Developmentally based psychotherapy, SI Greenspan, JI Downey

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G7(r4e):e_nB_seo_pe_oab­kne_sSr_R_IAe_(bvRioe:owDkeerdveevloiepwm)e.nJtaPlslyycBhaostehderPPsyrcahcothRereasp1y9, 9b8y; Developmentally Based Psychotherapy By Stanley I. Greenspan Madison, CT, International Universities Press, 1997, 462 pages, ISBN 0-8236-1199-x, $65.00 Reviewed by Alan R. Beeber, M.D. Stanley Greenspan's book details a new developmental theory that attempts to unify and extend the practice of psychotherapy. Drawing on his extensive clinical work and research, he elucidates the earliest stages of human development and clarifies the impact that difficulty in these stages has on the development of personality and psychopathology. He points out that although many experienced therapists intuitively incorporate developmental principles into their own eclectic approach, few therapists apply these principles in a systematic way. Adopting a more comprehensive developmental approach, he asserts, can expand the range of patients that can be helped by psychotherapies. Therapeutic strategies can be constructed to deal with complex psychopathological problems such as the role of constitutional factors in anxiety states and affective disorders, problems in forming and maintaining relationships, and problems of severe character pathology. In his second chapter, Greenspan amplifies the basic principles of his developmental model. Most patients have characterologic difficulties and display interactive patterns related to the very early phases of character formation. Therapies that aim to help patients verbalize feelings or alter behaviors are helpful within a narrower range of patients. These therapies, however, will not prove helpful to patients with more severe pathology. This is because of the therapist's tendency toward over- or underestimation of the patient's developmental level and overreliance on interpretive verbal techniques. For example, patients are mistakenly assumed to be able to picture and verbalize their feelings, when, in his view, they lack this highly differentiated
representational system. Four basic principles of the developmental model and the six levels of early development must be used to build a developmental profile. Examples illustrate how this approach can determine the therapeutic tactics most helpful to each patient (e.g., support versus interpretation). In chapters 3 through 7 the author details the early developmental phases, giving examples of psychopathological problems that have their origins at each level. He points out the importance of constitutional, maturational, and interactional/environmental factors in the development of these problems and shows how a parent'sor therapist'smode of interaction can worsen or ameliorate the difficulties. The final three chapters focus on clinical techniques to enhance representational capacities. Greenspan says that most patients require extensive structural changes (referable to the previously unmastered levels of skills such as self-regulation, boundary definitions, and gestural communication) before they can benefit from the more traditional verbal interpretive approaches. The appendix describes his model for assessing these developmental levels. This text has many strengths. Greenspan's descriptions of early development are rich and thought-provoking. They provide another dimension for understanding personality development and psychopathology, building on and expanding the works of Freud, Piaget, Mahler, Kernberg, Kohut, and others. His unique perspective will give many therapists pause about their overreliance on interpretive techniques that focus primarily on conflict. This book will be a welcome addition to the library of any serious student of psychotherapy. However, therapists expecting a text with simple constructs for addressing vexing clinical problems will find instead a rich and complex text that will require careful study to enable integration of these concepts in a systematic way. Overestimating the patient's ability to experience and represent feelings unnecessarily
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prolongs therapy into a lengthy, intellectualized process resulting in little or no progress, Greenspan maintains. He uses as examples patients who go off on tangents, rely on gestural behavioral communication, or withdraw into aloof detachment in the transference and in their lives generally. It should be noted, however, that the developmentally informed interventions of Greenspan's own model often take many months or more to lead to structural change. Other therapeutic models have differently addressed many of these same issues. Davanloo, for instance, has shown that these modes of behavior may not represent this kind of structural difficulty in the personality but may instead be "tactical defenses" employed by the patient to manage anxiety in the transference situation. For example, obsessive patients may describe thoughts or a behavior, or they may use a vague intellectualized term that covers how they feel (such as "bothered"). Character pathology may originate with constitutional factors, as Greenspan postulates; however, it would be costly to consider these tactical defenses as representing deep structural problems requiring lengthy interventions to bring these patients to the level at which they can experience and represent their feelings. With proper identification and clinical intervention, these tactical defenses are often rapidly relinquished. Patients with highly syntonic character pathology are able to experience and represent their feelings. Certainly, the extent to which these behaviors and modes of communicating represent tenacious structural difficulties or readily yielded tactical defenses can be empirically tested. This text is rich in clinical examples and is complex and thought-provoking in its formulations. I recommend it highly to psychotherapists and researchers in child development, regardless of their school of thought. Dr. Beeber is associate professor of Psychiatry at the Health Science Center, College of Medicine, State University of New York, Syracuse, NY.
e7d(4. )S:_cNB_ho_a_osfeh­kr_sJR_LR_:(e_bvToiheoewk eCrdeovnietewm).pJoPrsayrcyhKotlheienriaPnrascot fRLeos n1d9o9n8;, The Contemporary Kleinians of London Edited by Roy Schafer Madison, CT, International Universities Press, 1997, 456 pages, ISBN 0-8236-1055-1, $65.00 Reviewed by James L. Nash, M.D. Roy Schafer, Ph.D., notes in his epilogue to The Contemporary Kleinians of London that he has held an interest in Kleinian theory and writings since the 1950s. One assumes that Dr. Schafer's well-known autonomous and original thinking allowed him to transcend the political forces within the field that operated to suppress exposure to Kleinian thinking in many of us who obtained psychoanalytic training in the United States in the 1950s, '60s, and '70s. Schafer emphasizes throughout the book that Kleinian thinking is firmly grounded in the thought of Sigmund Freud; he emphasizes this point by referring to the contemporary British Kleinians as "Kleinian Freudians." Melanie Klein seems to have seen herself as Sigmund Freud's spiritual if not biological daughter.1 Her theories of early infantile experience arose directly from the foundations of object relations theory found in Mourning and Melancholia. The contemporary Kleinians of London ("these Kleinians," as Schafer calls them, to distinguish them from their South American brethren) seem to have expunged from their perspective most of the colorful but highly controversial concepts that Melanie Klein espoused and that apparently gave American psychoanalysts such pause. The U.S. vision of Klein was of a non-physician with questionable clinical bases for her ideas (read "wild speculations") who was destroying the psychoanalytic scaffolding that the much more conservative Anna Freud was staunchly upholding in the decades after her father's illness and death. Sigmund Freud's apparent determination not to undercut his daughter by agreeing with Klein must have been tormenting to a talented and ambitious woman whose psychoanalytic birth was through the (originally)
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mainline giants, Abraham and Ferenczi. As Schafer effectively demonstrates in this collection of essays (most previously published), the contemporary descendants of the grande dame seem almost to stick to the party line. Steadfast interpretation of the transference from an objectivist stance is their main focus, and this is certainly ego psychologically and psychoanalytically fundamental. To be sure, little or no attention is given to the Oedipus complex, and one wonders if these Kleinians are not inclined to reduce even straightforward neurotic formations to their core concept of the dyadic struggle to achieve the depressive position. On the other hand, seasoned psychoanalysts and beginning psychotherapists alike are increasingly faced with patients who manifest serious disturbances in the borderline and narcissistic spheres and who present formidable technical problems for the therapist. Fundamental Kleinian concepts such as projective identification and containment, splitting, the paranoid-schizoid position, and pathological organizations, elusive though they may be in definition, are helpful in unlocking the "stuckness" and the negative therapeutic reactions that beset many a therapy and leave the therapist gasping for a breath of understanding. The Contemporary Kleinians of London contains 18 essays written by 12 authors. Only two chapters are original; many are printed with permission of the International Journal of PsychoAnalysis, which of course was founded by Ernest Jones in 1920 and whose pages saw much of the original Kleinian thought unfold. One might quibble with an expensive volume containing so much previously published work, but Schafer has chosen these essays with care (and with clear regret over space limitations and omissions) and with attention to the use of detailed clinical descriptions to demonstrate the elusive concepts and the way these Kleinians do their work. Schafer adds a personal introduction to each essay and thereby serves as a guide for the uninitiated. Hanna Segal and Betty Joseph, perhaps the most widely known of the contemporary Kleinians, contribute two
and three chapters, respectively. Irma Brenman Pick is here, as are John Steiner and eight others. Schafer encourages the reader to give careful study to the case material and to read beyond this sampler. The reviewer found Grosskurth's biography of Klein a helpful companion volume.1 The Contemporary Kleinians of London is not an easy read for the Kleinian novice, but such a reader will emerge from the experience with a wish to read and know more. The dark veil imposed by fear of Klein has been lifted, and her ideas, becoming better known, will now be explored for their usefulness and truth value. Roy Schafer has helped lift the veil. Dr. Nash is Associate Professor of Psychiatry and director of psychiatric residency training, Vanderbilt University School of Medicine, Nashville, TN. REFERENCE 1. Grosskurth P: Melanie Klein: Her World and Her Work. New York, Knopf, 1986 GS7(ir4mo):ow_nZB_thio_Gl_boa­Makn_csdh_R(_bTJe_oJrv:aoinMekwsfraoesdrvtmeieraiwnti)go. nJF,aPmbsyilcyhMoTitnhuecrahPpinrya:ScJt,oRLuernsee1Wy9s9-Yo8f,; Mastering Family Therapy: Journeys of Growth and Transformation By Salvador Minuchin, Wai-Yung Lee, and George M. Simon New York, John Wiley & Sons, 1996, 251 pages, ISBN 0-471-15558-6, $39.95 Reviewed by Joan J. Zilbach, M.D. As an educated general reader, I have read The New Yorker for more years than I can recall. In recent issues I recognize and appreciate the changes that have occurred, and I also experience some pleasure as I reminisce about the past. As a family therapist, I had a similar experience as I read Mastering Family Therapy: Journeys of Growth and Transformation. I first met Sal Minuchin at a meeting of the American Association of Orthopsychiatry
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in the mid-1950s, at a roundtable gathering of therapists interested in treating families. This was a very new endeavorthe early stages of a fascinating journey for all of us. Among others around the table were Don Jackson, Lyman Wynne, Dick Auerswald, and Murray Bowen. The conversations were vigorous, intense, and at times contentious. We were embarking on a long journey, creating and developing the now large and well-recognized field of family therapy. Structural Family Therapy, under the leadership of Dr. Minuchin, emerged early as a significant school. This school of family therapy has continued to grow and change, and the thread of that story path is woven into the text of this book. Mastering Family Therapy contains personal and interesting recollections of Minuchin's journey. At the outset there is a brief discussion of the early history of family therapy organized in categories: "Activist Family Therapy," as practiced by Minuchin and his colleagues and Satir; "A Dissenting View," which describes Gregory Bateson and the MRI group, including Watzlawick; and the work of a few other major figures as summarized under the heading "Interventionist versus Restrained Therapy." These brief discussions of the past "masters" may not be clear or understandable to new students of family therapy. They are summary evaluations by Minuchin, and the omissions may be of interest to more knowledgeable and senior family therapists. The main body of the book consists of nine interesting stories. They are best read as semiautobiographical novelettes co-constructed by a supervisor (Dr. Minuchin) and his various supervisees. Some of the plots are more compelling than others. Minuchin as supervisor-playwright-storyteller and change agent is a dominating presence throughout the varying stories. Their titles ("The Feminist and the Hierarchical Teacher," "One Head, Many Hats," "The Poet and the Drummer," "The `Oedipal Son' Revisited," "Into the Crucible," "Confronting the Gorilla," "Men and Dependency: The Treatment of a Same-Sex Couple,"
"The Shit-Painter," and "Filling the Empty Vessel: Andy Schauer's Story") provide some indications of the flavor and variety of the plots. The co-storytellers/therapists also vary in character and experience, and they are usefully self-revealing in their portrayals of the supervisory/transformational experience. The supervisory issues in these stories will be familiar to senior family therapy supervisors. Readers less familiar with Structural Family Therapy will benefit from the details of the supervisory process as experienced and described by both supervisor and supervisee. The intent of supervision, says Minuchin, is to produce "a complex, flexible therapist having a successful experience with a family in therapy." Later in the book this process is called the "self-transformation" of the therapist. This emphasis represents a major change: the inclusion of and emphasis on the "self" of the therapist in the intricacies of family therapeutic interactions. The references to this change are intermingled with the stories. Structural Family Therapy has changed since the days of Minuchin's Families and Family Therapy,1 which has become a standard text. This new book and other writings have been influenced by the recent emphases on social constructionism2 and other developments in understanding self and therapeutic change. The supervisory process occurs in a group, but there is little explicit attention given to understanding the group processes. This is puzzling, since Minuchin emphasizes the importance of the group: "[T]he supervisor uses his relationship with each supervisee, together with the group processes that he instigates as leader of the supervision group, as the mechanism to elicit therapist expansion" [my italics]. Mastering Family Therapy: Journeys of Growth and Transformation is an important historical document in the development of the field of family therapy. As Minuchin himself says in the epilogue, "I am a tinkerer, a meddler, a storyteller, some kind of playwright." I would add, "and historian." Enjoy the stories of this journey, which perhaps will expand readers' appreciation of themselves as family therapists.
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Dr. Zilbach organized the first family therapy program at Judge Baker Guidance Center, 1960­ 1976. She is a faculty member of the Fielding Institute, Santa Barbara, CA. REFERENCES 1. Minuchin S: Families and Family Therapy. Cambridge, MA, Harvard University Press, 1974 2. Gergen K: The social constructionist movement in modern psychology. Am Psychol 1985; 40:266­275 T(_br_ao_no_skfOBerroesenocvchkiees wraRwn)e.divtJziCeMPwosuGyendct:heProtsrtyahcnhesorftehPrerrnaaccpety,PRaaenssEio1rn9ost9,ic8b;Rye7l(aM4t)ia:o_n_snh_i_Dp­: Psychotherapy, an Erotic Relationship: Transference and Countertransference Passions By David Mann London and New York, Routledge, 1997, 212 pages, ISBN 0-415-14852-9, $65.00/$18.95 Reviewed by Morris G. Oscherwitz, M.D. This book is an excellent contribution to the understanding of erotic transference and countertransference in the psychoanalytic psychotherapeutic process. Mann, a British object relations theorist, private practitioner, and educator, draws on clinical developmental and new infant-observational theory to focus on the technical management of the erotic transference and countertransference. He presents abundant case material drawn from his own practice as well as work he encounters in clinical workshops in England and Europe. He also presents an outstanding review of the psychoanalytic literature, the poetry, the mythology, and the philosophy of love. He begins by defining erotic transference as the center of fantasy life and avers that the erotic transference-countertransference dyad is potentially the deepest, most useful, and most constructive aspect of the analytic process if it is understood, dealt with, and not transgressed. The origins of the individual's erotic experiences are in the relationship with the mother. The taboo of the erotic motherinfant dyad is the basis of the resistance to
dealing with these passions. It seems unlikely to Mann that the capacity to love is an endresult of therapy rather than an integral part of the work process itself. Mann carefully reviews Freud's paper "Observations on Transference-Love" (1915) and the classical position of viewing erotic transference predominantly as a resistance. He then makes a forceful case for transference love as an expression of the positive transference and the patient's search for a new transformational object. Transference love, he argues, allows psychological growth and new opportunities for individuation and intrapsychic change. The author delineates his similarities with and differences from the theoretical positions of Bergmann, Blum, Ogden, Person, Searles, Schaeffer, and Stoller on transference love. He holds that transference love and normal love are the same, indistinguishable and both real and genuine. Transference love is ubiquitous and is not limited to the therapeutic setting. The erotic development in a psychoanalysis is a therapeutic opportunity rather than merely a problem of resistance. The erotic can be a cover for narcissistic, aggressive, and projective dynamics, but it should not be considered a whole phenomenon of resistance just because it may have these constituent parts. Thorough expositions of the problems in the Anna O. and Dora cases lead to the discussion of the erotic subjectivity of the analyst. No matter how experienced the analyst, it is the area of erotic subjectivity that he or she finds most difficult. The twin dangers are that the analyst will, on the one hand, repress, deny, and split off feelings, leading to displacement or projection onto the patient or, on the other hand, become overwhelmed by the feelings, leading to acting out with the patient. The erotic countertransference is divided into four positions by Mann: the erotic preoedipal mother, the erotic oedipal mother, the erotic preoedipal father, and the oedipal father. Erotic desire in the analyst should be considered in terms of the oedipal triad, and as such it is a part of normal and healthy development.
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Mann explores Freud's study on the Wolf Man, "From the History of an Infantile Neurosis" (1918), to lead into a discussion of primal scene fantasy and primal scene transference and countertransference. The imaging of the primal scene is indispensable to the psyche. Good-enough images of the primal scene are a prerequisite for two people to be in a creative, intimate relationship together. The homoerotic transference-countertransference poses particular difficulties within the broad range of erotic transactions in psychoanalysis. This matrix takes on a more anxious and sometimes paranoid quality in same-sex analytic dyads. The fear of enactments is greater, each member fearing a homosexual seduction. A full analysis is dependent on the therapist having the courage to grapple as much with the homoerotic as the heteroerotic in the transference. The positive homoerotic transference and countertransference matrix within analysis reproduces family transferences and plays a crucial maturational role. These desires have a deep influence on integrating maternal and paternal erotic identifications within the transference. Mann defines perversion as a state of mind rather than as specific sexual activities. Transference perversions attempt to reduce the therapist to a thing, an object devoid of individual qualities. This inevitably results in a countertransference perversion as well. The latent hostility of perversions turns the love into hate, the good into bad. The perverse fantasies are the only form of object relating that is available to the patient. These patients may gradually relinquish their perverse states of mind when the transference is experienced as genuinely intimate rather than as sadomasochistic. In summary, Mann argues that the erotic bond that links the transformational psychoanalytic couple in dialogue binds the unconscious of both participants whether they like it or not. The relationship obliges the dyad to experience the other in terms of unconscious erotic fantasy. This will take both participants, like lovers, to familiar places and also to where
they have never been. This is a mutative process. Recognition of the transference-countertransference erotic fantasies contributes heavily to the creative process that is analytic. The ability to experience erotic desires that are objective and do not impinge on others is an indication of healthy ego functioning and development and mature awareness of the differences between self and others. With adequate working-through of the erotic transferencecountertransference fantasy process, the patient is prepared for object relationships in the outside world that will not be as fraught with the binding repetitions of the past and will offer more freedom and creativity. I found Mann's book very enjoyable reading and his concepts useful and refreshing to my clinical work. I did not find any part of it objectionable or unreasonable. It should be required reading for students and experienced practitioners alike. Dr. Oscherwitz is Training and Supervising Analyst, Cincinnati Psychoanalytic Institute, Cincinnati, OH. cJrh,eovStihaeenwSBrdah)op.loeyJrpkPWpsAseRiy-trMchehMvC,oie:hAthwiClnedeoarrduesPntorteaprnctortduaRAnloesdfusoesrl1e9snDc9ce,en8Mti;sn,7aPe(r4dst)yii:nct_hed_oda_al_bne­aylB_yT_tsi_(cib_aPonostyiks- Countertransference in Psychoanalytic Psychotherapy With Children and Adolescents Edited by John Tsiantis, Anne-Marie Sandler, Dimitrius Anastopoulous, and Brian Martindale Madison, CT, International Universities Press (published for the European Federation for Psychoanalytic Psychotherapy in the Public health services), 1996, 176 pages, ISBN 0-8236-1084-5, $37.50 Reviewed by Moisy Shopper, M.D. This is a rich, compact volume. Despite the seminal article by Winnicott, "Hate and the Counter-transference" (1949), child therapists have been slow to discuss countertransference issues. Children's preference for
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action, their closeness to primary process thinking, and the role of the therapist as play participant interact to enhance countertransference reactions. Preoedipal preverbal traumata communicated in nonverbal and regressive modes tend to evoke preoedipal issues in the therapist that may have been poorly or incompletely analyzed. Nevertheless, countertransference can become a resource in working with the child, particularly with regard to those split-off parts that become "contained" in the therapist. The countertransference issues in child analysis and psychotherapy entail emotional interactions with and by parents who, while supportive of the treatment and its goals, cannot tolerate the very changes so fervently desired. In the introduction, John Tsiantis's brief summaries of each of the 11 chapters serve to create bridges and connections between them. Anastopoulous and Tsiantis provide an exhaustive review of countertransference issues, achieving an excellent balance of completeness, condensation, and historical viewpoints enhanced by their own critical comments. This chapter could easily become required reading in the training of all child psychotherapists. In a brief chapter, Judith Trowell demonstrates how the skills required to observe young children, if focused on the observer's inner responses, provide exceptionally useful information about the inner child. Alex Holder spent 20 years at the Anna Freud Center treating children four to five times per week and the last 10 years in Hamburg, where government restrictions limit sessions to twice a week. The significant differences in containment, regression, momentum, intensity, elaboration of fantasies, and depth of transference are well addressed. Holder emphasizes that all of these specific patient factors are mirrored in the analyst as well. The clear advantages of high-frequency meetings are identified. Holder's unique experiences and his thoughtful and incisive comments are more worthy of repeated reading than
summarization. Holder conceptualizes the differences convincingly. Anne-Marie Sandler discusses the countertransference difficulties of the therapist when the patient is overwhelmed by the shame of a worthless and devalued self-image and similarly refuses to value the help and the person of the therapist. In this way the patient is spared the intolerable disappointment of an object relationship. Franзois Ladame takes the theoretical position that language is the "unique tool" of psychoanalysis, and cautions us neither to "despise" nor to "prize" countertransference. Ladame redefines countertransference as a challenge from the patient that is experienced by the therapist as "narcissistically frightening." Ladame suggests group discussions rather than individual supervision in helping the therapist deal with these anxieties. Using clinical vignettes, Jacqueline Godfrind shows how readily countertransference errors can arise from the parents' attitudes toward the child, toward the treatment's progress, and toward the therapist herself. Didier Houzel uses a Kleinian orientation of "psychic envelopes," part/whole objects, and bi-sexuality involved in the primitive splitting of maternal and paternal part objects. I found the material hard to comprehend and the clinical vignettes unconvincing. Tsiantis discusses the formidable challenge of an inpatient setting for traumatized adolescents. Challenges in this setting include splitting in the transference, projective identifications with the staff, the balance between the therapeutic individual role and the administrative team role, and the multiple opportunities for acting out of transference/countertransference roles among all involved. Tsiantis attributes success to the training and the "stamina" of the nursing staff, their consultation, and their treatment as respected team members. The traumatized adolescent in long-term residence is adept at recreating with the staff his or her own traumatic circumstances. Tsiantis demonstrates how experience, thoughtfulness, and attention
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to the subtle and not so subtle interplay between transference and countertransference among all those involved can be therapeutic. Ten pages of valuable references are complemented by a very serviceable index. There might be some difficulties for the American reader in encountering terms and conceptualizations that are not in everyday use here, but it is obvious that the authors know more about analytic work in the United States than we
know about the Europeans. I think the book will be used as a standard text (perhaps also the advanced text) for those therapists who treat children and their parents in depth. I suspect it will become the standard reference and a classic in its time. Dr. Shopper is in private practice and is Supervising and Training Analyst, St. Louis Psychoanalytic Institute, St. Louis, MO.
VOLUME 7 · NUMBER 4 · FALL 1998

SI Greenspan, JI Downey

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