Transtheoretical practice of psychotherapy.

The state of the art of psychotherapy suggests that new paradigms are necessary to combine or transcend diverse perspectives of psychopathology and treatment.(1,2) In the psychoanalytic realm, this refers to the integration of drive, ego, object relations, and self approaches,(20 and to the more global synthesis of conflict and deficit models that reside at the contemporary core of major clinical controversy.(3) In tandem with this conceptual schism has been the dual nature of the psychological healer as scientific versus humanistic, and the current call for complementarity of these two contrasting modes in the modern role of the psychotherapist as an empathic listener.(4) This integrative model of psychotherapeutic practice acknowledges the joint impact on psychic structure formation of unresolved conflictual urges and wishes interfaced with early environmental deficiencies and traumas in the real-object world of the patient.(3) In terms of treatment, it recognizes the pivotal roles of both erotic and narcissistic transferences in the therapist-patient relationships and in the respective stances and strategies of the listening and empathic practitioner.(4) Moreover, by bridging theoretical concepts and actual applications, an experience-near working model aims to address the pressing problem of lack of synchrony between theory and practice.(6,7) TRANSCENDING CLASSICAL VERSUS SELFOBJECT TRANSFERENCES(N1) It has long been suggested that neither the use of symptoms and syndromes nor adherence to specific schools of psychotherapy may be sufficient in designing psychotherapeutic strategies for a wide range of patients.(7,10,11) In this behalf, Kohut and Wolf(11) have made the intriguing observation that "It was not the scrutiny of the symptomatology but the process of treatment that illuminated the nature of disturbance of...patients (p. 44). Clinical and experimental studies of change agents in psychotherapy throughout the ages have revealed that the relationship between therapist and patient is the supraordinate influence that transcends particular techniques.(12,13) More specifically, it is the establishment of transference, or rather, the fundamental type of transference that is formed--classical (or advanced) versus narcissistic (or primitive)--that has remained as perhaps the most telling dimension of patient evaluation and of the kind of therapy that ensues.(11,14) These two expressions of patient relatedness, viewed as maturational markers, continue to comprise critical transferential axes upon which all psychotherapeutic practice pivots.(15,16) Historically, although the formation of a transference neurosis has generally been used to describe the unconscious constellation of events that project the therapist into a position of unsurpassed regard and displaced desire in the patient's conflictual psychic life, Freud(17) initially applied the term diagnostically to separate those patients who could, from those who could not, develop such an ardent and ambivalent attachment without further decompensation; he did not believe that the latter group (narcissistic neurosis) was treatable. Today, the increasing identification of severe character pathology has indicated that the intrapsychic structural organization of these patients may well be very different from their psychoneurotic counterparts. However, instead of simply excluding them from traditional treatment, current theory as well as therapy applies new techniques to accommodate such underlying differences, particularly ego disturbances of self-image, faulty self-esteem, and partial object relations as well as primitive defense mechanisms of splitting and dissociation that often characterize their clinical picture.(9,14) For Kohut,(9) it denotes that two kinds of narcissistic (selfobject) transference considered pathognomonic for self disorders are direct repetitions within therapy of very early infant/parent interactions: mirror transference, in which a faultily responded to need for acceptance and confirmation is revived; and idealizing transference, which recreates the patient's need to merge with a source of idealized strength. …