Principles of Intensive Psychotherapy

By Frieda Fromm-Reichmann

“Principles of Intensive Psychotherapy” is a 1960 treatise by German psychiatrist Frieda Fromm-Reichmann. Within it, she looks at the subject of intensive psychotherapy, outlining the methods and reasons behind them with reference to real cases. This volume is highly recommended for anyone with an interest in psychotherapy and it would make for a fantastic addition to collections of related literature. Contents include: “The Psychiatrist: Personal And Professional Requirements”, “Insight Into The Emotional Aspects Of The Doctor-Patient Relationship”, “The Psychiatrist’s Part In The Doctor-Patient Relationship”, “The Psychiatrist’s Attitude Toward Cultural And Ethical Values In Its Relatedness To The Goals Of Psychotherapy”, “Considerations Of The Psychiatrist In The Establishment Of The Treatment Situation”, etc. Frieda Fromm-Reichmann (1889 – 1957) was a German psychiatrist and contemporary of Sigmund Freud who fled Nazi oppression by emigrating to America during World War II. Many vintage books such as this are increasingly scarce and expensive. It is with this in mind that we are republishing this volume now in an affordable, modern, high-quality edition complete with a specially-commissioned new biography of the author.

• Language: English
• Publisher: Read Books Ltd.
• Release date: Jan 4, 2013
• ISBN: 9781447481768

Book preview

PART I

THE PSYCHIATRIST: PERSONAL AND

PROFESSIONAL REQUIREMENTS

CHAPTER I

Insight into the Emotional Aspects of the

Doctor-Patient Relationship

THE average psychiatrist who has acquired some knowledge of the principles of intensive psychotherapy has, by and large, studied only the psychotherapeutic process and the problems concerning the patient’s personality. Unless he has undergone psychoanalytic training, not much attention has been given to the investigation of his own personality. Unless the psychiatrist is widely aware of his own interpersonal processes so that he can handle them for the benefit of the patient in their interpersonal therapeutic dealings with each other, no successful psychotherapy can eventuate.

It is to the immortal credit of Sigmund Freud that he was the first to understand and describe the psychotherapeutic process in terms of an interpersonal experience between patient and psychiatrist and that he was the first to call attention to and study the personality of the psychiatrist, as well as that of the patient and their mutual interpersonal relationship. Only those psychiatrists who have done psychotherapy both before and after being acquainted with Freud’s concepts will be able to realize the full extent of the significance of his discovery of the laws governing the interpersonal exchange between doctor and patient. I personally remember only too well the time when I dealt psychotherapeutically with mental patients, before I was acquainted with Freud’s teachings. I realized, with distress, that something went on in the patients’ relations with me, and in my relations with them, which interfered with the psychotherapeutic process. Yet I could not put my finger on it, define it, or investigate it. What a relief it was to become acquainted with the tools furnished by Freud for investigation into and awareness of the doctor-patient relationship! Prior to these discoveries psychiatrists had been in the dark both to the detriment of their patients and to the disadvantage of their professional self-respect (38, 39, 40, 41, 46).

The debt of gratitude to Freud for his discovery of the need to study the doctor-patient relationship, in regard to the patient’s as well as the doctor’s part in it, still holds true regardless of the fact that Freud and his disciples subsequently nullified part of its far-reaching implications. As we know, Freud taught that all our relationships with other people, including the relationship of the mental patient with his doctor, are patterned by our early relationships with the significant people of our environment in infancy and childhood. Our later interpersonal difficulties have to be understood in terms of these early interpersonal tie-ups. The vicissitudes of the patient’s experiences with the doctor, in particular, have to be investigated and understood for psychotherapeutic purposes. Since they are transferred, that is, carried over from unresolved difficulties in interpersonal relationships with the significant people of the patient’s early life, they are transference experiences.

In the same way, the countertransference experiences of the doctor, as they, in their turn, come up and interfere with the psychotherapeutic process, must be investigated, understood, and, if possible, eliminated in terms of their being transferred from the doctor’s early interpersonal experiences with the significant people of his infancy and childhood.

It is true that the patterns of our later interpersonal relationships are formed in our early lives, repeated in our later lives, and can be understood through the medium of their repetition with people in general and through the mutual aspects of the doctor-patient relationship in particular. There is, however, danger in carrying this insight too far. At the present developmental phase of dynamic psychoanalytic psychiatry, we still believe that it is not only helpful but indispensable for psychotherapeutic success to study the patient’s and the psychiatrist’s mutual relationships in terms of their repetitional characteristics. But we keenly feel that this should not be done to the point of neglecting to scrutinize the reality of the actual experience between therapist and patient in its own right. This viewpoint is also inherent in Freud’s original teachings. But his transference doctrine gave an opening to obviate the fact of the actual experiences between therapist and patient then and there. In practice, this at times has carried with it the danger of inducing therapists to neglect the significance of the vicissitudes of the actual doctor-patient relationship as opposed to its transference aspects.

To illustrate: After a long period of painful procrastination, a patient in all seriousness and sincerity finally succeeded in conveying to the therapist what he considered to be his actual central difficulty. Conditioned to listening to the patient’s stream of irrelevant talk, which he had unsuccessfully tried to break through thus far, the psychiatrist was not alert to the importance of the information finally offered. The patient, feeling hurt, became desperate and angry, questioned the usefulness of the psychotherapeutic process, and proceeded to evince open hostility. It is true that the patient reacted in this way because of his being especially sensitive to signs of just such lack of alertness because of similar warping and thwarting experiences with a significant adult in his early life. The patient’s awareness of these experiences could be awakened or increased by studying them as he transferred them to the psychiatrist. But was it not of equally great, or even greater, importance for him, and more so for the doctor, to realize and admit that the patient was justified in his desperate anger against the therapist himself? After all, the therapist had failed the patient in his professional obligations by his lack of alertness when the patient most needed his discerning attention.

It may also be true that the psychiatrist’s special sensitivity to the patient’s meaningless chatter, hence his failure in being alert to the changed contents of the patient’s communication, could be due to a pertinent experience in his own childhood. Suppose the doctor as a child had had to listen to the endless inconsequential talk of an elderly grandmother, to the point of becoming unable in his early years to pay attention to any significant communication of hers or of any other person’s, which may have been interpolated into grandmother’s chatter. But the knowledge of this countertransference character of the therapist’s blunder does not eliminate the necessity of realizing his professional failure as such.

Recently the significant vicissitudes of the psychiatrist’s relationship to his patients has been brought increasingly into the focus of therapeutic attention. This holds true for its transferred and for its factual aspects (112). Every psychiatrist now knows that there must be a fluctuating interplay between doctor and patient. This inevitably follows from the interpersonal character of the psychotherapeutic process. The psychiatrist who is trained in the observation and inner realization of his reaction to patients’ manifestations can frequently utilize these reactions as a helpful instrument in understanding otherwise hidden implications in patients’ communications. Thus the therapist’s share in the reciprocal transference reactions of doctor and patient in the wider sense of the term may furnish an important guide in conducting the psychotherapeutic process. I will elaborate further on this important topic in this and other chapters of the book.

To return to patients’ transference reactions, there is another point of departure from Freud’s original teachings about transference in the concepts of psychoanalytic psychotherapy as they are outlined here. This variance stems from the fact that our thinking does not coincide with Freud’s doctrine of the ubiquity of the Oedipus complex, the positive (sexual) attachment to the parent of the opposite sex, with concomitant rivalrous hatred for the parent of the same sex. Consequently, we do not understand as a foregone conclusion that the difficulties of therapists in their relationships with patients and vice versa stem from, or are only a repetition of, their unresolved Oedipus constellations (109).

H. S. Sullivan has introduced the term parataxis instead of transference and countertransference. Parataxic interpersonal experiences are distortions in people’s present interpersonal relationships. They are conditioned by carry-overs of a person’s previous interpersonal experiences prevalently from infancy and childhood but not always or necessarily from entanglements with his parents (147).

So much for this preliminary discussion of the concepts of transference and countertransference and parataxis in their relevance for the understanding of the interpersonal processes of the psychiatrist. They will be discussed further throughout the book, especially in the sections on Transference and Parataxic Distortions (pp. 97–107) and Security Operations, Resistance (pp. 107–18).

At this point they are mentioned only to facilitate the realization that the interpersonal processes of the psychiatrist as a private and as a professional person must be investigated and recognized both in regard to the possibility of their being distorted as countertransference, as parataxic experiences, and equally so in regard to the present interpersonal situation. This is one reason for requiring a personal psychoanalysis as part of the training for doing intensive psychotherapy.

CHAPTER II

The Psychiatrist’s Part in the Doctor-Patient Relationship

1. LISTENING AS A BASIC PSYCHOTHERAPEUTIC

INSTRUMENTALITY

WHAT, then, are the basic requirements as to the personality and the professional abilities of a psychiatrist? If I were asked to answer this question in one sentence, I would reply, The psychotherapist must be able to listen. This does not appear to be a Startling statement, but it is intended to be just that. To be able to listen and to gather information from another person in this other person’s own right, without reacting along the lines of one’s own problems or experiences, of which one may be reminded, perhaps in a disturbing way, is an art of interpersonal exchange which few people are able to practice without special training. To be in command of this art is by no means tantamount to actually being a good psychiatrist, but it is the prerequisite of all intensive psychotherapy.

If it is true that the therapist must avoid reacting to patients’ data in terms of his own life-experience, this means that he must have enough sources of satisfaction and security in his nonprofessional life to forego the temptation of using his patients for the pursuit of his personal satisfaction or security. If he has not been successful in securing the personal fulfilments in life which he wanted and needed, he should realize this. His attitude toward the sources of dissatisfaction and unhappiness in his life must then be clarified and integrated to the extent that they do not interfere with his emotional stability and with his ability to concentrate upon listening to the patient. This is a second reason for making a personal psychoanalysis a training requirement for a psychiatrist. Additional reasons will be discussed later.

The statement that the patient should not be a source of satisfaction and security to the therapist is, of course, not in reference to their actual, overt dealings with each other, since it is considered common knowledge that the professional relationship between psychiatrists and patients precludes any sort of nonprofessional mutual intimacy. What I am referring to is the danger that the discontented psychiatrist may use in fantasy the data collected from the patient as a substitutive source of satisfaction.

For example, a patient may tell a therapist who has just experienced an unhappy love relationship about problems of a similar nature. The psychiatrist should be sufficiently detached from his own problems so that he does not relate himself to the patient’s experience and indulge in an orgy of self-referral. Or: a woman psychiatrist, who has passed the menopause and who regrets having only one child, hears about the third or fourth pregnancy of one of her patients. There should be no preoccupation with the denial of her own wishes intruding into her concentration upon the patient’s report of her pregnancy. Again: a patient relates to the psychiatrist the progress in a happy courtship. Having in mind the lack of glamour in his own life, the psychiatrist may use the patient’s review as one might use fiction or screen romance, namely, as a starting point for fantasies of his own. This fantasied projection of himself into the role of the patient or the patient’s partner prevents the doctor from concentrating exclusively upon listening to the patient in his own right.

The same sort of experience may take place when a patient relates success or failure in prestige in any field. Whenever wishes or ambitions, fulfilments or failures, similar to those in the psychiatrist’s career are touched upon, he must avoid the danger of using the patient’s narrative as a starting point for dream satisfactions of his own, rather than using its narration as a source for collecting further helpful data about the patient. Although this ultimate goal has already been stated in the Hippocratic oath, the psychiatrist will only rarely be able, of course, to fulfil this ideal. Should he be unable to do so, he is expected to be aware of it, so that he can safeguard against the possibility of undesirable therapeutic consequences. This holds true for fantasies in the realm of both satisfaction and security.

In speaking about satisfaction and security as the two goals of fulfilment which man pursues, I follow H. S. Sullivan’s definition (147). Satisfaction, he says, is the result of fulfilments in the realm of that which has to do with the bodily organization, the glandular processes, the need for sexual gratification and sleep, and the avoidance of hunger and physical loneliness. Security refers to the fulfilment of what has to do with the cultural equipment of a person, whereby the word cultural refers to everything which is man-made. Security, then, means fulfilment of a person’s wishes for prestige, that is, the acceptance by and the respect of society as well as the achievement of self-respect. Security also means a person’s being able to use successfully his powers, skills, and abilities for interpersonal goals within the range of his interests.

2. THE PSYCHIATRIST’S NEED FOR

EXTRA-PROFESSIONAL SOURCES OF

SATISFACTION AND SECURITY

How, then, does the therapist’s need for satisfaction and security have bearing upon his ability to listen, in addition to the previously discussed danger of allowing the material received from the patient to arouse his own fantasy?

Satisfaction of hunger has been mentioned as a necessary fulfilment; in our culture that means to have or to earn the money with which to buy food. The psychiatrist earns this money by means of his professional dealings with his patients. In that sense, practicing his profession is a legitimate source of satisfaction for him. What he has to safeguard against, however, is making psychotherapy with one patient the sole source of his satisfaction. In order to avoid having this happen, it is recommended that, in starting private practice, the young psychiatrist begin psychotherapy with two patients, or combine intensive psychotherapy with one patient with additional psychiatric activities of another type, such as part-time institutional work, teaching, consultations, etc. However unimportant this may seem to the inexperienced, psychotherapy with only one patient as the single source of income may easily be doomed to failure.

Sexual gratification has been quoted as another goal of satisfaction in man’s life. The therapist has to safeguard strictly against using the patient, actually or in fantasy, for the pursuit of lust, so that sexual fantasies with regard to the patient or the partners whom the patient mentions, or identifications with the patient or his partners regarding their sexual experiences, do not interfere with the psychiatrist’s ability to listen.

Obviously, man’s need for sleep should not be sought by the therapist while attending to his professional obligations. But, unfortunately, I am giving away no secret when stating that there are therapists who fall asleep while they are supposed to listen, especially if they sit behind their patients and they do not see each other. There are even rationalizations on the part of psychiatrists for such unforgivable errors in procedure—such as I only fall asleep if the patient produces irrelevant material and wake up as soon as the patient’s productions become relevant. In marked contrast to such flimsy rationalization, I wish to emphasize strongly my viewpoint that the answer of the therapist to the patient’s producing irrelevancies is not to take a nap but to listen sufficiently alertly so that he can interrupt and direct the patient toward the production of more relevant material. This statement implies a change of attitude with regard to the technique of free associations as used in classical psychoanalysis. I will elaborate on this topic later. If the psychiatrist indulges in napping during the psychotherapeutic interview, it interferes with his ability to listen and to conduct the interview adequately. It also has the implication of lowering the patient’s self-respect as the doctor evidences how little interested he is in the patient and his communications. This may prove to be quite disastrous to the psychotherapeutic process, because the self-esteem of a psychiatric patient is very low to begin with. His lack of self-respect and his insecurity are, as a rule, wittingly or unwittingly, one of the reasons for his needing psychotherapy. One of the important principles of intensive psychotherapy to which I shall have to refer time and again is that the psychiatrist endeavor to improve patients’ self-respect and that, by all means, he should avoid hurting it.

The classical psychoanalytic setup of the psychiatrist sitting behind the patient, who is lying on the couch, may imply the danger of encouraging any inclination on the part of the psychiatrist to drowse. At the time when the technique and methods of classical psychoanalytic therapy were developed, this position was considered desirable to induce a state of complete relaxation in the patient, which would make it possible for him to associate freely and to eliminate embarrassment while relating delicate and painful material. Moreover, the founder of classical psychoanalysis, Sigmund Freud, felt that he personally was not up to having patients look at him for eight hours daily, and he assumed that many of his colleagues might encounter the same difficulty (38).

Since then there has been a marked development in psychoanalytic insight and technique (93). Many psychoanalytic psychiatrists now feel that it is no longer necessary to listen to free associations over a long period of time in order to become acquainted with patients’ psychopathology, and before administering any active psychotherapeutic intervention (5, 6). This is due to the increase in knowledge about the dynamics of mental processes which has been gained during the last fifty years. In addition, many topics, the communication of which was formerly fraught with extreme hesitancy and shyness, have gradually lost the connotation of embarrassment for most people in this culture during the last fifty years. Indeed, Freud’s teachings are largely responsible for a more normal attitude toward the discussion of formerly prohibited sexual subject matter. Suggestions in technique, which he originally made to conform with the sensitivities of his contemporaries, are therefore now outdated by the very results of his teachings.

As to the hardship for the psychiatrist to be gazed at daily for eight hours, I believe that there were two reasons, both of which can be discounted today. One was that the therapist was liable to share the embarrassment of his patient while listening to difficult communications. The second was the original psychoanalytic concept, according to which the therapist was supposed to show no signs whatsoever of reacting to, or participating in, the patient’s communications. The more colorless and the more inanimate the countenance of the psychiatrist appeared, the more nearly he approached the ideal of serving the patient as a recording machine on which he could record whatever was on his mind. This inanimate attitude also served as a safeguard against the psychiatrist’s becoming personally involved with his patients and with the emotional experiences which they were reciting. The consistent control of facial expression, posture, and gestures which the psychiatrist had to exert under these conditions made it very hard indeed for him to be exposed to his patients’ visual scrutiny all day long (63, 64).

Nowadays, many psychiatrists no longer think of the therapist as unresponsive to and only a mirror of the patient’s utterances. We consider him a participant observer in the psychotherapeutic process. Also, we do not believe that it is necessary or desirable for the psychiatrist to bar responsive reactions of spontaneity from the psychotherapeutic scene, as long as his responsive facial expressions cannot be used by patients as a means of orientation inadvertently guiding their productions and behavior. Also they must, of course, be genuine responses to patients’ communications and not colored by his private collateral experiences.

With these two concepts in mind, I consider it, by and large, much more desirable to have an arrangement which makes it possible for both the patient and the therapist to look at each other or not as the occasion may warrant. Prohibiting the use of visual contact as an aid in the therapeutic process is an unnecessary deterrent and makes for an unreal situation. This holds true especially for psychotic patients, whose lack of orientation in the outer world has to be counteracted by the visible and audible reality of another person. I will elaborate further on this topic while discussing the psychotherapeutic process (65).

As to the fourth goal of human satisfaction, the avoidance of physical loneliness, it goes without saying that the patient should not be used for its achievement. This does not mean advocating that the psychiatrist be an obsessional denizen of our culture, wherein touching another person or being touched by him is considered taboo unless there is an intimate relationship. The contrary is true. At times it may be indicated and wise to shake hands with a patient or, in the case of a very disturbed person, to touch him reassuringly or not to refuse his gesture of seeking affection and closeness. However, it is always recommended that one be thrifty with the expression of any physical contact.

A psychiatrist who is lonely must see that his own need for physical contact does not interfere with his coming to the correct conclusions about patients’ needs. He must safeguard against a lack of alertness in listening due to this interference of his own unresolved needs.

Security operations should interfere just as little with the psychiatrist’s ability to listen as should his personal needs for satisfaction. The psychiatrist who needs the individual patient to build up his prestige and to prove to himself that he is able to use his powers and his skills successfully will be in danger of trying to impress his patient instead of being impressed by the patient’s needs and difficulties. This could hold true especially for the young psychiatrist, who might try to counteract his own insecurity in two ways which would interfere with his ability to listen. First, he might feel called upon to hide his insecurity by displaying professional pompousness. Such an endeavor is highly undesirable; in fact, it may doom the psychotherapeutic procedure to failure. As stated before, every mental patient suffers from an impairment in self-assurance, that is, he is insecure and anxious. This being so, he will be most sensitive to the attempts of another person to hide his insecurity. If this other person is his psychiatrist, the therapist’s own ill-disguised insecurity will add to the patient’s anxiety. The patient will not feel free to confide in the psychiatrist and to believe in his ability to listen; therefore, psychotherapeutic collaboration will be defeated.*

The young psychiatrist who may feel called upon to try to impress patients might keep in mind, furthermore, how unnecessary this is because the patients who come to see him want help. They expect him to be competent to offer this help on the basis of his training and/or because of his having been recommended by another successfully treated patient or by an older psychiatrist. Patients tend toward health, and they are lonely. Their wish for help, their tendency toward health, and their loneliness are much more important to them than the chronological or professional age of the person to whom they turn for aid.

The second way in which the psychiatrist may try to bolster his insecurity, namely, by cultivating the patient’s dependence and admiration, is therefore equally unnecessary. This may interfere with the psychiatrist’s ability to listen even more than the direct display of pompousness. The cultivation of such attitudes pushes his patients into a state of dependence, instead of working toward growth, independence, and an ability to use their own judgment. To put it differently, the psychiatrist duplicates the demands for unqualified love and acceptance of authority which the parents or other significant adults of the patient’s childhood may have imposed on him to his detriment. In Freud’s terminology, he artificially cultivates the patients’ positive transference. As he does so, he can be reasonably certain that contrary results will be obtained in the long run. The patients will resent the psychiatrist’s interference with their tendency toward and wish for growth and independence, since these are among the reasons for which they came to see the doctor, and they will hate their would-be helper for failing them. In other words, the psychiatrist’s attempts at artificially cultivating his patient’s positive transference will necessarily breed a negative attitude in the patient toward the psychiatrist.

Some unfortunate results of the need of the insecure psychiatrist to use the patient as a test tube for his skills and powers should be mentioned at this point. Such a psychiatrist may be so preoccupied with the idea that his patients have to get well for the sake of his reputation that he will listen to them and conduct treatment in such a way that he deafens himself against and disregards the patient’s real needs and his striving for improvement. Or the insecure psychiatrist may feel that the patient must understand whatever the doctor feels called upon to point out, disregarding the question of whether or not the patient is ready to follow at the time. In the same vein, he may answer the patient’s failure to understand with an intensified irritation, which, in turn, will certainly becloud the legitimate issues of the psychotherapeutic process. Moreover, the patient is liable to feel that he is being used as a means of confirming the psychiatrist’s reputation rather than as an object of treatment in his own right. This attitude could well be conducive to the failure of treatment. In this connection, I recall the unhappy neurotic son of a powerful and influential father, whose life was dedicated solely to the increase of his father’s prestige and reputation. He expected everyone with whom he came in contact to function only in order to impress his influential father or to be seeking prestige as his father did. Of course, the patient expected his psychiatrist to behave accordingly. If I get well, he volunteered in his first interview, it will be quite a feather in your cap. The psychiatrist was fortunately not preoccupied with his reputation, so that he heard the patient and the implications