Generic Psychotherapy

Philosophy & Structure

William Dubin, Ph. D.

The Concept of Generic Psychotherapy

A metaphor underlying the concept of generic psychotherapy is the distinction between a brand name drug and the generic compound or compounds of which it is composed. The basic aim of generic psychotherapy is to find the essential active ingredients in each form of psychotherapy. It is my hope that a manageably small set of fundamental parameters can be found that be can be used to explain the therapeutic action across the various brands of psychotherapy. What is being explored are the commonalties which operate in the various therapies. Brand names can be thought of as -- behavior therapy, psychoanalysis, interpersonal psychotherapy, etc. etc. The generic elements have to do with the varieties of therapeutic relationship, specific technical interventions like, reflection, interpretation, desensitization, and so forth. There are other efforts similar to the set of basic concept being put forth in generic psychotherapy. These movements have been called "technical eclecticism", "theoretical integration", and "common factors".

Theoretical integration involves a commitment to a conceptual or theoretical creation beyond a technical blend of methods. The goal is to create a conceptual framework that synthesizes the best elements of two or more approaches to therapy. Integration, however, aspires to more than a simple combination; it seeks an emergent theory that is more than the sum of its parts, and that leads to new directions for practice and research (Norcross & Goldfried, 1992 p. 11-12).

The common factors approach seeks to determine the core ingredients that the different therapies share in common, with the eventual goal of creating more parsimonious and efficacious treatments based on those commonalties. This search in predicated on the belief that commonalties are more important in accounting for therapy outcome than the unique factors that differentiate among them ( p. 13)

For an extensive review of these concepts see Norcross & Goldfried, 1992 .

The question then arises as to how the notion of generic psychotherapy differs from eclecticism, integration, and common factors. Clearly, there is much overlap. However, I think of generic psychotherapy as a basic science of psychotherapy. An important emphasis has to do with how to think about the various concepts found in psychotherapy, and about how to relate them to basic thought that runs throughout science. These modes of thought leads one to both bottom up reductionism, and a to top down transpersonal world view. The meta concepts begin to provide a kind of theory about theories. The interest is in the essential experiences that all therapists see. A basic thrust is to help therapists remove the filters of their theories and move to a more immediately direct of experience of what is happening in the treatment. The various theories chunk the clinical experiences together differently. Rather than treating symptoms as an emphasis generic psychotherapy is more concerned with what clinical operations help a patient open up; what helps the patient alter his or her relation to whatever he or she may be experiencing. The particular content or the specific symptom is less central than how the patient relates to their experience. The focus shifts from a nosology of illness and a treatment armamentariun to experience centeredness. This does not mean that one discards conceptual maps, but it does mean that one does not act as if the maps were reality itself.

Some navigational aids are needed to help find ones way in the complex landscapes of the various realms of psychotherapy. These aids can take the form of a set of fundamental concept which begin to define the dimensions of psychotherapy space.

There are several basic considerations to help order ideas in the domain of psychotherapy. But first it should be noted that in keeping with the philosophy of these pages, which is a work that continues to evolve, these are not exhaustive or definitive lists. They are subject to your additions and corrections, and most of all we need your examples of applications of the concepts. So please read and respond.

Theories of Development

A 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). In important concept in Wilber's model is that the Western psychology only provides a limited view of human development. Both Eastern and Western spiritual traditions describe the development of consciousness beyond mental and rational thought to spiritual intuitive knowledge. A basic idea put forth in his book is the distinction between treating "hysterical" (neurotic) 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 life. 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 early view of cure using psychoanalysis, all be it a major undertaking, only addressed symptom relief. It did not address the broader issues of pervasive human suffering. Indeed, Western psychology as a whole offers only a truncated view of human development which offered little hope of treating common unhappiness. Psychologies of higher consciousness, i.e. Buddhism, offer, the prospect of transcending common unhappiness.Unfortunately, Freud pathologized higher states of consciousness, confusing them with regressive oceanic states. He fell into what Wilber calls the "pre/trans fallacy":

A major therapeutic confusion among various theorists stems from what I have called the "pre/trans fallacy" (Wilber 1980) which is confusing of pre-rational structures with trans-rational structures simply because both are non-rational. This confusion runs in both directions: pre rational structures (phantasmic, magic, mythic) are elevated to trans-rational status (e.g., Jung), or trans-rational structures are reduced to pre-rational infantilisms (e.g., Freud). It is particularly common to reduce samadhi (subtle or causal subject-object identity) to autistic, symbiotic, or narcissistic-ocean states. Likewise Atman, the one universal Self, is confused with the monadic-autistic ...self. ...In my opinion, such theoretical and therapeutic) confusion will continue to abound until the phenomenological validity of the full spectrum of human growth receives more recognition and study.

This brings us to Wilber's full spectrum model. Wilber states:

I have...attempted to develop an overall or spectrum model of psychology, one that is developmental, structural, hierarchical, and systems-oriented, and that draws equally on Eastern and Western schools. Vis-à-vis psychopathology the conclusion I reached was that the spectrum of consciousness is also a spectrum of (possible) pathology. If consciousness develops through a series of stages, then a developmental "lesion" at a particular stage would manifest itself as a particular type of psychopathology, and an understanding of the developmental nature of consciousness--its structures, stages, and dynamics--would prove indispensable to both diagnosis and treatment (Wilber, Engler, & Brown, 1986, p. 66).

Wilber gives three major components of development:

  1. The basic structures.
  2. The transition stages.
  3. The self-system.

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:

  1. Sensoriphysical -- the realms of matter, sensation and perception
  2. Phantasm-emotional -- the emotional-sexual level (the sheath of bioenergy, élan vital, libido, or prana...and the phantasmic level (Arieti's term for the lower or image mind, the simplest form of mental "picturing" using only images).
  3. Rep-mind -- the "representational mind" or Piaget's preoperational thinking ("preop"). There are two stages, symbols and concepts. An image represents an object pictorially. A symbol can represent it non-pictorially or verbally. A concept is a symbol which represents a class of objects or acts.
  4. Rule/role mind -- Piaget's concrete operational thinking. "Conop" can begin to take the role of others, and con perform rule operations like multiplication division, class inclusion, etc.
  5. Formal-reflexive -- Piaget's formal operational thinking. "Formop" can not only think, but it can think about thinking. Thus it is capable of self-reflexive and introspective thinking as well as hypothetico-deductive or propositional reasoning, i.e. if a , then b.
  6. Vision-logic -- Thinking beyond formal operational thought -- dialectical, integrative, creative synthetic, etc. The formal mind establishes relationships, vision logic establishes networks of those relationships. Just as formop "operates on" conop, so vision-logic "operates on" formop. ... Thus is the beginning of truly higher order synthesizing capacity, of making connections, relating truths, coordinating ideas, integrating concepts. In Wilber's view the highest integrative structure in the personal realm; beyond it lie transpersonal developments.
  7. Psychic -- ... the beginning or opening of transcendental, transpersonal, or contemplative developments: the individuals cognitive and perceptual capacities apparently become so pluralistic and universal that begin to "reach beyond" any narrowly personal or individual perspectives and concerns. According to most contemplative traditions, at this level an individual begins to transcend them.
  8. Subtle -- The subtle level is said to be the seat of actual archetypes, of Platonic Forms, of subtle sounds and audible illuminations, of transcendent insight and absorption.
  9. Causal -- The causal level is said to be the unmanifest source or transcendental ground of all the lesser structures.
  10. Ultimate -- Passing fully through the state of cessation or unmanifest causal absorption, consciousness is said finally to re-awaken to its prior and eternal abode as absolute Spirit, radiant and all-pervading, one and many, only and all -- the complete integration and identity of manifest Form with unmanisfest Formless. ... Strictly speaking the ultimate is not one level among others, but the reality, condition, or suchness of all levels.

(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:

A simple metaphor may be useful to explain this distinction. The basic structures themselves are like a ladder, each rung of which is a level in the Great Chain of Being. The self (of the self-system) is the climber of the ladder. At each rung of that climb, the self has a different sense of identity, a different type of morality, different set of self-needs, and so on. These changes in the sense of self and its reality, which shift from level to level, are referred to as transition structures, or more often as the self-stages (since these transitions intimately involve the self and its sense of reality.
Thus, as the self climbs from say, rung 4 to rung 5, its limited perspective at rung 4 is replaced by a new perspective at rung 5. Rung 4 itself remains in existence, but the limitations of its perspective do not. This is why the basic structures of consciousness are more or less enduring structures, but the self stages are transitional, temporary, or phase-specific (Wilber, Engler, & Brown, 1986 p. 76).

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.

Theories of Illness

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 Disorders

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.

Organic Disorders

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. An important area has to do with learning to recognize the distinction between errors in brain functioning and the efforts to cope with them. For example, some depressive disorders may have to do with mood alterations which are the result of faulty serotonin uptake. Learning to separate the depressed mood itself from seeing the mood as an indication of self worth (I am no good because I get depressed so often.) is very much the province of psychotherapy.

Cultural Constraints

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. However, 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 (2 + 3 = 5). Psychologically, the function self esteem regulation calls for cultural arguments, i.e. machismo. Machismo may be considered normal and healthy in one culture and hugely dysfunctional in another. Nonetheless, the cross cultural function, 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. In this case, self esteem regulation (the function) is seen in all cultures. The particular values and attitudes which are highly regarded (the argurments) may change from one culture to another.


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 stimuli which come from the inside, the instincts, sex, aggression, and the instincts of self preservation. 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.

Developmental Derailments

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.

Every phase in a child's development is best conceptualized in terms of the unique psychological field constituted by the intersection of the child's evolving subjective universe with that of its caretakers....Pathogenesis, from this intersubjective perspective, is understood in term of severe disjunctions or asynchronies that occur between structures of subjectivity of parents and child, whereby the child's primary developmental needs do not meet with requisite responsiveness from (self) objects. When the psychological organization of the parent cannot accommodate the changing phase specific needs of the developing child, then the more malleable and vulnerable psychological structure of the child will accommodate to what is available. (Atwood & Stolorow, 1984, p. 69)

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.

Excessive Agency or Excessive Community

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 reasonably 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.

State Shifting

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. The ambiguous figure is a good metaphor for illustrating how we tend to fall into old patterns and shift, sometimes unpredictably, from one mode of responding to another. Sometimes we may feel open, happy, and free. At other times we are constrained, anxious, and tight. Each of these states seems to have a grip on us. When we are open it is hard to think that we could be closed. When we are tight and anxious it is hard to believe that the tension will ever dissipate. It is difficult to change from the one state to the other simply by an act of will. We tend to get "stuck" in the one mode or the other. Predicting when there will be a transition from the one state to the other does not appear to be feasible.

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. Thus, some forms of illness can be seen as being chronically stuck in a maladaptive state and not being able to shift to a more adaptive view. Moods are another good example of states. When we are happy and enthusiastic everything seems bright and it is hard to think of the dark side. Conversely when you are depressed it is difficult to see the world and yourself positively.

Theories of Therapeutic Action

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. Essentially the patient feels that a relationship is established when h/she feels and believes that it is safe to disclose and explore aspects of his or her self that are painful, shameful, and/or troublesome. 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. 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. The quality of connectedness which permeates the relationship is more important than what is done to or with the patient. In order for the relationship to grow the therapist has to suspend his or her own personal concerns and focus empathically on the client. Empathy has been called "vicarious introspection". This requires the therapist to be receptive to the patient and tune into the patient's shifting 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 understand your struggle. The therapist's insight imparts 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 confers 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. Then it becomes possible for the patient to see how he or she is structuring the relationship in ways that repeat earlier patterns of dysfunction.

Understanding and Explaining

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.

Cognitive Restructuring (Reframing)

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.

Desensitization -- Exposure and Response Prevention

Desensitization can be used to treat 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, guilt, 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. However, 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 grave illness. So a major aspect of desensitization is altering the meaning that the client gives to his or her pain. What needs to be done in order to alter the meaning is a major therapeutic issue.

An important class of interventions which alter the meaning of symptoms 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. Consider a patient with a germ phobia who has the compulsion to wash his or her hands after any possible exposure to germs. In the proceedure of exposure and response prevention the patient is instructed to hold a dirty object. The therapist instructs to patient not to wash his hands. The response of washing hands is blocked and the patient is told 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. Thus it can be seen that process of desensitization alters the meaning that the feared objects have for the patient.

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). Resistances occur when something would emerge into consciousness that disturbed 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, which bring the frustrations of many practical worldly concerns. 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.

Making the Unconscious Conscious

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:

  1. Ground-Unconscious is basically a developmental concept. The fetus "possesses" the ground-unconscious: in essence, it is all the deep structures existing as potentials ready to emerge, via remembrance, at some future point. All the deep structures given to a collective humanity--pertaining to every level of consciousness from the body to mind to soul to spirit, gross, subtle, and causal--are enfolded or enwrapped in the ground unconscious, but they are not repressed because they have not yet entered consciousness. (p. 83)
  2. Archaic-Unconscious of the ego (the superego, the defenses, and the character-structures), were unconscious; and parts of the id were unconscious but not repressed. In [Freud's] words, "We recognize that the Ucs. does not coincide with the repressed; it is still true that all that is repressed is Ucs., but not all that is Ucs. is repressed." ... There can be no doubt about the instinctual sources [of dreams and phantasies]; but how is it to be explained that the same phantasies are always formed with the same content? ... I believe that these primal phantasies...are a phylogenetic possession. In them the individual...stretches the experiences of past ages." This phylogenetic or "archaic heritage" included, besides instincts, "abbreviated repetitions of the evolution undergone by the whole human race through long-drawn-out periods and from prehistoric ages." (P. 84) ...For Jung, of course the "phylogenetic heritage" consisted of the instincts and the mental-forms or images associated with the instincts which he eventually termed the "archetypes." (p. 85)
  3. Submergent-Unconscious Once a deep structure has emerged from the ground-unconscious and taken on some sort of surface structure, it can for various reasons be returned to a state of unconsciousness. That is , once a structure has emerged, it can be submerged, and the total of such structures we call the submergent-unconscious. The submergent-unconscious is that which was once conscious, in the lifetime of the individual, but is now screened out of awareness. ... The submergent-unconscious becomes unconscious for various reasons, and these reasons lie along a continuum of inattention. This continuum ranges from simple forgetting through selective forgetting to forceful/dynamic forgetting (the latter alone being repression proper) (p. 86-87)
  4. Embedded-Unconscious ...repression originates in some part of the ego; it is some aspect of the ego that represses the shadow-id. But Freud then discovered that part of the ego was itself unconscious. yet it was not repressed. He simply put two and two together and concluded that the unrepressed part of the ego was the repressing part. This part he called the super-ego: it was unconscious unrepressed, but repressing. "We may say that repression is the work of this super-ego and that it is carried out either by itself or by the ego in obedience to its orders...portions of both of the, the ego and the super-ego themselves are unconscious." But not repressed. (p. 88)
  5. Emergent-Unconscious Let us now examine someone who has evolved from the pleruoma to the body self to the ego-mind. There still remain in the ground-unconscious the deep structures of the subtle and causal realms These structures have not yet emerged; they cannot, as a rule emerge in consciousness until the lower structures have emerged. Since the higher structures encompass the lower ones, the higher have to unfold last.... The transpersonal (the subtle and causal) realms are not yet repressed--they are not screened out of awareness,...--they have simply not yet had the opportunity to emerge. We do not say of a two-year-old child that he or she is resisting the learning of geometry, because the child's mind has not yet developed and unfolded to the degree that he or she could even begin to learn mathematics.....on the developmental cycle, those deep structures which have not yet emerged from the ground-unconscious are referred to as the emergent-unconscious. For someone at the ego (or centaur) level, the low-subtle, the high-subtle, and low-causal, and the high-causal are emergent-unconscious. They are unconscious, but not repressed. (p. 90) (Wilber, 1980)

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.

Structure Formation

Via Optimal Frustration and Transmuting Internalizations (Kohut)

The idea of optimal frustration and transmuting internalizations comes from Heinz Kohut's work on restoring the self. :

...we can return to the question of just how psychoanalysis cures...The most general answer that self psychology gives to this question is a simple one: psychoanalysis cures by the laying down of psychological structure. And how does this accretion of psychological structure take place? The most general self psychological answer to this second question is also simple: psychological structure is laid down (a) via optimal frustration and (b) in consequence of optimal frustration, via transmuting internalization (Kohut 1984, p. 98-99).

He gives a three step progression in treatment:

  1. reactivation of need (in conflict-neurosis: of instinctual wish);
  2. non-response by the selfobject (in conflict neurosis: by the object);
  3. re-establishment of a bond of empathy between self and selfobject (in conflict-neurosis: between self and object. (Kohut, 1984 p 103).

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).

Structure Formation Via Optimal Responsiveness, Optimal Provision and Optimal Gratification

The concept of optimal frustration has been questioned by a line of important reconsideration by the intersubjective self psychologists. Bacal 1985 stated:

It has never been out intention, as analysts, to either traumatize or frustrate out patients, however optimally, but to understand them. Consequently the notion of optimal frustration is not tenable as a working clinical concept; however the idea of optimal gratification conceivable could be. For to be understood can be deeply gratifying and is, perhaps the most important function performed for us by our selfobjects. It is possible that the gratification of being understood by one's selfobject is of central importance in the curative process. If internal structure could not be built and defect repaired through the experience of being understood, the analyst would be wasting much of his time doing good work instead of making calculated errors thought to lead to manageable disruptions between himself and the patient and, thus to transmuting internalization through the associated optimal frustration and its understanding. ... We will as therapists, make mistakes, ... and, thus, inadvertently trigger or intensify the patient's frustration. The patient, moreover, will inevitably reenact his frustration with us in an attempt to right the original wrong. In many, perhaps in the majority of instances, if we understand, as and when our patients need us to, frustration will not be a factor in the therapeutic process.(p. 207)

Unblocking Developmental Arrests

Major sources of psychopathology are repression, regression, and developmental arrest. Repression has to do with having awareness dynamically blocked by a conflict. The techniques of making the unconscious conscious treat repression. Regression implies that one has developed adequately but has retreated to earlier modes of behaving in response to conflict or trauma. Developmental arrest implies that development has never taken place in the first place. It is sometimes difficult to distinguish regression from developmental arrest. It is also important to recognize that development does not necessarily proceed uniformly across all areas of growth. For example, some one may be highly intellectually developed and have great difficulty in intimate emotional relationships. However one thinks of it, there a clinically important class of problems has to do with some aspect of ones functioning being out of sync with his or her chronological stage of development. The notion of unblocking implies that there is some kind of obstruction. If the obstruction can be cleared away then development can proceed normally. I am not sure that unblocking developmental arrests can be addressed directly. The unblocking emerges as the treatment progresses. The patient has to become aware that there is some kind of blockage. The patient has to troubled by the arrest enough to want to change it. Finally, some kind of structure building is needed in order to create the behavior patterns, attitudes, and skills which forester the new growth.

Identification Shifting

The self psychologists speak of the cohesiveness, stability and the affective coloring of the sense of self. The qualities that I experience as cohesive or stable or that I feel good or bad about have to do with my identifications. i.e. I am a psychologist, a man, a father. All the roles and physical, emotional, cultural and intellectual attributes that I assign to myself can be thought of as my identifications. The mechanism of identification has to do with taking on the characteristics of some important figure in ones life. i.e. I am like my father. Altering who or what I feel I am can be a crucial ingredient in change. Unconscious identifications can have far reaching effects on ones behavior and sense of well-being. Making these identifications conscious and altering ones attitudes about them is often an important ingredient in therapy.

An important sequence of shifts of identification was given by John Weldwood . The essential line of development has to do with moving from being embedded and identified with ones experience to dis-idenfifying with experience.


Education, as such, has had a bad name in psychoanalytically oriented therapies. Usually when people come for therapy it is because the usual processes of education have failed. Most people know what is good for them. They have been repeatedly told what will help them. Nonetheless, they have a hard time doing what they know will help them. If they were able to utilize the education that they have had, they would not come for treatment. Indeed, a depressed patient once said, "Depression is when you can't do what you know will help you". However, to the extent that the problem is simple ignorance education is the treatment of choice. Further, elements of education are to be found in all forms of treatment. The patient has to be instructed on how to be a patient and on what to do in order to make the therapy work.


As with education, suggestion has not been well regarded by analytic therapists. Indeed, one of the great concerns among the early analysts was to clearly differentiate suggestion from interpretation. How much an interpretation is a suggestion is an important question. If a patient has unconscious sexual wishes, by definition the patient is truly unaware of his or her libidinous desire. If the analyst makes the interpretation, "You would like to have sex with your mother", how does the patient know that the analyst is not simply putting ideas in his mind (making a suggestion). The traditional answer to this question has to do with the way the patient responds. If the patient has a strong emotional response and memories of loving attachment to his mother emerge, then it is not likely that the analyst is simply suggesting something to him. The analyst has made a connection which has brought the wish to consciousness. This is not suggestion in the sense that the therapist is attributing a wish to the patient that the patient does not have. However, there are times when patients overlook alternative courses of actions or different ways of seeing situations. In these cases suggestion of alternatives can be beneficial. Suggestion does come in many shades. The thesaurus gives the following shades of meaning for the word suggestion: proposal, idea thought advice, proposition, recommendation, council, bid, and exhortation. I suspect that all of these meanings are used at one time or another during the course of an extended therapy.


Feedback can be thought of from several points of view. First, feedback is essential for almost any kind of control. This can be clearly seen in motor behavior. If I try to stand up I need the position cues which come from my muscles and joints to tell me the position of the various parts of my body. If I am anesthetized or neurologically impaired and do not have these cues my coordination will be impaired. Similarly in the social situation of a therapy session, the patient and the therapist are continually giving each other verbal and non verbal cues about how they are reacting to each other. These responses are a form of feedback which each uses to guide his or her behavior. In a very real sense the patient and the therapist are regulating each others behavior by continually giving indications of how each is responding to the other. Second, in a more limited sense, feedback can be thought of as the interventions that the therapist makes. Comments, reflections, interpretations, suggestions, etc. are forms of feedback that the therapist employs to help the patient gain a fuller view of him or herself. We tend to focus on the discrepancy between what we want and what we feel we are getting. We are less concerned with what we ourselves do. Thus feedback from the therapist helps us to see our own blind spots. It is central to any kind of therapy. For a more formal discussion of feedback see Servo Systems and Feedback.

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