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Psychotherapy

Volume 25/Spring 1988/Number 1

CLINICAL CHOICE POINTS: BEHAVIORAL VERSUS PSYCHOANALYTIC INTERVENTIONS


ARNOLD A. LAZARUS AND STANLEY B. MESSER
RutgersThe State University of New Jersey
Editor's Note: This article was presented as a debate at the conference named in the footnote. Although the format deviates from the style of the journal, the special nature of the debate prompted its inclusion.

A point-counterpoint clinical dialogue between a behavioral and a psychoanalytic practitioner underscores fundamental differences as well as shared points of emphasis. In discussing a case treated by Lazarus, Messer selected "choice points" where he would have intervened differently, while also noting significant commonalities. Lazarus's rejoinders and Messer's rebuttals help to clarify areas of divergence and convergence by focusing on practical rather than philosophical and theoretical issues.
Alongside the separate development of psychoanalytic therapy and behavior therapy have come efforts to juxtapose one with the other for the purpose of comparing, contrasting, or integrating these therapies. Such attempts have been carried out at quite different levels of analysis including the philosophical (Messer, 1986a; Schacht, 1984), the methodological (Franks, 1984), the metatheoretical (Messer & Winokur, 1980, 1984), the conceptual (Goldfried, 1980; Wachtel,
We express our gratitude to Allen Fay and Seth Warren for their incisive comments on an earlier draft of this article. A more extended version of this article was presented and commented on from a family systems perspective by Ellen Wachtel at the Third Annual Conference of the Society for the Exploration of Psychotherapy Integration, Evanston, Illinois, May 1987. Reprints may be ordered from Arnold A. Lazarus or Stanley B. Messer, GSAPP, Rutgers University, P.O. Box 819, Piscataway, NJ 08855-0819.

1984), and the clinical or technical (Rhoads, 1984; Wachtel, 1977). What the literature lacks, however, is clinical dialogue between behavioral and psychoanalytic practitioners focusing on specific therapeutic interventions. Such a dialogue can help ground the current debate regarding integration and eclecticism in clinical realities and practice in a way that philosophical and theoretical conceptualizations frequently cannot. A case discussion has the potential to reveal fundamental differences in practice between these therapies as well as to point to shared emphases and opportunities for integration. In the case presented below, Ms. Davis was treated by Dr. Lazarus, an eclectic, behaviorally based therapist, at two different stages: first "behaviorally" for circumscribed problems (symptoms), and at a later date, "multimodally" (Lazarus, 1981, 1985) for a much more pervasive range of dysfunctions. In reading through the case of Ms. Davis, Messer, a psychodynamically oriented theoretician and clinician, was to select "choice points" where he would have intervened differently, stating his rationale for eschewing certain strategies, while explaining what he would have done instead. Commonality of approach was also to be noted. We trust that this format will help to clarify areas of convergence and divergence between current versions of behaviorally based and psychoanalytically oriented therapies. The Treatment of Ms. Davis Stage 1 When Ms. Davis first consulted Lazarus, she was 32 years of age, a slim, attractive, and stylishly groomed woman who appeared somewhat tense and deferential. Recently married for the second

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time, the fifth-grade schoolteacher complained of two specific problems. 1. She was afraid to travel beyond a 10-mile radius of her home unless accompanied by her husband, her mother, or a trusted friend. This agoraphobic problem had followed an unexpected panic attack while she was in the throes of her divorce three years previously. 2. She was a compulsive hand washer who not only scrubbed her nails and fingers at least 10-15 times a day but also bathed or showered 4 - 6 times a day. Coincidentally or otherwise, she dated the onset of this pattern to an abortion at age 25. "Over the years, it has just become a lot worse," she declared. Prior to her second marriage, she had consulted a psychiatrist who prescribed Valium. Ms. Davis stated: "It did calm me down but not enough to cure my habits." A second therapist was consulted, who, she said, concluded that her symptoms were "deep-seated" and recommended intensive and somewhat extended therapy. "It all sounded too tedious and expensive so I just let it go. . . . But lately, it has gotten me down." Ms. Davis thereupon went on to explain that she and her husband were moving out of state in less than two months. "If possible, I'd like to leave my craziness behind and start in a new place without these old habits. . . . Do you think something can be done for me in less than two months?" When asked specifically what she wished to derive from the timelimited treatment, she stated: "Two things. I want to be less nervous so that I can drive places, and I want to wash and bathe like a normal person." Apart from being obsequious and tense, Ms. Davis impressed Lazarus as an anxious and timid woman who had other problems and "neurotic agendas." Nevertheless, could she learn to "drive places" and "wash and bathe like a normal person" in the short time at our disposal? She was informed that it would be possible to make substantial gains in a couple of months if she was truly motivated to change and was willing to carry out extensive, systematic, and anxiety-generating homework assignments. Since psychotherapy outcome data indicate that phobic and compulsive problems respond best to behavioral techniques (Rachman & Wilson, 1980), the treatments of choice were drawn from this discipline. It is well known that a therapist's credibility is buttressed by emphasizing that the recommended procedures have been endorsed by a respected secondary group (Janis, 1983). Thus, Ms. Davis was first given information about the value of deep muscle relaxation, imaginal and in vivo exposure, and response prevention, replete with selected journal articles and book chapters for her to peruse. (As a schoolteacher, she found this pedagogical emphasis especially congenial.) Relaxation training commenced in the office and was supplemented with cassette recordings for regular home use. Since she reported that positive and coping imagery exercises enhanced the relaxation effect and promoted an inner sense of "calm confidence," additional cassette recordings were made in the office, employing images that Ms. Davis found especially calming. Ms. Davis was asked to choose whether she first wished to tackle the "driving phobia" or her "compulsive washing" and she selected the latter. Since some degree of response prevention is virtually a sine qua non for the successful amelioration of compulsive habits (Rachman & Hodgson, 1980), and since Ms. Davis had read the pertinent literature on the subject, she was ready to begin. "Are you a thoroughly honorable person?" she was asked. The therapist went on to explain that response prevention was usually performed on an inpatient basis, carefully monitored by staff members. She was told that to succeed as an outpatient, she was entirely on her honor. Step one was in the form of an agreement that she would wash her hands no more than four times a dayonce in the morning, once before lunch and dinner, and once before bedtime. The maximum time to be spent washing, scrubbing her nails, and so on was one minute (for which purpose a timer was to be used without fail). It was impressed upon her that there were to be no exceptions to this four-times-a-day, one-minute-per-time regimenalthough she was allowed to rinse her hands very briefly after going to the toilet. She was reminded to employ the relaxation and imagery to offset the inevitable anxieties. She was to call the therapist at 9 PM each night to report on her progress. It was pointed out that her excessive washing might be a self-punitive measure to offset the guilt that the abortion had engendered, and like Lady Macbeth, perhaps she was attempting to "cleanse her soul." She was told: "I will assume that all of this is now in the past, that you have been punished enough and are now sufficiently cleansed to give up the symptoms." (The rationale for this statement is that it could trigger a pattern of selftalk that would assuage her guilt and implicitly

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grant permission for the mitigation of self-punishing cognitions.) Ms. Davis was able to adhere to the handwashing schedule but tended to increase her showering time (up to 45-minute showers) to compensate. Response prevention (more accurately, response attenuation) was accordingly applied to Ms. Davis's bathing and showering. She agreed to have no more than one bath and one shower, or two baths or two showers a day, for a maximum of 15 minutes per shower and 20 minutes per bath. Moreover, the four-times-per-day, one-minute-pertime handwashing was not to be exceeded. She was informed: "I know this won't be easy, but if you really want to beat the problem, this is the way to go. Just bite the bullet." Again, Ms. Davis was invited to call nightly to report on her progress. During the third week, while maintaining the aforementioned frequency and duration of all her handwashing, bathing, and showering activities, she was instructed to expose herself to numerous stimuli that she characteristically avoided (e.g., using public telephones, borrowing and using a friend's comb or brush, handling money, playing ball with the children, and putting soiled laundry in a hamper without scrubbing or rinsing her hands thereafter). During this "exposure phase," Ms. Davis, of her own accord, added "car trips outside the safety zone" to her regimen. (The therapist had decided to table any in vivo exposure for her "driving phobia" until she seemed less agitated over the drastic reduction of compulsive washing and bathing. Since she reported, with pride, that she had driven to a shopping center some 20 miles from her house and had enjoyed browsing through several stores, she was encouraged to "forge ahead on all fronts.") Office therapy time (at weekly intervals) was devoted to repeated admonitions to avoid any "slips" because of the ubiquitous dangers of "intermittent reinforcement" that could bring her back to "square one." The continued relevance of systematic in vivo exposure was also underscored. In the office, imaginal desensitization was employedthe client clearly visualized herself coping with specific travel-related situations before venturing into them. Ms. Davis was, in fact, provided with a host of imagery techniques (e.g., picturing herself coping in various situations, imagining herself resisting the temptation to wash or shower, and visualizing several calmness-producing scenes to be used at will). She was also given more intensive training in deep muscle relaxation and rhythmic abdominal breathing exercises, all to be used in situations where she felt tense or anxious. By the time Ms. Davis and her husband left town, she reported having little difficulty in maintaining the agreed-upon washing and showering routines, and her driving distance exceeded a 50mile radius. Her use of Valium was down to 5 mg at bedtime, and she was encouraged to discontinue its use as soon as possible due to the addictive potential of the drug. She was strongly reminded of the need to maintain vigilance in her new environment or else a relapse would be almost inevitable. In the course of the next five to six months, several letters and a few telephone calls were exchanged between client and therapist, all pointing to the consolidation of her gains. Nevertheless, it had been evident from the start that Ms. Davis was basically unassertive, anxious, and tense. Lazarus had recommended a therapist who could help her deal with these issues, and he emphasized the advantages of an assertiveness training group. She followed through on neither of these suggestions. Ms. Davis consulted Lazarus again almost two years later. Her husband had left her for another woman, and she had just returned to New Jersey, deeply depressed and living with her parents. Before outlining the second phase of her therapy, there are specific issues and questions that revolve around phase one. The time-limited treatment sequence that Ms. Davis had undergone for her compulsions and phobic disorder was predominantly behavioral. In terms of treatments of choice, there is compelling evidence that performance-based-methods are usually superior to verbal, cognitive, or conversational procedures, especially in phobias and compulsions (e.g., Barlow & Waddell, 1985; Steketee & Foa, 1985). Nevertheless, there are several short-term or time-limited psychodynamic approaches, and it would be interesting to know whether Messer might have recommended and preferred a different modus operandi. Does he imagine that psychoanalytic interventions would have been as effective, more effective, or less effective than those that were administered? If Ms. Davis had approached Messer for help, how might he have proceeded? Messer's Response to Stage 1 Influenced, perhaps by the short time period available to treat Ms. Davis, Lazarus adopted the strategy of the traditional behavior therapist and directed therapy at the client's presenting com-

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plaintsagoraphobia and compulsive washing. While the traditional behavior therapist insists that therapeutic objectives are value judgments to be determined primarily by the client (Wilson & O'Leary, 1980), the psychoanalytic practitioner believes that the therapist must participate very actively in clarifying and formulating such objectives (Messer, 1986b). Regardless of whether the time available for treatment was long or short, I would have carried out a thorough evaluation to determine the extent of Ms. Davis's psychopathology, the nature of her personality disposition, and her personal history. This is not a matter of gilding the lily, of collecting data for its own sake, nor of merely satisfying the clinician's intellectual curiosity. Guided by a theory which views habits (or symptoms, as I would call them) as integrally related to the person's cognitive-emotional makeup, I would be acutely sensitive to the role they played in the client's overall psychic life. At the extreme, if Ms. Davis's dysfunctions were a way of preserving her sanity, of maintaining a tenuous hold on reality, they are preferable to a possible decline into psychosis. If such were the case, I would not be in a hurry to rid her of these symptoms. In Ms. Davis's case, I can be sure that an experienced clinician like Lazarus has satisfied himself that such a danger does not exist. Let us assume, therefore, that Ms. Davis has a masochistic or obsessive-compulsive personality disorder, or trends in one or both of these directions, and that a central problem, viewed psychodynamically, is guilt over actual "crimes" (having an abortion; leaving her husband) or a fantasized crime ("I wanted to kill my husband") which are not acceptable to her ego. She concretizes the sought-for absolution or cleansing of her guilt through incessant washing (as Lazarus astutely recognizes), and/or protects herself against recognizing or acting on her own feelings (murderous? sexual? dependency? guilt?) when away from home by having someone accompany her. The agoraphobia might also be viewed as separation fear kindled or rekindled by the breakup of her marriage. I would not assume, as does Lazarus, that all of this is now in the past, that she feels sufficiently punished, and that she is ready to give up the symptoms. If these dynamic issues are sufficiently strong or embedded, Lazarus's statement to her along these lines would have only a temporary effect in mitigating self-punishing cognitions or in assuaging guilt. Having clarified for myself some of these matters in the assessment interview(s), I would then be faced with the question of how best to utilize the two months at our disposal. If it seemed unlikely to me that any headway could be made in the short time available by virtue of the severity of the problems, my preference would be that she begin therapy when she arrives in her new location. If, on the other hand, I judged 1) that there were no clear contraindications to a brief therapy (such as severe depression, drug abuse, primitive defenses, etc.), 2) that she was a well-motivated client, and 3) that a suitable focus could be formulated, I might suggest a short-term contract built around that focus. I would probably want to see her twice weekly so that we would have about 15 sessions in which to work. There are now several well-formulated models of short-term therapy from which to choose (e.g., Davanloo, 1980; Malan, 1976; Mann & Goldman, 1982; Sifneos, 1979; Strupp & Binder, 1984). The brief dynamic therapies all share the following characteristics (Rasmussen & Messer, 1986; Winokur, Messer & Schacht, 1981): 1) formulating a focus in psychodynamic terms; 2) high therapist activity along the lines of the focus; 3) setting goals near the outset of therapy; and 4) special attention to the termination phase of therapy. In conducting the brief therapy, I would view my role more as a facilitator than as an educator as Lazarus conceptualizes it, although I would agree that both therapies share the goal of some kind of new learning. I concur, in general terms, with Lazarus's emphasis on client responsibility and participation in therapy and, like him, would convey this in some manner to the client. In dynamic therapy, however, what is considered essential is the client's cooperation in the process of looking inward at her conflicts and outward at the nature of her interpersonal relationships, rather than in doing homework conscientiously as prescribed in behavior therapy. I would not tell Ms. Davis that her symptoms were "deep-seated" as did a previous therapist, nor draw upon the authority of a respected secondary source (such as Freud) to buttress my credibility. I would view the latter strategy as too blatant an effort to capitalize on client suggestibility which, viewed from within a psychoanalytic value framework, relies too heavily on acquiescence to external authority. I would rather help Ms. Davis develop inner convictions about her problems and the therapy based on her own critical faculties. (Note, however, that this is a relative matter as there are suggestive

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elements in psychoanalytic therapy as well.) Instead, I would try to demonstrate, in vitro if possible, how her complaints were related to her history, her inner struggles, and her personality functioning. That is, like Lazarus, I would try to enlist her cooperation and her agreement to the therapeutic plan, but would do so by heightening her interest in self exploration. If this failed, and she was clearly not amenable to such an approach, I would be prepared to refer her to a broad-based behavior therapist like Lazarus. Lazarus Replies to Messer's Response to Stage 1 Perhaps one of the most significant differences between behavior therapists and psychoanalytically oriented clinicians is the extent to which the latter tend to pathologize. I have seen many clients who had been diagnosed as borderline characters, incipient psychotics, or narcissistic personality disorders, and who, from my perspective, suffered only from eminently treatable hypersensitivities, social skills deficits, and irrational beliefs. Even in the face of florid schizophrenia, when patients are responsive to antipsychotic medication, problems such as phobias and compulsions are amenable to the same behavioral treatments that Ms. Davis underwent (cf. Curran et al., 1982). At graduate school in the late 1950s, my psychodynamically oriented professors warned me that a neurosis is often a defense against a psychosis and insisted that "symptom removal" could have dire consequences. I thought that this canard had long since been laid to rest, and was therefore surprised to find it resurrected by Messer. In my experience, "if Ms. Davis's dysfunctions were a way of preserving her sanity, of maintaining a tenuous hold on reality," I would probably not have gained her cooperation. A behavioral maxim is that in the face of noncompliance, one returns to the drawing board and conducts a more thorough functional analysis in search of antecedents and maintaining factors that might have been overlooked. There are instances where habits or symptoms serve important functions or are reinforced by secondary gains. In these cases, the most heroic behavioral techniques usually meet with limited success as clients refuse to relinquish their "symptoms." Problems of "resistance" or behavioral nonresponsiveness have been discussed in some detail (Fay & Lazarus, 1982; Lazarus & Fay, 1982). By the time Messer had conducted his "thorough evaluation to determine the extent of Ms. Davis's psychopathology, the nature of her personality disposition, and her personal history," how would he still have two months at his disposal for 15 sessions of brief therapy? Instead of wasting time, it seemed preferable to enter into a highly targeted, time-limited treatment aimed at achieving the client's goalsto attenuate her driving phobia and compulsive washing. I am particularly struck by the fact that Ms. Davis sought treatment for her phobic and compulsive habits. Had she seen Messer or another psychodynamic practitioner, her stated desire to be freed from her specific fears and debilitating habits would have been discounted. At best, after ruling out serious psychopathology, drug abuse, primitive defenses, and so on, some "focus" would be selected for inward exploration. This is like setting out to buy a car and unknowingly walking not into a showroom but a school for mechanics and signing up for a course in transmission repairs! Since Messer, despite his psychodynamic lineage, describes himself as "a student but not a scholar of behavior therapy" (Messer, 1986ft, p. 1261), I expected him to concur with the behavioral recommendations, while perhaps also advocating the examination of basic conflicts and encouraging greater self-exploration. I know of no data provided by Mann, Davanloo, or Strupp & Binder that would point to special expertise in dealing with phobias or compulsions, nor am I aware that "looking inward at her conflicts" would have enabled Ms. Davis to leave town feeling less phobic and more mobile. Parenthetically, it might be mentioned that I find methods of cognitive restructuring, role reversal, the facilitation of "a-ha" experiences, the use of humor ("ha-ha" experiences), and the exploration of interpersonal conflicts far more engaging than the use of in vivo or imaginal desensitization, response prevention, flooding, and most other behavioral techniques. I employ not what intrigues or fascinates me personally, but what has been shown to be clinically effective. Messer's Rejoinder to Lazarus (Stage 1) Although there may be some truth in Lazarus's charge that psychoanalytic therapists tend to overpathologize, the countercharge is equally valid: behavior therapists too often constrict their attention to readily observable behaviors while neglecting the larger picture of pathology. Lazarus's strictly behavioral approach to Ms. Davis in Stage 1 is a case in point. By disregarding Ms. Davis's

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possible underlying personality disorder, and dealing only with her obvious behavioral dysfunction, Lazarus achieved a focused but not a broad-based success, certainly when judged from the point of view of her more pervasive problems. In buying a car it is often valuable in the longer run to learn something about its motor, transmission, and body construction even if one does not learn how to repair the car oneself. Clearly, I do not regard the assessment and evaluation phase as wasting time. Because the problem is framed more broadly in dynamic therapy than in traditional behavior therapy (as conducted by Lazarus in his Stage 1 therapy), it is essential to conceptualize the problems to be addressed by understanding as clearly as possible, in one to three sessions, the client's life experience and personality functioning. These early interviews are employed to chart a course (particularly if a short-term therapy is indicated) which includes the formulation of a dynamic focus as well as therapeutic goals. Moreover, the distinction between assessment and treatment proper is probably more apparent to the therapist than to the client who experiences the therapist's basic modus operandi from the outset, be it labeled assessment or treatment. For the client the process of treatment has begun from the first moment of therapistclient contact, so in this sense too, no time has been wasted. Mann, Davanloo, and other brief dynamic therapists will treat problems like Ms. Davis's in timelimited dynamic therapy (see Mann & Goldman, 1982; Davanloo, 1978), but will do so within a more broadly defined area of intrapsychic or interpersonal conflict. What we lack currently are studies directly comparing these two approaches along dimensions considered important by each kind of therapist, which would include symptomatic alleviation, conflict resolution, and behavioral and personality change. In the absence of such studies, I would point to the empirical findings of similar outcomes among therapies (Luborsky et al., 1975; Smith et al., 1980), as well as to value differences in what constitutes worthy outcomes. There are real differences here that cannot be overlooked, especially when comparing traditional behavior therapy focusing on symptomatic change, and psychodynamic therapy focusing on resolution or greater mastery of defined areas of client conflict or dis-ease. To my mind, this is not a matter of therapists indulging their own preferences and tastes in conducting one therapy or another while discounting client needs, as Lazarus contends, but in their value orientations as to what really matters to people and what constitutes genuine change. While I do consider myself a "student of behavior therapy," my approach to integration does not call for behavioral techniques grafted onto an exploration of basic conflicts, as Lazarus supposes and as others have proposed. Rather, I have pointed to a certain kind of de facto confluence of attitudes among cognitive and neobehavioral therapists on the one hand, and ego-analytic and short-term dynamic therapists on the other, which makes their therapeutic outlook and behavior more similar than was true in the past. I will elaborate below on how this applies, for example, to goal setting, approaches to promoting action or insight, the view of affect in the two therapies, and the nature of the therapeutic relationship. Stage 2 When Ms. Davis reappeared some two years later, she was literally unrecognizable. She was at least 40 pounds heavier, had cut her hair extremely short, had exchanged her contact lenses for unstylish spectacles, wore no makeup, and was dressed in loose-fitting jeans, a large tattered sweater, and battered sandals. For the previous three weeks, she had been staying with her parents, avoiding her friends, and "trying to come to terms with what has happened" to her. It appeared that she had been almost totally subjugated by her husband who, soon after they had relocated, had accused her of deliberately looking and dressing provocatively so that other men would be attracted to her. At his behest, she had cut her hair, grown fat, changed her style of dress, and had avoided using makeup because he liked only "natural women." While continuing to work as a schoolteacher, she bore the full responsibility for all household chores, and also mothered her husband's three-year-old daughter. A carpenter by trade, her husband worked for a construction company, but had strong literary aspirations. He devoted many hours each week to dictating communistic political commentaries, his own philosophies, various short stories, and a novel. Since they could not afford to pay someone to transcribe this material, it fell on Ms. Davis's shoulders. She would get up at 4:30 AM to fit this additional work into her daily schedule. Moreover, she stated that her husband insisted that she engage in several sexual practices that she found distasteful. Despite her ardent efforts to do his bidding, he met another woman whom

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he described as a "soulmate" and moved in with her. Ms. Davis appeared to satisfy many of the diagnostic criteria of a major depression, but the diagnosis was not clear-cut. An adjustment disorder with mixed emotional features could also be entertained. Her family physician prescribed Xanax and Elavil, and within two weeks she was calmer, sleeping better, and crying less. Ms. Davis stated that she was afraid that her "bad habits" were coming backshe was washing and showering to excess, and she felt her "old fears" when driving to visit a friend who lived 15 miles away. I took a firm stand. "Let's get rid of that nonsense now. Go right back to the response prevention, the mental imagery, and the desensitization." Fortunately, the "relapse" was short lived, and therapy was then concerned with the following issues: 1. Her sadness at ending the marriage. The most painful aspect here was her concern for her husband's child, whom she had grown to love very deeply and "who had come to feel like my own flesh and blood." 2. Ways of obtaining emotional support during her divorce. At the therapist's instigation, she renewed many friendships and obtained employment as a substitute teacher. 3. Her tendency to allow others (especially men) to dominate her and mistreat her. Ms. Davis's two marriages had followed a similar trajectory, although it was she who had initiated the divorce when her first husband finally "went too far" by bringing his paramour to live in their home. 4. Her general lack of assertiveness, her overcompliance, her poor self-esteem, and her gullibility. The therapist lent his approval to the fact that Ms. Davis was allowing one of her friends, a fashion consultant, to work on her appearance. Within three months she was back to her slim, well-groomed, attractive, stylish self. The mainstay of therapy during that period had been on her feelings of loss, regret, self-blame, and confusion. A major treatment focus revolved around her theme of underentitlement, of the subservient "script" she had followed (especially with men), and on the ravages of her Calvinistic upbringing. The therapist's role was supportive, accepting, challenging, didactic, and disputational. For example, the therapist explained again and again why Ms. Davis's perception of a deity was more diabolic than divine. She was asked to read several books (bibliotherapy), especially chosen to augment her overall assertiveness. Since she attributed many of her inadequacies to her mother's timidity and overzealous religiosity, and to her father's sexist and male chauvinistic outlook, several family meetings were held with Ms. Davis, her parents, and her sister (2 years younger). The goal here was to change some of the family communications visa-vis Ms. Davis as an adult, and to modify the subtle "you can't do it" parental messages that undermined her confidence. Thus, when her father offered to handle the divorce proceedings on his daughter's behalf ("I know how to deal with lawyers, and I will see to it that she won't be shortchanged!") Ms. Davis (having previously rehearsed a speech with the therapist in private) boldly stated that she would prefer to fight her own battles, and would look to her father for advice if needed. The father capitulated. The upshot of the family meetings, to quote Ms. Davis was: "I feel more respect coming from my parents, and my sister and I have grown a lot closer." Ms. Davis appeared to have no clear-cut sense of personal entitlement; the notion that she had rights seemed quite alien to her. It took a lot of persuasive power to convince her that a peoplepleasing, self-effacing outlook was anything but laudable, and that assertive living was not tantamount to a self-centered, egotistical modus vivendi. Thereafter, considerable time was devoted to additional behavior rehearsal and role playing, especially with regard to the handling of her divorce, and with respect to dealing with employers, colleagues, and certain "friends." It then struck the therapist that his relationship with Ms. Davis had too much in common with her other male-female interactions. She was playing the role of the obedient, and perhaps overcompliant client, presumably intent on pleasing the therapist, just as she had endeavored to please her father and her two husbands. Accordingly, Ms. Davis was urged to become her own person, and not to live for the therapist's approval or anyone else's approbation. Role playing and mental imagery were employed wherein she was called upon to upbraid the therapist and to go counter to his advice when not in agreement with it. Soon thereafter, a specific situation arose in which she exercised her "freedom of thought." Ms. Davis had learned that her first husband would be passing

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through New Jersey and asked the therapist whether or not she should meet him and "find out where I went wrong." The therapist took the position that this was inadvisable for two reasons: 1) it was best viewed as a relationship from the past and it would probably be better not to reactivate unpleasant memories; and 2) it was likely to lead to obsessive rumination and self-recrimination. At the next session she reported having gone counter to this advice, with excellent results. She and her first husband had gone out for dinner and, after a brief postprandial walk, had returned to her apartment and spent almost the entire night talking. He allegedly emphasized that the breakup of their marriage was entirely his fault and that his own immaturity was at the core of all their difficulties, and he had described her as a "rare gem." At this juncture (approximately six months into the therapy), Ms. Davis went on what she termed "a sex binge" with five different men in one week (each of whom she had met at a singles bar). "I think I wanted to convince myself that I can attract men, and that I can get them to do what pleases me for a change." While eschewing any moral imperatives, the therapist pointed out the dangers of contracting AIDS, herpes, and other venereal infections through indiscriminate sex. One of these men, a successful attorney, became a steady date for awhile until Ms. Davis rejected him because he had also tried to date one of her close friends. "That's the new me," she declared, "one false move and you're dead!" Semiparadoxically, the therapist wondered aloud to what extent the slavegirl mentality still existed within her, whether or not, sooner or later, she would revert to doing some man's unfair bidding. She laughed. "Only if someone is literally holding a gun to my head!" During the course of therapy, several additional topics were examinedMs. Davis's choice of men; her desire for children and residual guilt feelings over the abortion she had had; and her future plans (e.g., remarriage, having children versus adopting them, being able to let go emotionally of her stepdaughter). Ms. Davis was seen twice weekly for a month, weekly for three months, and once a fortnight for another four months (a total of 8 months or 29 sessions). Thereafter, she was seen approximately once every three or four weeks for another five months. (Booster sessions aimed at consolidating and extending treatment gains are excellent relapseprevention strategies.) Significant gains have accrued and have been maintained. She has been off all medication and has not reported or displayed any signs of depression or undue anxiety for at least 8 months. She weathered her divorce extremely well and has continued to work as a full-timefifth-gradeteacher. In her own words, she has "come to terms with a lot of things." The only residual dysfunction of any significance is manifested in her choice of men. She appears to have "rescue fantasies" and gravitates toward men who are her social and intellectual inferiors. In the rescue process, these men end up exploiting her, a pattern that was evident in her two marriages. This aspect of her conduct and residual problems with self-esteem are the focus of her treatment. Messer's Response to Stage 2 In this second phase of therapy, we see a different kind of therapist at work, one much more broadly based than the behavior therapist of the earlier phase. I would point particularly to Lazarus's attention to Ms. Davis's emotional life, including sadness over loss, anger with men, and guilt over assertion. I laud his attention to her need for emotional support, to the importance of her renewing social relationships, and to her becoming gainfully employed. These are valuable aspects of a supportive, ego-building psychotherapy which I endorse. In addition, there is now a recognition of the client's pervasive personality pattern, even if it is not named as such. I am referring to Ms. Davis's tendency to allow others, especially men, to dominate her and mistreat her, to the script of underentitlement, to her gullibility, lack of assertiveness, and sense of inadequacy. While Lazarus and I may agree on a diagnosis of depression on Axis I of DSM-III, I would now be inclined to consider an Axis II diagnosis of "self-defeating personality disorder" (which appears in the appendix of DSM-IIIRevised), or what psychoanalysts traditionally have referred to as a masochistic personality. Lazarus and I differ, however, in some of the ways in which we would address her personality problems. He attempted to persuade Ms. Davis through rational means that her outlook and style were not laudable and tried to show her by encouraging behavioral rehearsal and role playing how she might behave more assertively. By contrast, I would help her to become more fully aware of her self-defeating and submissive style by noting how eager she was to please me and how readily

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she abdicated her own initiative in wanting me to take the lead in therapy. I would ask her if this did not have a familiar ring, anticipating that she would tell me more about how she behaved similarly with her two previous husbands, with other men she dated, and, throughout her life, with her father. She would be encouraged to explore her wishes in this regard and what purposes they served, for example, to win a man's love, to avoid being angry with him, or to have anyone be angry with her for expressing her more mature needs for independence and control. Early memories typically arise spontaneously at this point, often with considerable feeling. She might relate how she saw herself as bad or undeserving as a child, and recognize how her parents' treatment of her contributed to the skewed sense of herself. Her positive and negative identifications with them would loom large, including her mother's timidity and overzealous religiosity. Despite the importance of her familial identifications, I would not recommend family sessions because I would view my task as helping her to take the initiative in differentiating herself from her family, which ultimately would be more ego strengthening than having her parents back off at my suggestion. The difference between us that I am highlighting is the role of therapist as facilitator, interpreter, or elicitor of the client's inner life in contrast to the role of persuader, environmental arranger, or teacher. Lazarus, in encouraging Ms. Davis to become more her own person, in urging her not to live for his approval, in telling her to go counter to his advice if she disagreed, paradoxically continues the role of the dominant and controlling man whom she will strive to please. I note how she then compliantly disregarded his advice not to see her first husband. Lazarus might view this act of defiance as a sign that the therapy is succeeding in helping her to become more confident and assertive; I wonder if it is not a sign of her growing attachment to Lazarus and a replay of her eagerness to submit to a man's directives. Like Lazarus, I suspect that the extremes of her new reactions to men ("One false move and you're dead") belies her comfortableness with her new persona. An indicator of Ms. Davis's attachment to Lazarus, in my view, is her subsequent flagrant sexual acting-out. My guess is that she harbors romantic and sexual feelings for Lazarus which she displaces onto other men by having sex with five of them in one week. I would not accept at face value her explanation that she was doing what pleased her. Like Lazarus, I would not view this as salutary, but as behavior to be closely examined in the therapyand not just because of the dangers of venereal infection or considerations of conventional morality. In helping her to express such feelings, one would have to interpret the defenses she would display in attempting to hide such intimate feelings. ("I am bad to have such thoughts; God will punish me; You will laugh at me or humiliate me"). Such exploration could help reveal more about her guilt feelings and religious beliefs and how these have affected her view of her own actions (having an abortion, leaving her husband) and the formation of her symptoms of washing and agoraphobia. By becoming more fully conscious and aware of such hitherto unconscious factors, she would, it is hoped, feel relief from her symptoms and enjoy a greater sense of mastery over her life. By experiencing a benign, caring, respectful, and attentive male therapist, she would see how it is possible to be treated by a man, which would serve her as a new introject. She would undergo a corrective emotional experience, and carry away a more benign feeling toward men and an enhanced sense of her own worth. To a degree, she is achieving this with Lazarus, but I believe that she is also complying with his strong directives and to this extent is prevented from fully attaining the sense of autonomy she so clearly desires. Regarding the termination of treatment, I would proceed differently than Lazarus. While it may be true that booster sessions can prevent relapseand for the more disturbed client this is particularly desirablethe tapering off of therapy in such a fashion can serve to dilute the strong feelings that typically arise when one finally separates from a significant other. In Ms. Davis's case, a more definitive termination could mean learning that she can experience sadness, appreciation, regret, even guilt or anger toward her therapist, and still be able to separate with an intact, enhanced sense of herself as an autonomous, self-initiating, and mature adult. Lazarus Replies to Messer's Response to Stage 2 Unlike Stage 1, the second treatment phase enters territories that are more nebulous and open to debate. Messer correctly points to the paradox of the compliant client who obediently disobeyed my directive, thereby remaining essentially acquiescent. Nevertheless, Ms. Davis subsequently

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dealt more assertively with her father (on two separate occasions), resisted unfair work demands from her (male) principal, and managed a difficult situation with her lawyer whose authoritative manner would probably have completely intimidated her prior to her assertiveness training. Messer's contention that her sexual acting-out was related to "romantic and sexual feelings" for me seems totally without any substance or foundation. There was never even the slightest hint that Ms. Davis harbored any physical or sexual feelings for me. In place of the sex object, the husband, or lover, there were signs that in her fantasies, she perceived me as the perfect father. Rather than wishing to share my bed, she may have pictured herself living in my home, seeing me in a purely paternal or avuncular role. From a social learning perspective (Bandura, 1986) two features predominate: 1) Her submissive mother seems to have served as the major feminine role model, and 2) there is evidence of an acquired cognitive schema to the effect that she is undeserving and unworthy of the best. These areas are now the focus of our ongoing treatment. Whether the tactics of Messer, Davanloo, Mann, Sifneos, or Strupp & Binder would prove more effective than those of Lazarus is an open question. Whatever corrective emotional experiences may actually ensue from the therapeutic relationship, I have no doubt that she regards me as "a benign, caring, respectful, and attentive male therapist." In my experience, an active-directive therapeutic posture does not truncate clients' capacities to develop a self-initiating, autonomous, and mature modus vivendi. Many clients, especially in the beginning phases of therapy, welcome guidance and direction, but as they grow more assertive, develop social skills, acquire interpersonal confidence, and experience better control over their feelings and behaviors, they introduce modifications into the patient-therapist relationship. To maintain therapeutic neutrality when the client is crying out for pedagogical assistance is, in my view, a serious error. Paradoxically, the less assistance you offer a dependent client, the longer that person is likely to cling to his or her dependent ways, but often, when smothered by the therapist, such individuals begin to develop and assert their autonomy. Certainly Ms. Davis has better control over her feelings, her relationships, and her habits; her self-esteem, while still needing improvement, is significantly greater, and she has a healthier overall sense of self (including her entitlements). Rejoinder to Lazarus Lazarus acknowledges the paradox of this obedient client complying with his directives to become her own person, but he sweeps aside my objection by pointing to the behavioral gains achieved acting assertively with her father, resisting unfair work demands from her boss, and managing a difficult situation with her lawyer. On the face of it, these are impressive gains, but at the risk of being accused of carping perfectionism, I must demur. I am not prepared to gauge the resolution of Ms. Davis's problems, as I have defined them, on the basis of such behavioral indicators alone (although I do not dismiss their potential importance). Lest I appear niggardly in my critique of the outcome of Ms. Davis's therapy, I will spell out my position in some detail. Lazarus and I now seem to agree on Ms. Davis's major disposition, which is to please others, to submit too readily to extraordinary demands (e.g., rising at 4:30 AM to type her husband's musings, making herself unattractive, etc.), to feel underentitled, and to retreat in the face of male power. Knowing this, how can we distinguish genuine improvementthat is, changes coming from an enhanced view of the selffrom Ms. Davis's ongoing attempts to satisfy her therapist. After all, she may merely be reenacting with the therapist the core neurotic conflict that she has demonstrated throughout her life: "If I ally myself with or submit to a powerful male, I will get the affection, caring, and sexual gratification, that I so desperately need." If the therapist is very active regarding his expectations and directives, rather than relatively neutral, how shall we determine whether the changes that have come about were self-initiated, deriving from a stronger sense of centeredness, rather than reflecting Ms. Davis's same old compliance with authority and willingness to do the bidding of others? Is Lazarus concerned about this question? Is he satisfied with the changes as they stand even if they turn out to reflect primarily her wish to please him? Strong therapist expectations can have a powerful influence on the client which, in the absence of her associations, memories, dreams, and so on, leave us no choice but to speculate about the meaning to her of his behavior. Lazarus has been gratifying her wish to be guided by a powerful man. Without knowing whether she is "doing it for Daddy," is intent on defying him, or has truly come to terms with her submissiveness, I am reluctant to endorse wholeheartedly the stated behavioral gains.

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If these gains are due to her effort to please, I also question how long-lasting they will be. If the changes were accomplished only to please the therapist, might they not dissolve once the therapist is not present to sustain them? [Lazarus contends that he is not too concerned whether or not changes are initiated in order to please the therapist. The new behaviors have an impact on the client's significant others, and in the final resort, the rewards that emanate from the environment will sustain and reinforce them.] I concur with Lazarus's belief that Ms. Davis sees him in a paternal or avuncular role. This does not preclude her experiencing him at other times as a potential romantic and/or sexual partner. Although Lazarus protests that "there was never even the slightest hint that Ms. Davis harbored any physical or sexual feelings for me," how can 1 be sure when the nature of their relationship was not deliberately opened up for discussion? Beyond this, as someone guided by psychoanalytic theory regarding masochism, I wonder, too, about masochistic fantasies that Ms. Davis may harbor to which Lazarus may be resonating in alluding to her "slave-girl mentality" and her "doing some man's unfair bidding." Concluding Remarks While it is true that behavior therapy is friendlier than it once was to some cognitive concepts espoused by psychoanalysts, and that some psychoanalytic therapists adopt a problem-oriented focus similar to behavior therapists, distinctive and fundamental points of departure remain clearly evident. Franks (1984) emphasized that psychoanalysis and behavior therapy "employ different language systems and different data bases," and "differ drastically with respect to such matters as what constitutes acceptable methodology, data, and outcome evaluation" (p. 237). Lazarus is anything but a rigorous behaviorist, and Messer is no dyed-in-the-wool psychoanalyst, and yet even between two self-styled liberal clinicians, basic differences remain. Our commentaries tended to highlight some of the different perspectives and clinical attitudes in psychodynamic therapy and behavioral or multimodal therapy (see Messer & Winokur, 1984, for further discussion of contrasting ways of knowing and visions of reality in psychoanalytic and behavior therapy). Nevertheless, there was also some similarity of outlook in Lazarus's Stage 2 multimodal approach and Messer's psychodynamic approach to this case, reflecting current trends in our two theoretical orientations (see Messer, 1986b, for an elaboration of such trends). We both set rather similar-sounding, but not identical goals for Ms. Davis after the assessment period (e.g., therapy was concerned with "her tendency to allow othersespecially mento dominate her and mistreat her"). In our discussing the optimal relationship to the client, we agreed on the importance of a caring, respectful, and attentive attitude. Lazarus noted, as did Messer, a predominant transference pattern ("She was playing the role of the obedient and perhaps overcompliant client, presumably intent on pleasing the therapist just as she had endeavored to please her father and her two husbands"). Note, however, that Lazarus largely used this information to encourage Ms. Davis not to live for his or anyone's approval, whereas Messer would have used it to enable her to fully express and analyze the range of feelings she would have toward him, in order to enhance her freedom to act in accordance with enlarged behavioral possibilities. Unlike some traditional behavior therapists, we were both very attuned to Ms. Davis's affective state, allowing her feelings of sadness and guilt to emerge. Lazarus moved quickly to dispel such negative feelings by suggesting immediate action, while Messer would have allowed their fuller expression even while exploring, in a less directive manner, some of the social and vocational options she could be pursuing. Finally, in the cognitive realm, Lazarus and Messer were both interested in examining Ms. Davis's scripts and saw these as guiding fictions or core constructs that must be addressed in psychotherapy in one fashion or another. References
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