The Concept of Generic Psychotherapy The Concept of Generic PsychotherapyA theory of normal psychological development provides the context into which theories of illness and of therapeutic action can be set. If one does not have a sense of what is considered normal it is impossible to delineate what would be considered pathological. The most comprehensive model of development that I know of is Ken Wilber's "full-spectrum" model of growth and development. Probably the best place for the reader to begin to get into the richness and complexity of Wilber's thought would to start with Transformations of Consciousness (Wilber, Engler, & Brown 1986). A basic idea put forth in this book is the distinction between treating "hysterical" symptoms and treating "common unhappiness". The distinction comes from a famous quote from Freud which appears at the end of Studies in Hysteria where Freud says:
When I have promised my patients help or improvement by means of a cathartic [early psychoanalytic] treatment I have been faced by this objection: 'Why, you tell me yourself that my illness is probably connected with my circumstances of my live. You cannot alter these in any way. How do you propose to help me then.' And I have been able to make this reply: 'No doubt fate would find it easier than I to relieve you of your illness. But you will able to convince yourself that much will be gained if we succeed in transforming your hysterical misery into common unhappiness. With mental life that has been restored to health you will be better armed against that unhappiness. (Studies on Hysteria written with Josef Bruer in 1893. SE Vol. 2 p. 308)
Thus, Freud's view of cure using psychoanalysis, all be it a major undertaking, was quite circumscribed. Indeed, Western psychology is only a truncated view of human development which offered no hope of treating common unhappiness. Psychologies of higher consciousness, i.e. Buddhism offer, the prospect of transcending common suffering. Indeed, Freud pathologized higher states of consciousness, confusing them with regressive oceanic states. He fell into what Wilber calls the "pre/trans fallacy":
This brings us to Wilber's full spectrum model. Wilber states:
Wilber gives three major components:
His idea of basic structures comes from what has been called the Great Chain of Being. Different versions of this idea give different numbers of structures, i.e. matter and spirit, or matter, mind body, and soul. Wilber gives ten basic structures:
(The above list was taken from Wilber in Wilber, Engler, & Brown 1986, p. 69-74.)
Wilber goes on to explain the distinction between the basic structures, outlined above, and transition states of self development:
Spelling out the implications of Wilber's model is a major undertaking. However, considering higher the stages of development that he outlines broadens our view of human development and gives the possibility of positive psychological health as contrasted to health being an merely the absence of pathology.
Generic psychotherapy seeks commonalties about the causes of psychological dysfunction which are considered by the various therapeutic orientations. It is important to keep in mind the distinction between nosologies (classifications) of illness, such as the Diagnostic and Statistical Manual of Mental Disorders DSM IV which does not purport to catalogue causes of illness, and theories of the causes the disorders. When one approaches the study of theories of illness sorting out the layering of classification and process becomes essential. A diagnosis emerges from relating clusters or syndromes of internally felt (symptoms) and/or externally observed (signs) to frequently observed patterns of disorder. The signs and symptoms of the dysfunction are what is seen on the surface. The theories are efforts to relate the felt and observable patterns to some underlying process which give rise to them. Diagnoses are not treated, people are. We do not treat an obsessive compulsive or a depression. We do treat a patient who happens to be feel depressed, or who gets caught up in compulsive rituals. Thus we start with the patient's complaint. Then we try to figure what is producing the complaint. That is, what underlying or overriding processes are at work which emerges as the complaint, or in many cases the complaints. Some important theories of illness are:
Genetic and or congenital factors are very important factors which have to be seriously considered in the understanding of any psychological disorder. An in depth exploration of genetic or congenital conditions is beyond the scope of this psychological approach. However, helping the patient or client adapt to the limitations and redefine the meaning of organic limitations is a central part of psychotherapy.
As with genetic and congenital factors, organic dysfunction has to be recognized and given its full and due consideration in the understanding of the impact that it has on psychological functioning. The study of organic illnesses is beyond the realm of this work. Nevertheless, working with the patient to adjust to the particulars of organic impairment is very much part of a psychotherapeutic intervention, i.e. coming to terms with ones physical limitations after a heart attack.
Just as it is necessary to thoroughly take into account organic factors, it is recognized that each of us functions in a cultural surround. No individual can be adequately understood without a deep appreciation of his or her cultural roots. However, cultural concerns is not a central focus of generic psychotherapy. Indeed one of the goals of a generic approach is to find a set of theories which is global and cross cultural. This search does not deny the richness, complexity, and importance of cultural diversity. After all, there is a set of basic human functions which is expressed differently in the various cultures. Thus, I am trying to differentiate the cultural stylistic differences from the essential psychological processes. This is like the function argument distinction. For example, the function addition requires two arguments, i.e. 2,3. Psychologically, the function self esteem regulation calls for a cultural argument, i.e. machismo. Machismo may be considered normal and healthy in one culture and hugely dysfunctional in another. This gets us into the issue of cultural relativism. Nonetheless, the cross cultural function of self esteem regulation operates regardless of the specific cultural values by which it is expressed. Loosing sight of the logical level distinction between the function and its argument can be the cause of much confusion and controversy.
The most fundamental definition of trauma that I know is Freud's conception of ego overload. The essential idea is that the ego is being continually bombarded by stimuli. The ego acts as a "reducing valve" which regulates the felt intensity of the stimulation. When the intensity of the stimulation threatens the integrity of the ego the situation is felt as being traumatic. In classical psychoanalytic theory the stimuli may come from the outside in the form of environmental stimulation. In addition there are internal forms of stimuli which come from the instincts, especially sex and aggression. In self psychological terms, when the cohesion, stability and/or positive affective coloration of the sense of self (Stolorow & Lachmann, 1980) is breached, the self is threatened, and some kind of defensive reaction is made. By this definition there is a whole range of intensity of trauma. Maxi trauma include life threatening situations of wars, natural disasters, and serious physical or sexual abuse. Less obvious trauma include a whole range of personal hurts which are felt as threats to feeling good about oneself (narcissistic injury). It is also possible to be traumatized by the intensity of ones own rage or sexual impulses. These responses are often complicated by moral injunctions against aggressive and sexual actions. Nevertheless, the power of a wish to kill a parent or a child may have all the psychological impact of being threatened with ones own death. Repression of these impulses and or memories is an important source of symptom formation.
It is important to note that development often does not proceed equally across the whole range of physical-intellectual-social-emotional-vocational development. i.e. One can have a serious genetic handicap and yet develop high levels of intellectual capabilities. There are spiritual leaders that have incredible psychic powers, but who have difficulties with intimate personal relationships. Although genetic, organic, cultural, social, economic, and traumatic factors may distort development, a serious class of developmental derailments emerge from repeated empathic failures that parents impose upon their children. Alice Miller's Drama of the Gifted Child (Miller, 1983) chronicled the subtle abuses that children suffer at the hands of their parents' narcissism. An important developmental sequence has to do with the child having to adapt to the parent's needs. Normally it is the parent who has to be empathic to the child's needs. Unfortunately, parents frequently have unresolved needs of their own and require their children to provide them with emotional support. In order to maintain the bond with the parent, the child sets its own needs aside and learns to accommodate to the parent.
Thus the child either rebels at the cost of straining the bond with its caretakers, or develops "structures of pathological accommodation" where "sequestered nuclei of an archaic self are preserved in conflict with, or in isolation from, the unresponsive self objects" (Brandchaft, 1988 p. 135) In simpler language, the child splits off from its authentic self and tries to please the parent by giving the parent what he or she needs--at the cost of its own legitimate needs.
The notion of pathologies coming from excessive agency or excessive community come from Wilber's ideas about holons. Briefly, a holon is a whole which is part of larger wholes and in turn contains smaller wholes. For example I feel myself to be a separate reasonable autonomous individual. However, I am part of a family which is part of a community. I am also aware of having parts of myself--my body, my thoughts etc. I can believe that I am so independent that I can disregard the concerns and feelings of the people that are close to me. This could produce a macho, or strong silent type mentality, which might be considered a pathology of too much autonomy. The women's movement has been eloquent in raising our consciousness to these patterns of relating Jordan et al 1991. Conversely, codependency is excessive community. That is, excessive reliance on a family member, typically a spouse, to provide a sense of self cohesion, stability, and positive feeling about oneself. In simple language the person is overly dependent and becomes seriously destabilized when their partner does not provide them with a strong calming presence.
One of the best examples of state shifting is viewing an ambiguous figure.
Consider the Necker Cube. . . 
As you look it is likely that you see the figure going either up to the left or down to the right. When you see it one way it is impossible to see it the other way. The one view locks out the other. There is a tendency to get stuck in one of the views. Life is a grand ambiguous figure that we are continuously trying to organize into meaningful configurations. There are clear adaptive advantages to being able to form stable views. When you are driving down the road you want to have clear stable vision. Indeed, we become frightened when our percepts shift unaccountably or uncontrollably. However, if your view did not get updated rapidly you would quickly be in danger because you might be out of touch with changes in the external reality. Similarly we tend to have specific views of the people close to us. As we develop we may not update our views to reflect what is happening currently.
The following list is at the core of generic psychotherapy. These are the basic concepts which can be found across the various therapeutic modalities and orientations.
Undoubtedly the most important factor in any kind of psychotherapy is the relationship. What is meant by the term "relationship" and how it has a therapeutic efficacy are crucial questions. At best, coming for treatment is something of an insult because there has been some difficulty with the usual way the patient has been handling his or her life. Essentially the patient feels that a relationship is established when the patient feels and believes that it is safe to disclose and explore aspects of his or her self that are painful, and/or troublesome. Building a relationship implies creating a safe space where the client can reveal more and more of his or her authentic self. Fundamentally, the relationship has to do with being in contrast to doing. It is not so much what is done to or with the patient that is important, but it is the quality of connectedness which permeates the relationship. In order for this to happen the therapist has to suspend his or her own concerns and focus empathically on the client. Empathy has been called "vicarious introspection". This requires the therapist to be open to the patient and tune into the patient's inner experience and nuance of meaning. This process enables the therapist to furnish profound understanding of the client's plight. The therapist's understanding validates the patient's value as a person who is genuinely suffering. It is very supportive and reassuring to have someone truly fathom your struggle. The very act of comprehension conveys a sense of competence. The patient gets the feeling that at last I have found someone who hears and believes me. This experience is reassuring and imparts a sense of hope. In its best form a sacred space is created in which the therapy pair can relate to each in an I-Thou rather than in an I-It manner.
Just what the therapeutic efficacy of the relationship is a major question. There is nothing new to the insight that compassion and love are healing. Something positive happens when two people connect in a caring way. There is a distinction between healing and therapy. Healing is a natural process. The healer provides conditions under which homeostatic and growth processes can flourish. Therapy has much more to do with technical intervention which is directed to the mechanisms of the dysfunction. Lawrence LeShan made a contrast between the gardener and the mechanic. The gardener cultivates organic growth. The mechanic repairs broken parts. There is a major distinctions between the therapies which make the relationship (the transference) a major focus, the psychoanalytic therapies, and the behaviorally oriented therapies which are more symptom focused. In the behavior therapies once the relationship "is established" it recedes into the background and attention is centered on changing specific troublesome behavior patterns. In the analytic therapies the relationship, or more technically, the unfolding of the transference, is fundamental. The objective is to establish conditions in which earlier relationship patterns reemerge directly in the experience of relating to the analyst.
Kohut stated "...the basic therapeutic unit of psychoanalysis [consists] of the two steps understanding and explaining" (Kohut 1984 p. 102). Clearly, if the therapist fails to understand and/or can not convey his or her understanding in terms
that are meaningful to the patient the therapeutic process will founder. Relationship is crucial but insufficient. In Bettelheim's words, "Love is not enough". Indeed, understanding and explanation help to create the relationship itself. The therapists understanding is what guides the therapeutic interventions. Explanation is a broader concept than interpretation. Interpretation, in the narrower sense, has to do with pointing out unconscious thoughts and wishes. Explanation covers a much wider range which can include all kinds of cognitive restructuring.
Desensitization covers a broad range of problems that people bring to therapy. One of the most essential dynamics in symptom formation are the defenses erected against pain, memory of pain, and or anticipation of pain. Here pain is being used in the most general sense, physical pain, fear, anxiety, depression, shame, etc. Most people operate on the pleasure principle where they try to maximize pleasure and avoid pain. Thus a major goal of therapy is to help patients learn to relate to their pain differently. There is an important distinction between pain and suffering. There is no way to go through life without experiencing pain at times. Suffering is the meaning that is given to pain. If I have a pain in my left arm, I can think it is from working out too vigorously, and not be concerned about. I have the expectation that it will pass of its own accord, and I don't pay much attention to it. If I think that it is referred pain from my heart and that I am having a heart attack, my reaction is likely to be one of alarm and great concern. The sensation of the pain, itself is the same. The meaning is very different. My suffering is much greater in if I think I am having a major illness. So a major aspect of desensitization is altering the meaning that the client gives to his or her pain. What has to be done in order to alter the meaning is a major therapeutic issue.
An important class of interventions has to do with exposure and response prevention. This approach is most clearly worked out by the behavior therapists. Treatment of the phobias provided the simplest and clearest examples. If a patient has a germ phobia and has the compulsion to wash his or her hands after any possible exposure to germs, then the patient is brought into contact with a germ laden object. The response of washing hands is blocked and the patient is instructed to remain with the anxiety that is generated when he refrains from washing. If the patient is willing to comply with this procedure, he finds that his anxiety dissipates after a while even though he does not wash his hands. This process of exposure to the dreaded stimulus and preventing oneself from responding in the symptomatic manner has the effect of desensitizing the patient to the feared object.
The procedure of exposure and response prevention is found in other kinds of therapy, although it is called by other names. In classical psychoanalysis the patient is instructed to free associate. The patient is told to lie on the couch, turn his or her attention inward, and tell the analyst exactly what is happening as it is occurring. Freud would tell his patients, "We are on a train together. Your have the window seat. Describe the passing scene to me". Freud did not believe that the associations would simply be a stream of random gibberish. Rather as the patient's defenses let down the underlying drives and wishes would start to assert themselves. Classical psychoanalytic theory is based on the notion of a conflict between the repressed sexual and or aggressive instincts and the prohibitions against expressing them. Avoiding germs, snakes or horses, has to do with avoiding external things. It is easy to see if the patient is approaching the dreaded germs. A more difficult case is to create conditions in which the patient faces his own sexual or aggressive impulses. There are two aspects concerning facing internal fears. One, admitting them to oneself, and two, admitting them to the analyst. Thus as the patient was free associating there would be blocks in the flow of associations. The patient would fall silent, or would engage in any one a great variety of resistances (anything that would distract him or her from truthfully reporting the immediate flow of what is coming into awareness). The explanation of the resistances is that something would emerge into consciousness and disturb the patient. The patient would have a conflict about admitting it to himself, and/or the analyst. The patient might then drive it out of awareness immediately, and repress or deny that it happened. Or the patient might do any one of a great number of things to divert attention from the troublesome thought, image, emotion, and or bodily sensation. In any case the outcome would be a break in the unrestricted flow of associations. This was a signal for the analyst to step in. The analyst might just note that there has been an interruption, or possibly make an interpretation about what he thought the patient may be reacting to that caused the disruption. All of these technical maneuvers were designed to help the patient become exposed to the feared material. And if the patient were able to continue the free association, the very act of free associating would in effect prevent the defensive response. Thus in a psychoanalytic framework we have exposure and response prevention, which has the effect of desensitizing the patient. The patient then has a choice of how to respond. He or she does not have to react in previously automatic and often unconscious ways. In learning theory terms, the link between the stimulus and the response is altered.
Exposure and response prevention is brought to an elegant height in a vastly different tradition, Buddhist mindfulness meditation. In this tradition the instruction is stark--just sit and allow yourself to observe whatever comes to consciousness, and simply witness what happens without trying to change or alter it in any way. Like free association this is very easy instruction to give and an extremely difficult one to follow. One of the great differences between mindfulness meditation and free association is that what happens in the mindfulness practice is not immediately told to the analyst. The meditator is much more on his or her own and does not get the immediate kind of feedback that is possible in analysis. Further, it is easier to avoid the conflicts about sharing the details of his experience with some one else. Of course the meditator has to deal with the teacher, but scrutiny of the relationship is not central to the process as it is in the analysis of the transference in psychoanalysis. In addition, the typical meditation teacher is not trained in analysis of resistance. So like any other approach, it has a limited range of applicability. To truly follow mindful practice requires great discipline and ego strength, qualities that many patients who come to treatment do not have. It is a very powerful practice. All distractions are removed and one is faced directly with the range and intensity of his or her inner condition. That is, one is focused in his or her inner states of being. The meditator comes to see how thoughts, feelings, and bodily sensations arise and pass away. He or she is repeatedly exposed to painful experiences, but he does not act to make the pain go away. Thus, this procedure is a pure form of exposure and response prevention. Although being mindful can and should be carried over into practical daily living, solo meditation practice is different from living in the rough and tumble of intimate relationships, and of the frustrations of many practical worldly affairs. A possible danger is that one will retreat into spiritual practices as a way to bypass troublesome unresolved developmental tasks, i.e. intimate committed relationships, and/or a stable career.
A generalization from this is that exposure and desensitization is rather situation specific. One can achieve blissful inner states, but become rattled by the demands of a unsympathetic boss or spouse. The Buddhists claim that it is possible to achieve a state which transcends the usual kinds of state specificity. This is a beautiful ideal and, but I have yet to meet such a realized person.
The meaning that we give to a thought, an event, a relationship, a wish, etc. has a profound effect on how we will react to it. For example, a patient who is subject to panic attacks thinks when his heart begins to pound thinks that he is having a heart attack. Thinking that he is in the midst of a fatal catastrophe, his heart begins to beat even harder and he starts to hyperventilate, sweats and gets dizzy. He thinks his demise is at hand. He rushes to the cardiologist, is examined, and his heart is found to be in good condition. The doctor says, "There is nothing the matter with you, it is only your nerves". The doctor reframes the situation. The meaning that the patient was giving to his symptoms is restructured from a fatal illness to a psychological reaction. A referral is made to a psychotherapist. Exploration with the therapist reveals he has become excessively vigilant to his own physiological reactions. He has developed a positive feedback loop. The thoughts that he has about his bodily sensations (their meaning) is that there is something terribly wrong with him. This thought frightens him, and the thought in turn intensifies his somatic reactions. The cognitive restructuring helps the patient to reinterpret his physical sensations. The patient learns to say to himself, "When my heart beats hard it does not mean that I am getting a heart attack". The discussion of servo systems indicated that the referent controls the output of the system. In psychological terms, as he comes to realize that he is not in danger, his physiology quiets down. The psychotherapist may then help him to see that bodily reaction was in response to an unconscious conflict rather than a heart attack.
The above example is a very simple circumscribed specific symptom focused situation. Actually cognitive restructuring is a major aspect of most forms of psychotherapy. How we think about ourselves, others, our jobs, etc. etc. occupy us most of waking hours. These thoughts can bring about intense emotional reactions. The ideas frequently structure what we regard as real and important. Most of us are deeply identified with our thoughts and with the way that we think. Thus altering the way that we think changes the way we react to our view of ourselves and of the world.
Making the unconscious conscious is a major focus of psychoanalysis. In Freud's early formulation he equated the id with the unconscious and gave his famous directive "where id was, there ego shall be" (Freud, 1933, SE:1953 vol. 22 p. 80). More generally however, if you are unaware of something it is not possible to deal with it effectively. So the notion of making the unconscious conscious has extensive applicability. What is meant by the term--unconscious is an important issue. Wilber (1980) gave five kinds of unconscious:
The most difficult form of making the unconscious conscious has to do with treating the submergent-unconscious. This is the dynamic unconscious, Ucs. In this case the thought, wish, or impulse is locked out of awareness by a conflict which results in the sustained repression of the thought, wish or impulse. Returning a repressed thought to consciousness involves much more than merely pointing out something to the patient. In Freud's schema if something were preconscious it could readily be brought to consciousness by making an deliberate effort to retrieve it. On the other hand, if there were repression the material is forced into the system Ucs. Simply refocusing attention and trying to recall the material would not bring it to awareness. An interpretation and/or working through the resistances which are engendered by conflicts which produced the repression in the first place is necessary. However, simply trying to make the unconscious conscious is generally insufficient. Freud's famous dictum, "Where there is Id let there Ego be", did not address many important issues, i.e. structural deficits.
As indicated above in Wilber's classification there are levels of consciousness which go beyond the range of awareness that is ordinarily addressed in Western psychology. Helping make the emergent-unconscious conscious has been the role of the spiritual disciplines. However, sometimes these levels do emerge and there is a growing interest in the spiritual development. Not pathologizing the higher levels nor confusing them with the prepersonal developmental levels is important. An important interface between psychotherapy and spiritual practice is mindfulness training. Mindfulness is sustained open awareness of whatever is happening at the moment. At least initially, mindfulness work is not so much making the unconscious conscious as it is making the conscious conscious. Most of the time we are thinking about our experience rather than simply experiencing it directly. We are often lost in thought and running "on automatic". Thus, we are not actually conscious of the is-ness of what is happening. Learning focus of attention and sustaining mindful choiceless awareness is an important gateway to enable the emergent-unconscious raise to awareness.
Literally catharsis means to purge. Psychologically, it has to do with vigorously letting out of feelings. Very simply, getting something off of my chest makes me feel better. The notion of catharsis is related to abreaction which is the process of releasing repressed memories and their associated feelings. This process releases pent up feelings, and restores a sense of equilibrium. Although "getting it out" leaves one feeling relieved, the long term therapeutic effect tends to be limited. A very good example is of pent up anger. Freud in his metapsychological paper on repression indicated that strictly speaking affects are not repressed. When we do not feel an affect it is simply un-activated. It is not repressed, and is not pent up. More accurately what is repressed are memories and wishes. If one has truly repressed memories or conflictual events, becoming aware of the memories and the feelings associated with them can be extremely helpful. Experiencing the memories and the feelings associated with them gives one a sense of release, relief, and of being rebalanced. It is my impression that what is the more lasting therapeutic ingredients in abreaction have to do with acceptance, and exposure and response prevention. An empathic therapeutic relationship expands the domain of what is considered safe and acceptable. The therapist is seen as a strong accepting presence who can tolerate disturbing thoughts, wishes, and affects. The therapist encourages the patient to move toward painful memories and affects. . Often patients are afraid of either spinning out of control or of getting stuck in a painful affect state. So they do not want to approach the dreaded matters. The therapist's sustaining acceptance and interpretation of the conflict and anxiety laden material encourages the patient to allow experience here-to-fore repressed of suppressed memories, wishes, and feelings. Finally, the patient allows the full intensity of the feared or previously unacceptable thoughts and feelings. Seeing that he or she is able to tolerate the intensity of the affect and that it dissipates rather escalates out of control, enables the patient to move toward and through the discomfort rather than away from it. Also realizing that the therapist is able to accept the outburst reassures the patient that he or she is an acceptable person who can has the strength cope with the conflict. Thus, the catharsis per se is part of a much larger process. Unfortunately, there is a tendency to focus on the drama of the catharsis rather than the patient work which creates the conditions for it to happen.
Much has been said about the efficacy of "getting out feelings". This is especially true when it comes to expressing anger. There is the concern about getting high blood pressure or some other symptom if the anger is held in. Indeed, an important theory of depression is that it is anger turned on to oneself. Although repressed anger may result in various symptoms, and the expression of the anger relieves the symptoms, I believe that the value of "catharting" the anger is often over rated. First, the experience of getting extremely angry can be traumatic. Many patients are disturbed by the intensity of their own anger. Even though at times it can be a relief to express anger, getting angry and sustaining anger is clearly a stress. It is very important to be in touch with ones anger and to know how to appropriately assert oneself. Knowing that you feel angry is crucial--expressing it is a matter of judgment. In cases of chronic anger the issue is much more what continues to generate the anger, than the catharsis of the anger itself. One can be angry forever without ever coming to terms with what is leading one to feel so irate. Thus, catharsis my help one feel better but the effect of the catharsis is likely to only be temporary.
The idea of optimal frustration and transmuting internalizations comes from Heinz Kohut's work on restoring the self. :
He gives a three step progression in treatment:
These steps require some elaboration. the first step has to do with what the psychoanalysts call establishing "the transference". There is a distinction between establishing rapport and establishing a transference. Rapport is a feeling of comfort and confidence that one develops with the therapist. The rapport may be rather superficial and have more to do with the likeability and/or charisma of the therapist than with a reactivation of the patients earlier modes of relating. When a transference is soundly activated, the patient's psychological state and mode of relating shifts from adult patterns to earlier varieties. (1) The therapist is no longer thought of as merely being a helpful person, and something special happens in the relationship with the analyst. Earlier longings, hopes, and fears emerge with some intensity. The patient wants something from or with the analyst. Love, protection, support are yearned for, (2) but the analyst does not actually provide what the patient seeks. This failure to give the patient what the patient wants is the frustration that Kohut discusses. (3) However, the analyst recognizes the patient's desires, understands their importance, and is able to respond empathically to the patient's wishes and needs. For example, the patient expresses upset at the thought that the therapist is going away on a vacation. The patient's wish is that the therapist not abandon him. The therapist does not forego his vacation, and thus frustrates the patient. However, the therapist understands how seriously upsetting his absence will be for the patient, and the situation is discussed fully. The process of (1) going through the frustration, and (2) of being understood, and of having his feeling validated, (3) enable to patient to be more accepting of his own concerns in part by making the therapist's compassionate exploration of his feelings part of his own repertoire for soothing himself (the transmuting internalization).
Kohut goes on to explore the issue about whether the structures are new or whether they the treatment simply rehabilitates structures that were present from childhood. Essentially he says that it is unlikely ;that structures are created
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