Annotated bibliography and outline, assignment help

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Provide an annotated bibliography (750-1,000 words total) of the assigned journal articles for Modules 5 and 6. Including the following for each article:

  1. The article citation and persistent link. These are provided above for you to paste into the assignment and are not included in the total word count. Be sure to verify the accuracy of the reference formatting as these can change during the insertion process.
  2. A written summary of the key concept(s) of the article. Why was the study done? What was the population studied? What did the researcher(s) conclude? What other information about this study do you believe is unique or important to recall? Are there specific statements made by the author that you wish to retain?

Construct an outline for a paper that will explain and synthesize the articles you read for this assignment with those you will read in Module 7. The paper will require identification of themes common to the articles as well as a statement of the conclusions that can be drawn when the articles are taken together as a single entity You will be writing the paper in the next assignment.

Please use Articles 1-4 for the annotated bibliography and Articles 1-6 for the outline. This is similar to the other annotated bibliography and outline you did for me a few weeks ago. I have also attached the previously annotated bibliography you completed for me as a reference. Same concept so please use this as your guideline. The annotated bibliography on the 4 articles need to be 250 words each. Please construct this one the same as the last one, again, attached for your reference.



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Copyright American Psychological Association. Not for further distribution. 8 TRANSFERENCE, COUNTERTRANSFERENCE, AND RESISTANCE: UNCONSCIOUS DETERMINANTS OF DILEMMAS Transference, countertransference, and resistance are all psychological processes that affect the ongoing nature of psychotherapy, and all are presumed to be unconsciously determined (Auld & Hyman, 1991). Transference is an unconsciously influenced emotional reaction of the patient to the psychotherapist and (in a less technical sense) other health care providers that originates from the patient's earlier experiences related to significant others, especially caregivers, and that are inappropriate to the present context or way in which the therapist is currently dealing with the patient. Countertransference is the unconscious reactions of the psychotherapist (and other clinicians as well) that are stimulated by a given patient, the characteristics of a given patient, and, in particular, to the transferences of a given patient, that is, "countertransference proper" (Orr, 1954). If not consciously recognized by the therapist, these internal reactions are likely to be dealt with inappropriately by the clinician in his or her verbal or behavioral responses to the patient. Finally, resistance is an unconscious influence within the psy- 127 http://dx.doi.org/10.1037/11110-008 Clinical Dilemmas in Psychotherapy: A Transtheoretical Approach to Psychotherapy Integration, by D. J. Scaturo Copyright © 2005 American Psychological Association. All rights reserved. Copyright American Psychological Association. Not for further distribution. chotherapy patient that acts against the therapeutic process, which results from the patient's wish to avoid the anxiety associated with his or her traumatic experiences, painful recollections, or personally unacceptable thoughts, wishes, or emotions that threaten to come into the patient's awareness. Because all three of these important psychotherapeutic concepts are presumed to be unconscious mental processes, that is to say, processes operating outside the level of awareness, they are all predicated on a psychoanalytic or psychodynamic conceptualization of psychotherapy (e.g., Freud, 1912/ 1958a). In addition, most psychodynamically oriented psychotherapists would likely agree that the ambiguity that arises out of each of these processes tends to be a major source of clinical dilemmas, although perhaps seen as specific to the psychoanalytically oriented psychotherapist. For instance, there is substantial ambiguity surrounding what aspects of the session have been generated by the clinician and the current treatment context versus that which may be a carryover from the patient's past experiences, both with transference in the patient and countertransference in the clinician. Historically, all of these terms—transference, countertransference, and resistance—have felt somewhat out of place to psychotherapists working within a cognitivebehavioral or family systems framework (e.g., Scaturo, 2002c). Although the psychoanalytic terminology may feel awkward in other theoretical paradigms, the dilemmas that these processes generate have been viewed increasingly by those working in the area of psychotherapy integration as sources of conflict that are common to most treatment contexts with health care providers from diverse theoretical orientations and disciplines. DILEMMAS OF TRANSFERENCE Transference is a term that is formally reserved to refer to the unconscious relationship that a psychotherapy patient has with his or her psychotherapist, and more specifically a psychoanalyst. However, there has been increasing recognition that such a relationship exists not only in other forms of psychotherapy (e.g., cognitive-behavioral and family systems) but in other health care contexts as well. In essence, there is the potential for a variant of transference to exist whenever there is a relationship with a health care "provider" who is taking on some sort of caretaking role with the patient, reminiscent of the patient's relationships with earlier caregivers (e.g., parental) in his or her life. When applied to interpersonal relationships outside of the psychotherapeutic context, the transferential phenomenon is technically designated as projective identification in object relations terms (J. S. Scharff & Scharff, 2003). However, this phenomenon, as well as its pervasiveness outside the context of psychotherapy, has become most evident in the literature on the doctor—patient relationship with the family physician. Recognition of the importance of this relationship in all of its forms (i.e., conscious and J 28 THERAPEUTIC PROCESS Copyright American Psychological Association. Not for further distribution. unconscious) in part accounts for the proliferation of case consultation seminars, known as "Balint groups," in family practice residency training programs at medical schools across the country to grapple with the psychosocial aspects of the medical patient (Johnson, 2001; Johnson, Brock, Hamadeh, & Stock, 2001). The name of these case consultation groups is derived from the seminal work in this area in the 1950s and 1960s by Michael Balint (1957), a British psychoanalyst. Balint's goal in conducting such case consultation seminars was to teach psychotherapeutic skills and recognition of the influence of the doctorpatient relationship to physicians in general medical practice (Keith et al., 1993). Because Balint's (1966) theoretical perspective was predicated on psychoanalysis, he tended to confine his attention to the patient's transferential and countertransferential relationship with the family doctor. That is to say, the patient's subjective distortions of the family doctor's relationship that emanate from the quality of the patient's past relationships with family, caregivers, and significant others, rather than from the objective current reactions of his or her family doctor, was of major concern to Balint. For the psychotherapist, these "parataxic" distortions (Sullivan, 1953) from the patient's past are most often considered to be the major foci of treatment. For the family physician, however, the patient's medical problems are the primary foci of treatment, rather than his or her emotional reactions or distortions in their relationship to his or her physician that are generally considered to be of secondary concern. Nevertheless, increasing the health care provider's recognition that such distortions by the patient (i.e., transference and transferential reactions affecting, in turn, the physician's countertransference to the patient) are ever present in the health care context is of enormous value in treatment and in clarifying doctor-patient communications about treatment. In the Family Physician's Office Consider, for example, a somewhat hostile young male patient in his early 20s in a visit to his primary care physician for a variety of symptoms of abdominal distress. A number of brief, one-word answers and hostile demeanor would appear to be unprovoked and seem to the physician as if to be "coming out of left field." In short, the patient's angry reactions appear to be excessive to the context and to be more than just the irritability associated with stomach distress. When emotional reactions are excessive to the context, the excess is likely an emotional overflow that comes from somewhere else, not simply "from out of left field" as is often the initial reaction, but usually from actual experiences in the patient's past. In this instance, a psychosocial history reveals that this patient was raised in a series of foster homes as a child with a series of caregivers who were minimally, or at least only temporarily, committed to this young man's physical and emotional well-being. A thorTRANSFERENCE, COUNTERTRANSFERENCE, AND RES/STANCE 129 Copyright American Psychological Association. Not for further distribution. ough history also reveals that some of these caregivers were variably physically, verbally, or psychologically abusive to this young man as a child. Although an understandable reaction from the primary care physician to the patient's apparent anger, especially a physician whose time constraints have been expanding exponentially in the current health care environment, might be a defensive reaction to the patient's cynicism or to simply ignore the evident hostility and provide a prescription, perhaps a more tempered response might engage the patient more so. A comment acknowledging the obvious and noting the history might provide a better doctor-patient connection: I can see that you are irritated, although I'm not sure what's causing it. I can see from your history that you have had a rather turbulent background, and I'm not sure if your previous contact with your doctors has seemed to you to be all that helpful, but here is what I think I can do to help .. . Such a preamble to the medical aspects of the interview is direct and nondefensive, expresses understanding and empathy, and leaves the conversational door open for further discussion, if desired by the patient. In the Psychotherapist's Office To the therapist, this same patient would be likely to present not only as hostile but also guarded, avoidant of conversation, and cynical or sarcastic in interaction. The transferential issues with the authority figure of the psychotherapist are played out with a kind of verbal sparring to keep the therapist at some degree of emotional distance. However, for the psychotherapist, in contrast to the role function of the family physician, the patient's unprovoked hostility in his or her office in particular, and in the patient's interpersonal world in general, may be the primary focus of the patient's contact with a mental health specialist. The patient, understandably, may see his reason for being there from a more externalized perspective. That is to say, the patient's viewpoint may be more from the confusion that he experiences in wondering why so many people (e.g., boss or coworkers) whom he meets in life seem to be either hostile or uncaring. The task of the psychotherapist, however, is to help the patient to examine and modify his own contribution and to the creation (and possibly the selection) of such familiar relationships to assist this patient in considering what he may do about improving this scenario in his life through the modification of his own contribution. However, the difficulty as well as opportunity for interpersonal learning, and a "corrective emotional experience," arise when such unprovoked hostility becomes incorporated into the relationship that the therapist has with the patient, not simply the patient's relationships with others outside of the consulting room. However, because both the ambiguity and intensity of such interactions make navigation difficult, this is where the psychotherapist's skill and training come into play. J 30 THERAPEUTIC PROCESS Copyright American Psychological Association. Not for further distribution. Two common emotion-laden areas of the patient's transference that have strong potential to stimulate a countertransferential reaction on the part of the therapist are that of the patient's anger and the patient's seductiveness toward the therapist. Take, for example, a patient with borderline pathology and a history of physical and verbal abuse followed by parental denial and invalidation of the abuse by his or her family. Such a patient may unjustly or inaccurately accuse the clinician of "not caring" about him or her after, for example, changing an appointment time. Following the patient's accusatory remarks, it is necessary for the clinician to respond to the patient, but how a given clinician might respond may vary, and such variations may have considerable impact on the therapeutic alliance. Ultimately, it will be important to point out the distortions that the patient is making in his or her perception of how the clinician has treated him or her by confronting the patient with real data (e.g., the therapist's history of very few canceled appointments with the patient), both now in the current situation and in the patient's treatment history with the therapist. However, it is critical that such confrontation not be a defensive reaction on the part of the clinician (such as a counteraccusation about the patient's missed or canceled appointments), but rather a matter-of-fact presentation that the patient's accusations do not conform to the reality of their clinical contact and history together. In doing this, though, the therapist runs the risk that the patient will perceive such confrontation as an invalidation of his or her experience, as was also a part of this particular patient's family history as noted above (e.g., "So you're telling me that it's all in my head!"). Such a misperception would likely be predicated on the pseudomutuality (Simon et al., 1985; Wynne, 1984; Wynne, Ryckoff, Day, & Hirsch, 1958) in his or her own family history in which there was the facade of harmony and an appearance of mutually respectful relationship with one another that is, in reality, undercut by the invalidating behaviors that follow. Clinically, then, it is incumbent on the therapist to point out to the patient that there is a substantial difference between what would be an "understandable distortion" by him or her given the family history and suggesting to the patient that "it never really happened." The second emotion-charged area of the patient's transference that is likely to generate some sort of countertransferential response is that of an erotic transference to the therapist that is manifested through some form of seductive behavior by the patient. At a surface level of understanding, some type of gratification or flattery in the therapist might be obvious and expectable from the seductive behavior of a patient, especially one who might be acknowledged by the common culture as generically physically attractive. Fortunately, most adept therapists are able to monitor this reaction in them and respond with clinical appropriateness. What may be more problematic for the therapist, however, is the countertransferential reaction that is idiosyncratically evoked by an erotic transference from a patient (regardless of TRANSFERENCE, COUNTERTRANSFERENCE, AND RESISTANCE 131 Copyright American Psychological Association. Not for further distribution. his or her actual physical attractiveness) that is reminiscent of the therapist's maternal or paternal figure from whom the therapist may have felt, for example, a paucity of gratification in his or her own family history. In such instances, these erotic transferences carry with them even more power to disorient the therapist and evoke an unconscious degree of personal gratification in the therapist that may make it increasingly difficult for the therapist to either monitor or make appropriate boundary management by the therapist more complicated. Transferences in such patients can evoke countertransferential reactions in psychotherapists that have the ability to start the therapist down a slippery slope of seemingly innocent responses that bring otherwise ethical therapists to tenuously skate the boundary of clinical ethics. Such responses are, in fact, ethical dilemmas that disguise themselves to the therapist as technical dilemmas, as noted previously in chapter 1. For example, the therapist may rationalize to him- or herself that this particular patient requires a greater degree of warmth from the therapist. At this point, such a quandary ceases to be a dilemma of psychotherapeutic technique and becomes primarily a dilemma of the therapist's countertransference. Indeed, many instances of sexual exploitation of patients in therapy might be avoided if the therapist were able to recognize the growing attraction and immediately seek consultation to either assist with the countertransference or make an appropriate referral of the case (e.g., Pope, 1994; Scaturo & McPeak, 1998). DILEMMAS OF COUNTERTRANSFERENCE The dilemma that every psychotherapist faces in grappling with strong countertransferential reactions is the question as to whether his or her reactions to the patient are stemming from, to paraphrase Frame (1968), "my life or my patient's life." In other words, the therapist must ask him- or herself, "whose agenda is being addressed in a given therapy session with a given patient or family, and why?" (Scaturo & McPeak, 1998, p. 6). A strong identification with a particular patient's life situation or defensive structure is not, by definition, a sign of poorly conducted psychotherapy. Rather, it is a marker of some increased intensity and complexity in the clinical context. In moments of greater candor, almost all psychotherapists will admit that they do not feel the same sense of rapport, identification, or closeness with each and every patient. In this respect, it is impossible to guarantee a uniform level of service to all patients as most managed care companies would like to claim. The psychotherapist, were he or she to have met certain patients prior to and outside of the clinical context, might easily imagine being friends with certain patients and definitively not with certain others. The patients with whom the therapist closely identifies, because of the therapist's almost instinctive understanding of their difficulties, stand to receive one of two things: either the very best or the very worst that such a clinician has to 132 THERAPEUTIC PROCESS Copyright American Psychological Association. Not for further distribution. offer. If the clinician has sufficiently worked through the particular emotional issue that runs parallel to the issue in the life of the patient and is able to thereby maintain adequate objectivity in therapy, then the patient stands to gain much from the hard-earned intuitive understanding, which that clinician has by virtue of his or her own life experience. However, if the therapist overidentifies with the patient's conflicts and loses proper clinical perspective, then a grave disservice is being rendered to such a patient. A powerful example of the intensity of these countertransferential feelings is portrayed in the dialogue of the play, Equus (Shaffer, 1973). The drama depicts a disturbed adolescent stable boy, named Alan Strang, in England who is undergoing court-mandated treatment after blinding six horses with a spike. The horses provided the boy with his first sexual experience. He would ride them naked in the evening until he reached the point of orgasm. The blinding incident occurred after his first sexual experience with a young woman that occurred in the stable with the horses present, leaving the boy feeling that he had betrayed them. The middle-aged psychiatrist, Dr. Martin Dysart, who is treating the boy is struggling with his own conflictual feelings surrounding the powerful yet destructive passion that his patient feels, a passion that has been long since absent in the therapist's own life and marriage. The following is an excerpt of a conversation that Dr. Dysart is having one evening with his friend, Hester Solomon, the magistrate who referred the boy for treatment (Shaffer, 1973, pp. 81-82)1: Dysart: He lives one hour every three weeks—howling in a mist. And after the service kneels to a slave who stands over him obviously and unthrowably his master. With my body I thee worship! . .. Many men are less vital with their wives. [Pause] Hester: All the same, they don't usually blind their wives, do they? Dysart: Oh, come on! Hester: Well, do they? Dysart: [sarcastically]: You mean he's dangerous? A violent, dangerous madman who's going to run around the country doing it again and again? Hester: I mean he's in pain, Martin. He's been in pain for most of his life. That much, at least you know. Dysart: Possibly. 'Reprinted with the permission of The Lantz Office and Scribner, an imprint of Simon & Schuster Adult Publishing Group, from Equus and Shrivings by Peter Shaffer. Copyright © 1973, 1974 by Peter Shaffer; copyright renewed © 2001, 2002 by Peter Shaffer. TRANSFERENCE, COUNTERTRANSFERENCE, AND RESISTANCE 133 Hester: Possibly?! . . . That cut-off little finger you just described must have been in pain for years. Dysart: [doggedly]: Possibly. Hester: And you can take it away. Dysart: Still —possibly. Hester: Then that's enough. That simply has to be enough for you, surely? Copyright American Psychological Association. Not for further distribution. Dysart: No! Hester: Why not? Dysart: Because it is his. Hester: I don't understand. Dysart: His pain. His own. He made it. [Pause] [Earnestly.] Look ... to go through life and call it yours—your life — you first have to get your own pain. Pain that is unique to you. You can't just dip into the common bin and say 'That's enough!'. . . He's done that. Alright, he's sick. He's full of misery and fear. He was dangerous, and could be again, though I doubt it. But that boy has known a passion more ferocious that I have felt in any second of my life. And let me tell you something I envy it. Hester: You can't. Dysart: [vehemently] : Don't you see? That the Accusation! That's what his stare has been saying to me all this time. 'At least I galloped! When did you?'. . . [Simply.] I'm jealous. Hester. Jealous of Alan Strang. Hester: That's absurd. Hester Solomon's reaction is not surprising. When one is not personally involved in the throes of a countertransference reaction of his or her own, then the intense countertransferences experienced by others can be easily perceived as "absurd." However, Dr. Dysart finds himself in the midst of a difficult dilemma. On the one hand, he has the unique ability to help his patient by virtue of possessing remarkable clinical talent and a personal understanding of the patient's problem. On the other hand, he is at risk for not being able to control his own feelings of envy of the patient and of losing adequate objectivity to properly conduct treatment. In this particular example, the possibility of maintaining objectivity seems unlikely given the above dialogue. As a result, Dr. Dysart faces a second dilemma surrounding his countertransference concerning this patient: 134 THERAPEUTIC PROCESS Copyright American Psychological Association. Not for further distribution. Does the therapist keep or refer such a patient (Scaturo & McPeak, 1998)? Although it seems prudent in the above example to strongly consider referral given the intensity, an alternative might be for the therapist to obtain formal consultation, initially, to decide whether or not keeping or referring the case would be most beneficial to the patient. However, even a straightforward referral may have substantial and varied meanings and impact for the patient within the context of transference (Gill, 1984). One patient-oriented reason as to why the decision to refer a given case should never be taken lightly concerns the potential for patients to view a referral out to another professional as a rejection by the therapist, even if the reasons are valid. Carrying the case with ongoing consultation may be an option, but only if the countertransferential reactions of the therapist are openly acknowledged and well articulated with the consultant with a view toward providing the patient the best possible treatment. Although discussions of countertransference traditionally have been relegated to therapists utilizing a psychoanalytic or psychodynamic method of treatment, there has been an increasing acknowledgment of the universality of this concept in cognitive-behavioral (e.g., Safran, 1998) and family systems treatment modalities (e.g., Framo, 1968). In a now-classic article frequently assigned in clinical training settings, Framo (1968) candidly, eloquently, and sometimes poignantly illustrates the range of the therapist's reactions to the patient in light of the resonance in the therapist's own life and family history, ranging from the benign internal response or reflection to the clearly problematic, inappropriate, and countertransferential response to the patient that has the potential for negative impact on the patient. Consider the following rather moving example of a statement made by the therapist during a family therapy session, followed by an internal reflection of the therapist in parentheses: Me to son: "While your mother was crying I noticed you looked very upset. It's hard for you to deal with her unhappiness, isn't it? You feel you have to do something, don't you?" (Only if parents are happy can children be. Me to mom at age of five: "Mom, don't cry ... I love you; you still have me. When I grow up I'm going to buy you a washing machine, so you won't have to work so hard.") (Framo, 1968, p. 19) Now, alternatively, consider the following intense, overdetermined statement made to the parents by the therapist stemming from a strong countertransferential overidentification with the parentified children, followed by the countertransferential recognition by the therapist in parentheses: Me to parents: "You exploit, make parents out of, and psychologically murder your children." (How much of my anger rides on the back of old angers? With which of my undigested introjects was I dealing? Who was I trying to rescue? On whom, really, was I wreaking revenge?) (Framo, 1968, p. 20) TRANSFERENCE, COUNTERTRANSFERENCE, AND RESISTANCE 135 Copyright American Psychological Association. Not for further distribution. The potential for all therapists, regardless of their own family history, to react with strong countertransference to emotion-laden patient scenarios is well exemplified by J. S. Wallerstein's (1990) work on the range of countertransferential responses associated with conducting therapy with fairi' ily members who are undergoing divorce. Wallerstein's observations conearning therapists' countertransferences over grappling with this family crisis are predicated on her longitudinal outcome study of the long-term effects of the children of divorce at 10-year (J. S. Wallerstein & Blakeslee, 1989) and 25-year (J. S. Wallerstein, Lewis, & Blakeslee, 2000) follow-up periods. The outcome of these studies has, in particular, challenged two of what Wallerstein referred to as our society's "cherished myths" about divorce. The first myth holds that if parents are happier, even if the price of their happiness entails the dissolution of the marriage and family, then the children will be inevitably happier as well. On the contrary, the results of Wallerstein's landmark study show that the children, on the whole, do not look emotionally happier and more well adjusted even if one or both parents are happier. These children have shown more aggressiveness in school, increased difficulties in learning, more depression, more likelihood of being referred for psychological services, earlier onset of sexual activity, more children born out of wedlock, less marriages, and more divorces than peers from intact families. According to J. S. Wallerstein et al. (2000, p. xxix): "Indeed, many adults who were trapped in very unhappy marriages would be surprised to learn that their children are relatively content. They don't care if Mom or Dad sleep in different beds as long as the family is together." The second cherished myth about divorce in our society is the belief that divorce is merely a temporary crisis that wields its most harmful effect at the actual time of the breakup. In other words, it is believed that if the parents do not fight, particularly not in front of the children, and are "rational" about the disbanding of the family, that the short-term crisis will resolve itself rather quickly. Rather, the reports from the children of divorce reveal that, unless there was domestic violence in the family, it is the many years of living in a divorced or remarried family that matter the most. What is of more importance to the children of divorce is the sense of loss, abandonment, and betrayal of childhood and the acute anxiety experienced when one reaches adulthood. These children enter adulthood with myriad unsettled questions regarding commitment, trust, and allegiance in intimate relationships. In essence, the life stories reported by Wallerstein and her colleagues (J. S. Wallerstein & Blakeslee, 1989; J. S. Wallerstein et al., 2000) belie the myths about divorce that our society has come to embrace. Given the fervor with which these collective myths have been created and maintained in our society, it is no surprise that psychotherapists are not immune from intense countertransferential emotions when confronted by the often-denied reality of a dissolving family in the clinical context. Powerful countertransferences may occur not only as "countertransference proper" 13 6 THERAPEUTIC PROCESS Copyright American Psychological Association. Not for further distribution. (i.e., reactions to the divorcing patient's rageful and seductive transferences to the therapist) but also as a normative response to marital breakdown and the diminished parenting of the children (J. S. Wallerstein, 1990). The collapse of the once-loved partner into the now-hated adversary can be frightening for a clinician to witness at close range. Such clinical experiences inevitably evoke anxiety in the psychotherapist and ultimately obscure objectivity and therapeutic neutrality. The divorcing individual brings to the psychotherapist the dilemmas that confront both clinician and nonclinician in his or her daily life: issues of love and hate, dependence and independence, and the myriad of bipolar problems of living in relationships with men and women. The psychotherapist is brought "up close" to not only the frequent impermanence of marital partnerships but also the enactment by a parent of the threat to abandon his or her children. The potential for the clinician to become lost in ambiguity is, perhaps, best exemplified by the unsettling perception that "There but for the grace of God go I" (J. S. Wallerstein, 1990, p. 339). Thus, it seems that regardless of the therapist's own family background, the possibility of a simply "neutral" response to such primitive emotions seems unlikely. That is to say, whether the psychotherapist originates from a family in which the parents loved one another for a lifetime, terminated their marriage in a bitter divorce, or stayed together in a lifeless marriage "for the sake of the children," the countertransferential reactions of the therapist are likely to be substantial. Furthermore, the dilemmas of countertransference are likely to occur whether the psychotherapist is carrying out divorce therapy and mediation with the couple and family, providing cognitive—behavioral coping strategies, or conducting psychodynamically oriented object relations reconstructive therapy on an individual basis with one or the other of the marital partners. As Gill (1984, p. 213) observed, "a transference relationship develops in every therapy, whatever the approach." Thus, the previous illustrations serve to point out the ubiquity of transference and countertransference in the psychotherapeutic context. DILEMMAS OF RESISTANCE A similar permeation exists for the phenomenon of resistance in the psychotherapeutic environment. To consider why this is, it is first important to consider exactly what the process of resistance is and what it is not. According to Auld and Hyman (1991, p. 114), [Resistance] is a force within the patient that acts against the therapeutic process, against the task of uncovering and dissolving the neurotic conflict. It is a force that works to maintain repression even at the cost of perpetuation, or even the expansion, of neurotic symptoms. . . . Resistance results from the patient's attempt to avoid the anxiety evoked in TRANSFERENCE, COUNTERTRANSFERENCE, AND RESISTANCE 137 Copyright American Psychological Association. Not for further distribution. the therapy when tepressed feelings, wishes, thoughts, and experiences threaten to return to awareness. The clinical dilemmas of resistance arise from the ambiguity of the patient wanting symptom relief and behavioral changes in his or her life, on the one hand, while feeling the safety of familiarity with the status quo, on the other. This ambivalence in the patient about psychotherapy and behavior change has given rise to several misconceptions about the nature of the patient's resistance. Auld and Hyman (1991) attempted to rectify some of these misconceptions by clarifying what resistance is not: Resistance is not an acting out of anger, resentment, or hostility against the psychotherapist. Resistance is not a refusal or oppositionality of the patient to accept the psychotherapist's ideas or suggestions. And, finally, resistance is not an attempt on the part of the patient to make his or her interactions with the therapist to be perplexing. These clarifications point out an important distinction between the psychodynamic conceptualization of resistance and the behavior therapy models of resistance as noncompliance to therapeutic instructions (Leahy, 2001). Twenty years ago, P. L. Wachtel (1982, p. xiv) observed the following: In the behavioral literature, references to resistance are scant. If one only reads about behavior therapy, one is likely to conclude either that behavior therapists do not understand or do not notice resistance or that their methods overcome resistance or make it irrelevant. According to the behavioral model, the failure of a patient to comply with therapeutic recommendations may be attributed to the therapist's selecting reinforcements that are not salient to the patient (e.g., teacher's praise for an oppositional adolescent) or noncontingent, or perceived as noncontingent, on the outcomes desired (Leahy, 2001). Accordingly, it becomes the therapist's job to construct ways in which to get the patient to comply with the treatment objectives (e.g., Lazarus & Fay, 1982). In this way, the behavior therapist's approach to the patient is strongly allied with the role of a teacher, instructor, or scientist. For therapists who view the process of psychotherapy as being embedded within the broader context of an interpersonal relationship, the inherent ambiguity of resistance is more readily acknowledged and more broadly understood. In contrast to the behavioral approach, the role functions of the psychotherapist are viewed as that of the compassionate listener and the empathic observer (Blatt & Erlich, 1982). The perceived differences in professional role functions have corresponding effects on how the patient's resistances are viewed. Thus, Blatt and Erlich, for example, believed alternatively that the psychotherapist's job is to assist the patient in recognizing his or her resistance when it occurs and assess its various possible meanings for the patient, particularly with respect to the patient's fear or apprehension about the anticipation of change. 138 THERAPEUTIC PROCESS Copyright American Psychological Association. Not for further distribution. Rather than viewing the patient's resistances in potentially critical or pejorative terms, as many patients themselves are prone to do, it may be important to assist patients in discovering the positive function of their resistance to change and the maintenance of their symptomatology (e.g., avoiding overwhelming anxiety or panic). K. Adler (1972) offered the metaphor of the "symptom as a friend" to the patient. In other words, the symptom behaves as a good friend might to prevent the patient from making a premature and disorganizing life decision that the patient might not yet be ready to undertake (e.g., an impending marriage, divorce, or job change; Mozdzierz et al., 1976). Thus, the continuance of the symptom, or resistance to change, serves the positive function of giving the patient more time to prepare and achieve a greater readiness for important life changes. The dilemma in therapy, of course, is how much of a "friend" is the symptom in its resistance to change, versus the deleterious effects (i.e., the emotional cost) of maintaining the status quo of the symptomatology? This view of resistance and symptomatology is predicated on Freud's (1926/1959a) concept of signal anxiety. Thus, the anxiety serves as a signal or warning to protect the patient against the disorganization of an even greater traumatic anxiety or move that might threaten danger and throw the patient into a state of disequilibrium. Recent examinations of the concept from the standpoints of cognitive psychology, learning theory, psychophysiology, and behavioral neuroscience, as well as psychoanalytic theory, have shown some convergence of thought on the function of resistance anxiety (Wong, 1999). The cognitive—behavioral and psychoanalytic perspectives on resistance need not be, however, diametrically opposed for the integrative therapist who is willing to entertain the elements of both in treatment. Rhoads (1984), for example, considered multiple ways in which aspects of the two approaches can be integrated and enhance one another. He believed that a psychodynamically oriented understanding of resistance and approach to intervention can be exceedingly useful when encountering resistance in the form of noncompliance in behavior therapy. Although behavioral noncompliance is far from being the only form of resistance, certainly behavior therapy patients have innumerable reasons for not counting baseline behaviors, not constructing charts and graphs, and not completing behavioral homework assignments in general. Rhoads recommended that, in such instances, the behavior therapist may shift to a more exploratory therapy with the patient concerning his or her feelings about having been asked to undertake such assignments and, perhaps, relate this to any similar reactions to such requests in earlier times of the patient's life, especially involving others who might have served as the relational prototypes in dealing with authority figures and their various requests or demands (i.e., to interpret the patient's transference resistance to the behavior therapist) in an effort to increase compliance. Rhoads (1984; Feather & Rhoads, 1972) also suggested that target behaviors for such behavioral approaches be predicated on a more comprehenTRANSFERENCE, COUNTERTRANSFERENCE, AND RESISTANCE I 39 Copyright American Psychological Association. Not for further distribution. sive psychodynamic understanding of the patient's psychopathology. For example, it has been proposed that one of the early sources for panic disorder and agoraphobia is the very real experience of some form of abandonment in the developmental history of such a patient (e.g., Friedman, 1985; Sable 1994, 2000; Scaturo, 1994). Once a psychodynamic connection to panic has been established in the treatment of a given patient, then it may be possible to tailor behaviorally oriented exposure therapy through systematic desensitization (Wolpe, 1992) to address both loci of the patient's anxiety (i.e., the fear of panic attacks in the present and the abandonment fears of the past). That is to say, rather than constructing a single hierarchy pertaining to the patient's fear of panic in only current contexts (e.g., a restaurant, grocery store, or a shopping mall), it may be possible to construct two separate hierarchies, one related to the above-noted anxiety-associated contexts of the present and one as a hierarchy of fears leading up to certain historical abandonment experiences of the past (e.g., the loss of a parent at an early age). It may also be possible for the therapist to construct a combined, overlapping hierarchy with graduated steps from both of the separate hierarchies moving up the hierarchy in an alternating fashion jointly desensitizing the patient to both sets of psychologically related fears, thereby providing a truer integration of past and present within a single behavior therapy regimen. In cognitive therapy, resistance has been defined as anything in the patient's thoughts, feelings, or behavior that interferes with the demand characteristics (Orne, 1962; Whitehouse et al., 2002) or subtle situational expectations of the cognitive therapy approach. These demand characteristics include emphasis on the here-and-now, structured sessions, continuity across sessions, problem-solving orientation, rational thinking, collaboration with the therapist, psychoeducation and information sharing, an active role for both patient and therapist, accountability as evidenced by identifying and measuring goals and attainment of goals, and compliance with self-help assignments. (Leahy, 2001, p. 11) Yet, even within this highly structured approach, resistance is seen as multifaceted and multidetermined. Leahy (2001) outlined several dimensions of resistance within a cognitive therapy model. First, a patient with depression, for example, may require a sense of validation for his or her feelings or perspective such that he or she truly believes that the therapist can understand the perceived helplessness and demoralization felt by the patient before the patient entrusts the therapist with a belief in the therapist's ability to help. Second, the patient may be resistant to change because of a need for self-consistency and the belief that he or she has been steadily committing him- or herself to a given course of action and is, thereby, reluctant to consider an alternative course (i.e., the discomfort associated with cognitive dissonance; Festinger, 1957). A third source of resistance to change might be HO THERAPEUTIC PROCESS Copyright American Psychological Association. Not for further distribution. the patient's personal need to view his or her past behavior as consistent with the view of his or her own sense of self or identity, that is to say, the patient's self-schema. (Horowitz, 1988). A fourth impediment to behavioral change may be a type of moral resistance in which the patient may feel an obligation to significant others in his or her life to maintain the status quo and not disrupt the equilibrium in the family. A fifth dimension of resistance might be the secondary gain or reinforcement that a given patient may receive from significant others or provide to him- or herself in assuming the social role offered by victimization. Sixth, the patient may feel unable to assume the risk and responsibility associated with making changes in one's life, providing for oneself, and the fear of losing what little one gets from a familiar coping strategy in life. And, finally, resistance may take the form of a self-handicapping strategy by the patient in which the "designated problem" by the patient is in fact a solution (i.e., an excuse) by which the patient is able to avoid making other, more substantial changes in his or her life. By recognizing the multifaceted nature of resistance, Leahy (2001) proposed the use of an integrative social-cognitive model of resistance. Accordingly, an "integrated social-cognitive model of resistance recognizes that resistance is often the result of emotional dysregulation (or overregulation), early (and later) childhood experiences, and unconscious processes" (Leahy, 2001, p. 20). This multidimensional model of resistance borrows heavily from its psychoanalytic predecessors that emphasize the self-protective mechanisms of psychological defenses and unapologetically acknowledges that many of these processes may lie outside of the patient's conscious awareness at given points in time. Even the staunch adherents of a psychoanalytic framework might find little to argue with in such a multidimensional approach to resistance. CONCLUDING REMARKS: FROM ORTHODOXY TO INTEGRATION IN THE NOVICE AND SEASONED CLINICIAN The clinical dilemmas that arise from the interpersonal ambiguities of transference, countertransference, and resistance to change span the major theoretical perspectives on psychotherapy regardless of whether the clinician believes or assumes that some of these resistances may be operative at an unconscious level of psychological functioning. Although adherents to other approaches that do not consider unconscious processes to be operative may view their clinical work purely from a cognitive or behavioral theoretical level of explanation, Leahy (2001, p. 14) observed that the notion of "theoretical purity" tends to be more common among novice clinicians. The more experienced and seasoned clinician generally shows a greater willingness to borrow concepts and methods from other modalities in an effort to enhance therapeutic effectiveness. Even the admonishment by P. L. Wachtel (1982) noted earlier concerning the limited understanding of the concept of resisTRANSFERENCE, COUNTERTRANSFERENCE, AND RESISTANCE 141 Copyright American Psychological Association. Not for further distribution. tance in the early behavior therapy literature was tempered by his observation that this is an illusion that disappears rapidly when one speaks with experienced behavior therapists about case material. In this respect, the movement toward integrative psychotherapy may well be an outcome or product of the maturation that has taken place in the field of psychotherapy. Reciprocally, advances in psychotherapy integration may also serve as a maturing force within the profession. The next chapter addresses the more consciously determined dilemmas that occur in the psychotherapeutic process related to the difficulty involved in the interpersonal negotiation of the therapeutic boundary between the neutrality of the therapist, on the one hand, and therapeutic engagement (and the therapist's self-disclosure) with the patient, on the other. 142 THERAPEUTIC PROCESS 4. Social Psychological Theories: Adler, Fromm, Homey, and Sullivan T he psychoanalytic theories of personality formulated by Freud and Jung were nurtured by the same positivistic climate that shaped the course of nineteenth century physics and biology. Man was regarded primarily as a complex energy system which maintains itself by means of transactions with the external world. The ultimate purposes of these transactions are individual survival, propagation of the species, and an ongoing evolutionary development. The various psychological processes that constitute the personality serve these ends. According to the evolutionary doctrine some personalities are better fitted than others to perform these tasks. Consequently, the concept of variation and the distinction between adjustment and maladjustment conditioned the thinking of the early psychoanalysts. Even academic psychology was swept into the orbit of Darwinism and became preoccupied with the measurement of individual differences in abilities and with the adaptive or functional value of psychological processes. At the same time, other intellectual trends which were at variance with a purely biophysical conception of man were beginning to take shape. During the later years of the nineteenth century, sociology and anthropology began to emerge as independent disciplines and their rapid growth during the present century has been phenomenal. While sociologists studied man living in a state of advanced civilization and found him to be a product of his class and caste, his insti114 Social Psychological Theories 115 tutions and folkways, anthropologists ventured into remote areas of the world where they found evidence that human beings are almost infinitely malleable. According to these new social sciences, man is chiefly a product of the society in which he lives. His personality is social rather than biological. Gradually, these burgeoning social and cultural doctrines began to seep into psychology and psychoanalysis and to erode the nativistic and physicalistic foundations of these sciences. A number of followers of Freud who became dissatisfied with his myopia regarding the social conditioners of personality withdrew their allegiance from classical psychoanalysis and began to refashion psychoanalytic theory along lines dictated by the new orientation developed by the social sciences. Among those who provided psychoanalytic theory with the twentieth century look of social psychology are the four people whose ideas form the content of the present chapter—Alfred Adler, Karen Horney, Erich Fromm, and Harry Stack Sullivan. Of these four, Alfred Adler may be regarded as the ancestral figure of the "new social psychological look" because as early as 1911 he broke with Freud over the issue of sexuality, and proceeded to develop a theory in which social interest and a striving for superiority became two of its most substantial conceptual pillars. Later, Horney and Fromm took up the cudgels against the strong instinctivist orientation of psychoanalysis and insisted upon the relevance of social psychological variables for personality theory. Finally, Harry Stack Sullivan in his theory of interpersonal relations consolidated the position of a personality theory grounded in social processes. Although each of the theories has its own distinctive assumptions and concepts, there are numerous parallels among them which have been pointed out by various writers (James, 1947; Ruth Munroe, 1955; and H. L. and R. R. Ansbacher, 1956). Our choice of the major figure for this chapter, Harry Stack Sullivan, is dictated primarily by our belief that he brought his ideas to a higher level of conceptualization and consequently has been a more pervasively influential theorist. Sullivan was considerably more independent of prevailing psychoanalytic doctrines; although he earlier used the Freudian framework, in his later work he developed a theoretical system which deviated markedly from the Freudian one. He was profoundly influenced by anthropology and social psychology. Both Horney and Fromm, on the other hand, kept well within the province of psychoanalysis in their thinking; Adler, although a separatist from the Freudian school, continued to show the impact of his 116 Theories of Personality early association with Freud throughout his life. Homey and Fromm are usually referred to as revisionists or neo-Freudians. Neither of them engaged in developing a new theory of personality; rather they regarded themselves as renovators and elaboraters of an old theory. Sullivan was much more of an innovator. He was a highly original thinker who attracted a large group of devoted disciples and developed what is sometimes called a new school of psychiatry. ALFRED ADLER Alfred Adler was born in Vienna in 1870 of a middle-class family and died in Aberdeen, Scotland, in 1937 while on a lecture tour. He received a medical degree in 1895 from the University of Vienna. At first he specialized in ophthalmology and then, after a period of practice in general medicine, he became a psychiatrist. He was one of the charter members of the Vienna Psychoanalytic Society and later its president. However, Adler soon began to develop ideas which were at variance with those of Freud and others in the Vienna Society, and when these differences became acute he was asked to present his views to the society. This he did in 1911 and as a consequence of the vehement criticism and denunciation of Adler's position by other members of the society, Adler resigned as president and a few months later terminated his connection with Freudian psychoanalysis (Colby, 1951; Jones, 1955; H. L. and R. R. Ansbacher, 1956). He then formed his own group, which came to be known as Individual Psychology and which attracted followers throughout the world. During the First World War, Adler served as a physician in the Austrian army and after the war he became interested in child guidance and established the first guidance clinics in connection with the Viennese school system. He also inspired the establishment of an experimental school in Vienna which applied his theories of education. In 1935 Adler settled in the United States where he continued his practice as a psychiatrist and served as Professor of Medical Psychology at the Long Island College of Medicine. Adler was a prolific writer and published a hundred books and articles during his lifetime. The practice and theory of individual psychology (1927) is probably the best introduction to Adler's theory of personalityShorter digests of Adler's views appear in the Psychologies of 1930 (1930) and in the International Journal of Individual Psychology (1935). Heinz and Rowena Ansbacher recently edited and anno- Social Psychological Theories 117 tated an extensive selection of passages from Adler's writings (1956) which is the best single source of information about Adler's Individual Psychology. Phyllis Bottome has written a book-length biography of Adler (1939). Adler's ideas are promulgated in the United States by the American Society of Individual Psychology with branches in New York, Chicago, and Los Angeles and through its journal, The American Journal of Individual Psychology. In sharp contrast to Freud's major assumption that man's behavior is motivated by inborn instincts and Jung's principal axiom that man's conduct is governed by inborn archetypes, Adler assumed that man is motivated primarily by social urges. Man is, according to Adler, inherently a social being. He relates himself to other people, engages in co-operative social activities, places social welfare above selfish interest, and acquires a style of life which is predominantly social in orientation. Adler did not say that man becomes socialized merely by being exposed to social processes; social interest is inborn although the specific types of relationships with people and social institutions which develop are determined by the nature of the society into which a person is born. In one sense, then, Adler is just as biological in his viewpoint as are Freud and Jung. All three assume that man has an inherent nature which shapes his personality. Freud emphasized sex, Jung emphasized primordial thought patterns, and Adler stressed social interest. This emphasis upon the social determinants of behavior which had been overlooked or minimized by Freud and Jung is probably Adler's greatest contribution to psychological theory. It turned the attention of psychologists to the importance of social variables and helped to develop the field of social psychology at a time when social psychology needed encouragement and support, especially from the ranks of psychoanalysis. Adler's second major contribution to personality theory is his concept of the creative self. Unlike Freud's ego which consists of a group of psychological processes serving the ends of inborn instincts, Alder's self is a highly personalized, subjective system which interprets and makes meaningful the experiences of the organism. Moreover, it searches for experiences which will aid in fulfilling the person's unique style of life; if these experiences are not to be found in the world the self tries to create them. This concept of a creative self was new to psychoanalytic theory and it helped to compensate for the extreme "objectivism" of classical psychoanalysis, which relied almost entirely upon biological needs and external stimuli to account for the dynamics of personality. As we shall see in other chapters, 118 Theories of Personality the concept of the self has played a major role in recent formulations regarding personality. Adler's contribution to this new trend of recognizing the self as an important cause of behavior is considered to be a very significant one (H. L. and R. R. Ansbacher, 1956). A third feature of Adler's psychology which sets it apart from classical psychoanalysis is its emphasis upon the uniqueness of personality. Adler considered each person to be a unique configuration of motives, traits, interests, and values; every act performed by the person bears the stamp of his own distinctive style of life. In this respect, Adler belongs to the tradition of William James and Wilhelm Stern who are said to have laid the foundation for personalistic psychology. Adler's theory of the person minimized the sexual instinct which in Freud's early theorizing had played an almost exclusive role in the dynamics of behavior. To this Freudian monologue on sex, Adler added other significant voices. Man is primarily a social and not a sexual creature. He is motivated by social and not by sexual interest. His inferiorities are not limited to the sexual domain, but may extend to all facets of his being, both physical and psychological. He strives to develop a unique style of life in which the sexual drive plays a minor role. In fact, the way in which he satisfies his sexual needs is determined by his style of life and not vice versa. Adler's dethroning of sex was for many people a welcome relief from the monotonous pansexualism of Freud. Finally, Adler made consciousness the center of personality. Man is a conscious being; he is ordinarily aware of the reasons for his behavior. He is conscious of his inferiorities and conscious of the goals for which he strives. More than that, he is a self-conscious individual who is capable of planning and guiding his actions with full awareness of their meaning for his own self-realization. This is the complete antithesis of Freud's theory which had virtually reduced consciousness to the status of a nonentity, a mere froth floating on the great sea of the unconscious. MAJOR CONCEPTS Alfred Adler, like other personality theorists whose primary training was in medicine and who practiced psychiatry, began his theorizing in the field of abnormal psychology. He formulated a theory of neurosis before broadening his theoretical scope to include the normal personality, which occurred during the 1920's (H. L. and R. R. Ansbacher, 1956). Adler's theory of personality is an extremely Social Psychological Theories 119 economical one in the sense that a few basic concepts sustain the whole theoretical structure. For that reason, Adler's viewpoint can be rather quickly sketched under a few general rubrics. These are (1) fictional finalism, (2) striving for superiority, (3) inferiority feelings and compensation, (4) social interest, (5) style of life, and (6) the creative self. FICTIONAL FINALISM. Shortly after Adler dissociated himself from the circle that surrounded Freud, he fell under the philosophical influence of Hans Vaihinger whose book The psychology of "as if (English translation, 1925) had been published in 1911. Vaihinger propounded the curious and intriguing notion that man lives by many purely fictional ideas which have no counterpart in reality. These fictions, for example, "all men are created equal," "honesty is the best policy," and "the end justifies the means," enable man to deal more effectively with reality. They are auxiliary constructs or assumptions and not hypotheses which can be tested and confirmed. They can be dispensed with when their usefulness has disappeared. Adler took over this philosophical doctrine of idealistic positivism and bent it to his own design. Freud, it will be recalled, laid great stress upon constitutional factors and experiences during early childhood as determiners of personality. Adler discovered in Vaihinger the rebuttal to this rigid historical determinism; he found the idea that man is motivated more by his expectations of the future than he is by experiences of the past. These goals do not exist in the future as a part of some teleological design—neither Vaihinger nor Adler believed in predestination or fatality—rather they exist subjectively or mentally here and now as strivings or ideals which affect present behavior. If a person believes, for example, that there is a heaven for virtuous people and a hell for sinners this fiction, it may be presumed, will exercise considerable influence on his conduct. These fictional goals were, for Adler, the subjective causation of psychological events. Like Jung, Adler identified Freud's theory with the principle of causality and his own with the principle of finalism. Individual Psychology insists absolutely on the indispensability of finalism for the understanding of all psychological phenomena. Causes, powers, instincts, impulses, and the like cannot serve as explanatory principles. The final goal alone can explain man's behavior. Experiences, traumata, sexual development mechanisms cannot yield an explanation, but the perspective in which these are regarded, the individual way of seeing them, which subordinates all life to the final goal, can do rt> (1930, p. 400). 120 Theories of Personality This final goal may be a fiction, that is, an ideal which is impossible to realize but which is nonetheless a very real spur to man's striving and the ultimate explanation of his conduct. Adler believed, however, that the normal person could free himself from the influence of these fictions and face reality when necessity demanded, something that the neurotic person is incapable of doing. STRIVING FOR SUPERIORITY. What is the final goal toward which all men strive and which gives consistency and unity to personality? By 1908, Adler had reached the conclusion that aggression was more important than sexuality. A little later, the aggressive impulse was replaced by the "will to power." Adler identified power with masculinity and weakness with femininity. It was at this stage of his thinking (circa 1910) that he set forth the idea of the "masculine protest," a form of overcompensation that both men and women indulge in when they feel inadequate and inferior. Later, Adler abandoned the "will to power" in favor of the "striving for superiority," to which he remained committed thereafter. Thus, there were three stages in his thinking regarding the final goal of man: to be aggressive, to be powerful, and to be superior. Adler makes it very clear that by superiority he does not mean social distinction, leadership, or a pre-eminent position in society. By superiority, Adler means something very analogous to Jung's concept of the self or Goldstein's principle of self-actualization. It is a striving for perfect completion. It is "the great upward drive." I began to see clearly in every psychological phenomenon the striving for superiority. It runs parallel to physical growth and is an intrinsic necessity of life itself. It lies at the root of all solutions of life's problems and is manifested in the way in which we meet these problems. All our functions follow its direction. They strive for conquest, security, increase, either in the right or in the wrong direction. The impetus from minus to plus never ends. The urge from below to above never ceases. Whatever premises all our philosophers and psychologists dream of—self-preservation, pleasure principle, equalization—all these are but vague representations, attempts to express the great upward drive (1930, p. 398). Where does the striving for superiority or perfection come from? Adler says that it is innate; that it is a part of life; in fact, that it is life itself. From birth to death, the striving for superiority carries the person from one stage of development to the next higher stage. It is a prepotent dynamic principle. There are no separate drives, for each drive receives its power from the striving for completion. Adler acknowledges that the striving for superiority may manifest it- Social Psychological Theories 121 self in a thousand different ways, and that each person has his own concrete mode of achieving or trying to achieve perfection. The neurotic person, for example, strives for self-esteem, power, and selfaggrandizement—in other words, for egoistic or selfish goals—whereas the normal person strives for goals that are primarily social in character. Precisely how do the particular forms of the striving for superiority come into being in the individual? In order to answer this question it is necessary to discuss Adler's concept of inferiority feelings. INFERIORITY FEELINGS AND COMPENSATION. Very early in his career, while he was still interested in general medicine, Adler put forth the idea of organ inferiority and overcompensation (English translation, 1917). At that time, he was interested in finding the answer to the perennial question of why people, when they became sick or suffer some affliction, became sick or afflicted in a particular region of the body. One person develops heart trouble, another lung trouble, and a third lumbago. Adler suggested that the reason for the site of a particular affliction was a basic inferiority in that region, an inferiority which existed either by virtue of heredity or because of some developmental abnormalty. He then observed that a person with a defective organ often tries to compensate for the weakness by strengthening it through intensive training. The most famous example of compensation for organ inferiority is that of Demosthenes who stuttered as a child and became one of the world's greatest orators. Another more recent example is that of Theodore Roosevelt who was a weakling in his youth and developed himself by systematic exercise into a physically stalwart man. Shortly after he had published his monograph on organ inferiority Adler broadened the concept to include any feelings of inferiority, those that arise from subjectively felt psychological or social disabilities as well as those that stem from actual bodily weakness or impairment. At this time, Adler equated inferiority with unmanliness or femininity, the compensation for which was called "the masculine protest." Later, however, he subordinated this view to the more general one that feelings of inferiority arise from a sense of incompletion or imperfection in any sphere of life. For example, the child is motivated by his feelings of inferiority to strive for a higher level of development. When he reaches this level, he begins to feel inferior again and the upward movement is initiated once more. Adler contended that inferiority feelings are not a sign of abnormality; they are the cause of all improvement in man's lot. Of course, inferiority 122 Theories of Personality feelings may be exaggerated by special conditions such as pampering or rejecting the child, in which case certain abnormal manifestations may ensue, such as the development of an inferiority complex or a compensatory superiority complex. But under normal circumstances, the feeling of inferiority or a sense of incompleteness is the great driving force of mankind. In other words, man is pushed by the need to overcome his inferiority and pulled by the desire to be superior. Adler was not a proponent of hedonism. Although he believed that inferiority feelings were painful he did not think that the relief of these feelings was necessarily pleasurable. Perfection, not pleasure, was for him the goal of life. SOCIAL INTEREST. During the early years of his theorizing when he was proclaiming the aggressive, power-hungry nature of man and the idea of the masculine protest as an overcompensation for feminine weakness, Adler was severly criticized for emphasizing the selfish drives of man and ignoring his social motives. Striving for superiority sounded like the war cry of the Nietzschean superman, a fitting companion for the Darwinian slogan of survival of the fittest. Adler, who was an advocate of social justice and a supporter of social democracy, enlarged his conception of man to include the factor of social interest (1939). Although social interest takes in such matters as co-operation, interpersonal and social relations, identification with the group, empathy, and so forth, it is much broader than all of these. In its ultimate sense, social interest consists of the individual helping society to attain the goal of a perfect society. "Social interest is the true and inevitable compensation for all the natural weaknesses of individual human beings" (Adler, 1929b, p. 31). The person is embedded in a social context from the first day of life. Co-operation manifests itself in the relationship between the infant and the mother, and henceforth the person is continuously involved in a network of interpersonal relations which shape his personality and provide concrete outlets for his striving for superiority. Striving for superiority becomes socialized; the ideal of a perfect society takes the place of purely personal ambition and selfish gain. By working for the common good, man compensates for his individual weakness. Adler believed that social interest is inborn; that man is a social creature by nature, and not by habit. However, like any other natural aptitude, this innate predisposition does not appear spontaneously but has to be brought to fruition by guidance and training. Because he believed in the benefits of education Adler devoted a great deal of his time to establishing child guidance clinics, to improving the Social Psychological Theories 12S schools, and to educating the public regarding proper methods of rearing children. It is interesting to trace in Adler's writings the decisive although gradual change that occurred in his conception of man from the early years of his professional life when he was associated with Freud to his later years when he had achieved an international reputation. For the young Adler, man is driven by an insatiable lust for power and domination in order to compensate for a concealed deep-seated feeling of inferiority. For the older Adler, man is motivated by an innately given social interest which causes him to subordinate private gain to public welfare. The image of the perfect man living in a perfect society blotted out the picture of the strong, aggressive man dominating and exploiting society. Social interest replaced selfish interest. STYLE OF LIFE. This is the slogan of Adler's personality theory. It is a recurrent theme in all of Adler's later writings (for example, 1929a, 1931) and the most distinctive feature of his psychology. Style of life is the system principle by which the individual personality functions; it is the whole that commands the parts. Style of life is Adler's chief idiographic principle; it is the principle that explains the uniqueness of the person. Everyone has a style of life but no two people develop the same style. Precisely what is meant by this concept? This is a difficult question to answer because Adler had so much to say about it and because he said different and sometimes conflicting things about it in his various writings. Then, too, it is difficult to differentiate it from another Adlerian concept, that of the creative self. Every person has the same goal, that of superiority, but there are innumerable ways of striving for this goal. One person tries to become superior through developing his intellect, while another bends all of his efforts to achieving muscular perfection. The intellectual has one style of life, the athlete another. The intellectual reads, studies, thinks; he lives a more sedentary and more solitary life than the active man does. He arranges the details of his existence, his domestic habits, his recreations, his daily routine, his relations to his family, friends, and acquaintances, his social activities, in accordance with his goal of intellectual superiority. Everything he does he does with an eye to this ultimate goal. All of a person's behavior springs from his style of life. He perceives, learns, and retains what fits his style of Me, and ignores everything else. The style of life is formed very early in childhood, by the age of four or five, and from then on experiences are assimilated and utilized 124 Theories of Personality according to this unique style of life. His attitudes, feelings, apperceptions become fixed and mechanized at an early age, and it is practically impossible for the style of life to change thereafter. The person may acquire new ways of expressing his unique style of life, but these are merely concrete and particular instances of the same basic style that was found at an early age. What determines the individual's style of life? In his earlier writings, Adler said that it is largely determined by the specific inferiorities, either fancied or real, that the person has. The style of life is a compensation for a particular inferiority. If the child is a physical weakling, his style of life will take the form of doing those things which will produce physical strength. The dull child will strive for intellectual superiority. Napoleon's conquering style of life was determined by his slight physical stature, and Hitler's rapacious craving for world domination by his sexual impotence. This simple explanation of man's conduct which appealed to so many of Adler's readers and which was widely applied in the analysis of character during the 1920's and 1930's did not satisfy Adler himself. It was too simple and too mechanistic. He looked for a more dynamic principle and found the creative self. THE CREATIVE SELF. This concept is Adler's crowning achievement as a personality theorist. When he discovered the creative self all of his other concepts were subordinated to it; here at last was the prime mover, the philosopher's stone, the elixer of life, the first cause of everything human for which Adler had been searching. The unitary, consistent, creative self is sovereign in the personality structure. Like all first causes, the creative self is hard to describe. We can see its effects, but we cannot see it. It is something that intervenes between the stimuli acting upon the person and the responses he makes to these stimuli. In essence, the doctrine of a creative self asserts that man makes his own personality. He constructs it out of the raw material of heredity and experience. Heredity only endows him with certain abilities. Environment only gives him certain impressions. These abilities and impressions, and the manner in which he 'experiences' them—that is to say, the interpretation he makes of these experiences—are the bricks which he uses in his own 'creative' way in building up his attitude toward life. It is his individual way of using these bricks, or in other words his attitude toward life, which determines this relationship to the outside world (Adler, 1935, p. 5). The creative self is the yeast that acts upon the facts of the world and transforms these facts into a personality that is subjective, dynamic, unified, personal, and uniquely stylized. The creative self gives Social Psychological Theories 125 meaning to life; it creates the goal as well as the means to the goal. The creative self is the active principle of human life, and it is not unlike the older concept of soul. In summary, it may be said that Adler fashioned a humanistic theory of personality which was the antithesis of Freud's conception of man. By endowing man with altruism, humanitarianism, co-operation, creativity, uniqueness, and awareness, he restored to man a sense of dignity and worth that psychoanalysis had pretty largely destroyed. In place of the dreary materialistic picture which horrified and repelled many readers of Freud, Adler offered a portrait of man which was more satisfying, more hopeful, and far more complimentary to man. Adler's conception of the nature of personality coincided with the popular idea that man can be the master, and not the victim, of his fate. CHARACTERISTIC RESEARCH AND RESEARCH METHODS Adler's empirical observations were made largely in the therapeutic setting and consist for the most part of reconstructions of the past as remembered by the patient and appraisals of present behavior on the basis of verbal reports. There is space to mention only a few examples of Adler's investigative activities. ORDER OF BIRTH AND PERSONALITY. In line with his interest in the social determiners of personality, Adler observed that the personalities of the oldest, middle, and youngest child in a family were likely to be quite different (1931, pp. 144-154). He attributed these differences to the distinctive experiences that each child has as a member of a social group. The first-born or oldest child is given a good deal of attention until the second child is born; then he is suddenly dethroned from his favored position and must share his parents' affections with the new baby. This experience may condition the oldest child in various ways, such as hating people, protecting himself against sudden reversals of fortune, and feeling insecure. Oldest children are also apt to take an interest in the past when they were the center of attention. Neurotics, criminals, drunkards, and perverts, Adler observes, are often first-born children. If the parents handle the situation wisely by preparing the oldest child for the appearance of a rival, the oldest child is more likely to develop into a responsible, protective person. The second or middle child is characterized by being ambitious. He is constantly trying to surpass his older sibling. He also tends to be rebellious and envious but by and large he is better adjusted than either his older or younger sibling. 126 Theories of Personality The youngest child is the spoiled child. Next to the oldest child he is most likely to become a problem child and a neurotic maladjusted adult. This theory has been tested a number of times but most of the findings do not lend support to it (Jones, 1931). EARLY MEMORIES. Adler felt that the earliest memory a person could report was an important key to understanding his basic style of life (1931). For example, a girl began an account of her earliest memory by saying, "When I was three years old, my father . . ." This indicates that she is more interested in her father than in her mother. She then goes on to say that the father brought home a pair of ponies for an older sister and her, and that the older sister led her pony down the street by the halter while she was dragged along in the mud by her pony. This is the fate of the younger child—to come off second best in the rivalry with an older sibling—and it motivates her to try to surpass the pacemaker. Her style of life is one of driving ambition, an urge to be first, a deep feeling of insecurity and disappointment, and a strong foreboding of failure. A young man who was being treated for severe attacks of anxiety recalled this early scene. "When I was about four years old I sat at the window and watched some workmen building a house on the opposite side of the street, while my mother knitted stockings." This recollection indicates that the young man was pampered as a child because his memory includes the solicitous mother. The fact that he is looking at others who are working suggests that his style of life is that of a spectator rather than a participant. This is borne out by the fact that he becomes anxious whenever he tries to take up a vocation. Adler suggested to him that he consider an occupation in which his preference for looking and observing could be utilized. The patient took Adler's advice and became a successful dealer in art objects. Adler used this method with groups as well as individuals and found that it was an easy and economical way of studying personality. CHILDHOOD EXPERIENCES. Adler was particularly interested in the kinds of early influences that predispose the child to a faulty style of life. He discovered three important factors: (1) children with inferiorities, (2) spoiled children, and (3) neglected children. Children with physical or mental infirmities bear a heavy burden and are likely to feel inadequate in meeting the tasks of life. They consider themselves to be, and often are, failures. However, if they have understanding, encouraging parents they may compensate for their inferiorities and transform their weakness into strength. Many promi- Social Psychological Theories 127 nent men started life with some organic weakness for which they compensated. Over and over again Adler spoke out vehemently against the evils of pampering for he considered this to be the greatest curse that can be visited upon the child. Pampered children do not develop social feeling; they become despots who expect society to conform to their self-centered wishes. Adler considered them to be potentially the most dangerous class in society. Neglect of the child also has unfortunate consequences. Badly treated in childhood, as adults they become enemies of society. Their style of life is dominated by the need for revenge. These three conditions—organic infirmity, pampering, and rejection—produce erroneous conceptions of the world and result in a pathological style of life. ERICH FROMM Erich Fromm was born in Frankfurt, Germany, in 1900 and studied psychology and sociology at the Universities of Heidelberg, Frankfurt, and Munich. After receiving a Ph.D. degree from Heidelberg in 1922, he was trained in psychoanalysis in Munich and at the famous Berlin Psychoanalytic Institute. He came to the United States in 1933 as a lecturer at the Chicago Psychoanalytic Institute and then entered private practice in New York City. He has taught at a number of universities and institutes in this country. Not only have his books received considerable attention from specialists in thefieldsof psychology, sociology, philosophy, and religion but also from the general public. The essential theme of all of Fromm's writings is that man feels lonely and isolated because he has become separated from nature and from other men. This condition of isolation is not found in any other species of animal; it is the distinctive human situation. The child, for example, gains freedom from the primary ties with his parents with the result that he feels isolated and helpless. The serf eventually secured his freedom only to find himself adrift in a predominantly alien world. As a serf, he belonged to someone and had a feeling of being related to the world and to other people, even though he was not free. In this book, Escape from freedom (1941), Fromm develops the thesis that as man has gained more freedom throughout the ages he has also felt more alone. Freedom then becomes a negative condition from which he tries to escape. What is the answer to this dilemma? Man can either unite himself with other people in the spirit of love and shared work or he can find 128 Theories of Personality security by submitting to authority and conforming to society. In the one case, man uses his freedom to develop a better society; in the other, he acquires a new bondage. Escape from freedom was written under the shadow of the Nazi dictatorship and shows that this form of totalitarianism appealed to people because it offered them a new security. But as Fromm points out in subsequent books (1947, 1955), any form of society that man has fashioned, whether it be that of feudalism, capitalism, fascism, socialism, or communism, represents an attempt to resolve the basic contradiction of man. This contradiction consists of man being both a part of nature and separate from it, of being both an animal and a human being. As an animal he has certain physiological needs which must be satisfied. As a human being he possesses self-awareness, reason, and imagination. These two aspects constitute the basic conditions of man's existence. "The understanding of man's psyche must be based on the analysis of mans needs stemming from the conditions of his existence" (1955, p. 25). What are the specific needs that rise from the conditions of man's existence? They are five in number: the need for relatedness, the need for transcendence, the need for rootedness, the need for identity, and the need for a frame of orientation. The need for relatedness stems from the stark fact that man in becoming man has been torn from the animal's primary union with nature. "The animal is equipped by nature to cope with the very conditions it is to meet" (1955, p. 23) but man with his power to reason and imagine has lost this intimate interdependence with nature. In place of those instinctive ties with nature which animals possess man has to create his own relationships, the most satisfying being those which are based upon productive love. Productive love always implies mutual care, responsibility, respect, and understanding. The urge for transcendence refers to man's need to rise above his animal nature, to become a creative person instead of remaining a creature. If his creative urges are thwarted, man becomes a destroyer. Fromm points out that love and hate are not antithetical drives; they are both answers to man's need to transcend his animal nature. Animals can neither love nor hate, but man can. Man desires natural roots; he wants to be an integral part of the world, to feel that he belongs. As a child, he is rooted to his mother but if this relationship persists past childhood it is considered to be an unwholesome fixation. Man finds his most satisfying and healthiest roots in a feeling of brotherliness with other men and women. But man wants also to have a sense of personal identity, to be a unique Social Psychological Theories 129 individual. If he cannot attain this goal through his own creative effort, he may obtain a certain mark of distinction by identifying himself with another person or group. The slave identifies with the master, the citizen with his country, the worker with his company. In this case, the sense of identity arises from belonging to someone and not from being someone. Finally, man needs to have a frame of reference, a stable and consistent way of perceiving and comprehending the world. The frame of reference that he develops may be primarily rational, primarily irrational, or it may have elements of both. For Fromm these needs are purely human and purely objective. They are not found in animals and they are not derived from observing what man says he wants. Nor are these strivings created by society; rather they have become embedded in human nature through evolution. What then is the relation of society to the existence of man? Fromm believes that the specific manifestations of these needs, the actual ways in which man realizes his inner potentialities, are determined by "the social arrangements under which he lives" (1955, p. 14). His personality develops in accordance with the opportunities that a particular society offers him. In a capitalistic society, for example, he may gain a sense of personal identity by becoming rich or develop a feeling of rootedness by becoming a dependable and trusted employee in a large company. In other words, man's adjustment to society usually represents a compromise between inner needs and outer demands. He develops a social character in keeping with the requirements of the society. From the standpoint of the proper functioning of a particular society it is absolutely essential that the child's character be shaped to fit the needs of society. The task of the parents and of education is to make the child want to act as he has to act if a given economic, political, and social system is to be maintained. Thus, in a capitalistic system the desire to save must be implanted in people in order that capital is available for an expanding economy. A society which has evolved a credit system must see to it that people will feel an inner compulsion to pay their bills promptly. Fromm gives numerous examples of the types of character that develop in a democratic, capitalistic society (1947). By making demands upon man which are contrary to his nature, society warps and frustrates man. It alienates him from his "human situation" and denies him the fulfillment of the basic conditions of his existence. Both capitalism and communism, for example, try to make 130 Theories of Personality man into a robot, a wage slave, a nonentity, and they often succeed in driving him into insanity, antisocial conduct or self-destructive acts. Fromm does not hesitate to stigmatize a whole society as being sick when it fails to satisfy the basic needs of man (1955). Fromm also points out that when a society changes in any important respect, as occurred when feudalism changed into capitalism or when the factory system displaced the individual artisan, such a change is likely to produce dislocations in the social character of people. The old character structure does not fit the new society, which adds to man's sense of alienation and despair. He is cut off from traditional ties and until he can develop new roots and relations he feels lost. During such transitional periods, he becomes a prey to all sorts of panaceas and nostrums which offer him a refuge from loneliness. The problem of man's relations to society is one of great concern to Fromm, and he returns to it again and again. Fromm is utterly convinced of the validity of the following propositions: (1) man has an essential, inborn nature, (2) society is created by man in order to fulfill this essential nature, (3) no society which has yet been devised meets the basic needs of man's existence, and (4) it is possible to create such a society. What kind of a society does Fromm advocate? It is one . . . in which man relates to man lovingly, in which he is rooted in bonds of brotherliness and solidarity . . . ; a society which gives him the possibility of transcending nature by creating rather than by destroying, in which everyone gains a sense of self by experiencing himself as the subject of his powers rather than by conformity, in which a system of orientation and devotion exists without man's needing to distort reality and to worship idols (1955, p. 362). Fromm even suggests a name for this perfect society: Humanistic Communitarian Socialism. In such a society everyone would have equal opportunity to become fully human. There would be no loneliness, no feelings of isolation, no despair. Man would find a new home, one suited to the "human situation." KAREN HORNEY Karen Homey was born in Hamburg, Germany, September 16, 1885, and died in New York City, December 4, 1952, She received her medical training at the University of Berlin and was associated with the Berlin Psychoanalytic Institute from 1918 to 1932. She was analyzed by Karl Abraham and Hans Sachs, two of the pre-eminent Social Psychological Theories 131 training analysts in Europe at that time. Upon the invitation of Franz Alexander, she came to the United States and was Associate Director of the Chicago Psychoanalytic Institute for two years. In 1934 she moved to New York where she practiced psychoanalysis and taught at the New York Psychoanalytic Institute. Becoming dissatisfied with orthodox psychoanalysis, she and others of similar convictions founded the Association for the Advancement of Psychoanalysis and the American Institute of Psychoanalysis. She was Dean of this institute until her death. Homey conceives of her ideas as falling within the framework of Freudian psychology, not as constituting an entirely new approach to the understanding of personality. She aspires to eliminate the fallacies in Freud's thinking—fallacies which have their root, she believes, in his mechanistic, biological orientation—in order that psychoanalysis may realize its full potentialities as a science of man. "My conviction, expressed in a nutshell, is that psychoanalysis should outgrow the limitations set by its being an instinctivistic and a genetic psychology" (1939, p. 8). Homey objects strongly to Freud's concept of penis envy as the determining factor in the psychology of women. Freud, it will be recalled, observed that the distinctive attitudes and feelings of women and their most profound conflict grew out of their feeling of genital inferiority and their jealousy of the male. Homey believes that feminine psychology is based on lack of confidence and an overemphasis of the love relationship, and has very little to do with the anatomy of her sex organs. Regarding the Oedipus complex, Horney feels that it is not a sexual-aggressive conflict between the child and his parents but an anxiety growing out of basic disturbances, for example, rejection, overprotection, and punishment, in the child's relationships with his mother and father. Aggression is not inborn as Freud stated, but is a means by which man tries to protect his security. Narcissism is not really self-love but self-inflation and overvaluation owing to feelings of insecurity. Homey also takes issue with the following Freudian concepts: repetition compulsion, the id, ego, and superego, anxiety, and masochism (1939). On the positive side, Homey asserts that Freud's fundamental theoretical contributions are the doctrines of psychic determinism, unconscious motivation, and emotional, nonrational motives. Horney's primary concept is that of basic anxiety, which is defined as 182 Theories of Personality . . . the feeling a child has of being isolated and helpless in a potentially hostile world. A wide range of adverse factors in the environment can produce this insecurity in a child: direct or indirect domination, indifference, erratic behavior, lack of respect for the child's individual needs, lack of real guidance, disparaging attitudes, too much admiration or the absence of it, lack of reliable warmth, having to take sides in parental disagreements, too much or too little responsibility, overprotection, isolation from other children, injustice, discrimination, unkept promises, hostile atmosphere, and so on and so on (1945, p. 41). In general, anything that disturbs the security of the child in relation to his parents produces basic anxiety. The insecure, anxious child develops various strategies by which to cope with his feelings of isolation and helplessness (1937). He may become hostile and seek to avenge himself against those who have rejected or mistreated him. Or he may become overly submissive in order to win back the love that he feels he has lost. He may develop an unrealistic, idealized picture of himself in order to compensate for his feelings of inferiority (1950). He may try to bribe others into loving him, or he may use threats to force people to like him. He may wallow in self-pity in order to gain people's sympathy. If he cannot get love he may seek to obtain power over others. In that way, he compensates for his sense of helplessness, finds an outlet for hostility, and is able to exploit people. Or he becomes highly competitive, in which the winning is far more important than the achievement. He may turn his aggression inward and belittle himself. Any one of these strategies may become a more or less permanent fixture in the personality; a particular strategy may, in other words, assume the character of a drive or need in the personality dynamics. Homey presents a list of ten needs which are acquired as a consequence of trying to find solutions for the problem of disturbed human relationships (1942). She calls these needs "neurotic" because they are irrational solutions to the problem. 1. The neurotic need for affection and approval. This need is characterized by an indiscriminate wish to please others and to live up to their expectations. The person lives for the good opinion of others and is extremely sensitive to any sign of rejection or unfriendliness. 2. The neurotic need for a "partner" who will take over one's life. The person with this need is a parasite. He overvalues love, and is extremely afraid of being deserted and left alone. 3. The neurotic need to restrict one's life within narrow borders. Such a person is undemanding, content with little, prefers to remain inconspicuous, and values modesty above all else. Social Psychological Theories 133 4. The neurotic need for power. This need expresses itself in craving power for its own sake, in an essential disrespect for others, and in an indiscriminate glorification of strength and a contempt for weakness. People who are afraid to exert power openly may try to control others through intellectual exploitation and superiority. Another variety of the power drive is the need to believe in the omnipotence of will. Such people feel they can accomplish anything simply by exerting will power. 5. The neurotic need to exploit others. 6. The neurotic need for prestige. One's self-evaluation is determined by the amount of public recognition received. 7. The neurotic need for personal admiration. A person with this need has an inflated picture of himself and wishes to be admired on this basis, not for what he really is. 8. The neurotic ambition for personal achievement. Such a person wants to be the very best and drives himself to greater and greater achievements as a result of his basic insecurity. 9. The neurotic need for self-sufficiency and independence. Having been disappointed in his attempts to find warm, satisfying relationships with people, the person sets himself apart from others and refuses to be tied down to anyone or anything. He becomes a lone wolf. 10. The neurotic need for perfection and unassailability. Fearful of making mistakes and of being criticized, the person who has this need tries to make himself impregnable and infallible. He is constantly searching for flaws in himself so that they may be covered up before they become obvious to others. These ten needs are the sources from which inner conflicts develop. The neurotic's need for love, for example, is insatiable; the more he gets the more he wants. Consequently, he is never satisfied. Likewise, his need for independence can never be fully satisfied because another part of his personality wants to be loved and admired. The search for perfection is a lost cause from the beginning. All of the foregoing needs are unrealistic. In a later publication (1945), Horney classifies these ten needs under three headings: (1) moving toward people, for example, need for love, (2) moving away from people, for instance, need for independence, and (3) moving against people, for example, need for power. Each of these rubrics represents a basic orientation toward others and oneself. Horney finds in these different orientations the basis for inner conflict. The essential difference between a normal and a neurotic conflict is one of degree. ". . . the disparity between 134 Theories of Personality the conflicting issues is much less great for the normal person than for the neurotic" (1945, p. 31). In other words, everyone has these conflicts but some people, primarily because of early experiences with rejection, neglect, overprotection, and other kinds of unfortunate parental treatment, possess them in an aggravated form. While the normal person can resolve these conflicts by integrating the three orientations, since they are not mutually exclusive, the neurotic person, because of his greater basic anxiety, must utilize irrational and artificial solutions. He consciously recognizes only one of the trends and denies or represses the other two. Or he creates an idealized image of himself in which the contradictory trends presumably disappear, although actually they do not. In a later book (1950), Horney has a great deal more to say about the unfortunate consequences that flow from the development of an unrealistic conception of the self and from attempts to live up to this idealized picture. The search for glory, feelings of self-contempt, morbid dependency upon other people, and self-abasement are some of the unhealthy and destructive results that grow out of an idealized self. A third solution employed by the neurotic person for his inner conflicts is to externalize them. He says, in effect, "I don't want to exploit other people, they want to exploit me." This solution creates conflicts between the person and the outside world. All of these conflicts are avoidable or resolvable if the child is raised in a home where there is security, trust, lov...
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Running head: ANNOTATED BIBLIOGRAPHY AND OUTLINE

Annotated Bibliography and Outline
Name
Institution

1

ANNOTATED BIBLIOGRAPHY AND OUTLINE

2

Annotated Bibliography
Scaturo, D.J., (2005). Clinical dilemmas in psychotherapy: A transtheoretical approach to
psychotherapy integration. Chapter 8, 127 – 142. American Psychological Association.
In this chapter of the book, Scaturo discussed the role of transference,
countertransference, and resistance in psychotherapy and how an integration of an
understanding of these concepts can significantly improve the outcome of the entire
therapeutic process. Transference as an unconscious mental process is considered as an
unconscious emotional reaction of mentally ill persons undergoing treatment to their
therapist or any other health care provider involved in previous treatments or
interventions that are not related to current therapies. In contrast, countertransference is
defined as the unconscious reactions of the therapist or other physicians that are triggered
by a particular patient in addition to his or her characteristics and transference, which if
the psychotherapist fails to recognize, will likely affect his or her spoken or behavioral
response to the patient. Resistance is an unconscious reaction developed by the mentally
ill patient and acts against the effectiveness of the therapeutic process. The information
contained in this chapter of the book will contribute significantly to my understanding of
the clinical dilemmas presented by these three psychotherapeutic concepts. Knowledge
of the depth of the influence of these concepts that are operated unconsciously by patients
and therapist in providing effective psychotherapy is very critical to identify appropriate
recommendations that can be proposed at the end of this paper. Finally, this approach of
blending conventional and unorthodox treatment procedures to improve the quality of
care will be valuable in developing modalities for new and improved therapeutic
processes for mentally ill patients, psychotherapist, and other health care providers.

ANNOTATED BIBLIOGRAPHY AND OUTLINE

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Hall, C. S., & Lindzey, G. (1957). Social psychological theories: Adler, Fromm, Horney, and
Sullivan.
This chapter of the book reviewed the important ...


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