH: A nd hoio d id you fe e l tow ard that? PT: That “upset" m e a lot. TH: Let's look at y ou r feelin g. PT: "D isappointed." T h e d eg ree to w h ich th ese w ord s w ere b ein g used as a cov er for h er real feelin gs m ay b e ju d g ed from th e obviou s sp o n tan eity of the follow ing passage, w h ich em erg ed after ch allen g e and w ork on the tran sferen ce. PT:

1 w as an g ry an d I fe lt h e w as unfair. W hen fin ally I got the courage to tell him he w as unfair, he d id n ’t agree. I was an g ry because on e o f the first things lue had ev er said w as that in ou r m arriage w e w ould have com m unication; an d he kept prom isin g m e," lf it ’s too much, I ’ll g iv e the dram a grou p up." I told him in the fir s t cou ple o f w eeks o f ou r m arriage it was too much. H e said,"W ell we'll g iv e it a try." I told him again it w as too much. H e d id n ’t see it ivas too much . . .

A gain I em p h asize th a t h ere th e an g er to w h ich she adm its n ow by itself is a d efen se ag ain st h er u n co n scio u s m u rd erou s rage, w h ich in su bseq u en t u n lockin g b eca m e h er m other. Sh e saw h er m o th er in the en tran ce of h er b ed room dressed u p in a w h ite coat, like a n u n , w ith a b u tc h e r's knife in h er h an d w an tin g to m u rd er h er (p ro jectio n ) and in the follow ing w eek she exp erien ced in ten se m u rd erou s rage w ith the visual im ag e o f h avin g m urdered h er m o th er w ith a b u tc h e r 's k n ife an d m u tilated the u p p er-m id d le ch est of h er m oth er and th ere w as the p assag e o f in ten se gu ilt-lad en feelin g. It is on that basis that I w ould say that a n g er h ere is a cov er w ord and has a d efen siv e fu n ction.

The Case of the Real Estate Lawyer W h en sh e en tered in to trea tm en t sh e fro m m ild e p iso d e s o f d e p re ssio n , relation sh ip s, p ro blem s w ith h er boss, ch aractero lo g ical problem s. T his p a tie n t h ad b een su b jected to an h er m ale colleag u es. This h ad b een d o n e

w as 37 years old , m arried , and suffered an x iety , p ro b lem s in in te rp e rso n a l m arital con flict and a w ide ran ge o f extrem ely cru el practical jo k e by on e o f to h er at an office party in fro n t o f the

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entire staff. T he patient could only describe h er em barrassm ent and hum iliation, w hile going to extraordinary length s to avoid any description of anger. TH: A nd hoiu did you feel? PT: "Stupid" and "em barrassed."

TH: W hat did you think? PT: I was so hu m iliated." I didn 't think at all.

TH: PT: TH: PT: TH: PT:

A nd then what else did you experience? "Em barrassm ent." Yes, hut in term s o f the inner feeling, ivhat type o f feeling? Let's see, “em barrassm ent," "shame." That is ju st loords. It doesn't tell us how you felt. "Terrible."

PT:

. . . it's still an "open w ound" "a little bit.'

PT:

I loas "not happy," let's put it that way.

PT:

I was "very unhappy" at that point.

After a great d eal of w ork on the th erap ist's part, th e w ord "a n g ry " did ev en tu a lly creep in to th e p a tie n t's resp o n ses. S h e th e n p ro ce ed ed to in tellectualization, saying that on a scale of 1 -1 0 she w as "p ro b ab ly " "8 degrees angry." TH: PT:

W hat ivas that 8 degrees o f an ger like? “C on fu sed."

H ere again the an g er that sh e adm its to, b u t at the sam e tim e intellectualizes it, is a tactical d efen sive organ ization of th e m ajor resistance. U n d ern eath is a highly prim itive m urd erou s rage and guilt feelin g in relation to h er fath er and then h er m other, both w ere alcoholics, h igh ly explosive and physically as weU as psychologically traum atizing.

Describing Anxiety Rather than Anger Sin ce m any patien ts do in fact exp erien ce anxiety w h en an ger is potentially aroused in them , the d escrip tion of an xiety rath er th an an g er is a d efen se that com es readily to hand. T his is on e o f the m ajor features of all ch aracter neurotics. M ost of them d o n 't experien ce an ger; w hat th ey exp erien ce is anxiety w h ich is in the service o f the m ajor resistance. H ere I describe tw o exam ples;

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The Case of the Manageress Sh e su ffered from diffu se sym ptom s and ch aracter d isturbances. Sh e is d escribin g an in cid en t that she w as an gry at h er m other. W h en pressed for the exp erien ce o f a n g er sh e on ly could d escribe anxiety: PT:

A ll of a sudden I becam c so an g ry tow ards her and I ju st becam e very "agitated" an d "nervous" an d I w ajtted to . . . TH: W hat w as the w ay you experien ced your anger? PT: I ju s t becam e very "agitated" an d "nervous" an d I w anted to . . .

PT: TH : PT: TH: PT:

Yes, an d hatred tow ards her w hen she told me that. But how did you experience the anger? I fe lt very "agitated" inside. W hat do you m ean agitated inside? "N ervous, " I started g ettin g "nervous" an d "agitated."

The Case of the Man with Violent Dreams W h en h e en tered in to trea tm en t he w as 30 years old and su ffered from sym p tom an d ch aracter d istu rbances. T h e trial therapy started w ith th e p h ase o f p ressu re as h e w as an xiou s w h en he en tered the interview . TH : L e t ’s to see how you fe e l abou t y ou r com ing here an d seeing me. PT: 1 fe lt "nervou s." TH: That is one, w hat else? PT: Uhh. T h e th erap ist exerts pressu re to the u n d erly in g feelin g and th en h e declares a n g er in th e tran sferen ce. TH : N oio you say you feel, you fe e l angry, let's to see hoio you experien ce you r anger. H ere again w e see a n o th er exam ple of the tactical d efen se of d escribin g an x iety ra th er th a n a n g er and w h at em erg es after a n u m b er o f u nlockin gs is a p rim itive m u rd erou s rag e tow ard the m oth er and tow ard the sister. T h is is a universal p h e n o m e n o n in all th ese p atients su fferin g from ch aracter n eu rosis and it is a m a jo r m istake if the th erap ist thin ks th at all w h at the p atien t is d efen d in g again st is anger.

Further Examples to Illustrate the Tactical Defense of Cover Words for Anger The Chess Player At th e tim e o f the in itial in terv iew h e su ffered from d iffu se sym p tom s and ch aracter d istu rb an ces.

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TH: PT:

You say that your supervisor was a pain, he was dem anding, he pushed you around. But how did you feel toiuard him? I felt "frustrated."

TH: But how did you feel toivard this man who was pushing you around? PT: I eventually felt "hostile" toward him. F u rth er p ressu re p ro d u ced h m ts of d eath w ish es and su b seq u en t breakthrough into the m ajor resistance unlocked his u nconscious m urderous feeling; first tow ards his sister, then tow ards his m other and w e equally saw violent rage, but to a lesser degree, tow ard his father w ith in ten se guilt. Again w e can reem p hasize that the w hole set of defen ses such as "frustrated ," "hostile," "anger," "d ea th w ishes" are tactical d efen ses of the m ajor resistance in relation to the volatile m urderous rage and guilt- and grief-laden feelings in relation to their biological figures.

The Hyperventilating Woman In the follow ing passage the p atient steadily retreats from the idea o f anger; first to "irritation " and th e n to "u p set"; TH: H ave you ever thought o f it like that? That there m ight be a connection between the an ger and hyperventilation? PT: I didn't think o f it in term s o f anger. I thought o f it in term s o f "irritation." "1 guess" som etim es I realized that I got very "upset" after my m other phoned me every day.

The Manageress This p atien t has b een d escribin g an in cid en t w ith h er m other: TH: PT:

You said that the discussion loas around pickling and the jars, and you w ere in such an ger w ith you r mother. Yes, an d "hatred" toivards her w hen she told m e that.

F urther pressure and challenge. PT: TH: PT:

I xoanted to start telling h er all kinds o f things that I felt toiuards her You mean you w anted to verbally . . . Yes, yes. Som etim es I w anted to "hit her" som etim es I feel 1 w ant to "kill h e r " . . .

To "kill h e r" by itself is a d efen se as she actually is not experien cin g her m urderous rage tow ard h er m oth er w ith in ten se gu ilt-lad en u ncon sciou s feeling.

The Case of the Butch W h en he en tered into treatm en t he w as 26 years old, suffered from diffuse sym ptom s and ch aracter distu rbances. T h e session is focu sin g on his feelin g in the transference:

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PT: "C onfusion." TH : W hat is that? W hat is “confusion?" PT: C onfusion is . . . TH : W hat is the w ay you experience y ou r confusion ? PT: Uh . . . "uncom fortable." PT: Yeah. TH : So you use the w ord confusion fo r being uncom fortable? PT: H m hm m . P ressure o n th e actual exp erien ce o f the discom fort led to an o th er d efen se "d islik e." T h e n w h en th ere w as p ressu re on the actual exp erien ce o f the dislike th e re w as m o b iliz a tio n o f th e ta c tic a l d e fe n se o f ru m in a tio n w h ich w as ch allen g ed . T h en h e d eclared b ein g fru strated : TH : A nd I qu estion you hoiv do you experience this dislike? You are not really an sw erin g how you experien ce that. You rum inate ivith a sentence.

TH: You fe e l fru stra ted w ith me? PT: Yeah, right now . . . TH : O kay. N oio w hat is the w ay you experience you r fru stration ? PT: 1 fe e l I am not able . . . T h ere is m ob ilization of th e d efen se of ru m in ation and diversification and the th erap ist exerts fu rth er pressu re for the actual exp erien ce of the fru stration. T h en h e declares: PT: I am g ettin g a bit, I ’m g ettin g a bit "aggravated." TH : A ggravated? PT: Yeah, " m ad,"a bit "mad." TH : You fe e l m ad?

"Confusion" as a Tactical Defense of Cover Word T h is d e fe n s e fu n c tio n s in th e se rv ice o f re sista n ce in th e fo rm o f d iv ersificatio n. It p articu larly com es in to op eration w h en th ere is a rise in tran sferen ce feelings.

Case of Man with Foggy Glasses W h en h e en tered in to trea tm en t h e w as in his forties, m arried and suffered from h eav y d rin k in g , ch ro n ic anxiety, ep isod es of d ep ression , p ro blem s in in terp erso n a l relatio n sh ip s, m arital con flict, sexual p roblem s as w ell as m ajor ch aractero lo g ical p roblem s. H e had en tered the in terv iew w ith an xiety in the tra n sferen ce. T h e fo cu s o f th e sessio n w as on p ressu re to ex p e rien ce his an n o y a n ce tow ard th e therapist.

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PT: I am a little "confused" b ec a u se. . . TH: N ou’ you move to confusion. Still w e don't know how you experience your annoyance. PT: I'm tense, I'm trying to “explain." The first defense, "con fu sed ," follow ed by the second, "becau se," w anting to give explanation. This often can function in the service of diversification; and often the therapist m ight explore the confusion, and the process totally m oves aw ay from the transference. This form of diversionary tactic is im portant to be identified. Here the an n oyan ce is a tactical defense of cover w ord against violent rage, m urderous rage; and that is the reason that the therapist's sim ple pressure to experience annoyance in the transference reactivated the tactical defense center w hich in this case is the m ajor resistance against the patient's m urderous rage and guilt. T h e follow ing is an o th er exam ple of con fusion as a tactical d efen se of cover word.

The Real Estate Lawyer T h e focus of the session w as on the experien ce of h er an ger and the patient used the cover w ord "co n fu sio n ." TH: PT:

You say you are 8 degrees angry an d I question you hoiv you experience this anger, and now you say “confused." Okay, "when" “a person" is very angry or "when" I'tfi very angry . . .

T h e follow ing is an oth er exam ple o f tactical d efen se of cover word.

The Case of the Microphone Man W h en h e en tered to treatm en t he w as in his forties, su fferin g from long-life ch aracter neu rosis w ith diffuse sym ptom disturbances. H e described an incident that he felt m ad: PT:

I fe lt “mad," I fe lt "aggravated."

Th erap ist's in terv en tion : call u p on the d efen se; ask for actual experience of aggravation. TH:

“I fe lt mad" is a sentence, "1 fe lt aggravated" is a sentence.

TH:

H ow did you feel?

In the sam e in terv iew the p atien t had described an in cid en t w ith his landlord w ho slam m ed the door on him and the therapist focuses on his feeling: PT:

Well, "annoyance."

PT:

Oh, "very annoyed."

Anger as a Cover Word for Murderous Rage As I h ave already m en tion ed , the an g er is the very su rface o f a m ajor colum n of m urd erou s rage in on e or m ultiple direction in relation to th e early figures. This can be illustrated by the follow ing case:

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The Case of the Auto Mechanic with Somatization W h en h e en tered in to treatm en t he w as 44 years old, su ffered from chron ic anxiety, sh arp ch est p ain, pain in his n eck, p roblem in his m arriage and episodes o f explosive d isch arg e o f a ffect in relation to his w ife. All m edical in v estigation s w ere n eg ativ e. In th e first fou r sessions th ere has b een m ajo r u nlockin g o f the u ncon sciou s w ith th e p assage of th e m u rd erou s rage in the tran sferen ce, and the tran sfer of the th erap ist to his fa th e r w h o w as a trau m atizin g figure th ro u g h o u t his early life. H e also cam e in tou ch w ith the actu al exp erien ce of his m u rd erou s rage tow ard his w ife, w h ich also b eca m e tran sferred to his fath er w ith the passage of in ten se guilt. In th e fifth session, h e en tered into the in terv iew anxious: PT: W ell on m y w ay here this m orning I . . . ( s i g h ) . . . TH : H ow you fe e l right noiv? PT: W ell I'm . . . I'm uh upset an d . . . TH : U pset m eans w hat? PT: I'm "angry" a t . . . H e h as freq u en t d eep sighs and the therap ist focuses on his anxiety: PT:

Yeh. I'm anxious. Yeah I think I know exactly w hy I'm anxious too, hut it has to do w ith som eth in g that ju st happen ed in traffic an d . . .

H e in d icates th a t h e has b een an xiou s follow ing a traffic in cid en t b efo re the in terv iew : PT: TH : PT TH : PT: TH : PT: TH : PT: TH : PT TH : PT: TH : PT:

It is som e insight I g ain ed into how m ad I got. H ow this therapy is g o in g toiuard m y "anger" an d how the . . . You see you talk about anger. Yeah. But w e kn ow so fa r it has been murder. I know that's the part that produces . . . But do you notice you use cover words? Yeh because it's an xiou s to say I'm a m urderer and that is becom ing m ore . . . But you use cover words. You know zvhat cover w ords m ean? Yeah I knoiv. A nd a w hile ago you covered the an ger by the w ord upset. Yeah. D o you notice that? Yes, yeh. So in stead o f you sayin g an g ry you say I am upset. Yeah but I didn't w anna com e in here an d say I fe lt like m urdering the w om an because she cut m e . . . w ell she cut m e off.

Tactical Defense of Cover Word for Emotional Closeness M a n y p a tien ts d efen d th em selv es as stron gly again st positive feelin gs as again st th eir n eg ativ e feelin g s and th ey pu t up a w all again st an y form of

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em otional closeness. In som e patients, resistance against em otional closeness is m uch m ore extensive. T he cen ter of this resistance lies w ithin the center of the pathogenic dynam ic forces o f the u nconscious, nam ely the b on d , the traum a, the pain of the traum a, reactive m urderous rage or reactive prim itive m urderous rage, intense guilt, grief, character d efen ses and the resistance against em otional closeness. O n the basis of this, w h en the therapist focuses on this resistance, it m ight m obilize a set o f tactical d efen ses to divert the therapist. An exam ple:

Masochistic Woman with Brutal Mother T h e th e ra p ist is fo cu sin g on th e p a tie n t's facad e an d b arrier in the transference: TH: A nd do you think there is som ething o f a facad e with me? PT: No. I fe e l that you see through the facade, and it m akes m e "embarrassed." 1 feel a little bit "naked." It's alm ost as if I'm sitting here with no clothes on and you're ju st looking at me. TH: "Naked" has to do with closeness, if you carefully look at it, hmm? PT: Closeness? TH: Yeah, that 1 am gettin g close to you r intim ate thoughts an d feelings. Do you have a problem with closeness, intim acy? PT: Uhh . . . TH: I have a feelin g that here w ith me you are trying to cover up you r feelings. PT: Yes.

In the follow ing passage the p atient has becom e in creasin gly sad: PT: TH: PT: TH: PT: TH:

Sad. A nd you don't w ant to share it with me. It's very painful. "I don't understand you." I'm not sure it's that. You see, right now you are very sad and you don't w ant to let it go. I'm trying to let go. You w ant to control.

In the follow ing passage the p atien t m oves to the tactical d efen se: "I d o n 't trust you :" TH: PT: TH: PT:

Right now 1 am sayin g you are fig h tin g the feelin gs. Let's look at your feelings. I fe e l very tight in m y throat an d I fe e l m y eyes . . . You see, right now you talk, not to let the feelin g com e out. A nd I don't know why. Because I don't loant you to com e too close to me. I'm afraid o f you in som e way. I "don't trust you."

P atient's tactical d efen se is sw ept aside: TH: I'm not sure it is trust. It is trem endous conflict an d fear, I don't knoiv from where it com es. There is a trem endous fea r o f intim acy an d closeness. O bviously it is sad.

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T h en sh e m oves to a n o th er tactical d efen se "m ak e fun of m e:" PT:

Som ehow I ’m afraid you 11 "make fun o f me" or som ething.

T h e p a tie n t's tactical d efen se is again sw ept aside: TH : PT: TH : PT: TH: PT: TH : PT: TH: PT: TH: PT: TH :

You see, these are all m echanism s you use to avoid you r painful feelin gs. You know it well. (Pause) M aybe I don't believe that you can . . . Yeah, but right now you know that these are all m echanism s fo r fig h tin g your very painfu l feelin g s. I can't g o arou nd cry in g in fro n t o f people every tim e they hurt me. You see, a w hile ag o I w as sayin g that you have a trem endous problem w ith the issue o f intim acy an d closeness. (W hispering, hardly au dible) I keep people very fa r away. Far aw ay uh hm m . (Pause) Is it m uch m ore w ith men or w om en? (She sighs deeply.) I don't knoiv. (H ardly audible) I don't know. I really don't know. M en have hu rt m e more, but I don't know if it's . . . So it has been m ore w ith m en? Oy\ly becau se I've had a series o f relationships w ith men that didn't w ork out. You m ean a series o f relationships w ith men that en ded up in disappointm ent? Uh hm m . (She is very sad, crying.) D isillusionm ent is so deep that I w onder if I can ev er love anyone. I don't kn ow w hat has happened, but m aybe a part o f you has decided that you w ill never let an y person g et close to you again.

T h e p o in t to em p h asize h ere is that th ere are a set of tactical d efen ses th at m ig h t com e in to o p eratio n w h en the therap ist focu ses on this m ajor resistan ce. H ere, w e saw a few : "I d o n 't trust you/' "you m ake fun of m e," "you reje ct m e."

Cover-Words: "Silly," "Stupid," "Funny," "Dumb." T h is form of tactical d efen ses su ch as "it w as a fu n n y situ ation ," " I kn ow it w as stu p id ," or "silly," " I felt d u m b ," "1 felt stu p id ," "I felt no good " are com m on ly en co u n tered . T h e fo llo w in g w ill illustrate:

The Case of the Machine-Gun Woman Sh e su ffered from ep isod es of clinical d ep ression , sexual difficulties and ch aracterolo g ical p roblem s. Sh e had seen a therap ist w h o h ad decid ed th at the m ajo r asp ect o f h er p ro blem th at n eed ed treatm en t w as sexual difficulties. T h e treatm en t con sisted o f h er lay in g d o w n on a cou ch; th e therap ist w as on th e o th er side o f the roo m w ith a cu rtain sep aratin g them from each other. T h e th erap ist w ou ld play m usic o n a tap e and th e p atien t w as m astu rbatin g w ith h er clo th es on and fan tasizin g . PT:

H e h ad m e d oin g various exercises "I g u e ss."

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TH:

W hat do you mean “guess?" (Tactical defense o f indirect speech)

TH: A nd what was your fantasy? PT: It was . . . it loas more tied into the tape and I can't remember what the tapes were. 1 fou n d the w hole thing "silly." TH: But now let us not call it "silly." T he focus is on the situation th at developed in h er previous therapy in w hich she passively com plied w ith h er therapist's decision and ended up by being exposed to hum iliation w h ich w as itself an expression o f characterological problem s; inability to assert herself, and the ten d en cy to en ter into situations in w hich she is used and abused. TH:

You go y ou rself on you r oion will, but then the focus is on sexual problem s which you have okay? PT: Uhmm. TH: But you say that you have had other m ajor difficulties but the focu s is on sex and you go alon g loith it? PT: Yeah, I know, it sounds "funny." T h e follow ing is an oth er exam ple of the tactical d efen se of cover w ord in a p atient w ho w ants to com m u nicate th at he m ay lose control over his violen t rage.

The Case of Henry-lV Man At the tim e of the initial in terv iew h e w as 28 years old, m arried, suffered from sym ptom s and ch aracter disturbances. T h e p atient had b een d escribin g a con fron tation w ith his w ife and her lover: TH: PT:

Was your fe a r that you m ight do som ething drastic? Yes, or that I m ight lose m y . . . "my reason," "or som ething."

Cover Words, Rumination

Ask for explicit statement

Case of Salesman W h en he cam e into treatm en t h e w as 26 years old, m arried, suffered from m ild obsessional n eu rosis o f recen t on set and problem s w ith con cen tration . TH: H ow w ould you describe y ou r sister-in-law in term s o f physical appearance? PT: Physically she is a very attractive girl, very well built. TH: H m hmm, in w hat way? PT: E r .. . loell: she is very pretty, she has a "big ch est" . . . the rest o f her body is nice. H ere the patient clearly felt th at the w ord "b reasts" w as too explicit, the deep reason for this bein g that it led in the direction of his feelin gs about his m other.

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Challenge defense in question

A n exam p le is a situ ation th at m obilizes v iolen t rage and the p atien t's resp o n se is u sin g b lan k et w ord s "I w as very sh ocked," "b ack in g up m entally," "p issed o ff m entally."

T7te Case of the Cement Mixer At th e tim e o f th e in itial in terv iew he w as m arried and su ffered from diffuse ch aracter an d sy m p tom s d istu rbances. H e described an in cid en t th at h e w as en rag ed w ith his w ife. T h e th erap ist is exerting pressu re for th e actual experien ce o f th e an ger: PT. I ivas "very sh o ck ed ." TH : That doesn't say how you experien ced you r an ger PT: I w as "backing up m en tally ." TH : Still that doesn 't say how you actually experience you r an g er PT: 1 fe lt an "empty, lonely sp a ce."

Jargon Words

Challenge defense in question

The Case of the Chess Player W h en th e th erap ist qu estion ed him about his difficulties h e said "d ev astated and d ep ressed ."

The Tactical Defense of Indirect Speech; Hypothetical Ideas Make explicit Challenge defense in question Call defense in question In in terv iew s w ith p atien ts this form of tactical d efen se is en co u n tered very frequently. For exam p le, "p robably," "m a y b e ," "I th in k," "I g u ess," "I su p p ose," and "so rt o f " to avoid th e tru e exp erien ce of feelin gs, o p en d eclaration o f so m eth ing painfu l or an xiety lad en . T h e tech n ical in terv en tio n s con sist o f caU th e d efen se in q u estio n ; ch a llen g e th e d efen se in question.

Indirect speech

Interventions

"1 su p p o se so." "S o rt of." "P robably ." "I gu ess w e

"W h y 'su p p o se?' You said h e w as a pain in you r n eck ." 'A gain , 'so rt of?' You see . . . you w an t to rem ain in d efin ite." "W h y 'p ro b ab ly ?' E ither you w ere an gry . . . " "You see? A gain you leave it in a state of Umbo."

probably." "I gu ess so." "I th in k m ay b e,

"Y ou 'g u ess so?' " "You leave it in a h y p oth etical w ay . . . 't h in k ,' 'm a y b e '. . . "

I m ust b e feelin g resen tm en t."

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T he follow ing exam ples illustrate this form of defense.

The Case of the Masochistic Engineer A you n g m an su ffering from diffuse sym ptom and character disturbances. T he focus is on his conflict w ith his son, and the therapist puts pressure on his feeling in relation to a recent incident; TH: H ow did you feel? PT: I "think," "maybe," "1 must," "perhaps" felt resentment.

The Chess Player TH: PT:

You said that you w ished that you r supervisor w ould be out o f your way? You m ean he w ould disappear in your life? "1 suppose s o ."

The Henry-W Man The patient had b een describing the incident that he w as enraged w ith his wife: PT.

M y w ife is a frail, I should say very girlish you n g person, "sort of." I never becam e physically violent with her, and the only thing 1 did "sort of," was that I gave her tivo slaps on the fa ce at that time.

The Masochistic Housewife W h en sh e en tered in to trea tm en t sh e su ffered from d iffu se sym ptom d istu rbances and m ajo r characterological problem s. PT:

Yes, "I must" feel resentful or angry toward him.

The Real Estate Lawyer PT: PT: PT:

I "probably" w as angry. "I'm sure" “I m ust have been" angry. The "probability o f me being a n g r y ..."

The Salesman PT PT PT PT

PT:

"I guess" IOC “probably" could have had tim e fo r intercourse. I have alw ays been "sort o f " attracted to that (i.e. breasts). "1 think" it was that that attracted m e about my sister-in-law. "I guess," "you could say," m y w ife is a sm all-breasted woman.

"I guess" it seem ed to m e that my brother used to be able to stay up later than 1 did at his age, "you kn ow ." TH: Your m other was m ore lenient w ith him and m ore strict with you? PT: "I guess" "you could say," that, yes.

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PT:

129

Yeah right. "I gu ess" so. "I guess" h e w as the favorite. "I gu ess" he w as then but . . .

TH : A n d you w ere right after him to fig h t, an d you were seven years older PT: "Possibly" right.

Masochistic Woman with Brutal Mother TH : C ou ld you g iv e m e on e o f the fan tasies ? PT: Uh, bein g raped, "in a w ay." PT: I relive the fa n ta sy m any times until I feel. "I guess," either "somewhat" d isgu sted w ith m y self or physically satisfied "in som e w ay. " TH : A n d w hat do you do w hile you have this fan tasy? PT: "I think" I'm touching m y self PT: I'm nude or at least m y gen itals are show ing "in som e w ay ."

The Hyperventilating Woman R ep eated attacks of h y p erv en tilatio n occu rred quite clearly in th e con text of situ ation s th a t m obilized a n g er in her. T h e th erap ist ev en tu ally raised th e question if h y p erv en tila tio n is a m ech an ism o f d ealin g w ith the u n d erly in g an g er in relation to h er m oth er; TH : PT

In oth er w ords the question is w hether the hyperventilation is a way o f dealing w ith the em ergence o f this anger, an d then also gettin g depressed? "Could be."

The Case of the Butch A m an in his tw en ties su fferin g from ch aracter neurosis. T h e in terv iew started b y him in d ica tin g th a t h e had a w arm feelin g for th e first evaluator, w h o w as a fem ale th erap ist, and h e h ad feelin g s abou t the ch an g e. T h e therap ist im m ed iately focu ses on th e p a tie n t's w arm feelin g for the first evaluator. T h is im m ed iately m ob ilized a set o f tactical d efen ses, avoid an ce: PT TH: PT TH:

Yeah "I g u ess s o ." "I g u ess so" hm m . D o you notice you're avoidin g me? Yeah. So cou ld w e look into that?

PT TH:

Yeah "I gu ess s o ." You '■g u ess so?"

The Man with Foggy Glasses T h e focu s o f th e session is on his feelings tow ard the therapist: PT:

"I think," "maybe," “I m ust" be feelin g resentm ent.

In th e in terv iew w ith p atients, this kind o f d efen se is en cou n tered again and

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again. T he patient explicitly uses anxiety-laden words but incorporates them into indirect speech so that the im pact is nullified. T h e follow ing are som e of them "I guess," "Probably," "Perhaps," "I think," "I guess you could say," "I m ust," "the probability o f m y b ein g angry," "So rt of," "Som ew h at," "1 assum e," " I m ust have been angry," "I think I am feeling resentful," " I thir^k m aybe 1 am feeling resentful."

The Strangler A m an in his forties, m arried, suffered from episodes of depression, anxiety, m arital problem s, conflict in in terperson al relationships and a w ide range of characterological problem s. H e en tered in to the initial in terview anxious. T h ere w as pressure tow ard his feeling w h ich m obilized a n u m ber of tactical d efenses. In th e forefront w ere "gu ess" and "p erh ap s." TH: H ow do you fe e l right now here? PT: N ot too bad, uh I'm, I'm having difficulty thinking clearly so I'm a bit . . . I "guess" I'm a bit ah, a bit nervous. TH: 1 say how do you fe e l right now? You say “you g u ess." PT: (sm all laugh) I fe e l nervous. TH: You fe e l nervous. Then w hy you say "guess?" PT: It's a w ay I have o f speaking, “I think" I say that a lot. TH: You mean that you are not definite a b o u t . . . TH: But you have to say "it seem s" that you are nervous, as if you are n o t . . . PT: Hm m . TH: H m m ? PT: That's, that's certainly w hat com es out all right. TH: Hm hm m , that you are alw ays indefinite, or is here ivith me? PT: Am I alw ays indefinite? (low voice) TH: You know w hat I mean by indefinite? That you say "perhaps, guess." PT: Yeah, I see ivhat you mean.

The Case of the Masochistic Secretary W h en she en tered in to treatm en t sh e w as in h er thirties, suffered from episodes of clinical d epression an d long-life ch aracter neu rosis. In the early part of the interview the therapist is focu sin g on h er feelin g tow ard h er husband: PT:

"I think," "I gu ess," "perhaps" I do have som e sort o f resentm ent toivard my husband. TH: W hy do you say "perhaps"? E ither you do or you don't.

The Man from Southampton W h en he entered in to treatm en t h e w as 47 years old, m arried an d suffered from a w ide range o f sym ptom and characterological problem s. T h e therapist focused on his sex life: PT:

I "think" m y sex life w as n ot satisfactory .

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The Woman with Fainting Attacks At th e tim e o f th e in itial interview , sh e w as 43 years old, single, su ffered from d iffu se an x iety , p a n ic a tta ck s, fa in tin g a tta ck s an d d istu rb a n ce s in the in terp erso n a l relation sh ip s. S h e h as b een in d ecisive ab ou t g ettin g h elp for herself. In th e v ery b eg in ru n g o f the initial in terv iew she in d icated th at sh e h as b een th in k in g a b o u t g ettin g h elp for h erself for the past 5 years. T h e focus of the session w as on h er in d ecisiv en ess and sh e in d icated th at sh e h ad m ixed feelings about gettin g p ro fession al help . T h e th erap ist focuses on h er feelings: TH : So you have p ostpon ed to get help for y ou rself fo r som e years. PT: Yes TH : Then you m ust have a stron g feelin g about gettin g help fo r you rself PT: I, "I g u ess," "I think" "I m ust" have feeling. TH: But you say you "guess" an d you "think." PT: Well, because I've . .. TH : I m ean, eith er you do or you don't.

The Case of the Masochistic Woman with Migraine Headaches W h en sh e en tered in to trea tm en t sh e w as 48 years old, divorced, su ffering from alm ost d aily attacks o f m igraine h ead ach es, ch ron ic state o f anxiety, and m ajo r con flict in in terp erso n a l relation sh ip s w ith a p attern o f lettin g h erself be used an d abused b y m en . PT:

"I a ssu m e," "I m ust" be depressed, first o f all it is a loss, secondly it is a letdoivn.

PT:

"I w ould say," "maybe" it is a depression.

The Case of the Microphone Man A m an in his forties, d ivorced , su fferin g from a w ide ran ge o f ch aracterological p ro blem s and m a jo r co n flict in th e in terp erso n al relation sh ip s w ith b o th m en and w om en . To th e q u estio n if his in terp erso n al d ifficulties are m ore w ith m en or w ith w o m en h e resp on d ed ; PT:

Uhh, "I think," "possibly" w ith men more.

H e had d escribed a n in cid e n t w h ere his girlfriend had kep t him w aitin g and h e w as ou tw ard ly passive b u t in d icated that h e w as in a b oilin g rage. TH : PT: TH;

D o you thin k passivity w as a defensive w ay o f dealin g with this boiling rage inside? "Probably." "Probably" again. You are again in a state o f limbo.

L ater on h e w a n ts to d escribe an in cid en t th at h e had a h igh d eg ree of rage inside.

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PT: Well, the worst situation, "1 suppose," was the n ig h t . . . TH: Again "suppose." TH: Do you n o tic e. . . you are leaving things in a state o f limbo "yes perhaps," "may be," "I suppose."

The Case of the Maid with Dermatitis W h en she entered into treatm en t she w as 35 years old. Sh e w as referred by her gynecologist because of frequ en t d erm atitis in h er genital area. She suffered from a com pulsion of w ash ing h er vagina rep eatedly after each sexual relation w ith h er husband and w as frequ ently seen by h er derm atologist as well as by her gynecologist. D uring the trial therapy the focus w as on h er feeling tow ards her husband: PT: TH:

"Perhaps" I do have r e s e nt me nt . . . my W hy do you say "perhaps?" Either you

husband. do or you don't.

L ater on she declares an ger and the therapist is exerting pressure to the actual experience of the anger. PT: TH:

"Maybe" I have an ger tow ard him. Again you say "maybe." Do you feel angry or don't you?

TH: H ow do you physically experience the anger toioards you r husband. PT: 1 could “perhaps" kill him. TH: But that is a thought, that is a sentence.

Summary and Conclusion In this Part I of a tw o-part article 1 briefly described a pow erful technique w hich aim s at rapid m obilization of the u nconscious, loosen ing the p atient's psychic system , reorganization of the unconsciou s and ch an g in g the situation from the dom inance of the resistance to a m ajor d om inan ce of the u nconscious therapeutic allian ce. I em p h asized th a t th e op tim u m m ob ih zation of th e u n con sciou s therapeutic alliance against the forces o f the resistance is one of the m ajor aim s of the therapist. It w as em phasized that the therapist's com prehensive know ledge about the new m etapsychology of the unconsciou s is essential to accom plish the task. T h en I indicated that on e of the m ajor features of the technique is that it m obilizes w hat I call tactical d efenses in the service of resistance. In the first part of this tw o-part article tw o m ajor sets of tactical d efen ses w ere discussed; nam ely the tactical d efen se of cov er w ords and of ind irect speech. A series of cases w ere p resen ted as clinical exam ples. Part II of this article will focus on the w ide range o f oth er tactical d efen ses w ith case exam ples.

References Davanloo, H. (1976) Audiovisual Symposium on Short-Term Di/namic Psychotherapy. Tenth World C on gressof Psychotherapy, Paris, France. ]u\y.

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D avanloo, H. (1977). Proceedings o f the Third International Congress on Short-Term Dynamic Psychotherapy. C entury Plaza, Los Angeles, California. November. Davanloo, H. (1978). Basic principles and techniques in short-term dynamic psychotherapy. (New? York: Spectrum ). Davanloo, H. (1980). Short-term dynamic psychotherapy (New York: Jason Aronson). D avanloo, H. (1983). Proceedings o f the First Summer Institute on Intensive Short-Term Dynamic Psychotherapy. W intergreen, Virginia. July. Davanloo, H. (1984). Short-term dynam ic psychotherapy. In Kaplan, H., Sadock, B. (Eds) Comprehensive textbook o f psychiatry (4th ed.. Chap. 29.11) (Baltimore, M D: Williams & Wilkins). Davanloo, H. (1984) Proceedings o f Audiovisual Immersion Course on Intensive Short-Term Dynamic Psychotherapy, sponsored by the San Diego Institute for Short-Term Dynamic Psychotherapy (San Diego, California. May). D avanloo, H. (1986). Intensive short-term psychotherapy with highly resistant patients. 1. H andling resistance. International Journal of Short-Term Psychotherapy 1(2), 107-133. Davanloo, H. (1986). Intensive short-term dynam ic psychotherapy with highly resistant patients. II. The course of an interview after the initial breakthrough. International Journal o f Short-Term Psychotherapy, 1(4), 239-255. Davanloo, H. (1986). Proceedings o f the Second European Audiovisual Symposium and Workshop on Intensive Short-Term Dynamic Psychotherapy sponsored by the Swiss Institute for Intensive Short-Term D ynam ic Psychotherapy. Bad Ragaz, Sw itzerland, June. Davanloo, H. (1986). Audiovisual Symposium on Intensive Short-Term Dynamic Psychotherapy presented at the Annual M eeting of the Royal College of Psychiatrists. Southam pton, England, July. Davanloo, H. (1987). Unconscious therapeutic alliance. In Buirski P (Ed.), Frontiers o f dynamic psychotherapy. C hapter 5, 64-88. (New York: M azel and Brunner). Davanloo, H. (1987). Intensive short-term dynam ic psychotherapy with highly resistant depressed patients. Part 1. Restructuring ego's regressive defenses. International Journal of Short-Term Psychotherapy, 2(2), 99-132. D avanloo, H. (1987). Intensive short-term dynam ic psychotherapy with highly resistant depressed patients. Part II. Royal road to the dynam ic unconscious. International Journal o f Short-Term Psychotherapy, 2(3), 167-185. Davanloo, H. (1987). Proceedings o f the Fifth Summer Audiovisual Immersion Course on Intensive Short-term Dynamic Psychotherapy. Killington, Vermont, August. Davanloo, H. (1987). Clinical m anifestations of superego pathology. Part I. International Journal o f Short-Term Psychotherapy 2(4), 225-254. D avanloo, H. (1987). Proceedings o f the Audiovisual Symposium on Intensive Short-Term Dynamic Psychotherapy, spon sored by the R ochester Institute for Short-Term D ynam ic Psychotherapy. Rochester, New York, October. D avanloo, H. (1988). Clinical m anifestations of superego pathology. Part II. The resistance of the superego and the liberation of the paralyzed ego. International Journal o f Short-Term Psychotherapy, 3(1), 1-24. D avanloo, H. (1988). The technique of unlocking of the unconscious. Part I. International Journal o f Short-Term Psychotherapy, 3(2), 99-121. D avanloo H. (1988). The technique of unlocking of the unconscious. Part II. Partial unlocking of the unconscious. International ]ou rm l o f Short-Term Psychotherapy, 3(2), 123-159. D avanloo, H. (1988). Central dynam ic sequence in the unlocking of the unconscious and com prehensive trial therapy. Part I. M ajor unlocking. International Journal o f Short-Term Psychotherapy, 4(1), 1-33. Davanloo, H. (1988). C entral dynam ic sequence in the m ajor unlocking of the unconscious and com prehensive trial therapy. Part II. The course of trial therapy after the initial breakthrough. International Journal o f Short-Term Psychotherapy, 4(1), 35-66. Davanloo, H. (1989). The technique of unlocking the unconscious in patients suffering from functional disorders. Part I. Restructuring ego's defenses. International Journal o f ShortTerm Psychotherapy, 4(2), 93-116.

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Davanloo, H. (1989). The technique of unlocking the unconscious in patients suffering from functional disorders. Part II. Direct view of the dynamic unconscious. International Journal of Short-Term Psychotherapy, 4(2), 117-148. Davanloo, H. (1990). Unhxking the unconscious (Chichester, England: John Wiley & Sons). Davanloo, H. (1990). Proceedings o f the Sixth European Audiovisual Immersion Course on Intensive Short-Term Dynamic Psychotherapy sponsored by the Swiss Institute for Intensive Short-Term Dynamic Psychotherapy. Geneva, Switzerland, June. Davanloo, H. (1993). Audiovisual Course on Intensive Short-Term Dynamic Psychotherapy presented at the 146th Annual M eeting of the American Psychiatric Association. San Francisco, California, May. Davanloo, H. (1993). Proceedings o f the Eleventh Summer Institute on Intensive Short-Term Dynamic Psychotherapy. Treatment o f Fragile Character Structure. Killington, Vermont, July. Davanloo, H. (1993). Proceedings o f the Eleventh European Audiovisual Immersion Course on Intensive Short-Term Dynamic Psychotherapy. Treatment o f Fragile Character Structure. Bad Ragaz, Switzerland, December. Davanloo, H. (1994). Proceedings o f the Audiovisual Immersion Course on the Technical and M etapsychological Roots o f Intensive Short-Term Dynamic Psychotherapy. Bad Ragaz, Switzerland, December. D avanloo, H. (1995). Intensive short-term dynam ic psychotherapy: Spectrum of psychoneurotic disorders. International Journal o f Short-Term Psychotherapy, 10(3,4), 121-155. Davanloo, H. (1995). Intensive short-term dynamic psychotherapy: Technique of partial and major unlocking of the unconscious with a highly resistant patient. Part I. Partial unlocking of the unconscious. International Journal of Short-Term Psychotherapy, 10(3,4), 157-181. Davanloo, H. (1995). Intensive short-term dynamic psychotherapy: M ajor unlocking of the unconscious. Part II. The course of the trial therapy after partial unlocking. International journal o f Short-Term Psychotherapy, 10(3,4), 183-230.

Management of Tactical Defenses in Intensive Short-Term Dynamic Psychotherapy, Part II: Spectrum of Tactical Defenses HABIB DAVANLOO McGill University, Department o f Psychiatnj, Montreal General Hospital, Montreal, Canada

Recapitulation In Part I o f the p resen t article I d escribed , very briefly, a tech n iq u e of in ten sive sh ort-term d yn am ic p sy ch o th era p y (IS-TD P) and em p h asized th at it can be applied to th e w h o le sp ectru m of p sy ch o n eu rotic d istu rb ances as w ell as those w ith fragile ch a ra cter stru ctu re. So m e o f the m ajo r features o f the tech n iq u e w ere d escribed w h ich can b e su m m arized as follow s: (1)

The tech n iqu e of direct access to the u nconscious; unlocking of the unconscious was briefly described. (2) The m ajor aim of the technique; to loosen the patient's psychic system and to change the balance from the dom inance of the resistance to the dom inance of the unconscious therapeutic alliance was presented. (3) I further indicated that the most im pressive fact in this whole transform ation is reorganization of the unconscious; optim ization of the unconscious therapeutic alliance; total breakdow n of all the forces m aintaining the major resistance; creating a situation which we may call 'D ream ing while Awake' w hich heavily speeds up the process and finally results in m ultidimensional structural character changes. (4) I em phasized that the therapist who wants to work with this technique must have a com p rehensive know ledge of the new m etapsychology of the unconscious w hich I have introduced over the course of 30 years of research. (5) It was em phasized that rapid mobilization of the unconscious mobilizes what I call tactical defenses. It is essential for the therapists to make them selves familiar w ith these tactical defenses used by the patient in the service of the resistance so that they can challenge each one the m om ent it appears. (6) The spectrum of these tactical defenses show s an extraordinary uniform ity across the w ide range of patients. (7) The continuum of tactical and major defenses was discussed and Part I heavily em phasized on the m anagem ent of two sets of tactical defenses nam ely cover words and indirect speech, and a series of cases w ere presented.

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In Part II of this tw o-part article I continue to discuss the m anagem ent of the spectrum of tactical d efenses com m only encou ntered. An attem pt will be m ade to present a series of case exam ples.

Rumination

Make explicit Ask decision, call defense in question Challenge defense in question

It is en cou ntered in a variety of patients, its central characteristic is an elem ent of intellectual repetitiousness, of going over and over som e subject, often w ith an air of doubt and ap p arent searching for the truth , w hich in fact is bein g used to avoid the em otional im p act of the truth.

Rumination

Intervention "You are giving a d escription 'th a t d oesn 't m ake sense.' H ow did you experien ce your an n oyan ce?" " 'Stu p id blood y d octors' is again a senten ce, but w hat was th e w ay you experienced this an n oyan ce?" " 'A stupid situation,' 'I felt h eated,' '1 felt both ered ' d oesn't tell us h ow you experienced your an n oyan ce." "W h a t do you m ean by 'u n fin ish ed task'?" " '1 know m yself.' You are ru m in atin g on that. T h at d oesn't tell us an ything ."

T he follow ing are a few exam ples.

The Case of the Salesman Su ffering from obsessional n eurosis from the extrem e left o f the spectrum . TH: PT:

You mean the breasts? S h e’s a large-breasted woman? Yeah. I think that is l o h a t . . . I d o n ’t k n o w . . . I have alw ays been sort o f attracted to that.

PT:

I guess because he was the youngest, sort o f thing. So I guess 1 used to think that he got more, or really he d id n ’t. B u t . . .

PT:

Yes, 1 gu ess he was then b u t . . . We are looking at it then . . . O kay . . . favorite? . . . favorite? H e loas the fav orite because he luas the youngest.

The Hyperventilating Woman Som e aspects of the in terv iew w ith this p atien t w ere p resen ted in Part I.

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TH:

Was there a sim ilar feelin g w ith y ou r hushand fo r ignoring you ? W ere you angry w ith him ?

PT:

W ell it w asn't a n g er O r m aybe it was. O r m aybe I don't know w hat an ger is.

T h e in terv iew focu sed o n h er m ale teacher, w h o ap p eared in h er recu rren t d ream . PT: A t the tim e 1 thought I loved him , hut I really j u s t . . . TH : You m ean you loved him in w hat sense? You had sexual feelin g fo r him? PT: Yeah, b u t . . . TH : But you say it in a hesitan t way. D id you or didn't you?

The Chess Player T h e follow in g is a passage from the in terv iew w ith the "ch ess player," a seg m en t o f w h ich w as p resen ted in Part I. It gives a striking illu stration of ob sessional ru m in a tio n in w h ich ev ery sen ten ce is factually tru e b u t w hich n e v e rth e le s s b lo c k s e m o tio n a l co m m u n ic a tio n . In th e last se n te n c e th e in tellectu alizatio n is h eig h ten ed by th e use o f w ords that are hardly ev er fou nd in ev ery d ay sp eech : PT:

I am defensive. I am aggressive. I becom e m ore defensive when I fe e l threatened. I am m ore threatened w hen I fe el m ore worn dow n an d less able to deal with situ ation s luhich are confronted. A nd m y “aggressivity" com es out in ivays that I am not as "privy to" as I w ould like to be . . .

Vague Rumination

Make explicit Pressure, challenge

Tactical d efen se o f v agu e ru m in ation is en co u n tered frequ en tly: "I am a little co n fu sed a b o u t th at," " I d o n 't u n d erstan d you right," "H ere w e go again ," "I felt okay," "I felt fin e," "I felt m yself ru n n in g from m yself," "1 am feeh n g con fu sed ," "I felt rid iculous" and "1 feel o u t on a lim b." T h e follow ing are a few exam ples:

Case of Man with Foggy Glasses A se g m en t o f the in terv iew w ith this p atien t w as p resen ted in Part I. T h e th e ra p ist is fo cu sin g o n h ow the p atien t exp erien ces his a n n o y a n ce tow ard h im , an d th e p a tie n t resp o n d s w ith a v ag u e ru m in atio n — "th a t d o e sn 't m ake sense. PT: TH:

W ell I said to m y self uh you knoiv to m e "It doesn't m ake sense.' But that is a sentence. (Pause)

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TH:

You say you w ere annoyed hut then I said how did you experience this annoyance. Noiv you are giving a sort o f description: "that doesn't m ake sense." H ow did you experience your annoyance?

Fu rth er pressure on his feelin g of an n oyan ce m obilizes further tactical d efenses— "stup id blood y doctors." PT: TH:

W ell in my . . . in my m ind I said uh you knoio "stupid bloody doctors." "Stupid bloody doctors" is again a sentence, but what was the loay you experienced this?

In addition to vague ru m in ation there is the tactical d efen se of generalization "d o cto rs," av oid ing to ad d ress th e tran sferen ce directly and th e therapist im m ediately challenges that: TH: H oio did you experience this annoyance? In term s o f thoughts, was stupid bloody doctors . . . but then you also m ake it plural, doctors. TH: W ho is the stupid bloody . . . ?

The Case of the Microphone Man W hich w as discussed in Part I. Focusing on the experience of his annoyance tow ard his landlord: PT:

Well by a "feeling o f heatedness" I guess.

PT:

I fe lt "bothered" and "burdened."

PT:

I fe lt "heated."

The therapist qu estion s him on the actual experien ce o f the an n oyan ce and he responds: PT:

"Stupid situ ation ."

The Case of the BB Gun Man W h en h e entered into treatm en t h e w as in his thirties, m arried and suffered from diffuse sym ptom s and ch aracter d isturbances. In focu sin g on the natu re o f his problem he said: PT:

Trouble with coping w ith everyday situation . . . N egative situations.

W h en the therapist asked for a specific exam ple he resp on d ed w ith: PT:

W ork not up-to-date. C ar trouble . . . things like that.

A ttem pt to und erstand the n atu re o f his difficulty, h e resp on d ed by saying:

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A ny u nfin ished task.

In terv en tio n : A ttem pt to m ake the statem en t explicit TH : A nd m y qu estion is this, w hat do you m ean by “unfinished task?"

Masochistic Woman with Migraine Headaches A spects o f th e in terv iew w ith tiiis p atient w ere p resen ted in Part I. PT:

W ould you g iv e m e an exam ple? H oio 1 should express m yself that w e get to the p oin t quicker. TH : H m m . A gain that is vague . . . to get to the point. W hich point?

h i th e sam e in terv iew the therap ist reflects on the p atien t's resistan ce against em otio n al closeness. TH :

H ow did you feel?

TH :

You don't ivant m e to get to know you. You haz>e a problem talking about y o u rself PT: I don't kn ow w hat is really "the real s e lf" TH : H m m . D o you notice you have a tendency to label? PT: I am learn in g that right noio. I som etim es think I know m yself TH : You see again you are rum in atin g on that. That doesn't tell us anything.

The Case of the Butch A seg m en t o f this in terv iew w ith this p atient w as p resen ted in Part I. T h e th erap ist is p u ttin g pressu re to the actual exp erien ce of the an g er tow ards his p artn er; PT: TH :

Wlmt I f e l t . . . a "rushing feelin g " o f a, o f a hate, o f a feelin g o f a hate fo r the guy. N ow you m ove to the "rushing feelin g o f hate" which is vague. You said that you fe lt an g ry tow ards him. H ow did you experience the anger. PT: (stutters) I f that is not an g er I don't know, I don't know what an ger is. TH : Let's not to ru m in ate on w hat an g er is. H ow did you physically experience the an g er you felt.

The Man from the United Nations W h en h e w as first seen , h e w as 54 years old and su ffered from lo n g -stan d in g irritable b o w el sy n d rom e. H e w as referred from the coro n ary in ten sive care unit w h ere h e w as ad m itted b ecau se o f severe ch est pain. H e had a q u arrel w ith his d au g h ters an d h e w as en rag ed , w alked o u t o f the h ou se w ith an explosive d isch arg e o f affect. Sh o rtly after th at h e had severe ch est pains an d h ad to be ad m itted , w ith n o o rg an ic findings. D u rin g the initial in terv iew the focu s w as on h is feelin g :

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TH: H ow do you feel here, right now? PT: / . . . "1 clam into myself." TH: That doesn't say how you feel. So let's see how you feel here with me? PT: "I fe e l my life d ied ."

PT:

" Ifeel confused" . .. "confusion."

Intellectualized Rumination

Challenge the defense

The Case of the German Architect A m an in his thirties su ffering from m ajor characterological disturbances and m asochistic ch aracter traits, h i the early part of the interview , the therapist is focusing on the patien t's difficulties, the ph ase o f inquiry. H e is vague and then m oves to ru m inate in an intellectualized fashion: PT: No, I'm not, I'm sim ply explaining that umm . . . TH: Noiu you are becom ing slow. PT: 1 beg you r pardon? No, I'm trying to say that umm, it becomes a more "plausible thing", ah, loith a more "plausible cause" when you realize . . . TH: Yeah, but you see this is very vague, you see you say the, still the question that I had loas what seem s to be the difficulties and so fa r you are in a sense rum inating in a vague fashion on the . . . PT: No, I'm not. I've definitely said I have a problem with com m itm ent, and that very much cam e hom e lohen I discovered the sam e problem elseivhere in people related to me w ho have the sam e background, ah . . . TH: So one problem that you have has to do with com m itm ent. PT: Yes, but don't forget that o f course it took m e many, m any years to even realize that I had a problem there. I mean I've been plodding in the dark fo r alm ost as long as I've been alive. Ah, xohich brings up an other point, maybe I have a problem w ith feelings.

Rationalization

Rationalization

Ask for explicit statement Challenge, dismiss the defense

Intervention "You see again you are n ot talking about feeling. A gain you m ove to 'b ecau se'."

Rationalization—the Word "Because" T h e w ord "becau se" is likely to in trod u ce a rationalization.

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The Case of the Salesman and his Sister-in-law T h e focus is o n his m o th e r's favoritism o f his y o u n g er broth er: PT: TH :

. . . h e w as the fa v o rite "because" he luas the youngest. Let's not g et to "because."

Rationalization that the Anger is Unjustified R atio n alizin g aw ay an g ry feelin gs is to find excuses for the o th er p erson 's action , lea d in g to th e feelin g th at the an g er is u n ju stified , keep in g in m ind that the a n g er b y itself is a tactical d efen se against v iolen t rage or m u rd erou s rage.

The Masochistic Housewife A spects o f the in terv iew w ith this p a tien t w ere p resen ted in Part I. H ere th e su b ject u n d er d iscu ssion w as the w ay sh e is passively com p lian t w ith th e d em a n d s of b o th h er m oth er and h er husband: PT:

Yes, 1 do g et an g ry w ith m y husband. But then I tell m yself “W hat can he d o ?"— m y m other d om in ates him as well.

The Case of the Hyperventilating Woman T h e su b ject is h e r h u sb a n d 's n eg lect o f her: TH : Yes, but you see again you are not talking about you r feelin gs. PT: Well, I fe lt an g ry but 1 loasn't sure that I was justified. TH : No, let's not g et into the intellectual aspect o f it. Let's look at you r feelin gs.

Intellectualization

Make explicit, challenge

AU d efen siv e in tellectu alizatio n con sists o f th in kin g rath er th an feeling.

Intellectualization

Intervention " 'If I had b een a m ale . . . ' n ow you w an t to m ove to in tellectu alize." "S till you h a v e n 't told m e abou t you r problem s and n ow you w an t to in tellectu alize ab ou t w h ere the p roblem com es from ." "You h ave n o t told m e the d ream , and n ow you are an a ly zin g it."

The Case of the Real Estate Lawyer A seg m en t o f th e in terv iew w ith this p atien t w as p resen ted in Part I. In the follow in g p assag e in w h ich sh e is still try in g to avoid ex p erien cin g h er anger, she

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uses generalization, hypothetical ideas, cover w ords, w hile the w hole passage consists of a theoretical discussion about the nature of h er reaction: PT:

"When" blood surges there "has to be" "some sort of" e m o t io m l. . . there "must have been" a trem endous . . . there luas an "emotional reaction" "for sure," "otherwise I w ould not" blush, my ears wouldn't get red.

Thinking Rather than Feeling As I h ave m en tion ed b efore, all defen sive intellectualization consist of thinking rather than feehng, b u t there is a type o f d efen se of w hich this description is particularly appropriate: instead of reacting em otionally to a situation the patient m akes som e intellectual ju d g em en t about it. In the follow ing exam ple the patient avoids h er in ten se feeling of rage by u sing the m uch m ore cognitive con cep t of curiosity and follow s this by using yet an oth er cover word.

Real Estate Lawyer PT: I ju st felt very "em barrassed." TH: But you see it is not absolutely clear how you felt. PT: I was "curious " as to w ho had done it, because at that point I was very "shocked. "

Intellectualization and the Word "If" T h e w ord " if" w ill alm ost certain ly b e used to in trod u ce som e defensive intellectualization.

Real Estate Lawyer PT:

I guess "if" I had been a m ale and som eone had done that to me my reaction loould have been . . . TH: No, let's not m ove to if you w ere male.

In the sam e in terv iew the focus w as h ow she felt about an incident: PT:

Well it has m ade an impact, otherw ise eight or 9 m onths later I w ould not still

b e ... TH: No, le t’s not g o after that. Let's see hoio you felt. PT: Okay, "if" I say I definitely was angry 1 w ould not be telling the truth, because at that point I didn't sort o f m entally rem ark to m yself all the feelin gs that I had, I mean I didn't analyze it. (Intellectualized ru m ination)

Intellectualization, Cover Words Henry-IV Man A segm ent of the in terv iew w ith this p atien t w as p resen ted in Part I. In the follow ing segm ent the focus is his m other, w h o had had an affair w ith a friend of the family:

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PT:

I fe lt fir s t o f all it ivas "shocking" that m y m o th e r . . . som ething m ust be w rong ivith her. TH : D id you fe e l rage w ith y ou r m other? PT: Yes. I really fe lt that she's . . . I really put the w orld o f people in tw o categories, people w ho are straight an d people w ho have . . . TH : D id you fe e l rage ivith her? PT: Yes, I fe lt rage w ith h er

Intellectualization and Diversification The Woman with the Fainting Attacks A p art of th e in terv iew w ith this p atien t w as p resen ted in Part I. In the follow in g seg m en t the th erap ist is exerting pressu re to describe on e or tw o in cid en ts of h er fa in tin g attacks. First, she resorts to the d efen sive w eep in ess then sh e w an ts to m ove to in tellectu alize into the cause of h er fainting attack and d iversify from g iv in g a d etailed d escrip tion of h er actual fain tin g attack, w h ich is an x iety p rovokin g. TH :

I m ean to g o to w hat is the cause o f passing out is not g oin g to help. It is very im portant fo r us to explore on e or tzvo incidences w hen you passed out that loe can g et a better picture o f w hat it is like. PT: That's w hy I'm cryin g because it's it's difficult fo r m e to talk about it. O kay I'll describe it. TH : M ost recent on e w ould be best. Finally, sh e d escribes in d etail tw o of h er m ajo r fain tin g attacks.

Generalization

Make it specific Challenge the defense

As I h av e em p h a siz ed m an y tim es, the u ltim ate aim o f ev ery in terv en tio n that th e th e ra p ist m akes is to b rin g th e p atien t to the direct exp erien ce of his feelings. D irect ex p erien ce in ev itab ly impUes feelin gs about so m eth in g specific, w h ich is w h y th e th erap ist asks th e p atien t to d escribe a specific in cid en t or to co n cen trate on his feelin g at a p articu lar m om en t, in clu d in g the h ere and now. T h e p atien t resists this p ressu re by k ee p in g his resp on ses as gen eral as possible co n tin u in g to d escribe g en era l situ ation s or m ake gen eralizatio n s ab ou t his feelin gs in stead of d escrib in g th em in an actu al situ ation — an d th e th erap ist's task is to ask for a specific situ ation o r in cid en t.

Generalization

Intervention "C ould you give m e an exam ple?" "B u t th at is v agu e and g en eral." "W e are n o t talking ab ou t a 'p erso n '. We are talking about y o u ." "B u t, you see, you are n o t specific." "C ou ld you give m e a specific exam p le?"

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The Chess Player TH: So you r sister's relationship with you is a hostile one. PT: H er relationship with "everybody" is a hostile one. TH: But loe are focu sin g on you.

The BB Gun Man W h en asked to give an exam ple the p atient continues to talk about general situations. PT; TH: PT: TH: PT:

I won't com m it m yself unless I'm sure o f something. Could you give an exam ple? I like "everything" done right. Yes, but that is vague an d general. W hether I w ork on the house, w hether I w ork . . .

The Case of the Manageress A segm ent of the in terv iew v^ith this p atient w as presen ted in Part I. In the follow ing passage the p atient generalizes in respon se to the question 'W h at w as it like?' T h e session w as focu sing on h er an ger tow ard h er m other: PT: TH: PT: TH: PT:

I started fig h tin g with her im m ediately, the m om ent she said that. W hat was it like w hen you w ere fig h tin g with her? Well, we've had very big fig h ts "all the tim e, " and scream ing back and forth. W hat loas the w ay you w anted to lash out physically? Well, I fe e l like hitting her "sometimes" because I feel she doesn't react.

It is im portant to keep in m ind th at certain w ords "all the tim e" and "som etim es" in the patien t's respon ses, in d icate th at he/she is n ot describing a specific m om en t but m akin g a g en eralizatio n about even ts over a period of time. T he sam e fun ction is served by the w ords "usually," "a lot," and by the word "w h en " w h en occu rrin g at the b eg in n in g of a sen ten ce. T h e therapist can be alerted, since it will alm ost certainly in trod u ce a generalization.

The Case of the Hyperventilating Woman T h e p atient is d escribin g a series of dream s sh e had had at o n e tim e about her teacher: PT:

Those w ere the dream s when I thought at one point 1 loved my teacher. "Most girls" fa ll in love ivith their m ale teachers, I think, b u t . . . TH: Let's not get to "most g ir ls ." Let's focu s on you.

The Real Estate Lawyer In respon se to a q u estion "w h at w as th at eight d egree of an ger like?" the patient used the cover w ord "co n fu sed ." T h e therap ist ch allenged this by sim ply p oin ting it out, and sh e resp on d ed by u sing tw o d ifferen t form s o f generalization:

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the rep eated use o f th e w ord "w h en ," accom p an ied b y the use of the w ords "a p erso n " as a su bstitu te for m ak in g a d irect statem en t abou t herself. This latter kind o f g en eralizatio n , w h ich in clu d es the use of the w ord "on e" as a substitute for "1," is also u sed frequently. TH : PT.

You say you are 8 degrees an g ry and 1 question you hmu you experience this anger, an d now you say "confused." O kay, "when" “a person" is very an gry or "when" I'm very an gry . . . "When" I'm very an g ry 1 don't think rationally.

T h e follow in g resp o n ses of this sam e p atient, to the im plied q u estion o f w hy sh e w as sm iling at a p articu lar poin t in the interview , also co n tain b o th form s of g en eralizatio n : PT:

O kay "when" "people" tend to g ig g le fo r no reason . . . Sm iling "usually" indicates happiness, com fort . . . "W hen" I sm ile it ’s a reaction w hich I give to "people" generally. I sm ile "a lot" for no reason.

"U su ally ," "a ll the h m e," "so m etim e s," "w h en ," "on e" as a su bstitute for "I," "a p erso n ," "a lo t," " I feel fru strated ," "I feel so m ew h at irritated ," "I feel angry," "I had positive feelin g ." T h ese are som e of the m ost com m on form s o f gen eralization en co u n tered . It is o f great im p o rtan ce to n ote th at the therap ist m igh t o ften use th ese sam e d efen ses. For exam p le, the p atien t m ight d eclare th at h e is frustrated and th e th erap ist resp on d s "H ow do you exp erien ce th e fru stration ." T h e patien t's fru stratio n o r a n g er is d irected at th e therapist b u t g en eralizes it in the form of b ein g fru strated . C lin ician 's a tten tio n to th ese tactical d efen ses is extrem ely im p o rtan t. So m e o f th ese tactical d efen ses are w ell en tren ch e d in to the m ajor resistan ce. T h e th era p ist sh ou ld take in to con sid eration th at in a large n u m b er of ch aracter n eu rotics, fru stration b y itself is a tactical d efen se against an g er and an g er is a d efen se again st v iolen t rage, m u rd erou s rage or prim itive m urderou s rage an d in ten se gu ilt-lad en feelin g in relation to the m u rd erou s rage w h ich in tu rn is co n n ected w ith th e trau m a and the pain of traum a. R ep eated b yp assin g of this form of tactical d efen se m akes the access to the m urd erou s rage and the guilt tow ard th e early figu re im possible. T h e follow ing exam ple illustrates this form of tactical d efen se an d its m an ag em en t.

The Case of the Strangler W h en h e en tered in to trea tm en t h e w as in his forties and su ffered from d iffu se sy m p tom s an d ch a ra cter d istu rbances. D u rin g the initial in terv iew there w as p ressu re tow ard his avoid ed feelin g in the tran sferen ce. T h ere w as clear ev id en ce th a t his ch a ra cter d efen ses w ere crystallized in the tran sferen ce and he d eclared fru stration : PT: 1 fe e l fru stration . TH : You fe e l fru stra ted w ith me. Is this w hat you say? PT: I fe e l fru strated , that's w hat I'm saying. TH: You fe e l fru stra ted at w ho? A gain you are crippled, to say y ou r are fr u s tr a t e d . . . is a cu t-o ff sentence. "I feel fru strated " is a cu t-off sentence. Frustrated at luho?

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PT: TH: PT: TH:

I'm... Again you're crippled, fru strated at who? Your hand again. I'm frustrated. Frustrated at who; First let's to establish at who are you frustrated. N ow your head goes there, your hand goes there . . . PT: (m akes grow ling sound) O rrrrrh . . . TH: . . . and then you m ove toward this crippled position. Frustrated at who? You said you are frustrated, fru strated at who? PT: Do I have to be fru strated at someone? TH: At luho are you fru strated?

Technically, the therapist should not exert pressure to the actual experience of frustration in the transference until this tactical defense is m anaged. T h e therapist continues system atic challenge to this tactical organization of the m ajor resistance. N ow the p atient m oves to the d efen se m echanism of denial "I am n ot frustrated at anybod y;" PT: I'm not fru strated at anybody. TH: Do you notice how crippled you are? You say you are frustrated, but at the sam e tim e you don't w ant to really spell out at ivhom you are frustrated. Look to your hand. N o io y o u are fidgeting. PT: Hm hmm. TH: "Hm hm m m . " PT: (laughs) TH: A t w ho are you fru strated? Let's first establish that. You have a tendency to flight, you have a tendency to run aw ay from any issues. PT: Yes. In th e follow ing passage th e re is h ea d -o n collision w ith the defian ce, d ea ctiv a tio n o f th e tra n sfe re n c e , an d em p h a siz in g th e c o n seq u en ces o f m aintaining the resistance in the transference. TH: PT:

You have done it 46 years o f your life, an d if you loant to do it you can do it and g o to your grave. No, 1 don't w ant to do it.

O ften the tactical d efen se can b e well en tren ch ed w ith the m ajor resistance and should b e consid ered as such. As w e see, the process is on system atic challenge to this d efen se of gen eralization; "D o 1 h ave to be frustrated at som eon e." T h e ch allen g e in the above passage has fu rth er intensified the rise in the tran sferen ce, and the therapist m onitors it via u ncon sciou s anxiety in the form o f tension in the striated m uscles. H e h ad d eep , sighing respiration, the rate of w hich has increased , w hich clearly ind icates to the therapist that the rise in the tran sferen ce feelings is in the upw ard position. It should b e em phasized that it w ould be a m ajor m istake for the therapist to explore the p atien t's feelings. The therapist w ell kn ow s th at the n atu re and the d egree of th e resistance and the com plexity of the p sy ch o p ath olog y are extrem ely d ifferen t from tho se patients w ho are placed on the left or the extrem e left o f the sp ectru m o f psych oneu rotic disorders. We retu rn to the in terv iew w h ere w e had left it.

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TH;

PT:

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So let's to see at w hom you are fru strated. (Pause) (Fu rth er ch allen g e to gen eralization) A gain you are terrified at lookin g at my eyes an d declaring. (d eep sigh)

TH: A gain y ou r sigh. D o you notice you r hand? You are totally crippled to look at my eyes an d tell m e at w ho you are fru strated. Because fru stration refers to som eth in g negative huh? PT: Yes. TH :

But you are paralyzed to look to m y eyes . . . Let's establish at who are you fru strated ?

Finally, in the follow in g p assage h e d eclares "I am fru strated at yo u :" PT:

I am fru stra ted at you.

N ow th e th erap ist p roceed s an d exerts pressu re to the actual physical exp erien ce o f fru stratio n in the tran sferen ce and the process m oves to pressure, c h a lle n g e a n d c o m p o site form o f h e a d -o n co llisio n an d fin ally to m ajo r b rea k th ro u g h into th e u n con sciou s, his m u rd erou s rage tow ard his w ife, his m other, his fath er and his b ro th e r w ith in ten se guilt and th en grief-laden u n co n scio u s feelings.

Diversionary Tactics

Block the defense

D iv ersio n ary tactic is a freq u en tly used tactical d efen se, m ost freq u en tly used in th e early p art o f th e trial th erap y d u rin g th e p h ase of rise in the tran sferen ce w h en th e forces o f th e resistan ce are still in a d om in an t position in relation to the u n co n scio u s th era p eu tic alliance. D efin itely w h en the process en ters to the ph ase o f op tim u m m ob ilization of the u ncon sciou s th erap eu tic alliance again st the resistan ce, o n e w ou ld n o t see th e em erg en ce of this form o f tactical defen ses.

Diversionary tactics

Intervention "I q u estio n ed you, h ow did you exp erien ce the an n oy an ce? N ow you are m ov in g to so m eth in g else." "D o you n otice I qu estion ed you abou t the exp erien ce of y o u r resen tm en t tow ard m e, b u t you are av oid ing m y q u estio n an d w an t to talk ab ou t you r ch ild h ood ." "W e are focu sin g on you r b roth er right now, you rep eated ly w an t to b rin g you r sister into it." "L e t's to focus on you rself first."

Case of Man with Foggy Glasses W h en h e en tered in to trea tm en t h e w as in his early forties and suffered from a w ide ran g e o f sy m p to m s and ch aracter d istu rbances. H e en tered th e in terv iew w ith a n x iety w h ich h ad tra n sferen ce im p lication ; started the session w an tin g to talk ab o u t h is con flict w ith his w ife regard in g the issu e o f d rin kin g in th e garage, b eh in d h e r b ack , u sin g th e d iv ersion ary tactic to avoid his feelin g in the

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transference. T he therapist blocks the d efense and focuses on his anxiety, his frequent deep sighs and w hat em erges is that h e has feelings about having b een on the w aiting list; PT: TH : PT: TH: PT:

1 had "called" back and 1 got no reply, 1 got no reply so . . . Let's to see how you fe lt about that. I loas annoyed quite frankly. A nnoyed? Annoyed. I mean I said to my s e l f . . .

D iversification w as blocked. TH: You mean you w ere annoyed an d that is past or you are annoyed? PT: No I was annoyed at that time. TH: N ot anym ore you mean? PT: Uh no, w hen I called hack and you know there was an im m ediately kind o f reply. TH: So w hat you say is this; you w ere annoyed but you are not annoyed anymore. So that is the case you mean? PT: Yes.

TH: PT: TH:

H ow did you experience y ou r annoyance? Well I said to m y self uh you know to me it doesn't m ake sense. But that is a sentence. (Pause) TH: You say you w ere annoyed but then I said how did you experience this annoyance. N ow you are g ivin g a sort o f description: “that doesn't m ake sense." How did you experience you r annoyance?

The Case of the Microphone Man In focusing on actual experien ce of an n o y an ce there w as m obilization of the tactical d efen se of d iversification and th e th erap ist's in terv en tio n is calling upon the resistance and b lock in g the d iv ersion ary tactic: TH: C ould you tell m e how did you experience this annoyance? PT: Well through . . . through tw o or three different m edium s I think, one was . . . TH: I questioned you how did you experience the annoyance? N ow you are m oving to som ething else.

The Case of the Butch T h e focus of the session w as o n b ein g "fru strated " and "aggrav ated " w hich im m ediately w as follow ed by b ein g "m a d " tow ard th e therapist, an d th e therapist was exerting pressure for the actual experience. H e im m ed iately uses d iversionary tactic. PT:

1. . . I've never been through som ething like this. I . . . there is . ..

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H ere, th e p atien t w an ts to d iversify and the therapist im m ed iately blocks it and b rin gs h im b a ck to the actu al exp erien ce of his feelin g in the tran sferen ce, w h ich ev en tu ally lead s to the b reak th ro u g h o f the im pulse in th e tran sferen ce.

The Case of the Manageress T h e focu s of the sessio n is h er p roblem w ith an g er "it su rfaces v ery easily" and th e th erap ist asks h er for a specific exam ple: PT:

Well, I can g iv e you an exam ple o f w hen I z’isit m y parents. For som e reason I try to, like, sp eak to m y mother. She's alw ays very nice an d everything, but som ehow ju s t invokes this an ger in m e an d 1 ju st rem em ber all kinds o f things from my childhood.

In terv en tio n : therap ist exerts pressure on the resistance, "could you give m e a specific exam ple in th e cu rren t, m ost recen t tim e?" Later on the focus w as on her an g er tow ard h er m other. Sh e described a recen t in cid ent w h en sh e w as v ery angry b u t su d d en ly m oved aw ay and diversified speaking of a past situation that w as h igh ly significant. As I h ave in d icated before, the therapist m ust vigilantly avoid this form o f d iversification, w h ich is a trap, ev en if the co n ten t is h igh ly significant. TH : C ou ld you g iv e m e a specific exam ple in the current, m ost recent time? PT: I spoke to m y m other last w eek an d she said, "I’m not pickling very m any things because I don't h ave an y jars," an d I said to her, "Well, you can go an d buy jars," an d she said, "No, w e don't buy ja rs, I don't have an y ja rs," an d I im m ediately becam e v ery an gry an d started fig h tin g w ith her because . . . w hat it sym bolized fo r m e is that w hen loe w ere y ou n g they neglected us, they never w anted to pay fo r anything. T h e th erap ist b locked this d iv ersion and b ro u g h t h er b ack to the recen t in cid en t, w h ich led ev en tu ally to h er m u rd erou s feelings tow ard h er m other.

Chess Player T h e focu s is his b roth er: PT:

Yes, I have a recollection that m y brother an d I fou g h t like hell, like cats an d dogs all the time. TH : F ightin g like cat an d dog. PT: W ait, not ju s t w ith m y brother, w ith m y sister too. TH : I know, but w e are fo cu sin g on y ou r brother right noio, hm m ? You repeatedly also w an t to brin g y ou r sister into it.

Masochistic Woman with Brutal Mother A seg m en t o f th e in terv iew w ith this p atien t w as p resen ted in Part I. T h e focus is o n th e p a tie n t's earliest m em ory : PT: TH :

The fir s t tim e m y m other hit me, H m hm m .

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PT: I also rem ember . . . TH: W hat was that m em ory that your m other hit you?

The Case of the German Architect T he initial interview started by the therapist questioning him about the nature o f his difficulties. H e w as vague and the therapist's attem pt w as to m ake him more specific. Th en he said " I guess it is uh . . . com m itm en t." T h en h e m oved to diversify and generalize and the therapist im m ediately blocks it; PT:

It seem s to be very difficult an d it seem s to run in the fam ily and since I've discovered that, uh that all m y brothers and my sister have that problem . . . TH: Yeah but let's to focu s on y ou rself first. PT: Yes, loell all I'm saying is that since they all have that problem uh loe can point to a cause which is our upbringing. TH: Yeah hut you see let me to question you this; you are now m oving to the cause o f it before you tell m e what the problem is. Do you notice that? PT: Yeah yeah I understand that. TH: You see m y question luas what is the difficulties that you have? But noiu you are m oving to the issue o f the cause.

Not Remembering Call defense in question Challenge defense in question I h ave already described the con tin u u m o f n o t rem em bering. At on e end o f the continuu m the tactical d efen se is quite conscious, p reten d in g n o t to rem em ber; at the o th er end the p atient g en u in ely b ein g u naw are of som eth ing held at bay by the m ajor d efen se of repression. Two exam ples of the form er w ere sh ow n by the "m asoch istic w om an w ith the b rutal m other," w h o first did n ot w an t to adm it her feelings against the previous interview er, and then did n ot w ant to give any details o f h er m asturbation, w h ich will be p resen ted shortly. T h e follow ing are som e exam ples of the types of in terv en tion .

Not remembering

Intervention "H ow is y o u r m em ory? You h ave problem s w ith your m em ory ?" "N o w you r m em ory collapses on you ." "N o w you m ov e to the p osition th at it is difficu lt to rem em ber." "W h y do you th in k you can n o t rem em b er?" "I am n ot sure it is th at you d o n 't rem em ber, but that som ehow you w an t to leave it in the m iddle of n ow h ere." "H ow long ago is that?"

The follow ing are a few case exam ples:

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Masochistic Woman with the Brutal Mother TH: PT:

I know it is difficult to tell m e w hat you w anted to tell him. YJe are talking about thoughts an d ideas. "I don't rem em ber" w hat I w ould have told him . . . I'm feelin g em barrassed . . . I w ould have called him a fucker.

TH : A n d w hat do you do w hile you have this fantasy? PT: Uh, "1 don't rem em ber " TH: I m ean you're m astu rbatin g an d have this fantasy, or . . . ? PT: 1 think I'm touching m y self In th e first of th e ab ov e exam ples, the first in d ep en d en t evalu ation had taken p lace a b o u t a w eek previously and w as clearly quite fresh in th e p atien t's m ind. In th e fo llo w in g th ree exam p les the ev en t in q u estio n had h ap p en ed p ro gressiv ely earlier, so that each o n e in the seq u en ce probably involved a g reater d eg ree of rep ression th an the last. N ev ertheless, in all th ree cases pressu re and ch allen g e w ere effectiv e in b rin g in g the relev an t feelings to the surface.

The Real Estate Lawyer T h e ev en t w as less th an a y ear ago: TH: PT:

A re you talkin g in a hypothetical w ay or are you sayin g you w ere angry? O kay, fo r m e to id o itifi/ exactly how I fe lt is very difficult because "I d o n ’t recall" hoiu I felt.

The Chess Player T h e situ ation u n d er d iscu ssion had arisen 4 years ago: TH: A n d w hat ivas the w ay you fe lt when y ou r supervisor luas exerting pow er over you? PT: That is "too long ago to g et in touch w ith. " TH : You say you w ere pushed around. But how did you feel tow ard this man loho zoas pu sh in g you around? PT: I even tu ally fe lt hostile toivard him.

The Masochistic Woman with the Brutal Mother T h e p a tie n t's d eep ly loved g ran d m o th er had died 14 years ago: TH : PT: TH : PT: TH : PT:

W here is sh e buried? N ear P hiladelphia som ew here. You m ean you don't know w here she is buried? I n ever w ent, I n ever g o back to her grave. D o you rem em ber the burial? Vaguely, vaguely.

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TH:

You were 18 years o ld ! . .. A nd this woman meant a lot to you obviously. So how com e you don't remember? PT: I guess "I d o n ’t w ant to rem em ber" TH: 1 know. (The p atient is crying)

The Strangler After the first b reakth rou g h into the u nconsciou s, and m obilization of unconscious therap eu tic alliance against the forces o f the resistance, the therapist m oved to th e phase o f dynam ic in qu iry into his m arriage. W h at em erged w as that during intercou rse w ith his w ife h e has to resort to the m en tal im age of a specific w om an. W h en asked to describe the bod y of the w om an he could not rem em ber and there w as m obilization of the m ajor resistance. TH: PT: TH: PT: TH: PT: TH: PT: TH:

. . . do you notice again you r m em ory collapses? Yes. Yes what! Yes it collapses, "I don't rem em ber it." I mean you say you are an engineer. Yes. As an engineer you have a problem with your memory? No. Then how com e here you r m em ory with me im m ediately collapses? Do you notice the position here? PT: Um hmm. TH: W hat "hm hmm m ?" PT: I f e e l . . .

The Case of the Cement Mixer A segm en t of the initial in terv iew w ith this p atient w as presen ted in Part I. The focus of the session is on an in cid en t w ith his w ife a few w eeks prior the interview : PT: That is too long ago to g et in touch loith . . . '7 can't rem em ber." TH: H ow is y ou r m em ory? Do you have dijficulties with you r memory?

The Case of the Masochistic Woman with Migraine Headaches W h en she en tered into treatm en t she w as a 48 year old divorced w om an w ho suffered from m igraine h ead ach es— as often as 25 days a m on th — since th e age of 6, as w ell as from episod es of m ajor clinical d epression . H er last relationship w as w ith a m an nam ed D ick w h o w as in volved w ith a n o th er w om an , M aria, w ho w orked in the sam e office. T h e p atient had given D ick an ultim atum "E ith er M aria or m e," and D ick told h er that he had d rop p ed M aria. T h e therapist exerts pressure tow ard h er feelin g for M aria b ein g dum p ed by D ick and this m obilizes resistance:

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TH: A nd how d id you fe e l tlmt he dropped M aria fo r you, because she was arou n d 7 years w ith him , an d you w ere 2 m onths hm m ? Fu rth er p ressu re and ch allen g e to the resistance: PT: I didn't fe e l too g ood about it. TH : Yeah, but you see that is ju s t a sentence, "I didn't fe e l too g ood about it." That doesn't say how you feel. PT: I d id not fe e l guilty. TH : But that still doesn't say how you felt. "I did not feel gu ilty" is a sentence again. D o y ou notice, I question you how you fe lt but then you use sentences to describe y ou r feelin g ? N ow sh e m oves to th e d efen se "I d o n 't rem em ber," ch allen g ed :

w h ich is im m ed iately

PT: "I don't rem em ber" how I really felt. TH : N ow, how is y ou r m em ory usually? PT: Very good. TH : So, y o u r m em ory is very good, so how com e w hen it com es to you r feelin g fo r M aria w ho is dropped by Dick, sudden ly you r m em ory collapses? N ow you look puzzled. PT: ]a, becau se I try to put m y self into that time. TH : D o you notice how helpless you bccom e when I question how you fe lt tow ards M aria bein g dropped by D ick after you r dem and? PT: (Silence)

Denial

Make explicit Call defense in question

A m ost freq u en tly u sed m a jo r d efen se, b u t often is also used tactically. T h e follow ing are a few exam ples from a n u m b er o f cases:

The Case of the Hyperventilating Woman First th e p a tie n t actually d eclares th at sh e is an gry at h er h u sban d , b u t w h en p ressed sh e m oves to denial: TH; PT: TH : PT:

Yes, but you see again, you are not talking about you r feelings. Well, I fe lt a n g ry but I w asn't sure that I was justified. But still, y ou r feelin g s? Well, I didn't fe e l angry. I know I didn't fe el an gry then because . . .

The Real Estate Lawyer PT: I fe lt em barrassed, hum iliated. TH : Yes, but that doesn't tell us how . . . PT: I didn 't fe e l angry, 1 ju s t fe lt very em barrassed.

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The focus of the session w as on an incident w ith h er boss in w hich she was badly hum iliated. T he therapist exerts pressure on the experience of h er feelings and the patient uses cover w ords and em ploys denial. PT: I was so hum iliated I didn't think at all. TH: N ow what cam e to your mind? I'm trying to see ivbat went to your immediately.

mind

The Case of Henry-IV Man T h e follow ing exam ples are taken from the initial interview w ith this patient. In the first h e is trying to deny that his father had any special interest in him , in the second that he had any in terest in his m o th er's body. O n both occasions the d en ial w as very easily p en etrated , rev ealin g a high ly em otionally-charged situation u nd erneath . PT:

I've seen a picture o f him holding m e on his lap . . . It m ight have ju st been a photographer loho put me on his lap and then took the snap, hut it was maybe not representative o f w hat he did all the time.

PT:

Oh yes, as a m atter o f fa ct he had great interest in me . . . Later he told me that I w as his only son, that the two other boys had other fathers . . .

PT:

I saw her dressing, and . . . but 1 opened the bathroom door . . . but I never sort o f noticed anything.

PT:

She had curves. She had a beautiful fa ce also. She still has, an d she has nice fin gers, and a nice tone o f voice, beautiful eyes . . .

The Case of the Chewing Gum Man W h en h e en tered in to treatm en t he w as 29 years old, m arried, suffered from panic attacks, som atization and fu n ctional g astro-in testin al tract disturbances, phobic sym ptom s and characterological d isturbances. D u rin g the phase of d yn am ic inqu iry and the phase of exerting pressure the focus is on the regressive d ep e n d e n t seco n d ary gain aspect of his phobic sym ptom . T h e therapist is in qu irin g into the w ays his sym ptom s in terfere w ith his functioning; PT:

Oh yeah. In the kind o fio o r k I am in I could g o to W isconsin. I w ould g o to Texas. I could go anyw here, cause they have courses okay? That w ould mean 1 loould have to leave M ontreal, that that scares m e no end. I think, "what if I got sick over there?", becausc here I know if I am sick or cannot drive, she can— som ebody's there to take care o f me. That is the sam e thing w hen I am at hom e

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an d she g oes ou t an d I am m in din g the kid. I get nervous, not fo r m yself—I am afraid "what if I fa in t or g et sick w ith the kid there?" you know. I am preoccupied w ith "what if I g et sick ." H ere, th e tactical d efen se of d en ial "n ot for m yself." TH :

You said, "not fo r y o u rself" W hat does that m ean? Are you saying that you are m ore con cern ed abou t y ou r dau ghter than yourself?

Denial of New Ideas T h ere is a form o f d en ial w h ich d oes n o t em an ate from resistan ce rath er than from th e u n co n scio u s th erap eu tic alliance. H ere, for the sake o f brevity, I w ill give tw o e x a m p les— o n e o f a p a tie n t on th e ex trem e left o f th e sp e ctru m of p sy ch o n eu ro tic d isord ers and the o th er from th e m id-righ t o f the spectrum .

The Case of the Salesman As I h av e d escribed b efo re, this m an su ffered from a mild obsessional neu rosis a n d w as tre a te d in a sin g le in terv iew . T h e re sista n ce th at th e th e ra p ist en co u n tere d w as a series o f tactical d efen ses. T h e focus o f the session is on his b aby b ro th er: TH :

PT:

You w ere g la d to have a baby brother, but at the sam e tim e this baby brother is g ettin g a lot o f atten tion fro m you r mother. C ould w e look to you r feelin g about that? W hat I rem em ber is that 1 never had "temper tantrum s. "

In th e ab ov e p assag e, no o n e had said a n y th in g abou t tem p er tan tru m s— w hy sh ou ld su ch a n id ea b e m en tio n ed at all. T h e an sw er is that, u n d er pressu re from the th erap ist, the b a la n ce b etw een th e u n con sciou s th erap eu tic allian ce and the resistan ce h as b e e n sh ifted . T h e result is a com p rom ise; th e u n d erly in g feelin gs are b ro u g h t to th e su rface b u t are m en tion ed on ly to be d en ied. It is essen tial for the th erap ist n o t to fall in to the trap of taking the denial at its face value. O n the con trary, h e sh ou ld use it as a h igh ly im p o rtan t com m u n ication from the u n co n scio u s th e ra p eu tic allian ce, in d icatin g th at the th erap ist's pressu re is b eco m in g effectiv e an d th at as lo n g as he persists he will reach the feelin gs th at the p atien t is try in g to avoid. In th e "ca se o f th e salesm an ," th ese ev en tu ally em erg ed as foUows: PT:

I fe lt like pu n ch in g him. I resented it. I kept it in. But in the past 2 or 3 years I have talked abou t it to m y mother.

In th is exam p le, th e sta tem en t "1 n ev er had tem p er tan tru m s" w as no dou bt, literally sp eak in g , true. W h at w as b ein g u n n ecessarily d en ied by im p lication con sisted o f u n d erly in g feelin gs w h ich m igh t h ave led to tem p er tantru m s. N ow w e tu rn o u r a tte n tio n to an o th er p atien t, a resistan t p atien t w ith a m ore com p lex co re path ology, to elaborate on the d en ial as an in d icator th at th e b alan ce b e tw e e n u n co n scio u s th era p eu tic alliance and resistan ce has sh ifted , and the fo rm er h as taken a d o m in a n t p osition vis-a-vis the latter.

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The Case of the Man with Foggy Glasses W h en he en tered into treatm en t he w as in his forties, suffered from diffuse sym ptom s and character disturbances and life-long characterological problems. H e entered into the interview w ith anxiety in the transference. The process rapidly m oved to pressure and ch allenge to the tactical organization o f the p atient's m ajor resistance. T h ere w as rapid rise in the patient's transference feeling, intensification and crystallization of the p atient's character defenses in the transference, and then the process m oved to pressure and challenge to the m ajor resistance. T h en he spontaneou sly m ade the follow ing com m unication: TH: PT: TH: PT:

N ow you becom e silent again. I didn't g o around "thumping things. " N ow you are telling m e you did not go around . . . Yeh, I did not go around "thum ping things," okay.

Shortly after this, he em phasized: PT:

In m y w hole life I have never raised my hand against any creature.

This is exactly a com m u nication from th e unconsciou s therapeu tic alliance, and the process indicates th at the u nconsciou s therapeu tic alliance is taking a d om inan t position in relation to th e resistance. Shortly after that, h e talked about an in cid ent in w h ich h e w as en raged tow ard his brother-in-law . T h e patient's brother-in-law w as an gry w ith his w ife, an d th e patient, in a state of rage, stood b etw een his sister and his brother-in -law and told him that if h e raises his hand "I w ould n ot be responsible for w h at I d o." In describing this, all the indicators are that he is clearly experien cin g his rage. T h en th ere is a m ajor com m u nication from the u nconsciou s therap eu tic alliance d escribing an incid ent, som e 30 years ago, that h e w as n ear to m urd er an o th er stu dent. H e had the head and the hair o f the stu d ent in his h an d s, and w as b an g in g his h ead against the waU. PT: It's g oin g to crack open or it's g oin g to get badly dam aged, squashed as they say. TH: So it w ould have been squashed? P T Yeh. TH: A nd that m eans what? PT: Well he could have been severely dam aged you know, like he could have had a bad concussion or it could even have g on e to death. I don't know, it could have. TH: So you could have killed him then? PT: I could have probably. TH: A gain you im m ediately use the w ord probably. PT: I w ould have okay, but it didn't happen so . . . (The p atient is experien cin g the som atic p ath w ay of his m urderou s rage) W hat em erg es later o n is his m urd erou s rage tow ard his brother, w h o becam e the extrem e favorite o f the m other, as w ell as gu ilt-lad en feelin g and su bsequently his prim itive m urd erou s rage tow ard th e m o th er w ith gu ilt-laden unconsciou s feeling, as w ell as a great d eal of p ainfu l feelin gs abou t his life w ith his fath er and the pseud onym of this p atient is related to the m em ory of his last goodbye w ith his father. H e w as at the bed sid e o f the fath er u ntil the last b reath. H e used his

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eyeglasses as a d etecto r o f w h eth er o r n o t his fath er w as breath in g. D u rin g the last b reath o f h is fa th e r his eyeg lasses b eco m e foggy, h e clean ed th em and placed them b ack ag ain st h is fa th e r's m o u th and they d id n 't fog up again, w h ich m ean t that his fath er h ad died.

Retraction

Challenge the defense

This is a com m on tactical d efen se, particularly in patients w ith obsessive ch aracter stru ctu re. T h e p atien t adm its to a specific feeling and im m ediately retracts it. This can b e illustrated by the follow ing case. After the first breakthrough, th e p atien t d escribes an in cid en t w ith his p artn er w h o w as an gry w ith the patient. T h e p atien t w as m ad and angry. T h e therapist exerts pressu re tow ard the exp erien ce of an g er an d h e im m ed iately used the tactical d efen se of retraction.

The Case of the Butch TH :

H e d u m p ed you an d you say you fe lt an gry tow ard him. H ow did you experience the anger? PT: A n g ry is not the right word, m ay be it is not . . . ah . . . TH : A n d now you are m ovin g aw ay sayin g I did not fe e l angry. T h en h e m ov ed to a n o th er tactical d efen se b eco m in g slow and retarded, and th e th erap ist m ov ed to ch a llen g e th a t d efen se.

Externalization

Make explicit Challenge the defense

T h e ex tern alizatio n is a form of d efen se o ften used to avoid th e exp erien ce of a n g er and can v ery easily b e m issed; th e follow ing exam ples illu strate th e point:

The Chess Player T his p assage follow s im m ed iately th e passage that I h av e quoted b efore in w h ich th e p a tie n t had got as far as sayin g th at he felt "fru strated " by his supervisor. TH : You say “fru stra ted ." W hat was the w ay you experienced this fru stration ? PT: I fe lt "unfairly p u sh ed ."

The Case of the Hyperventilating Woman T h is p assag e also follow s the o n e I h ave alread y q u oted , in w h ich th e p atient h as ju st d escribed b e in g "u p se t" b y h er h u sb a n d 's n eglect. TH: PT:

B ut again w e don't kn ow w hat you m ean by "upset." I fe lt "it w as un fair.”

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TH: A nd what does that mean? "Unfair," "upset," being "sandwiched" into his life? PT: Well, "I fe lt he was being im m ature." In each exam ple the sentence begins w ith the w ords "I felt," so that the therapist m ight be easily deceived into thin kin g that the patient is describing feelings at all. The first patient states "un fairly pu shed" saying th at he is the victim in relation w ith his supervisor. O ften w h en the therapist does n ot detect the defense of externalization he m ight then m ove to the follow ing intervention: "W h a t did you feel abou t b ein g u nfairly pu sh ed ?" T h e sam e is w ith the h yperven tilating w om an: " I felt he w as bein g im m ature." H ere the patient is using im personal constru ction "it w as u n fa ir" to describe a situation, follow ed by the w ord "im m atu re" to describe h er husband. It is im portant to em phasize that externalization by the use of the pastparticiple passive is a trap against w hich the therapist n eed s to b e constantly aw are, especially w h en h e is pressing the p atient for feeling in the transference.

Vagueness

Make explicit Challenge the defense

It is frequ en tly used.

The Case of the German Architect The therapist is focu sing on th e nature of the patien t's difficulties and he rem ains vague. T h e therapist brin gs this to the focus: TH :

M y question is w hat seem s to be the difficulty and you use a bunch o f sentences that are vague. Do you notice that; PT: H m hm m m , hm hmm. TH: D o you notice that you are vague? PT: Yes I know, but I am. I mean 1 am very vague a b o u t . . . TH: So the first question fo r us is w hat are w e goin g to do about the vagueness because up to the tim e you are vague then w e wouldn't have a clear picture o f w hat seem s to be the problem . PT: U hm mm m . , .

Vagueness and Evasiveness The Case of the Salesman with his Sister-in-law In exploring his m o th e r's ph ysical ap p earan ce he b ecam e evasive; the tactical d efense of evasiveness is m obilized, ind icatin g the d egree o f anxiety that he felt about his eroticized relation w ith his m other. TH: I am talking about w hen you were a child— your m em ory o f her body an d her build. PT: Uh . . . not really an ythin g to speak o f . . , nothing in particular.

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TH : You m ean you don't have an y m em ory o f you r m other as a child? PT: I remember. . . TH : W hat do you rem em ber? PT: She w as "there," sort o f . . . (!) TH: I know she w as "there," hut w hat do you rem em ber? PT: I d o n ’t really, you know, in particular, nothing .. .

The Henry-IV Man In a p assage q u o ted earlier this p atien t had used the cov er p h rase "lo se m y n erv e or so m e th in g " in ord er to avoid ad m ittin g his fear of loss o f control. Im m ed iately b efo re this h e had tried to avoid the su bject b y th e use o f evasiveness. PT; Because I w as afraid o f my reaction after slapping her. TH : W hat w as y ou r fear? PT: M y fe a r w as that I . . . I don't know, but I w as . . . j u s t . . .

Evasiveness

Make explicit Challenge the defense

The Chewing Gum Man T h e focus o f th e session is on his d ep en d en ce on his w ife and o n his boss and th at w h en ev er his b oss leaves th e w orld ng area h e d evelops a panic attack. The th erap ist p u ts pressu re to h ow he explains this and h e becom es evasive and laughs: TH :

But in actu ality w hen he is also around, w hen he was also around you w ere really d oin g the jo b isn't that? PT: Sure I w as d oin g the job. W ell I w as d oin g a good job. TH : A n d then w hen h e w ould uh move, you know he w ould g o out an d then suddenly you start to h av e all these thoughts . . . PT: Yes. TH : . . . that som eth in g m ight g o w ron g w ith you. PT: H m hm m , that's right. TH : W hat do you think about this? PT: 1 (lau ghs) 1 don't know w hat to think about it.

Evasiveness Followed by Diversionary Tactic The Man from Southampton A se g m en t o f th e in terv iew w ith this p atien t w as p resen ted in Part I. In the follow in g p assag e th e p a tie n t is try in g to avoid th e p ain o f rem em b erin g that his relatio n w ith his feared an d h ated fath er had on ce b een a good one: PT:

T hat rem inds m e that before the W ar I rem em ber looking fo r m y fa th er w hen he w ou ld return fro m work. I cou ld see the pathw ay that he w ould take approaching the house.

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TH: W hat is your m em ory o f that path? PT: It was ju st a path across the field.

PT:

A nd I w ould see him w alking from . . .h e had to leave by the back and w alk down by the river an d across the pathw ay an d I w ould see him. We lived in a block of fla ts . . .

Further pressure brings ou t a m em ory o f his b ein g so excited on seeing his father that he fell d ow n the steps and cut his chin, and h ad to b e taken to hospital.

Obsessional Indecisiveness

Make explicit Challenge the defense

The Case of the Butch T h e focus o f the session is on the p atien t's w arm feeling for the fem ale therapist w h o had seen him as th e first evaluator and th e patient has feelings for the second evaluator; and the therapist focuses on the p atien t's feeling, and he becom es indecisive: TH: A nd how do you fee l about m e being cold, because you don't like the way I am, hm m ? PT: Yeah, I . . . 1 don't know, I don't know why. TH : You like it or dislike it? I mean w hich one? PT: Well, 1 am not com fortable w ith it. TH : Noio, you are not an sw erin g the question, I said do you like the w ay la m ? PT: I sort o f dislike i t . . . 1 don't hate it, I don't a h . .. This form of tactical d efen se of obsessional ind ecisiven ess need s to be challenged. T h en the p atien t d eclares th at h e dislikes the w ay th e therapist is. T h en the process m oves to the in terv en tio n of focu sing on th e actual experience o f the p atien t's feeling.

Somatization T h e d e v e lo p m e n t o f p h y sica l m a n ife sta tio n can o f co u rse b e used unconsciously as a m ajor d efen se against th e exp erien ce o f feeling. For exam ple, a total num bn ess described by the "m asoch istic w om an w ith th e daily attacks of m igraine h ead ach es" w as a m ajo r d efen se again st prim itive m urd erou s rage and guilt in relation to h er son (w hich had its roots in relation to h er m other). B u t in a som ew hat sim ilar "b u t m uch less u n con sciou s" w ay th e d escrip tion of th e physical m anifestation can be used as a tactical d efen se again st th e experien ce of feeling. The follow ing exam ples d em on strate this form of tactical d efense:

The Case of the Real Estate Lawyer The therapist is p u ttin g pressu re for the exp erien ce o f h er feelin gs w h ich has to do w ith anger.

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PT:

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"I w en t fla m e red ." "My stom ach w as in an uproar" "My stom ach w ent flip -flo p . " "W hen blood surges there has to be som e sort o f em otional reaction." "My fa c e w ent like a m a sk ."

The Case of the Man with the Chewing Gum H e su ffered from a w ide ran g e of sym ptom distu rbances, fu n ctio n al gastro in testin al tract d istu rb an ces, com p lain ed of dizziness, "I feel fragile," "I am not su re o f m y fo o tin g ." In his jo b h e b ecom es pale, his h an ds shake th e n h e b ecom es p an icky w h en ev er h is boss leaves the co u n ter or w h en his w ife leaves th e house fo r sh op p in g. T h e p a tie n t's use o f sym p tom s, m an y o f w h ich w ere som atic, as a w ay o f av oid in g his tru e feelin gs has alread y b een n oted . TH :

PT:

So in y o u r jo b you have to have y ou r boss around in order to function. A nd in y ou r p erson al life you cannot fu n ction w ithout y ou r wife. W hat do you think abou t all this? I don't h ave an y thoughts. W hat can on e do lohen one has all these sym ptom s?

The Case of the Masochistic Secretary A seg m en t o f th e trial th erap y o f this p atien t w as p resen ted in Part I. TH : PT:

You said you fe e l uncom fortable, w hat is the w ay you experience this being uncom fortable? I "B lush," I fe e l "hot in m y f a c e ," I chew an d bite m y lips.

In this case th e p a tie n t is d escribin g tw o d ifferen t m an ifestations, b lu sh in g w h ich is a n in v o lu n ta ry reactio n w h ile ch ew in g lips or b itin g h er finger is a n erv o u s h abit an d m ore or less u n d er con scio u s con trol an d , as w e saw in th e "real estate law yer," "g o in g flam e red " is an in v olu n tary reaction.

Action as a Defense Against Feeling If w e retu rn to th e C ase of th e "m asoch istic secretary," the th erap ist has focu sed o n h er feelin g an d sh e resp on d ed : PT:

I "blush, " 1 fe e l "hot in m y fa c e ," I chew an d bite m y lips.

As I h av e alread y in d icated ch ew in g h er lips, a n erv ou s h abit, is m ore or less u n d er co n scio u s con trol. T h e "real estate la w y er" also described the n erv o u s h abit o f "b itin g m y fin g ers."

The Real Estate Lawyer TH : PT: TH :

B ut say in g you fe lt terrible doesn't tell us how you experienced . . . O kay, I left v ery soon afterw ards. W hat w as it that you experienced?

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PT: TH: PT: TH: PT:

I tried to m ask it. I tried to laugh about it in fron t o f everybody. It is not clear hoiv you experienced your feelin gs at that moment. I g ot very em barrassed. I put his so-called gift aw ay and threw it in the garbage. W hat was the w ay you experienced this 8-degree anger? I d id n ’t say a w ord and I w alked away. M y fa ce went like a mask

Body Movement as a Defense Against Feeling A w ide range of b od y m ovem ents; m ovem en t of th e h an d, th e restless m ovem ents o f the legs, rh ythm ic m ov em en ts of the pelvis are seen during the passage o f the prim itive m urd erou s rage, and in particular prim itive m urderous torturous rage, in the tran sferen ce and w h en the therapist becom es actually tra n sferred to th e b io lo g ica l fig u re. W h a t follow s is a m a jo r g u ilt-lad en unconsciou s feeling. It is im p ortant to n ote th at as soon as the passage of the prim itive m urderous rage takes place there is no trace o f th ese b od y m ovem ents. "Explosive discharge o f the affect" in the form o f ban gin g the fist on the table w ith a loud voice or ev en b reakin g som e ob ject can b e used defensively to abort the buildup of violent rage and hom icid al im pulses.

Stubbornness; Defiance

Confronting conunent Challenge Head-on collision

D efian ce and stu bborn n ess can b e pu rely tactical d efen ses or can b e part of a m ajor resistance. T h ey are alm ost universal an d appear over and over again in different patients, particularly tho se su ffering from long-life ch aracter neurosis often in a regular sequ en ce as a resp on se to pressu re from th e therapist. H ere I will highlight this w ith the follow ing exam ple;

The Praying Mantis This you n g w om an 's pseudonym arises from h er fantasy o f m urdering a m an during sexual intercourse by stabbing him w ith a knife at the n eck level of the vertebral colum n. At the tim e o f the trial therapy she w as 22, com plained of severe phobias of seeing doctors, injections, genital exam ination, and of sexual penetration. She has alw ays refused gynecological exam ination and currently suffers from vaginal infection. The gynecologist had failed to do a gynecological exam ination. It was arranged for the nurse to introduce a speculum , w h ich w as not possible. She has suffered from disturbances in the interpersonal relationships, m ajor conflict w ith her parents so that she has m oved to an oth er d ty as a college student. In the early part of the in terv iew she described h ow h er phobia w en t b ack to childhood. T h e result had b een that for years sh e refu sed to b e seen b y h er doctor, and her m oth er has had to d escribe h er sym p tom s over th e p h o n e and receive instru ctions about how to treat her. Sh e described in cid en ces arou nd the age of four and five in w hich stu bbornly "I tu rn ed his office u psid e dow n ," and from thereon h er pediatrician treated her over the p h o n e, via h er m other.

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T h e th erap ist m ad e a su m m in g up rem ark: TH : Then you w ere stubborn in a way. PT: Very, I still am. TH : W as it on ly w ith the doctor? O r w ere you stubborn with others? PT: I w as qu ite stubborn as a child. T h ro u g h th e w h o le of th e early part of the in terv iew th e p atien t used the d efen se o f belle indifference, talking in a ch eerfu l w ay abou t ev en the m ost in tim ate and d istressin g su bjects. S h e h as n ev er had sexual in tercou rse. Sh e goes ou t w ith m en and a ttem p ts to h av e in tercou rse b u t b ecau se of v aginism us and severe pain the in terco u rse b eco m es totally im possible. T h en the therap ist focu ses o n h er m astu rbation : PT:

I have h ad orgasm s fro m m asturbating ever since I can remember. A nd I have been m asturbatin g ev er since I can remember.

T h e th erap ist w en t o n to ask abou t details, receiv in g an in itial reply w h ich was th e ep ito m e o f belle in d ifferen ce: TH : W hat are the fan tasies you have d u rin g m asturbation, an d how do you do it? PT: I ju s t sort o f g ra b m y crotch w ith m y han d (spoken w ith ap p aren t relish) TH ; A n d then w hat type o f fa n ta sies do you have? (The patient sm iles in a coy and em barrassed fash ion ) PT: I ju s t really don't w ant to g o into it. They em barrass m e very much. T h e p a tie n t's sm ile m ig h t h a v e b e e n tak en sim p ly as exp ressin g h er em b arrassm ent at b ein g asked su ch an in tim ate question, bu t there is m ore to it than that. Sh e is n ow em barkin g on the sam e kind of defiant stu bbornness as sh e has described w ith a n u m b er of gynecologists and pediatricians and oth er relationships, so that th ere is an obvious parallel b etw een these and the transference. TH :

PT: TH : PT: TH : PT: TH : PT: TH : PT:

You said that you have alw ays been a stubborn person, hm m ? A nd that you alw ays g et y ou r way. A nd this has been a pattern in both you r current life and in the p ast w ith y ou r pediatrician as a child an d currently w ith you r gynecologist. I don't kn ow if I g et m y w ay alw ays. N ot anym ore, certainly. W hen I w as a child I g ot m y way, alw ays. Yeah. But you said that w hen you see a d octor you m anage to get you r own way. N o . . . I m ean . . . I have to subm it to them eventually. I w ill go through a bit o f try in g to talk them ou t o f it in order to stall. Finally you g iv e in? Finally I g iv e in. A n d do you thin k that m ight be here w ith me? W e ll. . . l a m not g oin g to g o into those fantasies. You are sm iling. M aybe if I talk to you a secon d o r third tim e 1 m ight be w illing to. But on first m eeting, no, I won't. N ow m aybe that is stubbornness, b u t . . .

T h e th erap ist m u st b e extrem ely carefu l n o t to allow h im self to b e d raw n into th e b a ttle o f w ill. T h e sim ple tech n ica l in terv en tio n is a special form o f h ead -o n

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collision pointing out the therapeutic task, deactivation o f the transference, deactivation of the defiance. The details of this technique w ill be described in an oth er paper; the application of h ead -o n collision in the m anagem ent of defiance and oth er m alignant character defenses.

Tangents Tangents

Confronting remark Challenge Intervention "U su ally it is like this . . . you go round about the way." "You have a ten d en cy to go to tangents." "You have to give a lot o f pream ble." "C ould you describe that in cid ent w ith ou t circling around?"

This d efen se can b e seen in the w h ole spectru m of psychoneu rotic disorders, w ith the exception of those cases on the extrem e left of the spectrum . We see it m ore frequ ently in patients on the rig ht side o f the spectrum . It is on e o f those d efenses that need s im m ed iate in terv en tion , first b y clarification th en , if necessary, w ith pressure and challenge.

The Case of the Masochistic Woman with Frequent Migraine Headaches T he therapist has asked for a specific exam ple and sh e soon started to go into ta n g en ts, u n n e ce ssa ry d etail a b o u t irrelev a n t m atters, an d th e th erap ist's in terv en tio n is clarification rapidly follow ed by ch allen g e and pressu re to the defense: TH;

You see, you w ant to tell m e a b o u t . . . and your relationship but now you are m o v in g . . . PT: Yes, I am g ettin g there, no I'm g ettin g there. TH: U sually is it like this. That lohen you w ant to describe an incident you go round about the way. PT: }a, tangents (laughs). TH: But labelling it is n o t . . . We have to see w hat are you goin g to do about it.

The Case of the Englishman with Fainting Attack W h en he en tered in to treatm en t he w as 51 years old, m arried and suffered from a chron ic state o f anxiety w ith attacks of h yp erv en tilation and an episode w here he had fainted , fun ctional d isord er of th e g astro-in testin al tract w ith d iarrhea, flatu lence and sh arp -sh o otin g stabbing abd om in al pain, m ajor conflict w ith his w ife and daughters, sexual difficulty w ith an inability to h ave an erection and characterological problem . T he initial phase of the trial therapy in terv iew consisted o f inquiry, dynam ic inquiry, the phase of pressure and the m obilization of the tw in factors of the

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resistan ce an d th e tran sferen ce. T h e process th en m oved to the p h ase of pressure and ch allen g e a ltern a tin g w ith d y n am ic inquiry. T h e therap ist w as exploring the fam ily d y n am ics an d the p atien t d escribed an in cid en t w h ere his w ife had had a b ig arg u m en t w ith o n e o f h er d au g h ters, w ith exchange o f anger, and the next day sh e w as w ith d ra w n and d etach ed . W h ile d escribin g the in cid en t h e b ecom es circu m stan tial a n d goes in to tangen ts: TH : PT: TH :

N ow w hat w ay d id you g et involved? Still you have n o t . . . W ell I ’m tryin g to g et to that, I'm tryin g to get to that. But do you kn ow you have a tendency to go to tangents? Do you know w hat is tangents? PT: Yeah, y es I understand. TH : N ow you h av e to g iv e a lot o f pream ble, to g o on an d on, circle arou n d subject until you cou ld describe that issue. Do you notice that? M y question is this, is it here w ith m e or this is p er se you? That w hen you w ant to describe an event you have to circle arou n d an d arou n d until you com e to the point. The point is, at w hat poin t you g ot into this battleground betw een Susan an d you r wife? T h e n h e d escribed an in cid en t of exch an ge of an g er w ith th e loss of control.

Defensive Weeping, Crying and Spectrum of Regressive Defenses A sp ectru m o f regressive d efen ses can be used tactically, these are frequently en cou n tered an d th e therapist should look ou t for their em ergence. A few exam ples:

The Woman with the Fainting Attacks At the start o f th e in itial in terv iew sh e in d icated th at o n e o f h er problem s is fain tin g an d th e th erap ist asked the p atient. "C ould you give m e a specific exam ple o f you p assin g ou t?" T h is m obilized an xiety and sh e resp on d ed "You w an t the m ost d ram atic o n e or you w a n t th e on e th at is . . Th e th erap ist's resp on se w as "O bviou sly , if you ch o o se th e w orst o n e it w ould give us a b etter p ictu re." T h ere w as fu rth er m ob ilization o f an xiety an d sh e started cryin g, b ecam e weepy. PT: H ere I go. (sniffling) TH : W hat do you m ean "here you go?" because o f you r tears you mean? PT: (b low in g n o se , sighing) TH : From w here these tears com e from ? PT: (d eep sigh in g, so u n d s of w eep in g) TH : H ow lon g h ave you fe lt like this? This m orning? PT: (ch o k ed -u p voice) N o this is . . . w hen I think about passin g out 1 gu ess I have a phobia in uh situations so . . . because I'm afraid I'll pass out. T h e n sh e w an ts to m ov e to in tellectu alize in to th e cause o f h er fain tin g attack; TH :

I m ean to g o to w hat is the cau se o f passin g out is not g oin g to help. It is very im portant fo r us to explore on e or tw o incidences w hen you passed out that we can g et a better picture o f w hat it is like.

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FT:

That's w hy I'm crying because it's it's difficult fo r me to talk about it. Okay I'll describe it. TH: M ost recent one w ould be best.

T h en she described a m ajor fainting attack that she had 2 years ago in a subway. N ow the therapist m oves to explore in detail tw o of her m ajor fainting attacks.

The Case of the Masochistic Secretary T h e patient had declared that she frequently gets angry w ith her husband and the therapist is focu sing on how she experiences h er an ger in a specific incident: TH: H ow did you experience your anger toward him? PT: 1 cried. W h at em erges is that she becom es w ithdraw n and detached and further indicates that a t tim es she scream s and resorts to the regressive d efen se of tem per tantrum "I w ant to hit him ."

Talking to Avoid the Experience of Feelings Clarification It is a tactical d efen se seen in a w ide ran ge of situations, particularly to avoid the actual experience of painfu l feeling. We en cou n ter w ith this d efen se w h en the b reakthrou g h of in ten se gu ilt-lad en and grief-laden feelings is im m inent. It is particularly seen in partial u n lockin g o f th e u nconsciou s at the tim e o f the passage of painful feeling. Technically, the therapist w ould n o t en cou n ter this defense during the passage of th e in ten se guilt in m ajor unlockin g as weU as in m ajor extend ed unlocking. T h e m ain reason for that is optim u m m obilization of the unconsciou s therap eu tic alliance. T h e follow ing are a few exam ples;

The Case of the Microphone Man Im m ed iately after partial access to his u ncon sciou s the p atient has b ecom e visibly sad. H e w as d escribing his last visit w ith his father, w h o looked old er and tired. This intensified his sad ness an d the therapist con tin u es focu sing on the paHent's feeling, w hich is very close to b reakth rou g h and th e p atient uses the tachcal d efen se o f talking over and over to abort the b reakth rou g h o f the painful feeling: TH:

N ow when you say that, I have a feelin g here that there is a lot o f feelin g in you. But then you keep talking an d talking. Do you notice this here? It is very im p o rta n t. .. PT: The feelin g is that I w ished that w e had been really closer together. That lue could have talked . . . TH : Yeah, but let's to look to the feeling. PT: That we could talk with depth you see, and be close.

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TH : I see now there is this, uhh, deep-seated feelin g that you have fo r you r father, but by talking a n d talking w e cannot understand this feelin g. W hy is it that you don't w ant to look to y ou r feelin g s rather than to . . .

PT:

Yeah it is.

TH :

Hm hm m . Silence is threatening to you because under that w e see there is a lot o f fe e lin g fo r the man. (p atien t is sobbing heavily)

The Case of the BB Gun Man T h e th erap ist h as ach iev ed the first b reakth rou g h at w h ich th e situation ch an g ed from the d o m in a n ce of the resistan ce to d om in an ce of the u ncon sciou s th erap eu tic allian ce and th e p atien t h as becom e in creasin gly sad, w'ith tears in his eyes an d h e uses the tactical d efen se o f talking to avoid th e exp erien ce o f the in ten se p ain fu l feeling. PT: 1 have tears in m y eyes an d I don't even know why. TH : I know, let's g et to the tears fir s t an d then to see w hy an d see from ivhere do they com e from . U nderneath there is a m ajor w ave o f feelin g, but you w ant to talk to av oid to experience the pain ful feeling. PT: You see, 1 have the tears. TH: You w ant to talk, feelin g , feeling.

Nonverbal cues

Call defense in question Challenge defense in question

N o n v erb al cu es are extrem ely im p o rtan t to m on itor d u rin g the process and th ey can b e co n sid ered as a sig n alin g system of the u n con sciou s; for exam ple, any d eg ree o f the rise in th e tran sferen ce feelin g or an y d egree of m obilization o f the tw in factors, n am ely th e tra n sferen ce and the resistan ce, can express them selv es in a n o n v erb al way. T h e follow in g are a few exam ples:

The Case of the German Architect T h e focu s is o n his p ro blem w ith feelings and the therap ist exerts p ressu re by p ro b in g for feeling. Rise in tra n sferen ce feeling: In creased resistan ce: TH : PT TH : PT:

P roblem w ith feelin g s. Yeah. C ou ld you tell m e about that, I m ean that is a sentence "problem w ith fe e lin g ." Yes it is a sentence. U hm m m aybe my reactions to things that 1 should feel

TH :

are. . . Yeah but that again is vague, "my reaction to things" . . .

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O kay.

TH: PT: TH: PT: TH: PT: TH: PT: TH: PT:

N ow you turn you r head on the other side, do you notice that? Beg you r pardon ? You m ove your head on . . . Do you notice that in a sense your head moved? Yes I'm looking fo r another tack you see. Another? Tack. W hat does that mean? A . . . another approach. H m hmm. A nother approach to what? To explaining m aybe lohy I'm here.

C hallenging n on verbal cues and pressure tow ard the transference feeling; TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT: TH: PT:

N ow you r eyes also avoid me. Well, I mean I can't look at you all the time, one hundred percent o f the time. Do you notice that you avoid m y eyes? No, I don't avoid y ou r eyes. I look at you r eyes when you talk to me. U hhm m . But then I look aw ay so I can, ah, think fo r m yself where I don't have to concentrate on y ou r eyes, um m . . . A nd how do you fe e l when you look at my eyes? Fine, I . . . Fine m eans what, 1 mean fin e is an other vague . . . you sm ile now. Is that okay, I mean I sm ile? uh hmm. N ow you r eyes g o tow ard the ceiling. Right, that's quite right. Right, huh? Umm, how do I fe e l w hen I look at you. You are avoidin g me. This is the real issue. I'm avoidin g you? Yeah, is it or isn't it? I m ean you can tell me. No, I don't think I'm avoiding you particularly. N ow look, you have been vague so fa r . . . No. . . . you have not been specific so fa r and now we are focu sin g on your feeling, you say fin e. Well, that's w hat everybody in this country says, ah . . .

It is extrem ely im p ortant to take in to con sid eration th at on e of the m ajor features o f all patients su fferin g from long-life ch aracter neurosis is the presence of the resistance against em otion al closen ess w h ich im m ediately com es into operation in the tran sferen ce. T h e therapists w h o are w ell in tu n e w ith the u ncon sciou s u niverse can d etect th e p resen ce o f su ch a resistan ce in the transference b eh avior and n on verbal ch aracter d efenses.

The Real Estate Lawyer TH: A nd do you notice, also you look som eiohere else, you avoid my eyes.

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PT: TH : PT:

Oh. D o you notice that? It's not intentional.

TH: PT:

It doesn't m ake a difference, still you do. Do you notice that? Yes.

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TH : H ow do you account fo r that? A voiding my eyes. (O n ce m ore the patient sm iles) TH : A sm ile again. PT:

N ot sm iling, m aybe it's because you can see som ething, or you understand why I don't express an y feelin g an d . . . TH : A nd still you avoid m y eyes.

This rep eated co n fro n ta tio n w ith th e n on verbal signs, av oid an ce of eye co n tact an d o th er in d icators o f the p resen ce of the resistance against em otion al clo sen ess, aim s at m obilization of the tw in factors of the tran sferen ce and the resistan ce an d b rin g s h er n earer to ack n ow led g in g h er tran sferen ce resistance. PT: I have never in m y entire life expressed feelin g to anyone. TH : H m hmm. PT: To myself, to m y parents, to m y husband. TH : But you see again you are avoidin g m y eyes. (Again she sm iles). com es . . .

sm ile

The Case of the Butch H e d escribed an in cid en t w ith his p artn er w h o w as an gry w ith the pah en t. T h e th erap ist w as exertin g p ressu re to th e actual exp erien ce o f the an g er tow ards his partner. H is fist is c len ch in g and h e has freq u en t d eep sighs. PT: It w as like, ah . . . (deep sigh), like a boiling feeling. TH : U h h m m . PT: . . . like g ettin g very w arm , very hot, physically gettin g hot. TH : U h h m m . PT: M y body w as hot, m y hands started to sweat, an d I was shaking. TH: U h h m m . PT: I w as shaking. Fu rth er p ressu re to exp erien ce his anger. PT: A fe e lin g o f . . . (d eep s i g h ) . . . TH: A n d again you m ake a fist. PT: Yeah . . . a fist. TH: U h h m m . PT: That's a kin d of, that's the physical feelin g I had. TH : U h h m m . PT: . . . I am tryin g to . . . It's a reenactm ent o f that particular m om ent. T h e p assag e o f v io len t rag e tow ard th e p artn er is m obilizin g an xiety in the form o f ten sio n in th e striated m uscles; m uscles of th e h an d ; su p in ator and p ro n ato r o f th e forearm ; m akin g fist; ten sio n in the in tercostal m uscles w ith

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sighing respiration. T he boihng, heated feeling in the abdom en indicates that the som atic pathw ay o f the violent rage is being m obilized.

Passive-Compliance

Make Explicit Challenge

Passive-com phance can be a d efen se to preven t the patient from experiencing his true feeling. For exam ple, in the case of the "salesm an and his sister-in-lav^/' a you n g m an in his tw enties su ffering from m ild obsessional neurosis; the therapist focused on his rivalry w ith his brother, w ho had b ecom e the favorite of the mother. First h e used ration alization and ru m in ation , th en h e m oved to passivecom pliance to preven t him from experiencing his true feeling.

Case of the Salesman TH: Noiv ivhat are you r m em ories about your brother gettin g more? PT: Uh . . . g ee . . . (p a u s e ). . . getting m ore . . . TH: It had to do loith the attention o f your mother. PT: Yeah . . . it ahuays, like to m e I guess it seem ed that he used to be able to stay up later than I did at his age, you knmo. Not to do chores. TH: Your m other was m ore lenient with him an d more strict with you? A nd your brother had a heavenly deal. PT: I guess you could say that, yes. TH: That he was the favorite o f you r mother? That he becam e the star? PT: Yeah . . . okay. TH: W hy do you say “yes . . . okay?" Is it, or isn't it?

Passive-Compliance, Rumination, Rationalization, Vagueness The Case of the Salesman T h e therapist used the ch allen g in g phrase o f w h eth er his you n ger brother had becom e their m o th er's favorite. T h is led to m obilization of a series of tactical defenses. TH: PT: PT: PT: PT:

Your m other ivas m ore lenient with him an d m ore strict with you? And your brother had a heavenly deal. "Yeah, o kay ." (passive-com pliance) "I guess h e was then, b u t . . ." (Rum ination) "He loas the fa v o rite because he ivas the y ou n gest." (Rationalization) "Possibly rig h t." (Vagueness)

The Strangler T h e trial therapy started w ith th e p h ase of pressure and as soon as th ere was tangible evid en ce that his ch aracter d efen ses w ere crystallized in the transference

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171

the th erap ist m ov ed to the p h ase o f ch allen g e. T h ere w as m obilization of the tactical d efen se o f p assiv e-com p lian ce "I d o n 't k n o w " and m obilization of the resistan ce ag ain st em otio n al closeness: TH: PT:

A gain you m ove to the "I don't know." M oving to the helpless position. Hoiv do you fe e l ivhen you look to m y eyes? I don't know.

TH : H m hm m . So "I don't know " is an other system like "Igu ess so," "perhaps,"huh? PT: Yeah. TH : N ow this is an oth er fo rm a t o f the . . . huh? (Pause) TH : D o you notice that you are very much detached from me? PT: Yes. TH : W hat? PT: W hy? TH : A n d there is som e kind o f a w all betw een you an d me.

The Case of the Woman with the Diamond Ring S h e w as 35 y ears old w h en sh e en tered into treatm en t, gave ab u n d an t ev id en ce of a p a ttern o f passivity, com p lian ce and self-d ep reciation in m ost o f h er in terp e rso n a l relation sh ip s. H er first m arriag e w as to a m an w h o w as paranoid an d sh e allow ed h erse lf to b e used and abused by him and finally en d ed up in d ivorce. S h e h ad p ro blem s in h er second m arriag e, su ffered from episod es of clinical d ep ressio n , m asoch istic ch aracter traits lettin g h erself be used and abused. S h e had h ad a b aby d u rin g h er first m arriag e w h o died at birth and sh e had p assiv ely com p lied w ith the d octors w h o d iscouraged h er from goin g to the fu n eral. H er b eh a v io r in the in itial in terv iew show ed a sim ilar p attern o f passivity, c o m p lia n c e , v a g u e n e ss an d se lf d e p re c ia tio n . T h e th e ra p ist had clearly estab h sh ed the p arallel b etw een h er b eh av io r in the tran sferen ce and that of the ou tsid e relatio n sh ip s; th e en try of th e tran sferen ce. T h e focus is on the set of tactical d efen se s "I d o n 't rem em b er," "I d o n 't know ," "1 w as so d u m b ," "It w as a b su rd :" TH; D id you fe e l that you ivanted to see the baby? PT: "1 don't rem em ber." I think . . . Yeah, I w anted to see . . . TH : D id you ? PT: No. They didn't w ant m e to see the baby. TH : W hy didn't they w ant you to? PT: I don't knozv. TH : I am not su re that you don't know, or is it that in a sense you . . . PT: You see . . . I don't believe, you knoio, "I w as so d u m b " . . . I ju st don't think . . .

TH :

Let m e clarify on e thing here. H ave you noticed that du rin g this period o f tim e w hen ever w e are g ettin g into som e o f the im portant issues you say either it is absurd," o r "/ don't rem em ber," or "I don't know," an d now you say you ivere "dum b. " H ave you noticed that w henever loe approach an y o f these painful issues you becom e very vague?

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Later on she declared an ger in the transference. T h en the process m oved to pressure for the actual experience of the anger in the transference. It is im portant to note that an ger by itself functions as a d efen se against the violent prim itive m urderous rage and in ten se guilt, in relation to h er m other, h er father as well as h er brother, w hich is u n d er the m ajor resistance o f repression.

Generalization, Vagueness, Vague Rumination, Cover Word, Jargon Word and Sarcastic Laughter The Case of the Son of the Australian Journalist W h en h e entered in to treatm en t he w as in his forties, suffered from sym ptom s and character d istu rbances and a long-life ch aracter neurosis. The session starts w ith the ph ase of inquiry: TH: PT:

W hat is the problem that you loant to get help fo r it? Either behavioral problem s or if not that then w hat I feel 1 have uh by ways o f blocks okay.

PT:

Well I fe e l at tim es uhmm . . . there are certain times that I'm functionin g on about seven or eight pistons an d there's other times I'm w orking o n a . . a couple o f cylinders. TH: You mean seven to eight percent o f you r potentiality? PT: Pistons, seven or eight cylinders, okay, (sarcastic laughter) Therap ist attem pts to m ake it specific; he fu rth er m oves saying "Ju st to im prove m yself," then h e says "P ersonal grow th . . . I think 1 h ave som e blocks."

Cover Words, Generalization, Indirect Speech, Rumination and Nonverbal Character Defenses The Case of the Board-Like Professor At the tim e of the initial in terv iew he w as 56 years old and suffered from a w ide range of sym ptom d istu rbances and m ajo r syntonic ch aracter pathology. H e suffered from ch ron ic anxiety, som atization and depressive disorders, problem in his m arriage and w ith m em bers o f his family, episodes of explosive discharge of affect in relation to his w ife, and at tim es actively suicidal. H e has b een treated by his fam ily physician for the past 20 years for various fu n ctional disorders. Becau se of the research protocol, h e had seen the first in d ep en d e n t evalu ator and w h en he arrived for the second in d ep en d e n t evalu ation h e had feelings abou t rep eating him self. The process m oved to the p h ase of pressu re tow ard his feelin g, rapid rise in the tran sferen ce and m obilization of a set of tactical d efen ses: PT: 1 feel "irritated." TH: Irritated at loho? (Pause) TH: Noiu you see you look dozen there.

M anagement o f Tactical Defenses: Part U

PT:

173

Well, you, I "guess."

TH:

Yeah, that is "guess," that is a state o f limbo. A re you irritated with m e or aren't you irritated w ith me? Let's fir s t establish that. PT: I don't see w here, w here w e are going. TH: Let's not to g et to w here w e are g oin g . . . D u rin g th is v ery eariy p art o f the trial th erap y h e has had a n u m b er of "sm iles," a v o id an ce of eye con tact, lo okin g at the w all, rise in an xiety in th e form o f ten sio n in th e striated m uscles in th e form of clen ch in g o f th e h an d s, d eep sighs, ten sio n in th e in tercostal, tic in the facial m uscles, tic in th e periorbital m uscles in th e form o f closu re o f th e eyelids, im m obile board-like position and each o f these n o n v erb al d efen ses is clarified an d ch allenged .

Vagueness, Rumination and Intellectualization The Case of the German Architect T h e trial th erap y started w ith the p h ase o f inquiry. In an sw er to the question "co u ld you tell m e w h at seem s to b e the p roblem ?" p atien t resp on d ed w ith v ag u en ess, ru m in a tio n , and w an ts to in tellectu alize if his d ifficulties are n orm al or ab n o rm al: PT. TH : PT: TH :

Uh . . . no, not exactly. This is one . . . So you don't know exactly w hat the problem is, hm m ? I'm here, ah, 1 only have ah, som e hazy idea w hat m ight be the problem . N oio if I question you w hat seem s to be the difficulties that you have, w hat then you w ould say there? Because you are sayin g you have a hazy idea about you r difficu lties w hich is . . . PT: W hich I'm not even sure ivhether those difficulties are m y re . . . norm al part o f bein g a hum an being, ah, how ever . . . TH : So you have several difficu lties that you question if is norm al or . . .

PT: Yes, I know, TH: So the fir s t B ecause up w hat seem s

PT:

but 1 am vague, I m ean I am very vague a b o u t . . . question fo r us is w hat are w e goin g to do about the vagueness? to the tim e you are vague then w e w ouldn't have a clear picture o f to be the problem .

If, m aybe if I kn ew w hat the difficulty w as I w ouldn't be here.

Passive-Compliance, Rumination, Indirect Speech, and Nonverbal Character Defenses The Case of the Board-Like Professor T h e th erap ist is p u ttin g pressu re to th e actu al exp erien ce of irritation in the tran sferen ce. T h e re is fu rth er rise in the tra n sferen ce, fu rth er crystallization of the

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patient's character d efenses in the transference in the form o f a set of tactical defenses: TH: H ow do you experience your irritation towards me? PT: (Pause) TH: N oio your head goes like this. PT: Uh huh. TH: We know you r han d is in clenching state like that;you r body is totally immobile. PT: I sit like this m any hours o f the day. TH: D oesn’t m ake a difference your rum ination that I sit like this. Right now you say you are irritated loith m e and my question is this: how do you physically experience your irritation? A nd your hand isclenching and your body is im m o b ile. . . TH: N ow you are rum inating still. You are not telling me how you experience physically you r irritation. PT: 1 ,1 feel tense here, 1 f e e l . . . TH: So that is anxiety. PT: Yes, Well I "guess" so. TH: "Guess" so. PT: 1 don't, I don't know how to, I don't knoiv. TH: "1 don't know " is a helpless position. PT W e ll. . . From the above case-exam ples, it b ecom es clear that the tactical defenses appear in m any d ifferen t form s, and th at they occu r in sim ilar form s over and over again in different patients. The classification given above is n o t hard-and-fast and there is a very considerable d egree of overlap b etw een on e type of the d efen se and another. W h at is im p ortant for th e therapist is to m ake him self fam iliar w ith them . This is sum m arized in Table 1.

Summary and Conclusion H ere it is im p ortant to su m m arize w hat has b een p resen ted in this tw o-part article: (1)

(2)

(3)

(4)

1 briefly described a powerful technique which aims at a rapid breakdown of all forces m aintaining the m ajor resistance and rapid mobilization of the unconscious therapeutic alliance. I emphasized that the task of the trial therapy is loosening the patient's psychic system, reorganization of the unconscious; changing the situation from the dom inance of the m ajor resistance to a major dom inance of the unconscious therapeutic alliance and mobilization of the whole unconscious system. O ur clinical research clearly shows that the optimum mobilization of the unconscious therapeutic alliance against the forces of the major resistance is one of the basic aims of the therapist and it can be achieved in every patient, no matter what the degree of the major resistance. It was emphasized that one of the features of the technique, that is rapid mobilization of the unconscious, instantly mobilizes what 1 call tactical defenses in the service of resistance, and it is essential for the therapist to be familiar with these defenses.

Mana;fcmcnt i\fTiKtical DcfcuM'i: Part II

173

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that ucu haze?

T h e th erap ist is exerting pressu re by rep eatin g the question in the direction of the specifidt>-: Yeah, uv// irt that they do?j't j.vp tc mind. Well 1.1 p ie> f . . . nun/ly 1 Scv it asnot a difficulty. TH: UTiy yi’u sav "ALzufv.’’ " PT: W ell because you re, you ‘re l iezcin^ it as a . . . TH: You say 1 z'iav it. 1 said zchat seem s tobe the identi'^iable dit^cultu? PT: I think I'm stuck zcith the Zivrd "identinable. ~ I don't identity it. PT:

As w e see, the p atien t d eclares that he does n ot "id en tifia b le ,” and w e can n o t be surprised. In ou tco m e in d icates th at he w as n o t able to u nd erstan d ; "E v er\ th in g "It is like talk in g C h in ese to a p erson w h o d oes not speak Ln th e follow ing passage, the therap ist exerts pressure p atien t th a t h e d o esn 't h ave any problem s:

u nd erstan d the w ord evalu ation , he clearlv w as u n d er the cem en t," C h in ese.” by fxiin tin g ou t to the

TH: H m hm m , so zchat you say is this, you don't hazv anu problem . PT: A aah I thin k m ore I don't identify. TH : W hy you say you “think?" PT: I don t identify it. TH: So you don't have any difficulty. T h e sh ort passage of pressu re has m obilized som e tran sferen ce feeling w hich, for the first tim e, is sign alling itself by anxiet\- in the form of tension in the striated m u scles as h e takes a d eep sigh. We retu rn to the interview . PT: TH:

H m m m m , I'm sure I hazv troubles zrith as^vcts o f my life. But you say you ijrt' "surt’ " won have, as if in a sense you are not definite, StY you say you are sure you have difUculty. PT: H m hm m . TH: But still that is not zrry definite. You say you are sure you hazv difficulty: zchy you say you are sure? (Pause) Either you have or you don't hazY?' P T Vt’s. (I^ u se ) /. . . TH : You have a hesitation here. PT: Yes because I'm searchin g for . . . TH: You said you are sure you hazv som e difficulty. It is im p o rta n t to n ote th at in the b eg in n in g the process is alw ays slow and in a specific w av is verbalized to the patient. E\ en if the therap ist reflects on the p a tie n t's sm ile, it d oes n ot have a ch allen g in g tone. It is very m uch com m u nicated in th e form of a clarif\dng rem ark. O ften th erap ists are tem p ted to m ove to ch allen g e, or to hea\y ch alleng e. D o in g th at is a m a jo r m istake. T h e p atien t can easily becom e con fu sed . D u rin g the ab ov e p assag e, th e re is av oid an ce, av oid an ce of eye con tact, o th er resistan ces such as th e resistan ce ag ain st the em od onal closeness, w h ich the therapist only registers for fu tu re interv en tion s. PT: TH :

H m hmm. So there m ust be som ething that you say.

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Intensive Short-Term Dynamic Psychotherapy PT: TH : PT: TH: PT: TH: PT: TH:

Yeess. But with hesitation you say yes. Yes, in that I cannot identify it. You sm ile and say that. Yes, I cannot identify it. Hm hmm. Then how com e you com e to the conclusion that you have difficulty? H m m m m . . . (pause) Because to be hum an is to have . . . W hat you say is "because one is hum an one must have difficulty." That is abstract . . . generalized loay. We are not talking about every human, w e are talking about you. PT: Yes. TH: So, here our focu s is you. You say you have difficulties, hut at the sam e time you are unable to tell me w hat are the difficulties. PT: Yes. TH: I mean you don't com e fo r nothing a hundred miles? PT: No, no, no. In the above passage, the therapist con tin u es to exert pressure, further clarifying rem arks, h elp in g the p atient see if h e can id entify the natu re of his problem . As w e saw, h e generalized. This w as n ot challenged b u t rather pressure was exerted by m aking a clarifying rem ark, u ndoing the generalization and also b y em phasizing that the m ajor focus is him . N ow w e retu rn to the interview : PT: Yeah, Uhmmm . . . TH: A nd now you r head goes . . . PT: Yeah as I'm trying to think, the areas I'm sure of m i g h t . . . I say again I'm sure, are m y parents. TH : H m h m m . PT: But I don't know w hether that's uh . . . T h e therapist avoids ch allenge. T h e p atien t's diversification and rum ination are h an dled by n o t respon d in g, and the therapist m oves to the original question even in a m ore gentle way, as w e see in the follow ing passage: TH: 1 mean what arc the difficulties that in a sense m otivates you to tell to you rself I should get help or to do som ething about it? PT: H m m m m . . . o f w anting to know . . . ofiv an tin g to know. TH: Yeah you say you have difficulties so then? There m ust be som e difficulty that you com e to the conclusion that there is som ething w rong som ew here. (Pause) Further pressure is exerted by d irecting the in terv iew tow ard a specific area w here the patient has difficulty. H e has b eco m e in creasin gly slow and the therapist asks him w h at h e accou nts for his slow ness. H e says: PT:

Looking a t .. . looking fo r the problem , looking at the problem , trying to express the problem.

T h ere has b een a gradual but system atic rise in the p atien t's transference feelings and there has b een a few sigh in g respirations, w h ich indicate tension in

Central Dynamic Sequence: Phase o f Pressure

203

the striated m uscles. At this poin t of the in terv iew he declares that he is anxious. For a m o m en t h e d eclared th at his h eart w as p ou n d in g and h e felt b u tterflies in his ab d o m en . T h e focu s is on his anxiety. T h e anxiety has a tran sferen ce im p lication , has to d o w ith feelin gs that are m obilized in him in the tran sferen ce. As w e w ill see in the follow ing passage, the p h ase of pressu re has m om en ts of ch allen g e: TH: PT: TH: PT: TH : PT: TH : PT: TH: PT: TH: PT: TH: PT:

A nd that an xiety has to do xoith w e then? You personally? O r w hat? You prefer the bu ildin g or me? Oh oh no, it's the interaction w ith w hoever I'm goin g to be interacting today. So then obviously is me. A n d tom orrow if it w ere som ebody else it w ould be . . . N oiv you see im m ediately . . . you prefer not to . . . Oh w ith you here now yes, w ith you. H m hm m . Isn't that? H m hm m . So could w e look to you r anxiety about seeing me? Okay. You w ou ld like m e to describe it? H m m ? B ecause you have an xiety about seeing me. Yes I do. '

T h e ab ov e p assage sh ow s exertion of pressu re by h old in g the process in the tran sferen ce, w h ich clearly the p a tien t rapidly w ants to m ov e aw ay from . T he focu s is on an xiety and the u n d erly in g feelin g in the tran sferen ce. W h at w e can say is that th e p h ase of p ressu re has resulted in m obilization of the tran sferen ce feelin g s, crystallizatio n o f the resistan ce in the tran sferen ce, as w ell as lo osen in g of the p sy ch ic system .

Phase of Pressure and Challenge; Pressure towards the Transference Feelings TH : PT: TH : PT: TH: PT: TH:

W hat else do you fee l about seein g m e besides anxiety? H m m m . . . I know it w ill be tough, uhh . . . It's, it's sort o f am bivalent thing in that I kn ow it'll be tough an d that's fin e but I . .. You see you say there's a sort o f "am bivalent th in g ." T here is an am bivalen ce w ithin m e here. But you referred to it as "thing." Yes. W hat do you m ean by "thing"? A m bivalent thing; w hat do you m ean by am bivalen t thing?

The Issue of Ambivalence T h e p a tie n t h as b eco m e anxiou s. T h ere is clen ch in g of the h an ds, p ressin g of the th u m b s ag ain st ea ch other, ch a n g in g th e position of his seating (a sort of a d efen siv e p osition ). T h e th erap ist exerts pressu re by p oin tin g ou t n o n v erb al cues. In th e follow in g p assag e, w e see a shift from pu re pressu re to ch allen g e, first a

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Intensive Short-Term Dynamic Psychotherapy

passing m om en t of challeng e and then clear challenge. T h e therapist m akes sure that the patient becom es m ore and m ore acquainted w ith the process, his character d efenses and so forth. N ow w e retu rn to the interview and the focus is o n am bivalence. PT: Oh m aybe I mean ambivalence. There is . . . TH: A m bivalence means one part o f you wants to com e and part o f you doesn't want to come. PT: Right. TH: So this means that h a lf o f you is here and h a lf o f you is not here. PT: Is resisting being here. TH: Hm hm m so then let’s to see, we have a m ajor obstacle to start with. That a part o f you is here, a part o f you is not here. You are one fo o t in, one fo ot out. So let's to see. P T Yeah. TH: But then if you are half-here, h a lf-o u t. . . PT: Hm hmm. TH: . . . Then this process is goin g to be defeated. PT: I guess.

Pressure and Challenge T h e process now enters the p h ase o f pressure and challenge. TH : PT: TH: PT: TH: PT TH: PT: TH: PT TH: PT: TH:

Because in a sense . . . Yeah. . . . you are not here fully. Uhhh 1 don't knoio that I can attest to that. You see again you are rum inating about it. Yeah. "Yeah", w hat yeah? I I'm not convinced o f that. You say y ou rself that you are am bivalent about being here. Yes. M eans nam ely part o f you luants it and part o f you doesn't w ant it. Hm hmm. A nd lohat I say is this, that the part that doesn't w ant is not here then. A nd that in a sense im m ediately creates a barrier here, huh?

Further Pressure and Challenge: Further Mobilization of the Resistance in the Transference TH:

So then first w e have to see w hat w e are goin g to do about the part o f you that doesn't w ant to be here? P T Okay. TH: So could ive see w hat w e are goin g to do about that? PT: Hm hmm. TH: "H m hm m " lohat?

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PT: Yes I w ould be interested in seeing that. TH: S eein g w hat? PT: The barrier, 1 m ean dealin g with the barrier. TH : N o you say in a sen se a part o f you is not here, is resisting to be here. PT: Hm hmm. TH : O kay? PT Yes. W h at follow s is d eactiv ation o f the tran sferen ce, fu rth er ch allen g e and headon collision w ith the resistance. If the research protocol is a m ajo r u n lockin g, the p ro cess sh ou ld rem ain in the tran sferen ce an d the b reak th rou g h of the m urderou s rage in th e tran sferen ce; th e tran sfer of the m urdered b od y to th e biological figure in this case is m u ltip le— m other, b ro th er and father. H is u n con sciou s m urderou s rage an d in ten se gu ilt in the forefron t is at his y o u n g er b ro th er w ith w hom he had a v ery d istu rbed relation from the early phase of life, and w h o eventually m u rd ered h im self by sh oo tin g h im self in the head.

Summary and Conclusion In this article, I b riefly p resen ted the cen tral d yn am ic seq u en ce in the process of rapid and d irect access to the u n con sciou s and the ap p lication o f the p h ase of pressu re. T h e m a jo r aim and the tech n ical in terv en tio n s o f exerting pressu re w ere d iscu ssed b y p re sen tin g and an aly zin g a n u m b er o f cases from the sp ectru m of resistan ce. T h e cases p resen ted d em on strated that the p h ase o f p ressu re aim s at m ob ilization an d in ten sificatio n o f the resistan ce; to create som e d egree of crystallizatio n o f th e resistan ce b etw een the p atien t and the therapist. I em p h asized stron g ly th at the m ain factors that in flu en ce the cou rse of an in terv iew are th e d eg re e o f resista n ce and th e ex ten t o f the tran sferen ce co m p o n e n t in it. T h e th erap ist's task is to p u rsu e his inquiry, m ake it d yn am ic and exert in crea sin g pressu re tow ard the avoid ed feeling. I fu rth er em p h asized th at the tech n ical in terv en tio n s th at I h ave in trod u ced to exert p ressu re aim at th e rapid d ev elo p m en t o f the tw in factors of resistan ce and tra n sferen ce feelin gs. 1 stressed th at th ro u g h o u t the in terv iew th e therapist is co m m u n ica tin g as m u ch w ith the p a tien t's u ncon sciou s as w ith his conscious. It w as em p h asized th at the resistance n eed s to b e crystallized to the poin t at w h ich it can b e ch allen g ed m ean in g fu lly and effectively. W h en the resistance is m ob ilized , w h eth er after a p eriod of pressu re or at on ce, th ere usually follow s a p eriod of in ten sifica tio n of resistan ce, and system atic ch allen g e begins.

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Davanloo, H. (1977). Proceedings of the Third International Congress on Short-Term Dynamic Psychotherapy, Century Plaza, Los Angeles, California, November. Davanloo, H. (1978). Basic Principles and Techniques in Short-Term Dynamic Psychotherapy. New York: Spectrum. Davanloo, H. (1980a). Short-term Dynamic Psychotherapy. New York: Jason Aronson. Davanloo, H. (1980b). Proceedings of the Audiovisual Course on Intensive Short-Term Dynamic Psychotherapy, presented at the 133rd Annual M eeting of the American Psychiatric Association, San Francisco, California, May. Davanloo, H. (1981). Proceedings of the Audiovisual Course on Intensive Short-Term Dynamic Psychotherapy, presented at the 134th Annual M eeting of the American Psychiatric Association, New Orleans, Louisiana, May. Davanloo, H. (1982). Proceedings of the Audiovisual Course on Intensive Short-Term Dynamic Psychotherapy with Resistant Patients, presented at the 135th Annual M eeting of the American Psychiatric Association, Toronto, Canada, May. Davanloo, H. (1983). Proceedings of the First Summer Institute on Intensive Short-Term Dynamic Psychotherapy, W intergreen, Virginia, July. Davanloo, H. (1984a). Short-term Dynamic Psychotherapy. In Kaplan, H. and Sadock, B. (Eds), Comprehensive Textbook of Psychiatn/, 4th edn. Baltimore, Maryland: William & Wilkins, Chapter 29.11. Davanloo, H. (1984b). Proceedings of the Second Summer Audiovisual Immersion Course on Intensive Short-Term Dynamic Psychotherapy, New York City, New York, July. Davanloo, H. (1985). Proceedings of the First Audiovisual Symposium on Intensive Short-Term Dynamic Psychotherapy, sponsored by the Swiss Institute for Intensive Short-Term Dynamic Psychotherapy. Pfafers, Switzerland, June. Davanloo, H. (1986a). Intensive short-term psychotherapy with highly resistant patients. I. Handling resistance. International Journal of Short-Term Psychotherapy, 1(2), 107-133. Davanloo, H. (1986b). Intensive short-term dynamic psychotherapy with highly resistant patients. II. The course of an interview after the initial breakthrough. International Journal of Short-Term Psychotherapy, 1(4), 239-255. Davanloo, H. (1986c). Proceedings o f the Second European Audiovisual Symposium and Workshop on Intensive Short-Term Dynamic Psychotherapy, sponsored by the Swiss Institute for Intensive Short-Term Dynamic Psychotherapy. Bad Ragaz, Switzerland, June. Davanloo, H. (1987a). Unconscious therapeutic alliance. In Buirski, R (Ed.), Frontiers of Dynamic Psychotherapy. New York: M azel and Brunner, Chapter 5, pp. 64-88. Davanloo, H. (1987b). intensive short-term dynamic psychotherapy with highly resistant depressed patients. Part I. Restructuring ego's regressive defenses. International Journal of Short-Term Psychotherapy, 2(2), 99-132. Davanloo, H. (1987c). Intensive short-term dynam ic psychotherapy with highly resistant depressed patients. Part II. Royal road to the dynamic unconscious. International journal of Short-Term Psychotherapy, 2(3), 167-185. Davanloo, H. (1987d). Clinical manifestations of superego pathology. International Journal of Short-Term Psychotherapy, 2(4), 225-254. Davanloo, H. (1987e). Proceedings of the Fifth Annual Audiovisual Exploration of the Unconscious:

Technical and Metapsychological Roots of Intensive Short-Term Dynamic Psychotherapy, Killington, Vermont, August. Davanloo, H. (1988a). Clinical manifestations of superego pathology. Part II. The resistance of the superego and the liberation of the paralyzed ego. International journal of Short-Term Psychotherapy, 3(1), 1-24. Davanloo, H. (1988b). The technique of unlocking of the unconscious. Part I. International lournal of Short-Term Psychotherapy, 3(2), 99-121. Davanloo, H. (1988c). The technique of unlocking of the unconscious. Part II. Partial unlocking of the unconscious. Uiternational journal of Short-Term Psyclwtherapi/, 3(2), 123-159. Davanloo, H. (1988d). Proceedings of the Audiovisual Symposium 0)i Intensive Short-Term Dynamic Psychotherapy, sponsored by the Postgraduate Center for Mental Health. Puerto Vallarta, Mexico, February.

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D avanloo, H. (1988e). Proceedings o f the Sixth Annual Audiovisual Exploration of the

Unconscious: Technical and Metapsychological Roots of Intensive Short-Term Dynamic Psychotherapy, Killington, Vermont, August. Davanloo, H. (1989a). Central dynam ic sequence in the unlocidng of the unconscious and com prehensive trial therapy. Part I. M ajor unlocking. International journal of Short-Term Psychotherapy, 4(1), 1-33. Davanloo, H. (1989b). Central dynam ic sequence in the major unlocking of the unconscious and com prehensive trial therapy. Part II. The course of trial therapy after the initial breakthrough. International Journal of Short-Term Psychotherapy, 4(1), 35-66. Davanloo, H. (1989c). The technique of unlocking the unconscious in patients suffering from functional disorder. Part 1. Restructuring ego's defenses. International Journal of ShortTerm Psychotherapy, 4(2), 93-116. D avanloo, H. (1989d). The technique of unlocking the unconscious in patients suffering from functional disorders. Part II. Direct viewf of the dynamic unconscious. International Journal of Short-Term Psychotherapy, 4(2), 117-148. D avanloo, H. (1990). Unlocking the U)iconscious. Chichester: Wiley. D avanloo, H. (1992). Proceedings of the Eighth Annual Audiovisual Immersion Course on Technical and Metapsychological Roots of Intensive Short-Term Dynamic Psychotherapy, sponsored by the Swiss Institute for Intensive Short-Term Dynamic Psychotherapy. Glion-Sur-M ontreux, Swritzerland, October. D avanloo, H. (1993). Proceedings of the Eleventh Annual Audiovisual Exploration of the

Unconscious: Technical and Metapsychological Roots o f Davaidoo's Psychoanalytic Technique. Fragile Character Structure, Killington, Vermont, July. D avanloo, H. (1994a). Presented at the Tioelfth European Audiovisual Symposium and Workshop on Technical and Metapsychological Roots of Dr. Davaidoo's Intensive Short-Term Dynamic Psychotherapy, spon sored by the Dutch Associates for the Short-Term D ynam ic Psychotherapy. Amsterdam , The N etherlands, April. Davanloo, H. (1994b). Proceedings of the Audiovisual Course on Intensive Short-Term Dynamic

Psychotherapy: presented at the Sesquicentennial Annual Meeti>ig of the American Psychiatric Association, Philadelphia, Pennsylvania, May. Davanloo, H. (1994c). Proceedings of the Audiovisual Immersion Course: Fundamentals of the Metapsychology o f the Unconscious in Davanloo's Psychoanalytic Technique, Bad Ragaz, Sw itzerland, June. D avanloo, H. (1995a). In tensive short-term d ynam ic psychotherapy: Spectrum of psychon eu rotic disorders. International journal of Short-Term Psychotherapy, 10(3,4), 121-155. Davanloo, H. (1995b). Intensive short-term dynamic psychotherapy: technique of partial and m ajor unlocking of the unconscious with a highly resistant patient. Part 1. Partial unlocking of the unconscious. International Journal of Short-Term Psychotherapy, 10(3,4), 157-181. D avanloo, H. (1995c). Intensive short-term dynam ic psychotherapy: m ajor unlocking of the unconscious. Part II. The course of the trial therapy after partial unlocking. International Journal o f Short-Term Psychotherapy, 10(3,4), 183-230. D avanloo, H. (1995d). Proceedings of the Audiovisual Immersion Course on Meta Psychological

Conceptualization of Character Resistance, Transference, Guilt and Unconscious Therapeutic Alliance in Davanloo's Psychoanalytic Technique, Bad Ragaz, Sw itzerland, December. D avanloo, H. (1996a). M anagem ent of tactical defenses in intensive short-term dynamic psychotherapy. Part 1. Overview, tactical defenses of cover words and indirect speech. International Journal o f Short-Term Psychotherapy, 11(3), 129-152. D avanloo, H. (1996b). M anagem ent of tactical defenses in intensive short-term dynamic psychotherapy. Part II. Spectrum of tactical defenses. International journal of Short-Term Psychotherapy, 11(3), 153-199. D avanloo, H. (1996c). Proceedings of the Audiovisual Immersion Course on the Metapsychological

Conceptualization of Character Resistance, Transference, Guilt and Unconscious Therapeutic Alliance in Davanloo's Psychoanalytic Technique, Bad Ragaz, Sw itzerland, D ecem ber D avanloo, H. (1997a). Proceedings o f the Fifteenth Annual European Audiovisual Symposium on Davanloo's Psychoanalytic Technique, sponsored by the Italian Institute for Intensive

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Short-Term Djmamic Psychotherapy and the Departm ent of Psychiatry of the University of Florence. Florence, Italy, March. Davanloo, H. (1997b). Proceedings of the Immersion Course on the Technical and Metapsychological Roots of Davanloo's Psychoamlytic Technique: Patient with Fragile Character Structure, Hotel Bristol Conference Center, Bad Ragaz, Switzerland, December. Davanloo, H. (1998a). Proceedings of the Sixteenth Annual European Audiovisual Symposium on Davanloo's Psychoanalytic Technique, sponsored by the German Society for Davanloo's Intensive Short-Term Dynamic Psychotherapy and the Departm ent of Psychiatry of Freidrich-Alexander University. Erlangen, Germany, March. Davanloo, H. (1998b). Proceedings of “Audiovisual Exploration of the New Metapsychology of

the Unconscious; Technical and Metapsychological Roots of Davanloo's Intensive Short-Term Dynamic Psychotherapy", presented at the Training Program of the German Society for Davanloo's Intensive Short-Term Dynamic Psychotherapy. Niirnberg, Germany, June. Davanloo, H. (1998c). Proceedings o f the Seventeenth Audiovisual Exploration of the Unconscious

Technical and Metapsychological Roots of Davanloo's Psychoanalytic Technique. Technique and Metapsychology of the Process of Working Through: Fragile Character Structure, M ontreal, Canada, November. Davanloo, H. (1999a). Proceedings of the Audiovisual Immersion Course: Audiovisual Exploration of the Metapsychology of the Unconscious in Davanloo's Psychoanalytic System, sponsored by the German Society for D avanloo's Intensive Short-Term Dynamic Psychotherapy and the Department of Psychiatry of the University of Erlangen-Niirnberg. Erlangen, Germany, March. Davanloo, H. (1999b). Proceedings of the Nineteenth Audiovisual Exploration of the Unconscious: Technical and Metapsychological Roots of Davanloo's Psychoanalytic Technique, Montreal, Canada, August. Gaillard, J. M. (1989). Trial therapy model of initial interview and its major functions. Part 1. International Journal of Short-Term Psychotherapy, 4(3), 195-215. Gaillard, J. M. (1992). Neurobiologicalal correlates of the unlocking of the unconscious. International Journal of Short-Term Psychotherapy, 7(2), 8 9-107.

Intensive Short-Term Dynamic Psychotherapy— Central Dynamic Sequence: Phase of Challenge HABIB DAVANLOO McGill University, Department of Psychiatry, Montreal General Hospital, Montreal, Camda

In this article, the author primarily focuses on the phase of challenge as well as on the phase of pressure and challenge. H e outlines the various types of challenge and with extensive use of vignettes from clinical interview s, dem onstrates the application of challenge to the resistance, both in and outside of the transference.

Introduction T h is article c o n c e rn s itse lf w ith the cen tral d y n am ic se q u en ce in the p ro cess o f rap id an d d ire ct a ccess to th e u n co n scio u s. I focu s p rim arily on the p h a se o f ch a lle n g e. I h a v e alread y in d icated th at th e co u rse of an interview ' d e p e n d s v ery la rg ely o n th e rap id ity of th e d ev elo p m en t o f th e tw^in factors o f resista n ce an d th e tra n sfe re n c e feelin g s. W h ere th e se tw o factors are n o t im m e d ia te ly d e te c ta b le an d are slow to d e v e lo p , th e p h a se o f p re ssu re b e g in s w ith th e sea rch for resista n ce. W h en th e resistan ce is m ob ilized , w h eth er a fte r a p erio d o f p re ssu re or at o n ce , th e re u su ally follow s a p eriod of in te n sific a tio n o f th e resista n ce. I h av e em p h a sized th a t th e resistan ce n eed s to b e cry sta lliz ed to th e p o in t at w h ich it can be ch alle n g ed m ea n in g fu lly and effectiv ely.

The Phase of Challenge C h allen g e is th e key in terv en tio n in the w h ole tech n iq u e, b o th Inten sive Short-Term D y n am ic P sy ch o th erap y as w ell as the n ew form o f Short-Term P sych oan aly sis, and lies on a sp ectru m from relatively m ild at o n e en d to exceed in g ly p o w erfu l at the other, cu lm in atin g in the h ead -o n collision.

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Challenge; Resistance and Therapeutic Alliance O n e of the essential ingredients o f the therapist's attitude in this technique is that w hile m aintaining the greatest sym pathy and respect for the patient, he has n eith er sym path y n or resp ect for the p atien t's resistance and con veys an atm osphere of considerable d isrespect for it. As a large part of the patient is identified w ith his defenses, this part of him becom es angry at having them treated w ith such disrespect. But u nderneath there is another part of him that begins to turn against them , to appreciate profoundly the therapist's relentless d eterm ination to free him from his b u rd en and to sense dimly the relief h e w ould feel if this could be accom plished. This sets up tension betw een one part of the patient; the resistance, and an oth er part; the therapeutic alliance. Until a m ajor breakthrough has b een achieved, the tw o opposite parts of the patient, the resistance and the therapeutic alliance, are alw ays in operation at the sam e tim e, and the therapist's task is to tilt the balance betw een these tw o opposing forces in favour of the therapeutic alliance, b i the first breakthrough, the situation changes from the d om inance of the resistance to the dom inance of the unconscious therapeutic alliance; and in a m ajor breakthrough, w e have a m ajor m obilization and dom inance o f the unconscious therapeutic alliance against the resistance. In an extended repeated unlocking, w e have an optim al m obilization of the unconscious therapeutic alliance and, correspondingly, a m ajor breakdow n of the resistance.

Relationship between the Phases of Pressure and Challenge T h e ph ase of pressure m ay con tain passing m om en ts o f ch allenge, but system atic ch allen g e is n ot b eg u n u ntil resistance has tangibly crystallized b etw een therapist and patient, i.e. the p atient is n ot m erely trying to avoid his painful feelings— w hich no d ou bt he does aU the tim e— ^but is specifically and rep eated ly resisting the therap ist's attem p ts to reach them in the interview situation. N ot only m ust the resistance b e ch allen g ed , b u t th e p atien t's attention m ust b e d raw n to it and its n atu re clarified for him . This wiU have the m axim um effect w h en the p atient can n o t avoid recog nizin g it. T h erefore, the therapist m aintains and in creases his pressure, but w ith h old s his ch allen g e until h e ju dges this poin t has been reached . It is obvious that the ch allenge need s to b e adapted to the particular type of d efense that the patient is using, and th ere are various types of challenge. T h e follow ing are som e exam ples: • Pointing Out: drawing attention, always implies calling in question • Countering • Blocking

C hallenge need s a great d eal of d iscussion and is best in trod u ced by a series of exam ples.

Challenge to the Resistance Outside of the Transference T h e therapist is focusing on th e im pulse:

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TH : PT: TH :

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D id you fe e l that you luanted to physically lash out at him? I g u ess so. You say you "guess."

H ere th e th erap ist is p oin tin g ou t and q u estion in g the d efen se. C hallen ge creates a state o f ten sio n b etw een the therapist and the patient. T h e fact that in this p articu lar in terv en tio n the therap ist m akes no attem p t to explain w hy h e is q u estio n in g th e w ord "g u e ss" is an exam ple of speakin g to the u n con sciou s and creatin g a state o f m ystification for th e p atien t's conscious. This serves to further in crease the ten sio n . T h e foUov^ng is a n o th er exam ple; TH : PT: TH :

You had the idea that he m ight becom e sexually interested in you? Yeah, it w as that, 1 guess. But you say you "guess."

It is im p o rta n t to em p h asize the ch oice of w ords in the various form s of ch allen g e: "D o you n o tice "; "N o w you are m ov in g to the position . . . " ; "H an g in g it in th e m id d le of n o w h e re "; "L ea v e thin gs in the state o f lim bo "; "Is it like that alw ays"; "B u t you see." All th ese phrases draw the p atien t's atten tio n to the d efen ses an d clarify th em for the patient. B u t th ey do m uch m ore th an this. T h ey co n v ey a n a tm o sp h ere of con sid erable d isresp ect for the resistance. Q u estio n in g , d raw in g atten tio n and p oin tin g ou t is th e sim plest form of ch allen g e; to do n o m ore th an d raw atten tion to the d efen se or to the fact that so m e th in g is b ein g avoid ed. Sin ce this is alw ays d on e in such a w ay as to call the d efen siv e m a n eu v re in q u estion , it is a m ore pow erful form of ch allen g e than m ig h t a p p ea r at first sight. In the latter part o f this article, it will be seen to b e an extraord in arily effectiv e w ay for th e therap ist to co u n ter certain d efen ses in the tra n sferen ce w ith o u t allow in g h im self to be d raw n into the b attle of wills.

Further Example of Challenge to the Resistance Outside of the Transference The Case of the Real Estate Lawyer PT: TH :

O kay, I left very soon afterw ards. You see, you are m oving aw ay from lohat you felt at that m om ent. (Q uestioning)

PT: TH :

I tried to m ask it, I tried to laugh about it in fro n t o f everybody. But, still, you are not say in g how you felt. (Pointing O ut)

PT: I didn't fe e l sick. I gu ess m aybe it w as . . . TH : But you are talkin g about w hat you did not feel. I am talking about w hat you did feel. (P ointing O ut)

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The Man with the Chewing Gum I have already discussed this case in the Phase of Pressure. T he patient's wife will not travel w ith him in con n ection w ith his w ork (w hich he needs h er to do to preven t the onset of his phobic anxiety), because she is unw illing to leave their sm all daughter. H e tries to rationalize his feeling: FT. But w hat else can she do? TH: But still you are not talking about you r feelin g when she says no. FT: I m ight get a little upset.

The Tickling Woman D u rin g the interview , she speaks of h avin g had an abortion and she tries to control the w aves o f painful feeling. W h en this is pointed out, she m oves to rationalization: TH: FT: TH:

You see, I fe e l there is an upsurge o f som e feelin g in you right now and you are trying to push it aside. A m 1 right? Yeah, you are, but it is "because" 1 am fin d in g it hard to get onto exactly w hat it is, because . . . But, still, you are right now fig h tin g the feelin g by talking.

H ere, I w ill p resen t a series of abbreviated exam ples, all con tain in g the elem en t o f calling in question expUcitly and pointing out.

Challenge in the Form of Pointing Out and Calling the Defense in Question " 'I felt terrible' is ju st a sentence." "You are back again to the issue o f em barrassed." "You are helpless to tell m e w h at you r in n er experience w as." "D o you notice you are totally incapable of telling m e h ow you felt?" "N o w you are giv in g m e a picture that you can n o t in fantasy im agine . . . " "You m ove to the position that it is difficult to rem em ber." "H ow is you r m em ory? Do you have problem s w ith you r m em ory?" "S o your m em ory collapses on you ." "1 am n o t sure it is th at you d o n 't rem em ber b u t th at som ehow you w ant to leave it in the m iddle o f nowhere." The above are a few exam ples of ch alleng es in volving p oin ting ou t and calling in question the d efen se of n o t rem em b erin g . T h e follow ing are exam ples of challenge in the form of p oin tin g ou t the d efen se of v ag u en ess: "W h y d o n 't you w ant to be specific?" "I w on d er if you n otice that you rep eated ly use the phrase: '1 d o n 't know ?' " D iv ersio n ary Tactic— the p atien t uses a diversion ary tactic and the therapist challenges it b y p oin tin g out: "Again you avoided m y question ." G e n e ra liz a tio n — the p atien t is u sin g gen eralizatio n and th e therapist ch allenges by p oin ting out: "B u t, you see, you are n o t specific."

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Hypothetical Idea— th e follow ing is ch allen g e in v olv ing p oin tin g out and callin g in q u estio n th e d efen se o f a h y p oth etical idea: "You say you w ere angry, you are talkin g in a h y p oth etical w a y " Rumination, Denial and Avoidance— the follow ing are m ore exam ples of ch allen g es in v olv in g p o in tin g o u t and calling in q u estion the d efen ses of ru m in atio n , d en ial an d avoid an ce: "D o you see you are u sing a m ere se n ten ce to d escribe a feelin g ?" (ru m in ation ), "You are attem p tin g to give m e a p ictu re th at you w ere n ot curiou s about you r m o th e r's b o d y " (d en ial); "Still, you p refer n o t to d eclare that you w ere actually in terested " (den ial); "You m ean you are sm iling for no reason "; "You see you p refer to talk to avoid ex p erien cin g h ow you feel" (avoidance).

The Case of the Man with the Broken Fist I h av e alread y p resen ted this case in the p ap er on the P hase of Pressure. T he th erap ist is fo cu sin g on the p atien t's feeling: TH : So let's see, w hat is the w ay you feel? PT: Inept. TH: "Inept" doesn't say how you feel, that is a word.

TH: W hat type o f the feelin g that generates in you? PT: N ot bein g able to fu n ction . TH : But that is not a feelin g. PT: N ot fu n ction in g. TH : I t ’s not a feelin g.

Countering Form of Challenge to the Resistance T h is m ay take variou s form s. T h e th erap ist m igh t ask the p atien t to m ake a d ecision , w h ich is o ften used w h en a p atien t u ses such d efen ses as in d irect speech , v ag u en ess an d ru m in ation . A n oth er form of cou n terin g is "tea rin g aside the d e fe n se ." H ere th e th erap ist m akes explicit or asks th e p atien t for an explicit sta tem en t o f w h a t the p atien t is avoid ing. This form o f ch allen g e is often used again st cov er w ord s, in tellectu alization an d denial. T h ese form s of ch allen g e are o ften used in sequ en ce. Asan exam ple, the p atie n t is d escrib in g his sex life: "I g u ess," "I su p p ose," "it w as satisfactory," and th e th era p ist ap p lies a co u n terin g form of ch allenge: "W as it satisfactory or w asn 't it?" T h e follow in g are a few exam ples of co u n terin g form of ch allen g e to the resistan ce:

The Case of the Salesman A y o u n g m arried m an su ffered from a m ild obsessional n eu rosis, from the extrem e left o f th e sp ectru m o f p sy ch o n eu ro tic disorders. H e resp on d ed v ery w ell to th e p h a se o f in q u iry and gave a v ery clear an d lucid accou n t of th e ev olu tion of his sy m p tom n eu rosis.

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In the follow ing passage he uses cover w ords and rum ination and the therapist is challenging it in the form of countering. T he therapist is focusing on the Sister-in-Law : PT: Well, she is very pretty, and she has a big chest. TH: You mean the breast? She is a large-breasted woman? PT: Yeah, I think that is w h a t. . A don't k n o io . . . I have alw ays been sort o f attracted to that. TH: W ould you say that was the part that attracted you the most? In an oth er part o f the interview , he uses rationalization and the therapist challenges in the form of cou ntering, asking for an explicit statem ent. D uring the interview , the question w as w hy the patient used to have fights w ith his younger brother: PT:

H e used to w ant tofolloiv m e around an d I did not w ant tliat. H e was too young. TH: You mean that was the factor? PT: Yeah, yeah. TH: Was that the factor, or was it that he had becom e the favorite o f your mother? Was there favoritism ?

The Case of the Hyperventilating Woman This is a you n g m arried w om an in h er late tw enties, su ffering from chronic anxiety, p erfo rm an ce anxiety, attacks of hyperven tilation , m ajor conflict in her m arriage, characterological problem s, the n eed to b e used and abused, and inabihty to assert herself. Sh e uses ru m in ation and th e therapist challenges in the form of countering. T he p atient is speakin g of h er m ale teach er w h o appeared in a recu rren t dream ; PT: A t the tim e I thought I loved him , but I really j u s t . . . TH: You mean you loved him in ivhat sense, you had sexual feelin gs fo r him? PT: Yeah, b u t . . . TH: But you say it in a hesitant xoay. Did you or didn't you?

The Case of Henry TV Man T his p atien t suffered from ch aracter n eu rosis and w as m arried, and w hat precipitated his com in g in to trea tm en t w as fin d in g his w ife h avin g an affair w ith her teacher. T h e p seu d on y m , H en ry IV, is his m em ory o f his fath er sm ok in g his pipe and h avin g his d og next to h im , and th e p atient referred to his father: "H e was like H en ry IV." T h e p atient u ses d en ial th at liis fath er had an y in terest in him. H e is speakin g o f a p h otog rap h of him self w h en h e w as sm all and sitting on his fa th e r's lap, but he tries to d en y that this m ean t that his father had an y special interest in him : PT:

It might have ju s t been a photographer w ho put m e on his lap an d m aybe it wws not representative o f what he did all the time.

Central Dynamic Sequence: Phase c f Challenge

TH: PT:

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H e had arran g ed a photographer to take a picture o f you on his lap— this means som e interest in you. H e ivants to have a picture o f you. O h yes, as a m atter o f fact he had a great interest in me.

In th e follow in g p assage, the sam e p atient uses the d efen ses of cov er w ords and in tellectu alization . T h e th erap ist challenges in the form o f countering, m akin g it explicit. T h e p atien t had ju st d escribed h ow his m oth er had had an affair w ith a friend o f the fam ily; PT: TH: PT: TH: PT:

I felt first o f all, it was shockin g that my m other . . . som ething m ust be w rong loith h er D id you fe e l rage with y ou r m other? Yes. I really fe lt that she's . . . I really put the w orld o f people in two categories, people w ho are straight an d people w ho have . . . D id you fe e l rage with her? Yes, 1 felt rage w ith her.

Challenge in the Form of Blocking T h is form of ch a llen g e con sists of b ru sh in g aside the p atien t's defen sive m an eu v re an d b rin g in g him b ack to the point. It is used w ith m any d ifferen t types o f d e fe n s e s , in p a rtic u la r d iv e rsio n a ry tactics an d v ario u s fo rm s of in tellectu alizatio n s. T h e follow ing are a few exam ples.

The Case of the Chess Player T h e follow in g p assage is from an in terv iew w ith a p atien t w ith a high degree o f resistan ce w h o h ad m ajo r problem s in in terp erson al relation sh ip s, problem s w ith in tim acy an d clo sen ess, a high ly self-d efeatin g an d self-sabotagin g p attern , an d m asocliistic ch a ra cter traits; goin g from the frying pan into the fire. T h e focu s is on his brother. H e uses d iv ersion ary tactics and the therapist ch allen g es it by b lock in g : Yes, I have a recollection that m y brother and I fou ght like hell, like cats and dogs all the time. TH : Fighting like cat and dog. PT: W ait, not ju s t w ith m y brother, with m y sister too. TH : I know, but w e are focusing on you r brother right now, hm m ? You repeatedly also w ant to bring y ou r sister into it. PT:

In a n o th e r p art o f the in terv iew w ith the sam e p atient, he again uses d iv ersio n ary tactics: TH:

W hat w ere y ou r sister's an d brother's reactions to you r being you r m other's

favourite? Oh, o f cou rse they w ere jealou s. M y sister is a very sick person. She's still angry abou t the past— she's totally angry. TH : M m hm m . PT: She's still liv in g in . . . TH : So h er relation ship with you is a hostile one. PT:

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The therapist focuses on the hostility and the actual experience of rage tow ards the sister, but the patient w ants to diversify to his b rother w hich is blocked. In the sam e interview , he used the defense of generalization and the therapist challenges by blocking: TH: So your sister's relationship with you is a hostile one. PT: H er relationship w ith everybody is a hostile one. TH: But w e are focu sin g on you.

The Case of the Masochistic Woman with the Brutal Mother W h en she en tered into treatm en t, the p atient w as a thirty-tw o-year-old divorcee w h o suffered from ch ron ic anxiety, perform ance anxiety, disturbances of in terperson al relationships, m ajor problem s w ith intim acy and closeness, selfd efeating and self-sabotaging pattern s, gravitating tow ards m en w ho w ould use and abuse her, and m asochistic character traits. T h e therapist is focusing on the anxiety in the transference. Sh e uses diversionary tactics to avoid the tran sferen ce, and the therapist challenges in the form of blocking: PT:

W hat com es to m y m ind is that there are m any things I'd like to understand about myself. Since I loas a child 1 have been plagued by a certain type o f dream which 1 fe e l is "somewhat representative o f my behavioral patterns." TH: You mean you have recurrent dreams? PT: Uh hmm, and 1 think it's indicative o f a certain split som etim es in the way Ife e l. TH: A nd w hat you say is that those dream s reflect on som e o f you r problems in PT PT:

life? Yes. Okay, let's stay with this an xiety fo r a moment.

The Case of the Man with the Broken Fist This is a professional artist w h o suffered from d istu rbances of interpersonal relahonships, chron ic anxiety, m ajo r problem s w ith intim acy and closeness, depressive episodes, b ein g suicidal. The focus of the session is on the anxiety in the transference. H e uses diversionary tactics to m ove aw ay from th e tran sferen ce, and the therapist challenges it by blocking: TH: A nxiety has to do with m e then? PT: You p erson ally ? . . . It is the interaction with w hoever I am goin g to interact luith today. TH: So then obviously it is me. PT: A nd tom orrow if it ivere som ebody else . . . TH: N ow you zoant to m ove aw ay from you r anxiety and feelin g in relation to me.

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In the sam e interview , th e focus w as on the n atu re o f his difficulties, and he w as n o t able to id en tify them . T h en he w an ted to diversify to his parents: PT: TH:

The areas I am sure I m ig h t . . . 1 say again ! am sure, are my parents. N ow you w ant m e to m ove to i/our parents before you tell m e the nature o f your difficulties.

The Case of the Real Estate Lawyer At th e tim e o f th e initial interview , this patient w as 37 years old, m arried, and su fferin g from lo n g -term ch aracter neurosis. T h e p recip itatin g factor that b rou g ht h er to trea tm en t w as an in cid en t in the office. H er boss had p resen ted h er w ith a gift box w h ich he g av e h er in fron t o f som e thirty people w orkin g in h er office. W h en sh e o p en ed it, she fou nd the replica of a penis w ith a note: "A w o m an 's best frie n d ." A fter th is in c id e n t, sh e b eca m e sy m p to m atic w ith an xiety, p oor co n cen tra tio n , sleep d istu rb an ce, etc. D u rin g the trial therapy, sh e had sm iled freq u en tly and used g en eralizations. T h e th era p ist's q u estion is w hy the p atient sm iled. Sh e uses gen eralization w h ich th e th erap ist ch a llen g es by blocking: PT: TH:

Sm iling usualli/ indicates happiness, c o m fo r t. . . I am talkin g abou t you, let's not get to the general.

In th e sam e interview , sh e uses in tellectu alization w h ich the therapist again ch allen g es by blocking: PT: TH:

Well, it has m ade an impact, otherzvise S or 9 nuviths later I w ould not still be . . . No, let's not go after that. Let's see how you felt.

Later, sh e uses in tellectu alization and the use of "If." PT: TH :

1 g u ess if I had been m ale an d som eone had done this to m e my reaction w ould have been . . . Let's not to m ove to if you ivere male.

The Case of the Hyperventilating Woman T h is p a tie n t h as alread y b een m en tion ed . Sh e is describin g a series o f dream s th at sh e has h ad at o n e tim e about her teach er: PT:

Those w ere the dream s w hen I thought at som e point I loved my teacher. girls fa ll in love w ith their m ale teachers I think, b u t . . , TH: Let's not g et to "most g ir ls ," let's focu s on you.

Most

In a n o th e r p art o f the interview , she uses ration alization w h ich is blocked: PT: TH :

W eil I fe lt an g ry but 1 wasn 't sure that I was justified. N o, let's not g et into the in tellectu al aspect o f it. Let's feelin g .

look at you r

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The Case of the Salesman This case has already been m entioned. In this part of the interview , he uses rationalization w ith the use of "becau se." T h e question at issue is w hether his m other show ed favouritism tow ard his you n ger brother: PT: H e luas the fav ou rite because he was the youngest. TH: Let's not get to "because." This patient in the sam e in terv iew uses rum ination: TH:

Then obviously there was a wish on you r part that you w ould not think o f sex in terms o f you r parents. PT: I m ight have been. I can't really . . . It is . . . I was thinking back to then, and it is hard to say. TH: But that doesn't help us. We need to look at you r thoughts.

Further Aspects of Challenge Outside of the Transference Element of Drawing Attention to the Defense In th e follow ing exam ple, both the challenge and the elem en t o f draw ing attention to the d efen se are m ade stron ger by th e w ords "you see." PT: TH:

. . . So 1 guess 1 loas annoyed w ith my m other because even though . . But you see you are using the ivord "guess."

.

T he challenge can also b e stren g th en ed by the use of a rhetorical question: TH: PT: TH:

Then you loere angry. Yes, 1 guess I loas. W hy do you say you "guess"?

The Case of the Cement Mixer This w as a m arried m an su fferin g from ch aracter neu rosis; obsessional neurosis and characterological distu rbances, w h o en tered in to the interview w ith anxiety. T h e follow ing passage is from one o f the psy ch o th erap y sessions; draw ing attention to the d efense. TH: PT: TH:

You are anxious right now. I guess I had rage with me. 1 gu ess on the w ay to here. W hy do you say you "guess?" . . . an d it is not clear you are talking about rage or m urderous feelin g ? . . . We know from the previous sessions, underneath the anger is m urderous feelings. PT: Probably . . . it's very difficult to com e an d sit here an d say I have m urderous feelin g s tow ards m y wife. TH: W hy do you say "probably"? A fu rth er exam ple: TH:

W ere you jealous o f her?

Central Dynamic Sequence: Phase of Challenge

PT: TH :

I g u ess so. do you say you "guess"?

PT: TH :

I m ight g et a little upset. You "might"? You prefer not to be definite.

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In the follow in g th ree exam ples th e therapist u ses a n u m b er o f d ifferen t types o f ch allen g e. In ad d itio n to so m e o f tho se alread y en co u n tered , th e th erap ist asks for a d irect an sw er as a co u n ter to vagueness. In each exam ple, as th e resistance crystallizes m ore strongly, the th erap ist escalates his ch allen g e in a system atic way.

The Tickling Woman PT: TH : PT: TH :

I f I w eren't m arried I w ou ld probably have gon e out w ith him. But you say "probably. " Well, 1 w ou ld have m ost likely, I c a n ’t see w hy not. I can't see an y reason w hy I wouldn't. D o you notice that w hen you are talking about any issue you are using all kinds o f sentences, w hich indicates that you don't w ant to com m it yourself? D o you notice that?

The Real Estate Lawyer T h is case w as d escribed earlier, and th e follow ing passage is from th e sam e in terv iew : PT: I probably w as an g ry but I . . . TH : N ow you say "probably" you w ere angry, PT: W ell I am su re I m ust have been angry. 1 mean, you know, like . . . TH : N ow you are m oving to the position that you "must have been" angry, as if you are not sure.

TH :

But you see fir s t you say you m ust have been angry, w hich is not com m itting yourself. W ere you angry or loeren't you angry? PT: I probably was. TH : "Probably" again is h an gin g it in the m iddle o f nowhere.

The Importance of Drawing the Patient's Attention to the Defense In rev iew in g th ese ch alleng es, it is im portant to note the choice of the words: "D o you n o tice . . . ?" "N o w you are m ovin g to the position ----- "H an g in g it in the m iddle of n o w h ere"; "L ea v in g it in th e state of lim bo"; "Is it like that alw ays?" "N o w you m ov e to a silen t p osition "; "You p refer to look to the opp osite w all"; "D o you n otice th at y o u r face has no expression and you retreat to a board-like position?" All th e se p h rases d raw th e p a tien t's a tten tio n to the d efen ses and th e therapist system atically clarifies th em an d m akes the p atien t acq u ainted w ith them . B u t it is

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extrem ely im portant to take into consideration that they do m uch m ore than this. T h ey con vey an atm osphere of considerable disrespect for them . I have already m entioned that one of the essential ingredients o f the therapist's attitude in both techniques— Intensive Short-Term D ynam ic Psychotherapy and the new form of Short-Term Psychoanalysis— is that, w hile m aintaining the greatest sym pathy and respect for the patient, the therapist has n eith er sym pathy nor respect for the patient's d efenses that have w arped his character. T he patient m ust com e to reah ze th a t th e se d efen se s, th e resistan ce, are in fact d ev astatin g ly counterprod uctive; b o th em otionally and intellectually they have to see the destructive organization of the resistance and its devastating im pact on their life. O bviously, th ey have to h ave a d irect experience of th e path ogen ic organization w ithin their unconsciou s w hich is responsible for the p atient's sym ptom s and character disturbances.

Fundamental Rules: Technical and Metapsychological Knowledge H ere I form u late very briefly a n u m ber of the rules and som e of the im portant tech nical and m etapsychological know ledge: (1) The therapist must be well acquainted with the nature of the resistance; major resistance and tactical organization of the major resistance. (2) He must have extensive metapsychological knowledge about the unconscious defensive organization; obsessional defenses, spectrum of regressive defenses as well as primitive system of defense. (3) Once the phase of challenge has begun, it is absolutely essenHal for the therapist to challenge and pressure each defense as it is mobilized to the front line of the psychotherapeutic process. This rapid challenge and pressure to the resistance is essential to mount the tension until the final breakthrough into the unconscious takes place. If he does not do this, the tension subsides and will never reach the threshold to achieve the direct access to the unconscious (4) The therapist knows that a high rise in the transference feelings, the intensification of the transference component of the resistance, is the central triggering factor in breakthrough into the unconscious. (5) The threshold to achieve the direct access to the unconscious always correlates with the degree of mobilization and intensification of the transference component of the resistance and the direct experience of the transference feelings. But this threshold can be of moderate degree, which results in partial direct access to the unconscious; it might be of a high degree, which results in the spectrum of major direct access to the unconscious; the threshold might be achieved at an optimum mobilization which creates extended and rapid direct access to the unconscious. Optimum mobilization has a central and key position in the new form of Short-Term Psychoanalysis. (6) Direct access to the unconscious and unconscious therapeutic alliance. The whole descriptive term of unlocking of the unconscious refers to the dominance of the resistance by the unconscious therapeutic alliance and, as I have already mentioned, the first breakthrough refers to the first dominance of the resistance by the unconscious therapeutic alliance; in major unlocking of the unconscious, we have a major dominance of the resistance by the unconscious therapeutic alliance; in optimum mobilization of unconscious therapeutic alliance, there is a total breakdown of the resistance.

Central Dynamic Sequence: Phase o f Challenge (7)

(8)

(9)

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The therapist must not give up. He must be prepared to continue with his system atic w ork until he achieves breakthrough in the first session and then for session after session. I would like to em phasize that I am not at all suggesting that every therapist who is w orking with the technique must use exactly the same form of words and phrases in the application of the phase of challenge. But as long as the therapist understands in depth the technical and metapsychological roots of the technique, he should be able to apply it with his own personality and style. If w e carefully review the examples of challenge given so far, it is possible to conceptualize challenge as follows: making a challenge consists of pointing out, questioning, countering or blocking a defense in such a way as to convey an attitude of scant respect for it.

Further Aspects of Challenge to the Resistance Speaking to the Therapeutic Alliance U ntil a m a jo r b reak th ro u g h has b een ach iev ed , the tw o op p osite parts of the p atien t, th e resistan ce an d th e th erap eu tic alliance are alw ays in op eration at the sam e tim e. It is obv iou s th at this b alan ce d ep en d s on w h ere th e p atien t is located w ith in th e sp ectru m o f resistan ce. In h igh ly resistant com plex patien ts, th o se w ho are severely trau m atized in the v ery early phase of their life, as w ell as in su b seq u en t years, th e resistan ce h as a very stron g hold. But, at the sam e tim e, it is the fu n ctio n o f the tech n iq u e and the th erap ist's task to m obilize the th erap eu tic allian ce, first con scio u s and th en u n con sciou s, and tilt the b alan ce b etw een these tw o o p p o sin g forces in fav ou r o f the therap eu tic aUiance. T h e final b reak th ro u g h is a d o m in a n ce of th e resistan ce by the u n con sciou s th erap eu tic alliance. It is im p o rta n t to n ote that no m atter h ow strongly the therap ist is focu sin g on th e resistan ce, an y in terv en tio n th at h e m akes w ill inevitably con tain at least som e kind o f th e im p lied m essag e to the therap eu tic alliance. It is also possible for the th erap ist to sp eak to the th erap eu tic alliance m ore directly. It ten d s to be used in its m ost d irect form in the later stages of an interview , w h en the u n con sciou s th erap eu tic allian ce h as b e e n partly m obilized, but the m ajor resistan ce is far from b ein g at an end . I w ill fu rth er discuss this in a future forth com in g pu blication on h e a d -o n collision w ith th e resistan ce. A close exam ination of m an y exam ples of challenge will reveal the presen ce of this elem en t. For exam ple, in the w ords "you see," or "d o you notice" the therapeutic alliance is ad d ressed directly. In these exam ples, the em phasis w as on pointing out or q u estion in g the d efen se, b u t w h en the therapist includes an elem en t of add ressing the therap eu tic alliance, he usually also points out w hat is b ein g avoided, and the ch allenge m ay consist of little m ore than tliis. H ere I give tw o exam ples.

The Real Estate Lawyer In this p assag e from the sam e interview , the d efen se th at sh e u ses is so m atization and th e th era p ist's focus is on the in n er exp erien ce o f an ger: TH:

. . . Your fa c e is red, y ou r ears arc red, you r stom ach goes flip-flop, but still w e don't knoiv w hat y ou r inner experience loas.

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T h e follow ing passage is from the sam e interview . T h e defense she uses consists of negative statem ent, thinking n ot feeling: PT: 1 did not feel sick to my stom ach. I did not feel angry. I ju st felt very embarrassed. TH: But, you see it's not absolutely clear how you felt. You say you did not feel angry, you did not fe e l sick to you r stomach. PT: I was curious as to who had done it because at that point 1 was very shocked. TH: It is not clear how you felt. Do you see ive are having difficulty to see haw you felt?

The Case of Henry IV Man In the follow ing passage o f the sam e in terview from the H enry IV M an, the therapist points ou t both the d efen se and w h at is b ein g avoided; avoidance, denial. T h e patient is referrin g to his having failed to take n ote o f the signs that his w ife w as having an affair: PT: 1 m ust say 1 was very naive even though 1 . . . TH: Let's not g et into this. You see, now you prefer to use the word "naive" as a way not to look at som e o f these problems. P T Yes. TH: Because if you put in term s o f being "naive," then w e are going to dism iss some o f the very essential issues. Isn't that so? PT: Yes, that's right. In all these exam ples, the elem en t of add ressing th e therapeu tic alliance is reinforced by the w ord s "w e" and "u s" w h ich em phasizes th at the relation­ ship b etw een the patient and the therapist is a partnership. W h en m uch of the p ah en t is identified w ith his resistance, the result is a h eigh ten in g of tension w ithin him .

Challenge to the Resistance in the Transference W h en a patient en ters into the interview in a state o f resistance in the transference, the phase o f inqu iry is kept at bay, and the process m oves to the phase of challenge and pressure to the resistance in the transference. Similarly, w h en a patient enters into the interview w ith anxiety w hich has transference im plications, again the phase of inqu iry is kept at bay and the process m oves to the phase of pressure for further crystallization of the resistance in the transference, and then to the phase of challenge to the resistance. And, obviously, there are m any patients for w hom the transference is not the issue in the very early phase of the interview . Rapidly, or gradually, the tran sferen ce becom es a central issue and the therapist m ust be on the look ou t for w h en the patien t's transference feelings are becom ing an issue and he m akes an in terv en tion designed to bring them into the open. The intervention m ight consist of asking the question "H ow do you feel right now ?" or after describing a p attern in som e outside relationship, of d raw ing attention to the parallel w ith the transference by asking, "H ow about h ere w ith m e?" T he initial

Central D\/nainic Sequence: Phase of Challenge

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resp on se to such an in terv en tio n is alm ost invariably resistance. In the cases that 1 h ave p resen ted so far, th e Salesm an avoids an sw erin g the question altogether; the C hess Player resp on d ed \\ith intellectualization w h en the therapist focused on the tran sferen ce, "T h a t is so m eth in g very m uch u nd erstood "; the Real Estate Law yer used d enial, "For n o reason at all I am sm iling"; the M an w ith the C h e u in g Gum used both ind irect sp eech and cover w ords, "O n e d o esn 't like to be told"; the Hv7?er\’en tilatin g W om an gave an apparently relevant response w hich did not actually an sw er th e question , "I used to b e verv d efin ite"; and the P ra tin g M antis m ain tain ed h er resistan ce of stubbornness. T h e th erap ist's im m ed iate resp on se to these m an ifestations of resistance in clu d ed th e follow ing: p oin tin g out and blocking, "N o w you are goin g into the in tellectu al issu e"; "You m ean you are sm iling here w ith m e for no reason ?" p o in tin g o u t the a v o id an ce to the C hew in g G u m M an, "Still you ha\-en't said how you feel"; to the H y p erv en tilatin g W om an; "B u t do you notice you are in d efinite w ith m e?" T h u s, m an y of the p atien t's d efen ses are id entical to those used in n o n tra n sferen ce situ ation s, and th ese are h an dled by the therapist v\nth exactly the sam e k in d of ch allen g e. H ere, I illustrate fu rth er by the follow ing m ore extended exam ple o f a p atien t from the left side of the spectru m o f resistance:

The Case of the Manageress A y o u n g w o m a n su fferin g from ch aracter neurosis; sym ptom s and ch aracter d istu rb an ces; d istu rb an ces in in terp erson al relationships; conflict over intimac\' and closen ess. All h er relation sh ip s w ith m en end up in d isap p oin tm en t; she su ffered from an xiety; lo n g sta n d in g con tlict w ith her m oth er; episod es of verbal lash in g ou t, p articu larly in relation to h er m other. In the follow ing passage, the patien t h as feelin gs in th e tran sferen ce that the therapist is going too fast: TH: PT:

A n d hozv d o you feel a lm it m e g o in g fast? W ell, I'd lik e you to g o ju st a little sloicer, that is all.

TH:

B ut that d o e s n ’t say h ow you feel.

PT: TH :

W ell I don 't knou' h ow I fe e l, I haven 't th ou g h t a l m d h ow 1 feel. B u t ag a in you m o v e to this p osition o f “1 don 't k n o w ."

PT: TH :

W e ll,) don't. You see, o n e o f the thin gs w e see h ere is rep eated ly “1 don 't kn ow ," w hich is a h elp less p osition .

In so m e cases, particu larly on the left side of the spectru m o f resistan ce, a single su stain ed p eriod o f ch allen g e to the tran sferen ce resistance leads to the first b reak th ro u g h .

The Cheiving Gum Man As a lre a d y d iscu ssed , th e re w as m o b ilizatio n o f th e resistan ce in the tran sferen ce and the p atien t b ecam e tense and im m obile w h en the therapist b ro u g h t to his a tte n tio n th e seco n d ary gain in his sym ptom s: TH :

H o w d o y o u feel rig h t noiv? H a v e you n oticed that you h a v e b eco m e m u ch m ore s lo w a n d pmssive?

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Intensive Short-Term Dynamic Psychotherapy PT:

N o, I d o n ’t th in k so.

TH:

Still you haven't said hoio you feel when I pointed out to you that without your boss and you r w ife you are helpless. PT: Yeah . . . mm hmm. O ne doesn't like to be told that one is so dependent. TH: But still you are not talking about the w ay you feel. PT: Perhaps som eiohat annoyed. TH: But still it is "perhaps." PT: Yeah, I ivas annoyed . . . because the idea ivas that I loas like a child.

Further Example of Challenge to the Resistance in the Transference The Hyperventilating Woman As described above, the p atient h ad suffered an attack of hyperventilation after a p h on e con v ersation w ith h er sister. After som e pressure and challenge, she adm itted th at h er sister had m ade h er angry. T h e therapist proceeded to the question: "H ow do you experience your an ger?" to w hich she answ ered, "cried " and becam e tearful in the in terview itself. This w as the therapist's cue to open up the transference. This m obilized a series o f defen ses, each of w h ich w as challenged as it appeared: TH:

So you are holding onto y ou r feelin g right now, hm m ? Noiu hoio did you feel when I repeatedly say you use the words “guess so," or that you d on ’t com m it yourself?

T h e p atien t attem pts diversionary tactics: PT:

Well I used to be very definite, over-definite.

T h e therapist blocks this, brin g in g h er b ack to the transference: TH: But do you notice that you are indefinite w ith me? PT: Yes, I do. TH: Hotv did you feel when I insisted on this issue? You are smiling. PT: W e l l . . . ' TH: Hmm? PT: 1 fin d you very aggressive. T he therapist ch alleng es the p a h en t's perception: TH:

W hat is it about me that is very aggressive? Because I tell you that you are leaving things in the state o f limbo, guess so, hm m ? That m akes me aggressive, hmm ? PT: No, it is your tone o f voice. TH: But how did you feel? O n ce m ore, the p ah en t resorts to d iversion ary tactics: PT:

(Giggling) I guess I wasn 't prepared for that.

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225

T h e th e ra p is t p o in ts o u t th e a v o id a n c e ; TH:

You d id n ot sa y hozc y ou felt tozcnrds me. S till you are a v c id ir x hou' you felt to ic a rd me.

S h e u se s a d ilu te d , w a te re d -d o w n p h ra se : PT: TH :

(G ig g lin g a g a in ) O k a y I didn 't lik e it. "D idn't lik e it" m ean s zchat?

S h e d ig s in h e r h e e ls: PT:

1 d id n 't lik e it. tlw t's all.

T h e th e ra p is t p re sse s h e r fu rth e r: TH :

H o w d id y ou fe e l ichen y ou sa y you d id not lik e it^ You d islik e it, O kay^ D id it irr ita te you^ D id y ou g et irrita ted w ith me^

N o w th e p a tie n t u se s d e n ia l fo llo w e d b v ra tio n a liz a tio n : PT:

X o , not really. I k n o w that you h av e a m ethod.

T h e th e ra p is t b lo c k s th is diversionar\- tactic: TH: PT: TH:

N o, let's not g et in to rationalizTition a lv u t m y m eth od o r this a n d that. D id you feel irr ita te d for a m o m en t w ith m.e^ (S h e sta rts to g ig g le a g a in ) You are sm ilin g .

PT: TH:

I'm g o in g to an szcer “I g u ess so" ag ain . O kay, yes. You felt irrita ted ? You felt an g ry ?

S h e re so rts to d e n ia l ag ain : PT:

\ o t an g ry .

T h is d e n ia l o f a s tro n g e r w o rd , a n g er, a c k n o w le d g e s th e w e a k e r o n e b y im p lic a tio n , n a m e ly irrita tio n : TH:

Irrita ted , hn un ? A n d w h at d id y ou d o w ith y o u r irritation'?

PT:

I tried to calm m y s e lf a n d not to th in k o f it, you know .

TH: PT: TH:

B u t you a re irritated ? 1 tried to ra tio n a liz e why. You sta rted sm ilin g a n d try in g to ration alize, h m m ?

PT:

Yes.

T h e th e ra p is t calls th e d e fe n s e in q u e stio n : TH:

U 7 iy ’ U7iy d o y ou h a v e to co v er up y o u r irritation w ith m e?

PT:

B eca u se th at is h o ic I am w ith everybody.

S u d d e n ly th e p a tie n t b e g in s to talk m u c h m o re s p o n ta n e o u s ly : TH: PT:

T his is the w a y y ou a re in r v ery situ ation , y ou try to co v er up y o u r real feelings^ 1 d id n ot th in k a b o u t that m y s e lf Ivfore, hut it is true, p e o p le al-uHiys s^iid that a b o u t m e. "I can't r o e r im a g in e Ja n et Iv in g an g ry ," a n d th ey w o id d say that to m e. A n d 1 w ou ld say. "W hy do y ou Siiy th in g s lik e that? I co u ld Iv a n g r y . " She

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said no you couldn't. You can't say no and you can't be angry, because I always s m ile . . . It is highly significant that in the above passage, the patient h as com pletely aband oned the diluted w ord "irritated " in favour of the w ord "angry," and it is also clear that she is able to see the con n ection b etw een h er defense of snuling and the feeling o f a n g er B ut it should also b e taken into consideration that an ger by itself, here, is a tactical defensive m aneuvre against underljd ng m urderous rage and guilt. T h e therapist continues: TH:

So there are two things about you, hm m ? O ne is that you cannot say no, hmm? You sm ile when I say that. The other one is that you cannot get angry, and have you noticed that when you talk about anger you prefer the word irritation? Do you notice that? PT: Yes. TH: Because fin a lly you com e to say that you felt irritated with me. In a sense it is easier than to announce that you are angry w ith me, hmm? PT: Well, no, I don't get angry ever. TH: Let's fa ce it, you were irritated w ith me, weren't you? A nd you tried to cover it up, hm m ? But then you said this is a pattern in m any other relationships, hmm? Okay, goin g back to yesterday, how do you fe e l right now? This leads to th e first b reak th rou g h as th e patient, in a fu rth er outburst of spon tan eou s feeling, reveals the real reason w h y the p h on e conversation had m ade h er so angry.

Further Example of Challenge to the Resistance in the Transference The Case of Butch A you n g m arried m an in liis m id -tw en ties suffered from diffuse sym ptom d istu rbances and characterological problem s. H e en tered the initial in terview w ith som e m obilization o f th e tran sferen ce feelings and the process m oved to th e phase of pressure and rapidly to the p h ase o f pressure an d ch allen g e, w h ich resulted in fu rth er m obilization o f the tran sferen ce feelin gs and in ten sification o f the resistance in the tran sferen ce in the v ery early p art of the interview . T h e follow ing passage is from the ph ase o f challenge: TH:

That is another problem you have. H ave you ever considered that you m ight be a stubborn person as well?

Pointing out, calling in q u estion the stubbornness. PT:

No, I've never considered it.

T h e patient uses d en ial and the therapist ch allen g es it: TH: PT:

Hm hm, could w e look to that? I think everyon e is slightly stubborn.

Central Di/iiainic Scqucnce: Phase o f Challenge

111

T h e p atien t w an ts to resort to in tellectu alization and g en eralizatio n, and the th erap ist ch a llen g es b y b lock in g the d efen ses; TH : PT:

Let s not g et to everybody, w e arc talking about you. Because the focu s is you here. Okay.

TH : A re you a stubborn and defiant type o f the person? PT: Yeah. T h e th e ra p ist ch a lle n g es th e d efen ses and u n d erlin es the tran sferen ce im p lication o f th ese d efen ses; TH :

That in a sen se som ething like this, now he is g oin g to be after m y feeling I am g oin g to take a stubborn, defiant, cu t-off position with him. Do you see what I m ean? PT: Yeah, I see w hat you mean. TH : N oiv that he focu ses on m y feelin g , I am g oin g to fight him by being stubborn, by taking a defiant position. S y stem atic ch allen g e to th e resistan ce shortly follow s by h ead -o n collision and the b rea k th ro u g h in to th e u ncon sciou s, d irect access in to the m u rd erou s rage and guilt and grief-lad en u n con sciou s feelings.

Challenge to Transference Resistance T h e re are p a tie n ts th a t e n te r in to th e in te rv ie w w ith an x iety in the tra n sferen ce and som e d eg ree o f resistance in the tran sferen ce. In a research settin g w h ich d ep e n d s heavily on closed -circu it live in terv iew s, the procedure m ig h t stir up certain feelin g s in the patient. T h e p atien t is b ein g seen eith er by tw o in d e p e n d e n t e v a lu a to rs o r by a p sy ch ia trist-in -tra in in g an d th e n by the supervisor. T h e first ev alu ator m igh t in d icate to the p atient that h e w ill b e seen in o n e to th ree w eek s b y D r . _______ . But the p atient, d u e to certain u n fo rtu n ate c irc u m sta n c e s (e v e ry e ffo rt sh o u ld b e m ad e to avoid su ch u n fo re se e n circu m stan ces), m ig h t en d up b ein g seen in 2 - 3 m on th s w h ich m obilizes feelings in th e p a tien t, an d w h e n he en ters in to the in terv iew h e h as anxiety and feelings ab ou t b ein g k ep t w aiting. In su ch circu m stances, the p h ase of in qu iry is kept at bay an d th e th erap ist focu ses on the p atien t's feelings. T h e p h ase of p ressu re is alw ays sh ort an d m oves rapidly to th e ph ase of ch allen g e to the resistan ce in the tran sferen ce. H ere I w a n t to em p h asize that the p sy ch o th erap eu tic services m ust avoid any u n fo rtu n a te circu m stan ces. In th e above, w e are talking ab ou t a p atien t b ein g kept on th e w aitin g list tw o to th ree m o n th s in a research setting. But this sh ou ld not b e co n fu sed w ith m an ip u latio n o f the tran sferen ce. It should b e em p h asized that u n d e r n o circu m sta n ce s sh ou ld th e th erap ist m an ip u late th e tran sferen ce. M an ip u la tio n of th e tra n sferen ce should be consid ered u n eth ical an d from the tech n ica l an d m etap sy ch olog ical points o f view w ould h ave a m ajo r n egative im p act on th e p ro cess w h ich h eav ily em p h asizes and d ep en d s on th e m obilization o f th e u n co n scio u s th erap eu tic allian ce against the resistance. N ow I retu rn to th e issue of ch allen g e to th e resistan ce in th e tran sferen ce.

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The Case of the Masochistic Engineer W h en he entered into treatm ent, the patient w as in his early forties and suffered from chron ic anxiety, sexual problem s, episodes of clinical depression, m ajor problem s in his m arriage for w h ich h e and his w ife have b een in long-term treatm ent, w ith no change. H e has characterological problem s shifting from passivity and com pliance to stubbornness and defiance, resorting to regressive d efense of explosive discharge of the affect. H e had b een seen by a psychiatrist in training w h o had told him that he w ould be seen in a few w eeks. H e ended up bein g on the w aiting list for 3 m onths. The therapist m ight sim ply explain the situation and apologize, but obviously this is in no w ay goin g to help the patien t's feeling. T h e session starts w ith the phase o f inquiry, asking for the natu re of his difficulties that he w ants to get help for. H e is anxious but w ants to talk about his w ife. T h e therapist im m ediately focuses on his anxiety w hich has a strong tran sferen ce im plication. For the sake of brevity, the d ialogue has b een shortened and paraphrased in places, but n oth in g im p ortant has b een om itted. TH: H e specifically told you three weeks? A nd then you have been three months w aiting? PT: Yeah.

Pressure Toward the Feeling TH: Let's see how you fe lt about that? PT: 1 was annoyed, quite frankly. TH: A nnoyed? PT: Annoyed. I mean I said to m y self TH: You mean you w ere annoyed and that is past or you are annoyed? PT: No, 1 was annoyed at that time. TH: N ot anym ore, you mean? PT: Uh, no, when I called back and you knoiv there ivas an im m ediate kind o f the reply. TH: So w hat you say is this: you w ere annoyed but you are not annoyed anymore. That is the case you mean? T h e above passage show s the application of the phase of pressure to further m obilize the p atien t's tran sferen ce feelings and to further m obilize and crystallize the p atient's ch aracter d efen ses in th e tran sferen ce. T h is results in further rise in anxiety and m obilizes a set of d efenses. T h e p h ase of pressure con tin ues. The d ischarge p attern of the anxiety is in the form of ten sion in the striated m uscles. T here is clen ch in g of the h an d s and sighing respiration.

Pressure and Challenge TH: PT: TH:

Hoiv did you experience you r annoyance? Well, 1 said to m y self uh, you know, to me itd oesn ’t m ake sense. But that is a sentence. You say you w ere annoyed, but then 1 said how did you experience this annoyance. N ow you are givin g a sort o f description "That doesn't m ake sense." H oio did you experience you r annoyance?

Central Dynamic Scqucncc: Phase o f Challctige

229

At this v ery initial stage, resistan ce is in the tran sferen ce. The process en ters in to the p h ase o f p ressu re an d ch alleng e. As the p atien t's resistance is crystallized in the tra n sferen ce, th e th erap ist n ow can system atical!}- ch allen g e the resistance. In th e follow in g p assage, the therap ist is p oin tin g out and q u estion in g the d efen se , w h ich h e follow s by p ressu re tow ard the feeling: PT: TH:

W ell in m y . . . in m y m ind I said uh you know stupid bloody doctors. "Stupid bloody doctors" is again a scntcncc, but ivhat zcas the xcay you experien ced this? PT: Oh 1 didn't shoic an y outw ard uh yeh I felt uh . . . uh . . . well like you feel annoyed, I d o n ' t . .. TH: H ow did you experien ce this annoyance? In term s o f thoughts, was stupid bloody doctors . . . but then you also m ake it plural, doctors.

In th e ab ov e p assage th ere is p ressu re for the actual exp erien ce of the feeling and system atic ch allen g e to the resistance.

Further Challenge and Pressure TH: N ow you becom e silent again. PT: Yeh but I'm tryin g to remember. I'm trying to remember, I mean I'm . . . TH: H ow you felt you mean. PT: Exactly w h a t . . . TH: The sen tence you can rem em ber but the other part o f it you don't rem em ber PT: N o because you see . .. TH : Let's to look at it. W hy? W hy the sentence can be rem em bered but not the other part? In th e a b o v e p a ssa g e, at o n e lev el con com itan tly , he ch allen g es the resistance freq u en t sighs an d w e see a fu rth er rise in m ov es to th e d iv ersion ary tactic of b ein g b locked;

th e th erap ist exerts p ressu re but, of n ot rem em bering. T h e p atien t has the tran sferen ce feelings. Shortly, he con fu sed . T h e d iv ersion ary tactic is

PT: I am a little con fused because. TH: Nou' you m ove to the confusion. Still zve don't know how you experience your annoyance. T h e p h ase o f pressu re and ch allen g e in the tran sferen ce should system atically co n tin u e w h ich fin ally w ou ld lead to the b reak th ro u g h o f the tran sferen ce feelin gs; d irect exp erien ce of the m u rd erou s rage; m obilization of the u ncon sciou s th e ra p e u tic a llia n ce; p a rtia l or m a jo r d o m in a n ce of th e resistan ce b y the u n co n scio u s th e ra p eu tic alliance. T h ere are p a tien ts th a t en ter in to the in terv iew and th eir ch aracterological d efe n se s im m e d ia te ly b eco m e a m a jo r resistan ce in th e tra n sferen ce. The foUowang is an exam p le o f a resistan t p atien t on the right side of the sp ectru m of th e resistan ce.

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Intensive Short-Term D ym m ic Psychotherapy

The Case of the German Architect W h en the patient w as first seen, h e w as in his thirties, suffered from m ajor characterological problem s, disturbances in interpersonal relationships, m ajor problem s w ith em otional closeness and long-stand ing conflict w ith his family. The therapist d oes not know an ything about the patient. T h e setting o f the interview is teach in g and research; closed-circuit live interview . This case has b een discussed in oth er publications. T h e follow ing passage is from the initial contact: TH: Could you tell me what seem s to be the problem that you w ant to get help fo r it? PT: Uh . . . no, not exactly. This is o n e . . . TH: So you don't knoiu exactly w hat the problem is, hmm?

T h e p h ase of inqu iry is n ot possible. The process en ters to the phase of pressure.

Probing for Feeling, Increased Resistance TH: PT:

Problem luith feelings. C ould you tell m e about that? That is merely a sentence. Yes, it is a sentence. H m m , m aybe my reactions to things that I should feel are

TH: PT: TH: PT: TH: PT: TH: PT:

Yeah, but that again is vague. "My reaction to things . . . " Okay. N ow you turn y ou r head on the other side, do you notice that? 1 beg your pard on ? You m ove you r head on the . . . do you notice that in a sense your head moved? Yes, I'm looking fo r ah, another tack you see. A nother? Tack.

T h e follow ing passage show s th e phase of pressure w hich has elem ents of challeng e as the resistance rapidly has b eco m e crystallized in the transference; TH: W hat does that mean? PT: Ah, another approach. TH: U h lm m . PT: Umm. TH: A nother approach to what? PT: To explaining m aybe w hy I'm here.

Challenge to the Resistance T h e follow in g p assag e sh ow s th e p h ase o f ch a lle n g e to th e p atien t's resistance: PT:

Yes, I know but I am vague. I mean I'm very vague a b o u t . . .

Central Dynamic Scquencc: Phase o f Challenge

TH:

PT: TH : PT:

231

So the fir s t question fo r us, w hat are w e goin g to do about the vagueness? B ecause up to the tim e you are vague then loe ivouldn't have a clear picture o f w hat seem s to be the problem . Umm . . . Do you see wlwt I mean? Yes, I see w hat you mean.

TH :

B ecause up to the tim e you are vague then ah, w e w ouldn't understand what seem s to be the nature o f y ou r problem . PT: Uh hm m . Well, I c a n ’t tell you w hy . . . TH : Yeah, but you say "uh h m m ," but that doesn't solve our problem here because our problem here is fir s t to establish w hat seem s to be the difficulty that you have. But now if you w an t to be vague, then w e w ouldn't understand even w hat is the difficulty. Now, that is the first step. PT: Well, o f course, if m aybe if I kn ew w hat the difficulty w as I loouldn't be here. TH : Yeah, you see again you m ove to this, m aybe . .. PT Yeah. TH : . . . in other w ords again. Umbo state. T h ere is fu rth er in ten sification o f the resistance in th e tran sferen ce, and the p ro cess en ters th e p h a se o f h ea d -o n collision w ith the tran sferen ce resistance.

Summary and Conclusion In this article, I prim arily focu sed on the application o f the p h ase o f ch allenge in th e p ro cess of d irect and rapid access to the u ncon sciou s. H ere I su m m arize the k ey p oin ts that w ere d iscussed : (1)

(2)

(3)

(4) (5)

(6)

I indicated that challenge is the key intervention in both the technique of Intensive Short-Term D ynam ic Psychotherapy as well as in the new form of Short-Term Psychoanalysis, and it lies on a spectrum from relatively mild to exceedingly pow erful, culm inating in head-on collision. I em phasized and pointed out that one of the essential ingredients of the therapist's attitude is that, while he maintains the greatest respect and sym pathy for the patient, he has neither sym pathy nor respect for the patient's resistance, and conveys an atm osphere of considerable disrespect for the resistance. The relation betw een the phase of pressure and challenge was discussed. T here it was em phasized that the phase of pressure may contain passing m om ents of challenge, but system atic challenge should start w hen the resistance has tangibly crystallized betw een therapist and patient. W hen the resistance is m obilized, w hether after a period of pressure or at once, there usually follows a period of intensification of resistance. I em phasized that, the resistance needs to be crystallized to the point at which it can be challenged m eaningfully and effectively. C hallenge consists of pointing out, questioning, countering or blocking a defense in such a way as to convey an attitude of scant respect for it. Som e of the most im portant forms of challenge were presented and discussed system atically by the presentation of segm ents of interview s with a num ber of patients. C hallenge to the resistance outside of the transference as well as challenge to the resistance in the transference w ere discussed by presenting vignettes from a num ber of interview s.

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I then presented a brief summary of the fundamental principles as they apply both to the technique of Intensive Short-Term Dynamic Psychotherapy as well as to the new form of Short-Term Psychoanalysis. There I emphasized that the therapist must have extensive technical and metapsychological knowledge of the technique. Systematic challenge should start after crystallization of the resistance in the transference, and rapid challenge and pressure to the resistance is essential to mount the tension until the final breakthrough into the unconscious takes place. (8) The triple factors of resistance, transference and unconscious therapeutic alliance were discussed; it was pointed out that the first breakthrough is defined as the first dom inance of the resistance by the unconscious therapeutic alliance. The technique of direct access to the unconscious was briefly discussed, and it was pointed out that in parHal and major unlocking, we have partial or major dominance of the resistance by the unconscious therapeutic alliance, which applies to the technique of Intensive Short-Term Dynamic Psychotherapy. In the technique of extended, repeated major unlocking, we have optimum mobilization of the unconscious therapeutic alliance, and there I pointed out that this specific technique is central to the new form of Short-Term Psychoanalysis which allows for extensive, in-depth systematic investigation of the unconscious, with the aim of bringing extensive multidimensional structural character changes. (9) Finally, I emphasized that I am not proposing that every psychotherapist who is w orking with the technique must use exactly the same form of words and phrases in the application of the phase of challenge, but he must understand, in-depth, the technical and metapsychological roots of the technique and apply it with his own personality and character style.

References Davanloo, H. (1977). Proceedings of the Third Internatioml Congress on Short-Term Dynamic Psychotherapy. Los Angeles, California: Century Plaza, November. Davanloo, H. (1980a). Short-Term Dynamic Psychotherapy. New York: Jason Aronson. Davanloo, H. (1980b). Proceedings of the Audiovisual Course on Intensive Short-Term Dynamic Psychotherapy, presented at the 133rd Annual M eeting of the American Psychiatric Association, San Francisco, California, May. Davanloo, H. (1983). Proceedings of the First Summer Institute on Intensive Short-Term Dynamic Psychotherapy. W intergreen: Virginia, July. Davanloo, H. (1984a). Short-term dynamic psychotherapy. In Kaplan, H. and Sadock, B. (Eds), Comprehensive Textbook of Psychiatry, 4th edn. Baltimore, Maryland: William & Wilkins, Chapter 29.11. Davanloo, H. (1984b). Proceedings of the Second Summer Audiovisual Immersion Course on Intensive Short-Term Dynamic Psychotherapy, New York City, New York, July. Davanloo, H. (1985). Proceedings of the First Audiovisual Symposium on Intensive Short-Term Dynamic Psychotherapy, sponsored by the Swiss Institute for Intensive Short-Term Dynamic Psychotherapy. Pfafers, Sw itzerland, June. Davanloo, H. (1986). Intensive short-term psychotherapy with highly resistant patients. I. Handling resistance. International Journal of Short-Term Psychotherapy, 1(2), 107-133. Davanloo, H. (1987a). Unconscious therapeutic alliance. In Buirsld, R (Ed.), Frontiers of Dynamic Psychotherapy. New York: Mazel and Brunner, Chapter 5, pp. 6-lr-88. Davanloo, H. (1987b). Clinical manifestations of superego pathology. Part 1. International journal of Short-Term Psychotherapy, 2(4), 225-254. Davanloo, H. (1987c). Proceedings of the Fifth Annual Audiovisual Exploration of the Unconscious:

Technical and Metapsychological Roots of Intensive Short-Term Dynamic Psychotherapy, Killington, Vermont, August.

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Davanloo, H. (1 ^ 8 a ). Clinical manite^tations of >uperv^'> pathology. Part II. The ivsistancv of the superego and the liberation of the parah-zed ego. y I^ychc^hentpy. 3(1). 1-24. D avanloo, H. (,198Sb). The technique of unlocking the unainsciou>. Part 1. J'rffr-:,;.*;,-:.:.' Jou rm i o f Shcrt-Tcrrr. Piych.-’thcru n. 3(2). 9>)-121. Davanloo. H. (1988c). The technique of unlocking the unconi D.r.xinLv s Ps\,ch.\:'’..:lyt:: Jcchyiuue. Fragjlc C harader Structure. Killington. \erm ont, Julv. D avanloo, H. (1994a). Presented at the Twelfth European ,Audio\isual S\Tnposium and \Sorkshop on Technical and M etapsychological Roots of Dr. Da\ anloo s Intensi\ e ShortTerm D \iiam ic Psychotherapy; sponsored by the Dutch .Assixnates tor Short-Term CH-namic Psychotherapy. .Amsterdam, The .Netherlands. .April. Da\anloo, H. (1994b). Prcceedir.^s o' the .Audioi-isua! C.^urse oi: iKtensiiv Shon-Tcr’’: Dh’:.i’r::c Psychotherapy, presented at the Sesquicentennial .Annual .Meeting of the American Psychiatric Association. Philadelphia, rtnns\ I\ ania, .May. D a\anloo, H. (1993a). In tensive short-term dynam ic psychotherapy: Spectrum of p svchoneurotic disorders. lntcr!ut;o':al ,’* Short-Tc-;?: Psuchother.-.ru. 10(3,4). 121-135. Davanloo, H. (1993b). Intensi\ e short-term d\Tiamic psychotherap\': Technique of partial and m ajor unlocking of the unconscious with a highly resistant patient. Part 1. Partial unlocking of the unconscious. Interrmtional ]ournal o> Short-Term Psychother-.ipv. 10(3,4), 1 3 7 -lS l. D avanloo, H. (1995c). Intensive short-term d\Tiamic psychotherapy: .Major u nkxkin g of the unconscious. Part II. The course of the trial therapy after partial unlocking. I'lte’-natio'i^l Jourtuil ot Short-Term Psuchotherapu. 10(3,4), 183-230. D avanloo, H. (1993d). Priwedin^^s oi the Audiovisual Immersion Course on the .\ietarsychoio;Cical

Conceptualization of Character Resistance. Transtere’ice. Guilt and Llnco’iscious Theraivutic Alliance in Dai'anloo’s Psychi\inalutic Technique. Bad Ragaz, Switzerland, D ecem ber D avanloo, H. (19% a). M anagem ent of tacrical defenses in intensive short-term d\Tiamic psvchotherapv. Part I. 0\ er\ iew. tactical defenses of co\ er words and indirect speech. In 'ternoitional Journal of Short-Term Psychotherapy. 11(3), 129-132. D avanloo, H. (1996b). M anagem ent of tactical defenses in intensive short-term d\Tiamic psychotherapy. Part II. Spectrum of tactical defenses. Interr.rJional Journal o' Short-Term Psychotherapy, 11(3), 153-19^). D avanloo, H. (1996c). Proceedings o f the Ft'teenth .Audiovisual Exploration o f the Unconscious: Technical and Metapsycholo;^ical Roots o f I'ltensi'oe Short-Term Dynamic Psychotherapy. M ontreal, Canada, N ovem ber D avanloo, H. (1997a). Priveedin^s o f the Fifteenth .Annual European .Audiovtsual Sym fvsium on Davanloo's Psuchoanalutic Techmque, sponsored by the Italian Institute for Intensi\ e ShortTerm D\Tiarnic Psvchotherap\' and the Departm ent of Psychiatry of the U niversity of Florence, Florence, Italy, M arch. D avanloo, H. (1997b). PnvtVif(>iys i’/ the Immersion Course on the Technical and Meta-

psychokT^ical Roots of Davanloo's PsychMnalytic Technique: Patient u'ith Fra^^ile Character Structure, Hotel Bristol C onference Centre. Bad Ragaz. Sw itzerland. D ecem ber

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Davanloo, H. (1998a). Proceedings of the Sixteenth Annual European Audiovisual Symposium on Davanloo's Psychoanalytic Technique, sponsored by the German Society for Davanloo's Intensive Short-Term Dynamic Psychotherapy and the Departm ent of Psychiatry of Freidrich-Alexander University. Erlangen, Germany, March. Davanloo, H. (1998b). Proceedings of Audiovisual Exploration o f the New Metapsychology of the

Unconscious: Technical and Metapsychological Roots of Davanloo's Intensive Short-Term Dynamic Psijchotherapy', presented at the Training program of the Germ an Society for

Davanloo's Intensive Short-Term D 3mamic Psychotherapy. Niirnberg, Germany, June. Davanloo, H. (1998c). Proceedings of the Immersion Course: The Course of the Treatment of a Patient with Fragile Character Structure—Audiovisual Exploration, Hotel Bristol Conference Centre. Bad Ragaz, Switzerland, November. Davanloo, H. (1 9 ^ a ). Proceedings of the Audiovisual Immersion Course: Audiovisual Exploration o f the Metapsychology of the Unconscious in Davanloo's Psychoanalytic System, sponsored by the German Society for Davanloo's Intensive Short-Term Dynamic Psychotherapy and the Department of Psychiatry of the University of Erlangen— Niirnberg. Erlangen, Germany, March. Davanloo, H. (1999b). Proceedings of the Nineteenth Audiovisual Exploration of the Unconscious: Technical and Metapsychological Roots of Davanloo's Psychoanalytic Technique, Montreal, Canada, August. Gaillard, J. M. (1990). Trial therapy model of initial interview and its major functions. Part III. International Journal of Short-Term Psychotherapy, 5(2), 107-119. Gaillard, J. M. (1991). Im portance of phenom enological approach in patients with depression. International journal of Short-Term Psychotherapy, 6(2), 95-112.

Intensive Short-Term Dynamic Psychotherapy— Central Dynamic Sequence: Head-On Collision with Resistance H A BIB DAVANLOO McGill University, Department of Psychiatry, Montreal General Hospital, Montreal, Canada

In this article the author presents his technique of head-on collision with resistance and outlines the m ajor aims and the main technical interventions in head-on collision. In the second part of this article there will be an in-depth presentation of the spectrum of headon collision; a technical and metapsychological conceptualization.

Introduction 1 h ave alread y ou tlin ed the C en tral D yn am ic Seq u en ce: the phase of inquiry; dyn am ic inqu iry; pressu re; ch allen g e; tran sferen ce resistance; direct and rapid access to th e u ncon sciou s, and h ave em phasized that the resistance need s to be cry stalliz ed to th e p o in t at w h ich it can be ch allen g ed m ean in g fu lly and system atically. I h ave alread y in d icated th at the course of an y in terview d ep en d s to a great exten t on the rapid ity o f th e d ev elo p m en t of the tw in factors o f resistance and tran sferen ce. W h ere th ese tw o factors are n o t im m ediately detectable, and are slow to d ev elo p , the p h ase of pressu re begins w ith the search for the resistance. In p reviou s pu blications, I h ave p resen ted the p h ase of ch allen g e and em phasized that it is the key in terv en tio n in b o th the tech niqu e o f Inten sive Short-Term D yn am ic P sych oth erap y as w ell as in the n ew form of Short-Term Psychoanalysis; and I in d icated th at ch allen g e lies on a spectru m from relatively m ild at on e end to exceed in gly p o w erfu l at the other, cu lm in atin g in the h ead -o n collision. This article briefly presen ts asp ects o f the tech n iq u e of h ea d -o n collision w ith resistance.

Technique of Head-On Collision with Resistance H e a d -o n collision is used w ith in th e settin g o f resistan ce in the tran sferen ce or w h e n th e p a tie n t's ch aracter d efen ses, as the result of the ph ase o f pressu re or

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pressure and challenge, have b een crystallized in the transference. It m ay take various form s; there is a spectrum of h ead -o n collision; from single form at to com posite form s, and at the oth er end of the spectrum interlocking chain of headon collision, w hich is the m ost com plex of all the therapist's interventions.

The Major Aims of Head-On Collision These could b e sum m arized as follows; (1) (2)

Total blockade against all defenses maintaining the forces of the resistance To mount a direct assault on all the forces maintaining self-destructiveness, self-defeat and self-sabotage (3) To intensify the rise in transference feelings (4) Mobilization of the therapeutic alliance against the resistance; to tilt the balance between the two forces in favour of the therapeutic alliance. It is essentially addressed to the therapeutic alliance and directed against the selfdestructiveness inherent in the patient's conscious or unconscious refusal to abandon his resistance (5) To create a state of high tension betw een resistance and therapeutic alliance in the transference; the act of challenging the resistance combined with the conveyed lack of respect for it creates an extremely complex state within the patient, one in which he both wishes to cling to his resistance ever more strongly and at the same time begins to turn against it, and becomes both angry and deeply appreciative of the therapist's relentless determ ination to help him. This is what is meant by the tension between resistance and therapeutic alliance. When the process has created tension betw een resistance and therapeutic alliance in the transference, it calls for further head-on collision with the aim of mobilizing unconscious therapeutic alliance against resistance (6) The patient is brought face to face with his self-destructiveness with such com m unication as "good-bye," "doom ed," and "m isery" to both shock him out of the syntonic part of his resistance and challenge his unconscious therapeutic alliance to make a suprem e effort (7) In many cases, the head-on collision results in major com munication from unconscious therapeutic alliance (8) The aim is to loosen the patient's psychic system in such a way as to make the unconscious more accessible; mobilization of the unconscious (9) In the interlocking chain of head-on collision the aim is to loosen or to mobilize the patient's psychic system and to make a partial or major unlocking of the unconscious possible.

The Main Technical Interventions in Head-On Collision H ere I sum m arize the m ain tech nical in terv en tion s in h ead -o n collision. But the therapist m ust keep in m ind th at in an y given case som e of them are used m ore frequently and som e of them are n ot need ed . T h e follow ing is a sum m ary of the m ain techiiical in terv en tion s; (1) To point out and em phasize the problem and its effect on the patient's life (2) Keeping the responsibility with the patient: undoing the om nipotence (3) Emphasizing the patient's will: that the patient is the prime mover in seeking help

Central Dynamic Sequence: Head-On Collision with Resistance (4) (5) (6) (7) (8) (9)

(10) (11)

(12) (13) (14) (15) (16)

237

Em phasizing the therapeutic task and the patient's goal Em phasizing the partnership betw een the patient and the therapist To point out and em phasize the nature of the resistance To point out the consequences of the resistance C hallenging and em phasizing the self-destructive aspect of the resistance; challenging the self-destructiveness in the resistance Em phasizing and challenging the self-destructiveness in the transference resistance and em phasizing the consequences of the resistance in the transference Establishing and em phasizing a parallel betu'een self-defeating and selfsabotaging patterns in the transference and other relationships Em phasizing self-sabotaging and self-destructive aspects of the masochistic com ponent of the patient's character resistance; need for self-defeat and self­ sabotage; challenge directed at the perpetrator of the unconscious Deactivation of the transference; refusing the transference role the patient w ants to assign to the therapist Deactivation of defiance C hallenging the d epend ent transference pattern: the need to use the therapist as a crutch Challenge and pressure to the resistance against the em otional closeness Pressure to the unconscious therapeutic alliance

Nov^ w e can d iscuss the m ain tech n ical in terv en tio n s in h ead -o n collision. In an y giv en interview^, the therap ist ch ooses those that he con sid ers ap p rop riate to a specific p atient. As I h ave in d icated , h ea d -o n collisions are w ith in a spectru m , so m e fall w ith in th e sh ort-ran g e form of h ead -o n collision, oth ers fall in the categ o ry o f a com p o site form and at the end of the spectru m is in terlockin g ch ain o f h e a d -o n collision, all w ith specific ind ications. In som e cases, all th e tech nical in terv en tio n s, the m akin g o f the h ead -on collision, follow a logical progression , as in the C ase of th e M an w ith the B aseb all B at (D av an loo, 1984a, 1987a), b u t this is n ot n ecessarily the case w ith ev ery p atient. Further, I w ould like to em p h asize that alth ou gh th e w ord in g o f all th ese in te rv e n tio n s is v ery carefu lly th o u g h t ou t and is the result of the d e v e lo p m e n t an d re fin e in e n t o v er m a n y y ears o f au d io v isu ally reco rd ed research , it is obv iou s th at ev ery therap ist m ust find for him self the particular lan g u ag e w ith w h ich h e feels com fortable. O n the o th er h an d , he should h ave a th o ro u g h k n o w led g e ab ou t the tech nical and m etap sych ological roots of the tech n iq u e. N ow I will d iscuss b riefly som e o f the m ain tech n ical in terv en tion s.

To Point Out and Emphasize the Problem and its Effect on the Patient's Life T h e th era p ist m u st u n d erlin e the p a tien t's p roblem w h ich cau ses him su fferin g an d o ften m u st b eg in by rem in d in g him o f this fact in forcefu l term s. T h is is p articu larly im p o rtan t in patien ts w h o h ave a ten d en cy to m in im ize their p ro b lem s an d th eir su fferin g . H ere the therap ist m igh t use the w ords "M a jo r"; "M is e ry "; "S u ffe rin g "; and w h en ap p ro p riate th e w ord "Agony." T h e therapist sh ou ld m ake an attem p t to m axim ize the im p act o f this in terv en tio n : "You see, you k n o w y o u rself better, b u t you h ave a ten d en cy to m inim ize you r difficulties and y o u r su fferin g ."

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Undoing the Omnipotence: Keeping the Responsibility with the Patient U ndoing the om nipotence is closely linked w ith the deactivation of the transference. M any patients have a strong tendency to transfer to the therapist the role of som eone from the past. T he aim is to em phasize and bring the patient back into the reality of the task and to avoid getting involved in the patient's transference. As the therapist's m ajor task is to m obilize the unconscious therapeutic alliance against the resistance, he m ust at all costs avoid getting into the position o f im plying that the purpose of the interview is for him to change the patient, rather than for the patient to ch ang e him self. T h e therapist's task is to avoid getting into the position of b ein g om n ip otent and a figure of the past. Throu gh ou t the h ead -o n collision, the therapist repeatedly em phasizes the p atient's responsibility, "refu sing the transference role" that the patient is trying to im pose on him . To give an exam ple: "I d o n 't know , you h ave to decide." O r the h ead -on collision m ight con tain the question: "Is it or isn 't it?" As a result of this form of h ead -o n collision, the p atient accepts responsibility explicitly. The follow ing is from a h ead -o n collision and the therapist is retu rnin g to this them e w ith the w ords: "T h e problem . . . suffering . . . success or failure . . . are yours." In an oth er h ead -o n collision: "If w e fail, the m isery an d suffering is yours, but if this becom es a m ajor success, then the hap p iness and the freedom is yours."

Emphasizing the Patient's Will: That the Patient is the Prime Mover in S e e k in g H e lp

D uring both the initial in terv iew and th e course of the therapy, the therapist attem pts to m obilize the p atien t's w ill and this can b e in the form of h ead -on collision: "You h ave com e here on you r ow n w ill?" O bviously, the therapist m ust ch eck that the p atient really is th e prim e m over, rather than that he has been "sen t" by an oth er ph ysician or an o th er agen t, or that h e is only com in g out of com p lian ce w ith so m eo n e else. In th at case, h e shou ld apply a tech nical in terv en tion to create a shift and m ake it th e p atien t's will. Alw ays, on e of the elem ents of h ead -on collision con tain s em ph asis on the p atien t's will. For exam ple: TH:

(The C ase o f the Prai/ing M antis) A nd you have decided on you r oivn volition, I assum e, to do som ething about it. Am I right in saying that it is your oivn decision? O r is it that you cam e because you r counsellor referred you?

Emphasizing the Therapeutic Task and the Patient's Goal This com p o n en t of h ead -o n collision is closely linked w ith the elem en t of keeping the responsibility firm ly w h ere it lies. R eview in g a large n u m ber of headon collisions, I notice that it is o n e of the m ost frequ en tly used elem ents.

Emphasizing the Partnership between the Patient and the Therapist M ost o f the h ea d -o n collision em p h asizes the p artn ersliip , that the patient is a m ajor partner. W h en the therap ist is d irectly ch allen g in g a d efen se, h e assum es the role of adversary against the part o f the patient that is identified w ith his

Central D ijm m ic Scqiiencc: Head-On Collision with Resistance

239

resistan ce. W h en h e is sp eak in g to th e therap eu tic alliance, h e em p h asizes his role as ally; the follow in g is an exam ple: "O n e o f the m ajor tasks th at you and 1 h ave is th at you and I, w ith th e h elp o f each other, will explore and u nd erstan d w h ere the core o f y o u r p roblem lies." In m an y in terv en tio n s form in g p art of the h ead -on collision, the th erap ist m ay use the w ord "W e." B oth "You and I" and "W e" reem p h asize the partnership.

To Point Out and Emphasize the Nature of the Resistance T h e therap ist m ust p oin t ou t and specify the n atu re of the d efen ses that the p atien t is using: " If you m ain tain a d efian t, passive, cu t-o ff position . . "I f you are g oin g to av o id "; " If you rem ain help less and in cap ab le of seein g h ow you felt"; "As lo n g as you are g oin g to ration alize, in tellectu alize, ru m in ate and b e vagu e"; "You see you k eep ru m in atin g an d now you w an t to p rocrastin ate and take a stu bb orn , d efia n t position ."

Pointing Out the Consequences of the Resistance T h is co m p o n e n t is extrem ely im p o rtan t and som etim es it m ight be rep eated a n u m b er o f tim es. It ad d resses the d estru ctiv e organ ization of the resistance. In the C ase of th e P rayin g M antis: TH :

A s lo n g as y o u h a v e a n eed to cen so r y ou rself, w e w ill not he a b le to g e t to the co re o f y o u r p ro blem . W h at I really w an t to tell y ou is th is: that y o u set up a g o a l f o r y o u r s e lf to co m e h ere to u n d ersta n d y o u r p roblem , but by cen so rin g y o u r s e lf y ou are d efe a tin g the g oa l. N oiv m y q u estio n is this: if y o u r n eed is to d efeat y ou r g o a l, then w h y sh o u ld w e m eet a n d h a v e this in terv iew ?

Emphasizing the Self-Destructive Aspect of the Resistance; Challenging the Self-Destructiveness in the Resistance T h e th erap ist m u st in trod u ce explicitly the self-d estru ctive asp ect o f the resistan ce and th en h e can ch allen g e it w ith a rhetorical q u esh on : "And th ere will b e a self-d efeat in it, isn 't th at so? N ow m y q u estion is this, w h y should you o f your ow n will com e h ere to see if w e can g et to the bottom of you r problem and yet at the sam e tim e a n o th er part o f you w an ts to d efeat the aim you h ave set for yo u rself and p erp etu a te y ou r ow n m isery?" T h e follow ing is an o th er exam ple of ch allen g in g self-d estru ctiv en ess in th e resistance (T h e C ase of th e C hess Player): TH :

Isn 't th ere an e le m en t o f self-d efea t a n d self-sab otag e? W h y d o y ou p u t a g o a l f o r y o u r s e lf to co m e h ere o f y o u r ow n v olition so that to g eth er w e can g e t to th e core o f y o u r p ro b lem , b u t a t th e sa m e tim e y o u xoant to m a k e it a fa ilu re, lohich o b v io u s ly m ea n s p erp etu a tin g y o u r ow n su fferin g ?

Emphasizing and Challenging the Self-Destructiveness in the Transference Resistance and Emphasizing the Consequences of the Resistance in the Transference So m e form o f th e h ea d -o n collision is used after the resistan ce has been crystallized in th e tran sferen ce an d h as b eco m e a tran sferen ce p h en o m en o n . The

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therapist could open the h ead -o n collision w ith the w ords "L et's look at your relation h ere w ith m e." In the Case of the Praying M antis, w hich will be discussed later, th e patient w as in a state of resistance in the transference and becam e defiant. T he therapist introduces h ead -on collision: "L et's look at your relationship here w ith m e," and later on: "T h en I will b e useless to you ." This was follow ed by the question: "W h y should you w ant to m ake m e useless to you?" These com m unications carry d eep m essages. T h e w ord "u seless" can have tw o d istinct m eanings. O n e is concerned w ith the negation o f a p erson 's "active" role, w h ere the m eaning is pow erless or ineffective; w hile the oth er is con cern ed w ith the negation of a m ore "passive" role, w h ere the m ean in g is no longer available for use. In using this w ord, the therapist is con veyin g both m ean in gs, saying, on the one hand, that the patient is d estructively trying to ren d er him pow erless, and that, on the other, this will m ake him unavailable, w h ich is self-destructive. Based on our em pirical clinical research data of the kind of psych opath ology th at the therapist is w orking w ith b y m eans of this in terv en tion , m any patients, because of the buried rage, violent rage, prim itive m urderous rage and in ten se guilt, suffer from recurring p attern of form ing relationships and then d estroyin g them . This repeated pattern presents for a variety of reasons: overt traum a, covert traum a, attach m en t and bond, the traum atization of the b on d , and the pain of the traum a as w ell as m urderous rage and in ten se guilt. Su ch patients u nd er the im pact o f tliis dynam ic system , nam ely the p erp etrator of their unconsciou s, m ay constantly try to frustrate and irritate an oth er person to take aw ay his pow er, or m ake the oth er person suffer as they have suffered. But in the early stage of the interview , w hich w e are considering h ere, the therapist know s little or n o th in g abou t the origins of such problem s in the past life o f any patient. But this d oes n ot m atter. Based on our cu rren t kn ow ledge about the m etapsychology and stru ctu re of h u m an neu rosis, the therapist can use this form of in terven tion . In using these w ords, h e h as tw o aim s: (1) to deliver a m essage to the patien t's u nconsciou s that h e has sensed tliis kind of destru ctiveness in the tran sferen ce, and (2) he is speakin g to the u ncon sciou s therapeu tic alliance directly about the self-d estru ctiven ess in h eren t in such a relationship. It is im portant to n ote that this source of resistance has its origin in unconsciou s rage, or m urd erou s rage, and guilt- and grief-laden feelings. In addition, once the therapist has spoken in this way, he has covered resistance derived from all substructures o f the psy chic apparatus: d estru ctive m urderou s rage, in ten se guilt and self-p u nish m en t, and u ncon sciou s d efen sive organ ization , and so on. T h e therapist in u sing the w ord "u seless" carries all these liigW y significant m essages and the therapist usually u n d erlin es it and repeats it. Tliis u nd erlin ing and rep eatin g is extrem ely im portant. I d em on strate this in the follow ing passage from the C ase of the M asochistic W om an w ith the Bru tal M other, w hich 1 have presented in oth er publications: TH :

I f y ou don't w an t m e to g et to y o u r in tim ate th ou g h ts a n d fee lin g s, 1 w ill he u seless to you . It is as sim p le as that. B u t w h at I sa y is this; w h y d oes a y ou n g

PT:

in telligen t -woman o f y o u r a g e w an t to d o that? D o w hat?

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TH : To m ake m e useless to you. PT: No, I don't w ant you to be useless to me. TH : But it w ill happen if the "wall" is there betw een you an d me. I f you don't want m e to g et to y ou r intim ate thoughts an d feelin gs, then I w ill be useless. In th e ab ov e p assage, th e w ord "u seless" w as used fou r tim es, and it is also im p o rta n t to n o te th at the th erap ist is focu sing on the resistan ce against em otion al clo sen ess, w h ich I w ill discuss briefly later in this article.

Establishing and Emphasizing a Parallel between Self-Defeating and Self-Sabotaging Patterns in the Transference and other Relationships T h is is a n o th e r co m p o n e n t of the h ea d -o n collision, and usually the therapist h as so m e in fo rm atio n at this poin t about the p atien t's life in o th er relationships. T h en , on th at basis, h e can in clu d e in the h ead -o n collision the parallel in the tran sferen ce w ith the relation sh ip s ou tsid e the tran sferen ce. In the C ase o f the P rayin g M an tis; as a result o f h er refusal to allow sexual p en etratio n , m en w ould leav e h e r w ith anger. S h e w as stu b b o rn and refu sed to u n d ergo m edical p ro ced u res, su ch as a gy n ecolog ical exam in ation, and in the b eg in n in g o f the in terv iew had in d icated th at sh e w as obstin ate w ith h er ped iatrician as a child. T h e th erap ist had focu sed on the p atien t's sexual fantasy d u rin g m asturbation , the p o in t w h ere sh e goes to a m ajo r resistan ce in the tran sferen ce: TH:

H ow do you fe e l right now w hen I confronted you with you r need to m ake me useless to you, because if we fo llo io you r censorship I will be useless to you obviously? A nd let's face it, all men have been useless to you — you r relationships w ith all m en have been a failure.

In th e C ase o f th e T eeth -G rin d in g W om an; TH;

. . . We w ould not be able to understand you r problem , and w e w ould not be able to g et to the core o f y ou r problem an d then the end result w ould be that / w ould becom e useless to you, in the sam e w ay that m any years o f you r treatm ent with oth er psychiatrists have been useless. But my question is this, w hy do you w ant to do that?

and th e n the th erap ist m oves to h ea d -o n collision w ith the resistance against em otio n al clo sen ess in th e tran sferen ce.

Challenging and Emphasizing Self-Sabotaging and Self-Destructive Aspect of the Resistance; Masochistic Component of the Patient's Character Resistance; Need for Self-Defeat and Self-Sabotage; Challenge Directed at the Perpetrator of the Unconscious T h is is extrem ely im p o rtan t, and th ere are m any elem en ts involved: a wish to avoid p ain; far m ore im p o rtan t is the n eed for p u n ish m en t; the p resen ce of in ten se gu ilt w h ich is a p o w erfu l force in m ain tain in g the resistan ce; th e cen tral issue is th e p erp etra to r o f the u n co n scio u s w h ich con sists of the attach m en t and b o n d , the origin al trau m a, the p ain o f that traum a, prim itive m u rd erou s rage, in ten se guilt an d grief, and su b seq u en t traum as.

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Deactivation of the Transference; Refusing the Transference Role the Patient Wants to Assign to the Therapist T h e therapist m ust vigilantly m onitor that the patien t's conscious and unconscious perception of the therapist does n ot becom e coloured by the patient's perception of the people in his past. The aim o f deactivation is to bring the patient into reality.

Challenging the Dependent Transference Pattern; the Need to Use the Therapist as a Crutch Tills com p onent of h ead -o n collision is particularly im portant in patients w ho have b een very badly traum atized in the early part o f their lives, patients with fragile ch aracter stru ctu re w ho h ave had very traum atic experiences in the early years. O th er exam ples w ould b e the cases w h o had b een hospitalized due to illness in the early part o f their lives. An exam ple w ould b e the C hew ing G um M an, w ho w as hospitalized a n u m b er of tim es in the first few years o f his life; oth er cases w ould be those hospitalized in the very early phase of life such as prem atu re births, w h ich require incubators; and a p ath ogen ic fam ily life— a highly controlling, d em an d in g m oth er w ith no capacity for affectionate bond w ith the child, and, equally, an absent, in effective father. T h e therapist m ust ch alleng e any m anifestation of the sym biotic transference neurosis in the form of head on collision: " . . . And now' you w ant to use m e as a cru tch."

Rhetorical Question to the Therapeutic Alliance to Mobilize the Therapeutic Alliance against the Resistance T h e focus here is usually on a specific resistance. It is often used w h en a particular d efen se h as clearly crystallized and especially if the patient agrees; it can be used at an y poin t d urin g the h ea d -o n collision and also at oth er poin ts of the interview as well. It m igh t take the form of: "W h a t are w e goin g to do?" "W h at are you goin g to d o?", or "L e t's see w h at w e are goin g to do." T h ese phrases are going to address a specific resistance. As 1 ind icated, it is often used in h ead -o n collision but is also used out of h ead -on collision. For exam ple, in the C ase o f the M an w ith the Baseball Bat, it follow ed the p atien t's ag reem en t that, on the on e h an d, he continued to be resistant, w hile on the o th er hand he could n ot afford to fail. A nother exam ple is the follow ing patient w h o can n o t rem em b er the incident: PT: TH:

W ell, m ay he it is d ifficu lt for m e to rem em lv r the in ciden t. So let's see ich a t are w e g o in g to d o a lm it this Iv cau se obi'iou sly i f it g o es on like this, that you h av e d ifficu lty rem em berin g , then hozc a re u v g o in g to u n d erstan d y ou r problem ?

In the C ase of the G erm an A rchitect, w h ich I have described previously, one of the d efen ses that crystallized very early w as vagueness, w h ich the therapist pointed out. Eventually, the d ialogu e con tin ued as below , w ith the rhetorical question again form ing the first elem en t in the h ead -on collision:

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PT TH:

243

Yes, I knoio, but I am vague. So the fir s t question is, w hat are icc g oin g to do about the vagueness?

T his type of in terv en tio n , like m ost ot the oth ers in h ead -o n collision, is used to m obilize the th erap eu tic alliance against the resistance. In the follow in g p assage the therap ist uses h ead -o n collision in a com posite form . First, h e p oin ts ou t and em p h asizes the n atu re o f the resistance and then p oin ts ou t th e con seq u en ces of th e resistance. T his is th en follow ed b y ch alleng in g the self-d estru ctiv en ess in the resistance and then by em p h asizin g the parallel betw^een self-d efeatin g and self-sabotagin g p attern in the tran sferen ce and oth er relation sh ip s: TH:

You sec, if you con tinu e to be z'aguc an d if you continue to be eimsive and gen eralize an d continu e zcith vague rum ination an d keep things in the state o f Umbo, then w e w ould not g et to understand the core o f you r problem an d the end result w ould be that I w ould be useless to you like the 20 years o f your past therapy, okay? N ow my question is this, lohy you wajtt to do that?

Tlais com p o site form of h ea d -o n collision is follow ed by a rhetorical question to the th era p eu tic alliance. This passage is follow ed by the first b reakth rou g h as the p atien t b eco m es v ery sad and hold s his head in his h an ds w ith the passage of the painfu l feelin g , and crying.

Composite Form of Head-On Collision N ow w e can su m m arize the logical progression of a com posite form of headon collision w ith th e resistan ce. W h at the therapist is com m u n icatin g to the p atien t is as follow s. You h ave a serious problem w h icli is a m ajor p roblem and w h ich causes you p ain an d su fferin g. It is you r problem ; you h ave com e h ere of y ou r ow n volition seek in g h elp for you r problem and suffering. M y goal is to u n d erstan d y ou r pro blem an d m y fu n ctio n is to help you ach iev e you r goal. You are n ow u sin g th ese resistan ces but if you co n tin u e to use these d efen ses the p rocess w ill be a failure and you will be d efeatin g you r ow n goal. T his is self­ d estru ctiv e, it can o n ly resu lt in p erp etu a tin g you r ow n su fferin g and m isery. W hy do you w a n t to do that? In ad d ition th ere is d estru ctiv en ess d irected against m e w h ich is equ ally self-d estru ctive. M oreover, this is an exam ple of a p attern w hich ap p lies to o th er relation sh ip s as w ell. 1 d o n 't accept the role of target for your d estru ch v en ess w h ich you are tryin g to thrust u pon m e, 1 have no in ten tio n of allow in g you to m ake y o u r p roblem m y problem . TH :

PT:

Let's look at it, obviou sly you have a m ajor problem and this problem has been a sou rce o f m isery an d su fferin g an d agony fo r you. O bviously you are the one to decide: is it a m ajor source o f su fferin g or isn't it? Yes.

E m p h asizin g th e pro blem and its effect on the p atien t's life (1); k eep in g the resp on sibih ty w ith th e p atien t (2); d eactiv ation of the tran sferen ce (12). TH : A n d I assu m e you com e here on your oiun volition an d you m ust have a goal, oth erw ise you w ouldn't com e here.

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E m p h asizin g the p a tie n t's w ill; th e p a tie n t is the prim e m ov er (3); em phasizing the therapeu tic task (4). PT: TH:

That's right. The m ajor task that you an d I have ahead o f us is, loith the help o f each other, to understand you r problem and where the core o f your problem lies.

Em phasizing the partnership b etw een patient and therapist (5). PT: TH:

PT:

That's right. The fa ct is that the problem is yours, suffering is yours, happiness is yours, success is yours and the failu re is yours. But if you maintain a defiant, stubborn position, then what w ill happen here with me? N othing.

K eeping the responsibility w ith the p atient (2); em phasizing the natu re of the resistance (6); d eactivation of the transference (12). TH:

PT:

So in a w hile the session com es to an end, w e say goodbye, you go your way and carry on the m iserable life you have, an d 1 go my w ay and say I did my best but I failed. You sec, as long as you take a defiant, stubborn position we w ould not reach the goal an d w e w ould not be able to understand the core o f your difficulties and the -whole process w ill be doom ed to fail. Yes.

E m phasizing the natu re of the resistance (6); and consequ en ces of the resistance (7); in it there is deactivation of the tran sferen ce (12). TH:

You see there w ill be self-defeat an d self-sabotage in it. Isn ’t that so? Noiv, the question I have in m y m ind is, w hy should you o f you r own w ill com e here with the aim to understand you r problem an d to get to the core o f you r problem but at the sam e tim e another part o f you wants to defeat the goal that you set fo r y ou rself and w ants the perpetuation o f you r m isery and suffering? PT: 1 know. TH: Then I will en d up to be useless. PT: Yes. C hallen ging the self-d estru ctiven ess in the resistance (8); challengin g the selfdestru ctiveness in the tran sferen ce resistance (9). (The first breakthrough is taking place. The patient is sad with fears in his eyes.) TH: W hy you w ant to m ake me useless to you? PT: I don't want that. TH: A nd obviously throughout your life I assum e m any people have been useless to you. W hat I can say is that you have a m ajor self-defeating an d self-sabotaging elem ent in you . . . and this is right noxo in operation with me. Em phasizing self-d estru ctiveness in the tran sferen ce (9); and em ph asizin g a parallel b etw een self-sabotaging p attern in tran sferen ce and oth er relations (10). PT: TH:

Yc’s, i have . . . It is im portant that loe look at this self-defeating, and self-destructive pattern. If this proccss with me continues like this, w e arc bound to fa il to understand your

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PT:

difficulties an d to g et to the core o f y ou r problem. Then you have to carry you r problem the rest o f y ou r life . . . So this w ould lead to failure. That's right.

TH : PT:

Then the question fo r both o f us is what arc lue goin g to do about it? To overcom e it.

Pointing ou t the con seq u en ce of the resistance (7); challenging self-sabotaging and self-d estru ctive aspect of the resistance; addressing the m asochistic com p onent in the resistance (11); pressure to unconsciou s therapeu tic aUiance (16). T h e p a tie n t has b e e n in creasin g ly sad an d tearful. N ow the therap ist m oves to h e a d -o n collision w ith the resista n ce again st em o tio n al clo sen ess and the b reak th ro u g h in to th e u ncon sciou s.

Further Example of Head-On Collision The Case of the Chewing Gum Man In o th er pu blication s, I h ave described the p h ase of pressu re and ch allenge w ith this p atien t, w h o w as 29 years old w h en he en tered in to treatm en t and su ffered from m a jo r sym ptom d istu rbances such as anxiety, pan ic, fu n ctional and so m atization d isord ers, d izziness, loss of b alan ce, staggering, blu rrin g of vision, etc., as w ell as p h o b ic sym p tom s and ch aracterological d isturbances. T h e th erap ist exerted p ressu re w h ich consisted of m akin g com m en ts about the p a tie n t's seco n d ary gain. This m obilized resistance in the tran sferen ce and the p rocess th e n m oved to fu rth er ch allen g e and p ressu re to the resistance. Sh ortly after that, th e th erap ist fu rth er exerted pressu re, m akin g the com m en t: as a child the p a h e n t w as b ein g rocked arou n d the clock by his m other, au nts and gran d m oth er. T h is m obilized a m ajo r resistan ce in the tran sferen ce and the th erap ist m ov ed to h e a d -o n collision w ith the resistance in th e tran sferen ce. The follow ing p assage d em o n strates the form of h ead -o n collision w h ich resulted in th e b rea k th ro u g h in to th e u ncon sciou s. For the sake o f brevity, th e d ialogu e has b een sh orten ed and paraph rased in p laces, b u t n o th in g im p o rta n t has b een om itted. TH :

Then you run to your mother.

TH :

H ow lon g that sickn ess w ent zohich you r mother, you r aunt an d you r g ran d m oth er w ere sh iftin g an d then rocking you? (T he patien t becom es detached an d distant, an d has becom e vague loith avoidance. “I don't knoio," "Well I don't") (sigh)

PT

At this p o in t, th e p atien t takes a bubble gum from his p ocket and starts ch ew in g the gu m , w h ich clearly h as tran sferen ce im plications. TH :

H ow do you fe e l here w hen you talk about these things?

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I don't know, f e e l . . . Because a ivhile ago I felt that in a sense suddenly you had to go and have a gum.

The focus is on ch ew in g gum to overcom e the patient's nervousness, the same v^ay that he is d ep en d en t on tranquillizers to overcom e his anxiety. PT:

Well I never, never looked at the fa ct that I cheiv gum as a, as a, you knoio, an escape or som ething. TH: But you are doing it, you started to do it and still you are continuing cheioing gum and you say . . . PT: (Laughs) TH: You arc sm iling now. H ow did you feel when 1 said that you are still continuing with the chew ing gum ?

PT:

Yeah, it, it's a crutch.

PT: TH: PT TH:

Sure. So w henever you are anxious. O kay . . . Yeah. Then you are looking fo r a crutch.

T h ere is a clear inten sification of the tran sferen ce resistance. All the evidence indicates that he is angry, h old in g on his feeh n g and has b ecom e v ery detached, distant and non-involved. PT: I am mad. TH: M ad. W hat is the w ay you experience the madness? T h e re w as a h e a d -o n co llisio n w ith th e in te n sifie d resistan ce in the tran sferen ce and he finally took the ch ew in g gum ou t of his m ou th and becam e m ore an gry and n on-involved . This finally resulted in the b reakth rou g h into the unconsciou s w ith the m ajor passage of the painful feeling about his life w ith his father w ho had died from a m ajor stroke, and m ost of fa th e r's sym ptom atology such as loss of balan ce, staggering, dizziness, visual experiences, etc., are the sym ptom s that the patient currently has.

The Case of the Praying Mantis This form of h ea d -o n collision is very im p o rtan t because it illustrates a w ay of han dlin g a frequ en tly en co u n tered situation that is likely to cause m any therapists extrem e difficulty. In ou r research w e have a n u m ber o f patients w ith a sim ilar pattern and w e have classified all o f them u n d er the h ead in g of Praying M antis. The situ ation is as follow s. A n attractiv e, sed u ctiv e, viciously m an -h atin g, sadom asochistic you n g w om an d oes her b est to involve the therapist in her tran sferen ce, w h ich consists of lead in g him into a battle o f wills that sh e has every in ten tion eith er of w inn in g sadistically or of losin g m asochistically. T h e problem is how the therapist can p reven t, at all costs, falling into h er trap, an d m ake the

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p rocess a th era p eu tic triu m p h w ith ou t creatin g a battle o f wills and b eco m e angry or b eh a v in g sadistically him self. T h e tw o key factors for the therapist are; (1) relentlessly throw in g b ack the resp on sibility w h ere it lies, and (2) equ ally relentlessly refu sin g the tran sferen ce role in to w h ich sh e is tryin g to th ru st him . Both of these them es are cen tral to the h ead -o n collision; in this particu lar case, as will b e seen , they p ervad e all the th erap ist's in terv en tio n s. It m ay h elp an y th erap ist w h o finds h im self w ith a p atient of this kind to rem em b er th a t b eh in d the vicious attack on m en th ere alm ost certainly lies deep layers o f g reat p ain, th e traum a, th e covert o r overt traum atic exp erien ces of failed relation s, th e pain o f trau m a, m u rd erou s rage and gu ilt as weU as grief-laden feelin g s. If th e th e ra p is t ca n clin g to his k n o w led g e, b o th tech n ica l and m etap sy ch olog ical th ro u g h o u t all the stresses of the tran sferen ce relationship, he can w in th ro u g h to a situ ation in w h ich h e and the p atient are on the sam e side. W h en th e p a tie n t en tered in to treatm en t, she w as 25 years old. T h e im m ed iate cau se of h er seek in g h elp w as that she w as su fferin g from an in fectio n of her g en ital tract, but, b eca u se of h er ph obic sym ptom s regardin g m edical procedures, they cou ld n o t in sert the speculum and the gyn ecologist had b een u nable to p erfo rm th e n ecessary vagin al exam in ation. Sh e had p h obic sym ptom s, ch ron ic an xiety an d ep isod es o f pan ic attack w h ich dated b ack to h er ch ild h oo d . H er p ed iatrician refu sed to treat h er d irectly as sh e w as stu bborn "tu rn in g his office u p sid e d o w n ." H er m o th er had had to d escribe h er sym ptom s to the pediatrician ov er th e p h o n e an d th e n carry o u t h er treatm en t u n d er lo n g -d istan ce instru ction s. T h e p atien t h as a m ajo r p roblem w ith in tim acy and closen ess, is living alone qu ite d istan t from h er parents. H er cu rren t p attern in g w ith m en consisted of n ig h tly p ick -u p relation s in w h ich sh e led the m an on and b o th of them becam e v ery sexually excited , b u t, b ecau se o f vagin ism us and severe pain, she pu shed him aw ay as so on as h e tried to p en etra te her. T h e early part of the interview , n am ely th e p h ase o f in qu iry and dynam ic inquiry, p ro ceed ed sm oo th ly u ntil th e therap ist asked ab ou t h er sexual fantasies d u rin g m astu rbation : TH:

W h a t ty p e o f fa n t a s ie s do you have?

PT:

(P atien t is sm ilin g )

TH: PT:

You a r e sm ilin g . I ju s t really don 't w an t to g o in to it, they em b a rra ss m e v ery m uch. C an w e sk ip

TH:

th at on e? You s a id th at y o u h a v e a lw a y s been a stu b b orn p erso n , h m m , a n d that you a lw a y s g e t y o u r way. A n d this has been a p attern in both y o u r cu rren t life a n d in th e p a s t w ith y o u r p ed ia tricia n as a ch ild a n d cu rren tly zvith y o u r

PT:

g y n eco lo g ist. I don 't k n o w i f I g e t m y ivay alw ay s. N ot a n y m o re certain ly. W hen I w as a ch ild

TH: PT:

I g o t m y w a y alw ay s. Yeah, B u t y o u s a id that w h en y ou see a d o c to r y ou m a n a g e to g e t y o u r ow n way. N o . . . I m ean . . . I h a v e to su b m it to them ev en tu ally . 1 ivill g o th rou g h a bit o f try in g to talk them ou t o f it in o rd er to stall.

TH :

F in a lly y o u g iv e in?

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PT:

Finally I give in.

The therapist u nderlines the im portant— and hopeful— transference m essage. TH: A nd do you think that m ight be here w ith me? PT: W e ll. .. I am not goin g to go into those fantasies. TH: You're smiling. PT: M aybe if I talk to you a second or a third time I might be w illing to, but on the first meeting, No, I won't. N oio m aybe that is stubbornness b u t . . . T he above passage show^s a m ajor resistance in the transference w hich calls u pon h ead -on collision, w hich now unfolds as follows: TH:

W hat I am struck by is the fa ct that you have a problem which is a m ajor problem fo r you. I don't know, you have to decide w hether it is or not. But it seem s to be a m ajor difficulty fo r a youn g woman o f you r age to face.

In th e above p a ssa g e th e th e ra p ist is u sin g th e follow in g tech n ica l in te rv e n tio n s: p o in tin g ou t th e n a tu re o f th e p ro b lem (1); k eep in g the responsibility w ith the p atient (2); and deactivating the transference (12). PT: All right TH: A nd you have decided on you r ow n volition, again 1 assum e, to do som ething about it. Am I right in saying that it is you r own decision? O r is it that you com e because your counsellor refers you? Technical in terv en tion ; em ph asizin g the p atien t's will (3). PT:

No, m y com ing is based totally on m y oion decision and I have severed my contact loith him. TH: Let's look at it, you are in the state o f suffering, you have a problem which is quite a difficult one. O f you r own volition you have com e here, now by censoring y ou rself toe w ould not be able to g et to the core o f you r problem. O f course it is your problem ; but m y question to you is this "Why do you set up a goal to com e to understand you r problem hut at the sam e time . . . ?"

T h e above passage show s a n u m b er o f tech nical in terv en tion s of h ead -o n collision: Pointing out the problem and its effect (1); keep in g the responsibility w ith the p atient (2); em p h asizin g the p atien t's will (3); em p h asizin g the natu re of the resistance (6); poin tin g ou t th e con seq u en ces of m ain tain in g the resistance (7); and challengin g the self-d estru ctiven ess in the resistance (8). PT:

I don't see w hat m y sexual fan tasies have to do with it.

It is im portant to poin t ou t that at this poin t it w ould b e very easy for the therapist to say som eth ing like: "O b v iou sly you r sexual fantasies are a central issue." This w ould be a m ajor m istake as it w ould allow the process to m ove into a battle of wills, into an argu m en t w h ich the therap ist should avoid at all cost. M oreover, h er u ncon sciou s know s the im p o rtan ce of h er sexual fantasies perfectly w ell and there is n ot a slightest n eed to spell it out. T h erefore, he com pletely ignores her rem arks and con tin u es system atically w ith the next step in the headon coUision:

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TH : /4s lon g as you have a need to cen sor yourself, w e w ill not be able to get to the core o f the problem . W hat I really w ant to tell you is this: that you set up a goal fo r y o u rself to com e here to understand y ou r problem , but by censorin g y ou rself you are d efeatin g the goal. N oio m y question is this: if you r need is to defeat your goal, then w hy shou ld w e m eet an d have this interview ? . . . In th e a b o v e p a ssa g e th e th e ra p ist c o n tin u e s w ith h e a d -o n collision ; em p h asizin g the n atu re of the resistan ce (6); ch allen g in g the self-d estru ctiven ess in the resistan ce (8); an d ch a llen g in g the self-d estru ctiven ess in the tran sferen ce resistan ce (9). T h e in terv en tio n fu rth er aim s at sh ockin g the p atien t out of her id en tificatio n w ith h er ow n resistan ce and also d eactivates the d efian ce (13). We retu rn to th e interview . PT: TH :

W e ll. . . I fin d that a very difficult an d em barrassing area to talk about. I u nderstan d that, but at the sam e tim e if wc are goin g to get to the core o f your problem w e have to understand them ; an d you know that very loell, unless you loant to see this to be a fa ilu re an d useless to you?

In th e above p assage, th e therap ist again reem p h asizes the con seq u en ces of m ain ta in in g th e resistan ce (7) and the self-d estru ctive asp ect of the resistan ce in th e tran sferen ce (9) and k eep in g the respon sibility w ith the p atien t (2). N ow w e go b ack to th e interview . PT: No, I ivould not like that. TH : That is y ou r choice (keeping the responsibility with the patient) PT: 1 s t i l l . . . if you . . . I am w illing to tell you certain things that are com m on to m y fan tasies, but I won't g o into specifics. I f I tell you the things that happen in every fan tasy, tim e an d tim e again, which I w ould say is perhaps significant.

Head-On Collision Continues H ere th e p atien t is tryin g to reveal a little to gain a victory. This is not a ccep tab le, and o n ce m ore the therap ist m ust n ot con v ert the in terv iew in to a b attle of w ills. W h at h e d oes, th erefore, is to ch an g e the su bject ab ru p tly by asking ab o u t th e tra n sferen ce feelin gs, at the sam e tim e p ro ceed in g to the next tw o steps in th e h ea d -o n collision; TH :

H ow do you fe e l right now when I confronted you with you r need to m ake me useless to you? Because if w e fo llo w y ou r censorship I w ill be useless to you obviously. A nd le t’s fa c e it, all men have been useless to you, you r relationship w ith all m en has been a failure.

T h e th erap ist ch allen g es the p a tien t's self-d estru ctiven ess in the tran sferen ce resistan ce (9), em p h a siz in g the parallel w ith the self-sabotagin g p attern ou tside of th e tran sferen ce (10). PT: Well, that is qu ite true. TH : A n d I think you see it here w ith m e . . . that you w ant to ice skate around, you loant to beat arou n d the bush. M y question is this: that is fin e if you w ant to beat arou n d the bush, but w hat zuould be accom plished here?

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In the above passage the therapist m oves to another com ponent of the headon collision, nam ely, pointing out the consequ ences of the resistance (7). PT: W e l l . . . it seem s to me that you are perhaps m t being fa ir I mean 1 do n ' t . . . TH: Noiv let us look into my not being fair. PT: Because my counsellor and 1, we have had an argum ent like this, and I have fin ally been . . . Becau se, although the p atient has b een trying to argue, the therapist has refused to allow h im self to b e pu t in this position, h e know s the truth that he has not b een arguing, and avoids b ecom in g involved in the p atien t's transference. The purpose beh in d this is that o f an oth er im portant technical in terven tion in the h ead -on collision, nam ely, to refu se the tran sferen ce role that th e patient is trying to thrust upon him (12). TH:

W here have I given any evidence that I am arguing ivith you? O nly what 1 am telling you is that if you w ant to g et to the core o f you r problem . . .(deactivating the transference and refusing the transference role) PT: No, I am not talking about an argum ent. It is that w e are having an argum ent/discussion. We have opposing vieiopoints. TH: But where is the argum ent? PT: The argum ent is that you are trying to convince me . . . TH: 1 am not trying to convince you in any form . G ive m e a single piece o f evidence o f any loay in which 1 have tried to convince you. (Further deactivation o f the transference) PT: You are telling me— an d it is very reasonable, 1 m ust adm it— that you cannot help me if I don't tell you things. In the above passage, the therap ist retu rns to reiterate the h ead -o n collision. TH:

It is really y ou r life and that is . . .

H ere the therapist em ph asizes th e problem , "It is really you r life." PT: 1 am resisting, and you are correctly . . . TH: I think that is a problem you have. VVJiaf you are really saying is this, tlwt ive have to leave things in a state o f limbo and go on fo r a num ber o f additional sessions. PT: Now, 1 have been, look . . . I have ju st offered . . . T his w ord rep resen ts yet a n o th e r a tte m p t to in v o lv e the th erap ist in bargaining, and on ce m ore, the therapist co n tin u es as if h e had n ot h eard it: TH: You are m aster o f you r life. PT: Okay. TH: M isery is part o f your life and the sam e with happiness. I f I could be o f help to you. PT: Certainly. TH: There is nothing that I am convincing you. 1 am only pointing out you r need to defeat. But w ho is the defeated person? It is you, because the problem is yours. The co m p o n en ts o f h ea d -o n collision consist of: keep in g the responsibility w ith the patient (2); and ch allen g in g the self-d estru ctiven ess in the tran sferen ce resistance (9).

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PT:

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W e l l . . . I have j u s t . . . O k a y . . . I am telling you that it is a very sensitive thing w ith me. H owever, 1 have said that you have a good point, and . . . O kay . . . can I tell you things that happen in ev ery fantasy, but I don't w ant to g o into a specific fa n ta sy right now. But is it helpful to you if I tell you things that w ill com e out in every fa n ta sy that I have?

O n e o f th e basic p rin cip les, w h ich is a d yn am ic p rincip le o f political b arg ain in g , is th at w h en you h av e w on , you allow the o th er side a face-saving form u la, w h ich th e th erap ist n ow does; TH: Let's look at them. PT: Well, at this stage, I loill not tell you a specific fantasy. I am sorry. I ju st can't do that right noio. TH : W hat is the nature o f y ou r fan tasies? N ow , th ere b eg in s a process o f relen tless q u estio n in g abou t h er fantasies, in w h ich th e th erap ist b rin g s ou t far m ore th an sh e im agin ed sh e w as goin g to reveal. T h e fan tasies u sually in v olv e k n ifing the m an in the h eart or, particularly, in the b ack , at the n eck level o f the v ertebral colu m n , d u rin g and after in tercou rse. W hat fu rth er em erg ed is th at kn ifin g a t the v ertebral colum n is alw ays p resen t in sexual fan tasies w ith m en . S h e cam e to realize sp o n tan eou sly that in h er hom osexual fan tasies th ere is th e ab sen ce of m urder.

Fusion of Sexuality and Primitive Murderous Rage W h at em erg es is a fu sion o f sexuality and the prim itive m u rd erou s rage in h er u n co n scio u s, and th a t h er fa th e r had a p h ob ia of kn iv es and had a con stan t p reo ccu p a tio n th a t sh e m igh t cut herself. Fath er w as extrem ely possessive, com p u lsiv ely co n tro llin g an d h ad p reo ccu p atio n s that sh e m igh t b e raped as well. H er u n co n scio u s p rim itive m u rd erou s rag e fused w ith sexuality tow ards the fath er b eco m es th e focu s o f th e early p h ase o f th e therapy.

Summary and Conclusion In this article, I h av e briefly ou tlin ed th e tech n iq u e of h ead -o n collision w ith resistan ce, w h ich can b e su m m arized as follow s: (1)

(2)

(3)

I em phasized that the aim of the phase of pressure is to mobilize the resistance until it is tangibly crystallized t>etween the therapist and the patient; then the resistance can be challenged effectively. It was pointed out that challenge is the key intervention and that it lies on a spectrum, from relatively mild at one end to exceedingly powerful at the other, culm inating in head-on collision. H ead-on collision is often used within the setting of resistance in the transference; the therapist m ight introduce the head-on collision at the point of high tension betw een therapeutic alliance and resistance, his aim being to bring all forces to bear to tilt the balance in favour of the unconscious therapeutic alliance. If he has timed his intervention well, the therapeutic alliance begins to break through. T he m ajor aim o f head-on collision was discussed; in its com posite and interlocking forms, it aim s at the total blockade against all forces m aintaining

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the resistance. It is a direct assault on ail forces maintaining selfdestructiveness, self-defeat and self-sabotage. I further indicated that it aims to loosen the patient's psychic system, mobilization of the unconscious in such a way as to make it more accessible. (4) The main technical interventions in head-on collision were presented and discussed by analyzing a few vignettes of specific forms of head-on collision with a number of the patients. (5) There are specific forms of head-on collision which are primarily designed for loosening the patient's psychic system; mobilization of the unconscious. They have major indications in patients who are extremely resistant with syntonic character pathology. These forms of head-on collision are of great importance psychotherapeutically and scientifically, as well as in clinical research. In conclusion, there is a spectru m o f h ead -o n collisions, and each o f them is vs^ith a specific ind ication, such as: h ead -o n collision aim ing at the m obilization of the u nconsciou s and loosen ing of the psychic system ; interlocking ch ain of heado n collisions; and various form s o f h ea d -o n collision aim ing at b reakthrou gh into the u nconsciou s w h en the resistance is h eavily crystallized in the transference. T h ese are p resen ted in m an y au d iov isu al sym posia, cou rses and train in g program s, and will b e discussed in great detail in future publications.

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