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Relational Theory and the Practice of PsychotherapyReview - Relational Theory and the Practice of Psychotherapy
by Paul L. Wachtel
Guilford Press, 2008
Review by Robert Cohen, Ph.D.
May 3rd 2011 (Volume 15, Issue 18)

In every generation critics have warned of the imminent extinction of psychoanalysis as a therapeutic approach unless radical changes occur.  Recently, these tidings have come from some eminent insiders.  Owen Renik (2006), a prominent analyst within the drive-ego psychology tradition, criticized analysts for being too willing to keep long treatments going without suitable attention to whether therapeutic goals were being achieved.   Peter Fonagy (2010) a widely published researcher and clinician long associated with the Anna Freud Center in London, speculated that only a limited set of psychoanalytic techniques will remain recognizable in future treatments, as the pressure to support therapeutic techniques with objective empirical support advances.  Otto Kernberg (1996), who has melded an object relations and ego psychology approach into an empirically supported treatment for Borderline Personality disorder, has bemoaned the unscientific and restrictive nature of psychoanalytic training.

What underlies these critiques is the assertion that analysts tend to be too focused on advancing their own theories and practicing in their comfort zone rather than allowing the rubber of their technique to meet the road of practical clinical reality.   An implicit contention is that analysts have been self-absorbed to the point of neglecting relevant evidence that might significantly change psychoanalytic practice and advance the field. 

It is noteworthy that these criticisms come at time when interchanges between the various schools of psychoanalysis--unthinkable in the 1980s--have become commonplace.  While bitter disagreements remain, there appears to be a remarkable openness, as relational and interpersonal perspectives have become more mainstream in an American psychoanalytic world dominated by drive and ego psychologists.  The influence of modern-Kleinians has become ubiquitous.  If openness prevails, then how can the sky be falling?

An insight into the problem occurred to me recently when I took over a graduate course surveying the various non-psychoanalytic approaches to psychotherapy.  I was compelled to look back at the major schools of therapy and see if I had missed anything during my recent psychoanalytic training when I had been single-mindedly focused on all things analytic.   Though I had taught a similar course to undergraduates some years ago, I was surprised how relevant and stimulating I found the material from these other approaches.   What struck me was the way that developments in various schools had appeared to converge around ideas that were central to psychoanalysis.  In analytic circles, the therapeutic world outside one's psychoanalytic organization can sometimes appear as a primitive, simple-minded place where patients receive the most cursory and superficial treatments.  But I saw now that perspectives outside of psychoanalysis were grappling in serious ways with issues such as resistance, affect tolerance and expression, and the significance of ambivalence in the process of change.

These observations led me back to the recent criticisms of psychoanalysis. Perhaps one reason we can be so vulnerable to the charge of self-absorption is that we live in an unreal psychoanalytic world where controversial interchanges occur between factions that, in spite of their differences, view the therapeutic enterprise through a rather narrow lens.  Unspoken agreement reigns that proper psychotherapy is an extended, intensive often even a decade  plus effort to enter "deeper" psychic waters, in which the therapist eschews being directive or too specifically problem centered.  The past is always prologue, and a central focus of treatment.  

Why hasn't there been more interchange between psychoanalysis and the various schools of psychotherapy?   It is not that the psychoanalytic world is hermetically sealed off from other disciplines: much has been written about integrations between psychoanalysis and new understandings of the brain.   The causes are certainly multi-determined.  But it has become clear to me that we ignore developments in the other orientations at our peril.

It was therefore refreshing to encounter the recent work of Paul Wachtel, an analytically trained psychologist and a faculty member at New York University's post-doctoral program in psychoanalysis and psychotherapy who is one of the founders of the Society for the Exploration of Psychotherapy Integration.  In his latest book, Relational Theory and the Practice of Psychotherapy (2008), Wachtel vigorously argues for the relevance of a "relational" point of view which he connects with his own brand of psychotherapy integration, which he terms "Cyclical Psychodynamics."  

Wachtel's interest in therapeutic integration dates back many years.  In the seventies, curious about behavior therapy, he contacted prominent behaviorists to observe their work, resulting in two books, Psychoanalysis and Behavior Therapy (1977) and Psychoanalysis, Behavior Therapy and the Relational World (1997).  Wachtel's first became intrigued with behaviorism therapy developed while he was a graduate student at Yale, where he encountered the now forgotten work of Dollard and Miller, who integrated Freudian theory with experimental behaviorism (Miller, et al. 1941). Though he was trained in ego psychological approaches by individuals such as Roy Schafer, Wachtel became interested in the work of interpersonalists such as Horney and Sullivan who made current cultural and political factors more salient in their psychoanalytic theories than did the ego psychologists, who were content to relegate contemporaneous influences to the realm of an "average expectable environment."  

In this book, Wachtel adopts the mantel of the relational approach, drawing on the work of Mitchell, Aron, and others whose works he studied closely, and with whom he has engaged in productive dialogue. Wachtel is drawn to the relational label for its focus on a two-person model of therapy, its departure from an overly drive-focused perspective on the causes of psychopathology, and its insistence on factors in the real relationship between patient and analyst as curative.  While acknowledging the relevance of interpretation and self-understanding, Wachtel is critical of what he considers the historic overemphasis on insight in the psychoanalytic theory of change.  Wachtel returns to the work of Franz Alexander, whose insistence on the need for "corrective emotional experience" Wachtel believes was  misunderstood and unfairly maligned by the classical establishment in the 1940s and 50s. Like Alexander, Wachtel highlights the important possibilities for learning in the therapeutic relationship, when the patient discovers that unacceptable wishes or anxious expectations are not so frightening when experienced in the presence of a non-threatening other.  Wachtel is thus able to integrate the experience of the therapeutic relationship with the type of learning that occurs in behavioral approaches. Conditioned fears are extinguished when a threatening stimulus is experienced in a relaxed state. 

However, unlike behaviorist approaches that take a narrow environmentally determined approach, neglecting the internal world, Wachtel's "cyclical psychodynamics" emphasizes the psychoanalytic observation that patients are often unable to experience environments that will extinguish their fears.  Instead, patients unwittingly, and paradoxically tend to elicit from others the negative experiences they have learned to expect.  So therapeutic work involves attending to ways the patient behaves in ways that makes it hard for the therapist to provide the necessary corrective emotional experience.  In this way, psychotherapy is inherently a two-person experience, because the therapist is necessarily drawn into the patient's pathology. 

Here, Wachtel's approach jibes well with the contemporary psychoanalytic zeitgeist, in which analysts from all schools acknowledge the inevitability of enactment as a crucial experience in treatment.  Where Wachtel's approach departs from this consensus is in his understanding of what the patient enacts and how such enactments become an important part of therapeutic work. This aspect of Wachtel's approach is outlined in the first half of the book which is a theoretical overview of his understanding of the relational approach.  Here he criticizes both so called "classical" and relational schools for what he considers an untenable focus on what he calls an "archeological" approach to conceptualizing personality and development.  In Wachtel's view, some relational and more traditional  approaches believe that therapeutic change is predicated on unearthing early determinants of later personality that have become frozen and inaccessible to contemporary mental life.  For drive theorists, these buried treasures are fantasy structures consisting of drive-defense compromises tied to psychosexual developmental experiences, and they become enacted in the transference-countertransference matrix.   For many relational theorists, bedrock is the set of early internalized object relational schemes which appear in the consulting room, and the relational approach can end up focusing, in Wachtel's view, too narrowly on relationships from the past that color the present.  Wachtel does not dismiss the importance of early experience, but he does not conceive of early experience as causing patients' difficulties in a simple linear model.  Rather, early experience leads patients to avoid certain threatening experiences, and by doing so, patients inadvertently make their experiences worse, confirming their sense that what they can't face is dangerous.  Psychopathology, therefore, is not a repetition of the past, but a recreation and elaboration in the present context of tendencies from the past.  This view, according to Wachtel, necessitates study of the current context, where particular experiences elicit the patient's repetitive behaviors and the patient's ineffective attempts at coping can be captured and understood as they develop. Attention must be more on the present than the past, without neglecting the past as an historical catalyst for the present conflict.  "The deeper one probes into the person's history, experience, and unconscious wishes, fears, and fantasies," he writes, "the more it becomes evident how powerfully they are all linked to the ongoing patterns between people in the patient's life today (p. 121)."

In the second part of the book, Wachtel discusses the clinical implications of his relational approach.  Most useful in this discussion is Wachtel's description of the way what he terms "the default position" influences clinical work.  By the default position, Wachtel refers to the set of attitudes and technical precepts sometimes referred to as "classical" or Freudian in nature. Wachtel, however, is hesitant to ascribe tendencies to a particular tradition, because such attitudes can be found in all analysts, even those who might consider themselves progressive relationalists.  The persistence of the "default position" derives from the fact that much of psychoanalytic theory is transmitted through supervision and personal analysis.  Wachtel asserts:  "...[S]ince our profession is still relatively young, only a few generations separate the period of psychoanalytic hegemony from the current state of multiple and competing orientations and viewpoints. This means that even if one's personal therapist or one's most recent supervisors were not themselves Freudians, their supervisors, or their supervisors' supervisors were (p. 27)." 

The default position is evident in the belief that analytic treatment should not be too supportive or gratifying.  Therapists, while disclosing occasionally, must remain opaque and distant to allow deeper material to appear, and too much gratification or efforts to be directly helpful might preclude the patient ever making necessary progress to plumb the depths of his or her pathology.  The default position also proscribes direct interventions or suggestions, and frowns on elements of the treatment that are not strictly focused on the provision of insight. Wachtel also helpfully notes the way the default position leads analysts to be unduly suspicious and adversarial in their approach to patients, feeling the need to decode the hidden language of the unconscious and wrest the unknown part of the self into consciousness.  As Wachtel states:

All too often, the pursuit of insight in therapy has been an effort to get in the touch with the cold, hard truth. The assumption has been that beneath the patient's conscious experience of himself lurk motives and fantasies that are primitive and often destructive. The alternative described in this book, largely rooted in the evolving relational paradigm, but critical of certain versions of relational thinking that retain unnoticed elements of the default position, aims just as fully as the traditional approach at illuminating the patient's experience, going beyond the limits of the patient's conscious view of himself. But it does not aim to unmask, to reveal illusions, to "interpret" the patient's underlying aims and assumptions as more primitive or infantile than he realizes. Rather...it aims to expand his conscious experience of himself, to show there is more to him than he has thought (p. 193).

Wachtel advocates an affirmative stance with a chief aim being the enhancement of the patient's self-acceptance. Too often, Wachtel contends that the ways therapists attempt to acquaint patients with what they have warded off leads them to use stilted, artificial language that contains implicit criticism that the patient is misbehaving in some way by defending and resisting. We refrain from being too directly supportive, praising or encouraging, lest we step out of the therapeutic box drawn for us by the default position. 

The clinically oriented latter part of the book presents helpful examples of the ways in which all of us in our everyday work find ourselves unintentionally criticizing patients and undermining their self-esteem, as elements of the default position subtly find their way into our work.  Wachtel highlights the therapist's supportive approach in providing the necessarily conditions of comfort or safety to approach and integrate aspects of self that have been split off and repudiated. A particular strength is Wachtel's focus on the language of psychotherapy (also helpfully discussed at length in a previous volume (Wachtel, 1993)). For instance, in discussing the way dynamic therapists can help patient's more deeply process anxiety provoking material and desensitize their fears, Wachtel suggests formulating questions in ways to encourage patients to expose themselves more fully to what makes them anxious, with the assumption that only by such exposure can anxiety be overcome. Asking patients to try to "picture" an experience, or put themselves back in a situation, or to elaborate what it feels like to experience something conflictual can bring them to "full experiential contact with the avoided thought, wish, affect, or experience of self or other" (p. 207).   In this way, Wachtel seamlessly integrates the exposure paradigm of behavior therapy into treatments that are dynamic and exploratory.

Though there is much to admire and usefully apply clinically, at times Wachtel's critique of the default position prevents him from productively understanding the presence of such seemingly regressive attitudes.  I've found it striking how beginning therapists often gravitate to a critical, depriving and distant therapeutic stance though they have not been instructed to do so.  I've come to believe the anxiety provoking process of becoming a therapist, especially in the earliest phases, leads us to withdraw, become critical of patients, and close off the exploration we believe we want to pursue.  Wachtel says too little here about the therapists' own fears and how clinical work brings them to the fore.  Theory is one way therapists manage and control those aspects of our work that elicit uncomfortable experiences(Friedman, 1988).  It is not surprising then that in spite of the relational approach's promise of less rigid treatment, older technical models persist.  Even aspects of a progressive approach may at times serve the analyst's resistance to therapeutic work (see, for instance, Hirsch, 2008).

Still, this book encourages me about the future of psychoanalysis.  It suggests that the eclectic curiosity, and open-mindedness Wachtel exemplifies can lead us to a more patient-centered, humane and integrative psychoanalysis.

 

REFERENCES

 

Friedman, L. (1988). The anatomy of psychotherapy. Hillsdale, NJ: The Analytic Press.

Hirsch, I. (2008). Coasting in the countertransference. New York: The Analytic Press.

Jurist, E. L. (2010). Elliot Jurist Interviews Peter Fonagy. Psychoanalytic Psychology, 27, 2-7.

Kernberg, O.F. (1996). Thirty Methods To Destroy The Creativity Of Psychoanalytic Candidates. Int. J. Psycho-Anal., 77:1031-1.

Miller, N. E., Sears, R. R., Mowrer, O. H., Doob, L. W., & Dollard, J. (1941).  I. The frustration-aggression hypothesis.  Psychological Review, 48, 337-342.

Renik, O. (2006). Practical psychoanalysis for therapists and patients.  New York: Other press.

Wachtel, P.L. (1977).  Psychoanalysis and behavior therapy. New York: Basic Books.

Wachtel, P. L. (1997). Psychoanalysis, behavior therapy and the relational world. Washington, DC: American Psychological Assocation.

 Wachtel, P. L. (1993). Therapeutic communication. New York: The Guilford Press.

Wachtel, P. L. (2008). Relational theory and the practice of psychoanalysis. New York: The Guilford Press.

 

© 2011 Robert Cohen

 

Robert Cohen, Ph.D. practices psychoanalysis with adults and psychotherapy with adults, children, adolescents and couples in Ann Arbor.  He is associate professor of psychology at Madonna University and Director of Supervision and Training for the University's Masters of Science in Clinical Psychology Program and the Madonna University Psychological Services Clinic.


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