In a moving, posthumously published article contrasting his personal analytic treatment with Fairbairn and Winnicott, the internationally renowned British psychologist Harry Guntrip* (1975) wrote that “Theory...is a useful servant but a bad master, liable to produce orthodox defenders of every variety of the faith...Therapeutic practice is the real heart of the matter...” Few experienced psychotherapists would disagree with these beliefs, or that effective practice reflects both science and art.

Among the major treatment theories (psychoanalytic, psychodynamic, cognitive-behavioral, interpersonal) there are basically four ways in which clinicians relate to their patients. These therapeutic postures (Analytic, Replacement, Supportive, Relationship) are at the heart of psychological healing (Goldstein, 1979). The most effective therapist provides an optimal interplay of these postures during the treatment session, the weight of each stance being determined by the patient’s capacities and goals.

The Analytic posture establishes links between feared thoughts and feelings and life experiences so these become incorporated and life again makes sense. During the Replacement posture, necessary with the most severe psychological difficulties, deficient ego capacities are replaced with more effective ones such that greater control over thinking and behavior and a stronger sense of self are achieved. Here the therapist relates as an ideal mothering figure. Using the Supportive posture, the therapist, by providing advice, strengthens the patient’s present ability to cope with their stress; through the Relationship posture the patient gains a trusted friend.

Clinical examples follow.

(1) A fireman in his mid-forties with no previous treatment developed panic attacks. After evaluating him I related his symptoms to he having ignored his feelings and the effect of his job’s stress for too long (Analytic posture); provided information about panic attacks, coping strategies, and a self-hypnotic relaxation CD (Supportive posture); and told him suitably disguised anecdotes about others I had successfully treated with similar problems (Relationship and Supportive postures), my therapeutic stance changing throughout the course of each session. Such treatment is not necessarily lengthy: his symptoms disappeared after nine sessions.

(2) A lovely well-dressed woman in her late thirties was brought to my office by her husband. He was concerned about her difficulties with neighbors for she had again begun to scream and yell outside their home. Though having experienced a psychotic episode, her reality testing was adequate; she became calmer as we spoke; and her refusal to consider adjunctive psychotropic medication soon lost relevance as a treatment issue. During sessions I had the sense that, despite her impressive appearance, she was intellectually limited.

For I found myself speaking very slowly and using simple words, as one naturally does when interacting with such people. Since her precipitant distress derived from parenting and marital problems, I spent a few minutes each session with she and her husband together.

I provided her child guidance information and tried to effect change in the marriage (Supportive posture); and reduced her feelings of isolation by behaving as an ideal friend (Relationship posture). Because of the brevity of treatment and her intellectual limitations, using the Replacement posture to replace her deficient ego capacities with more mature ones was not attempted. By the seventh session the woman was calm and her symptoms were absent. But the outcome was not completely successful. I was unable to convince the husband to bathe more than once a week, and this was an understandable, major irritant to his wife.

(3) A mother was concerned about her eight-year-old daughter’s oppositional/defiant behavior, nightmares, and deteriorated school grades. These symptoms reflected, theoretically, elements of a borderline psychotic psychostructural organization (weakness of basic ego capacities governing the ability to control thinking and behavior, modulate mood, tolerate feelings, develop a sense of self, and others, deriving from faulty developmental experiences during the first three years of life).

The girl was a child model whose eventual goal was to get her own TV show. Thus during her therapy I and our (stuffed animal) friend, Bertram Bear, were required to compete in games and instructed by her in arithmetic. Once, when I proudly responded, “two times two is twenty two,” she banged her head with the heel of her hand and loudly exclaimed with exasperation, “God—what an idiot.” On another occasion she exploded her mouthful of Coke onto the wall upon hearing my best joke: What do bears do at Niagara Falls? Go over it in bearrels. (This humor is very age specific. Don’t try the joke on a ten year old.)

Late one evening I couldn’t find another of our friends and phoned her with frightening news: “Barry Bird has been birdnapped!” She told me to look in the refrigerator.

Upon leaving my office a week later, a bee stung her hand, which held an open, can of soda. “I’m never coming back. I’m never seeing Stanley again,” she screamed angrily. “What did you tell her?” I asked her mother. “I said, ‘Oh come on, you know that Stanley couldn’t have had anything to do with this!’” I gave her mother a sly look. “Are you sure?” I said softly.

During this child’s treatment, she and I interpreted her dreams; and we discussed her concern about her (obese single parent) mother’s health, as well as common childhood stresses.

I fostered psychological regression to replace her deficient ego capacities with more mature ones (Replacement posture); related her unconscious thoughts and feelings to painful symptoms to relieve them (Analytic posture); and was her non-judgmental friend (Relationship posture)—along with Barry Bird and Bertram Bear of course.

The science of therapy attempts to make therapy postures more effective. The skill of the therapist is reflected in their ability to accurately assess the patient’s ego capacities, emotional conflicts, and motives; and then to match therapy posture with patient need. These are tasks which the experienced clinician does automatically. I sometimes joke that I’ve been doing therapy for so long I can do it with my eyes closed and sometimes do. During optimal “fit” between posture and need, the treatment is experienced as going well. When unease is felt, there is disparity between the therapeutic posture presented (Analytic, Replacement, Supportive, Relationship, or some combination of these) and what is needed for the patient’s improvement. Within this provision lies the art of conducting therapy.
By varying these postures the therapist creates a positive force, which influences the patient’s psychological structures and creates change (Balint, 1968). Otherwise, following the biological theory of epigenesis, the individual will remain on their unchanged developmental path, one that is being continually strengthened by environmental and family influences (Bowlby, 1973). Though hindered by time and other constraints, the effective clinician enables healing by providing a better parenting than the patient earlier experienced.

References

Balint, Michael (1968) The Basic Fault. London: Tavistock.

Bowlby, John (1973) Separation: Anxiety and Anger. New York: Basic Books.

Goldstein, Stanley (1979) Troubled Children/Troubled Parents. New York: Atheneum,Guntrip, Harry. My Experience of Analysis With Fairbairn and Winnicott (How Complete A Result Does Psycho-Analytic Therapy Achieve?), Int. Rev. Psycho-Anal. (1975), 2, 145.

Correspondence regarding this article may be addressed to Stanley Goldstein at doc3612@yahoo.com