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The History and Empirical Status of Key Psychoanalytic

Article  in  Annual Review of Clinical Psychology · February 2006
DOI: 10.1146/annurev.clinpsy.2.022305.095328 · Source: PubMed


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Marna S Barrett
University of Pennsylvania


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17 Feb 2006 8:1 AR ANRV271-CP02-01.tex XMLPublishSM (2004/02/24) P1: OKZ

Annu. Rev. Clin. Psychol. 2006. 2:1–19
doi: 10.1146/annurev.clinpsy.2.022305.095328
Copyright  c 2006 by Annual Reviews. All rights reserved
First published online as a Review in Advance on November 28, 2005

Lester Luborsky and Marna S. Barrett
Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania 19104;
Annu. Rev. Clin. Psychol. 2006.2:1-19. Downloaded from

Key Words psychoanalytic theory, empirical support, therapy outcome
by BOSTON COLLEGE on 02/03/10. For personal use only.

■ Abstract Over the past century, the ideas set out in psychoanalytic theory have
permeated the field of psychology as well as literature, art, and culture. Despite this
popularity, analytic theory has only recently received empirical support. In this chapter,
we seek to highlight several fundamental concepts of analytic theory (the unconscious,
drives, defenses, object relations, Oedipus complex) and psychodynamic treatments
(transference, countertransference, interpretations, resistance). The first section of the
chapter offers a comprehensive definition and historical background for each concept.
This foundation is followed by a review of the empirical evidence supporting the
reliability and validity of these concepts, their impact on treatment, and their broader
influence on the future of psychology.

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
PSYCHOANALYTIC CONCEPTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Unconscious . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Drives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Parent-Infant and Parent-Child Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Oedipus Complex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Defenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
PSYCHOANALYTIC CONCEPTS IN THERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Transference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Countertransference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Accuracy of Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Evidence for the Unconscious . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Evidence for Drives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Evidence for Parent-Infant and Parent-Child Relationships . . . . . . . . . . . . . . . . . . 9
Evidence for the Oedipus Complex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Evidence for Defenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Evidence for Transference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1548-5943/06/0427-0001$20.00 1

. criticism continues to be leveled against many of the original con- cepts. . Although psychoanalytic therapists have been reticent and even resistant to empirical investigations of analytic theory.2:1-19. . .. . . . . . . have been extensively discussed and re- searched (e. the Oedipus complex is a Annu. and their importance in our understanding of personality development has been demonstrated. . 14 INTRODUCTION Psychoanalytic concepts are prevalent throughout the field of psychology as well as in literature. chapter. . . . Although certain aspects of Freud’s concepts are not strictly speaking falsifiable (e. . and popular culture. 12 Evidence for Interpretation . . . . . . . . we want to highlight the impact of several psychoanalytic concepts on the field of psychology. . Weinberger & Westen 2001). we have divided the chapter into two parts: Part one offers a com- prehensive definition and understanding of the key concepts as well as a review of each concept’s historical roots. . . . . . . . superego). . . . due to practical limitations. . Downloaded from arjournals. and Tangney (1994) for empirical discussions of the validity of these concepts. Rev. . . For example. see also Wallerstein 1986. . PSYCHOANALYTIC CONCEPTS Psychoanalysis and psychoanalytic theory have evolved considerably since the 1930s. . . several rigorous studies of key concepts have been conducted. . . . . . . For instance. . . . . . . . . . . . . . . . ego. . . .g. . .org primary theme in Shakespeare’s Hamlet and in later plays such as Eugene O’Neill’s Morning Becomes Electra. . . . . . 14 THE IMPACT OF PSYCHOANALYTIC CONCEPTS . particularly about the issue of falsifiability (Macmillan 2001. . . theorists have shifted their attention to the role of affect and motivation as determinants of personality (Westen 1998). . . . . . . . . . .. . . . a number of them are accessible to empirical investigation. . The psychoanalytic con- cepts described in this chapter are especially well known. . . . . . . rather than focusing on a distinct tripartite personality struc- ture (i. . . . . For personal use only. . . 17 Feb 2006 8:1 AR ANRV271-CP02-01. originate in the theoretical writings of Freud and the developments of psychoanalysis. To this end. . . . . . . . .g. . . . . . . . .annualreviews. . . . ego. . . . . art. Oedipus complex). . .e. . . . . . . . . id. . Clin. ego. . although key to original psychoanalytic thinking. . however. . . . . . . . . . . 2006. . . . Despite this evolution. . . . . .1 The concepts highlighted in this chapter include 1 See Filsinger & Stilwell (1979). superego). .. . . 13 Evidence for the Accuracy of Interpretation . In this by BOSTON COLLEGE on 02/03/10. . . . they form the basis of modern psychoanalytic theory and dynamic therapy. Part two provides empirical documentation of the reliability and validity of these psychoanalytic concepts and describes their use- fulness in future endeavors. . However. 12 Evidence for Resistance . . . . we have chosen to omit some concepts that. id. . Psychol.tex XMLPublishSM (2004/02/24) P1: OKZ 2 LUBORSKY  BARRETT Evidence for Countertransference . . . . . . . . Many of these concepts. id. Stephenson (1982). . . . . . . . .

However. Oedipus complex. or security. defenses (repression. transference. such as parent-infant and parent-child interactions. trust. autonomy. Psychol. a person will fight to keep these feelings out of awareness or out of consciousness. life ex- Annu.2 Drives A second concept central to analytic theory is the role of instinctual drives in de- termining human development. In the life of an adult. Unconscious One of the main underpinnings of analytic theory is that painful or unacceptable feelings are pushed out of the realm of awareness (by defenses).tex XMLPublishSM (2004/02/24) P1: OKZ IMPACT OF PSYCHOANALYTIC CONCEPTS 3 the unconscious. . unresolved periences will often cause a reawakening of the underlying conflict. 2006. For personal use only. a fundamental assumption of psychoanalytic theory is that the unconscious exists and allows resolution of the discontinuity between mental health symptoms and causation (Shevrin et al. 17 Feb 2006 8:1 AR ANRV271-CP02-01. In order to avoid pain or discomfort (according to the pleasure principle). fantasy. Touching on this “nerve” or emotional hotspot heightens the person’s anxiety and distress. but more recent models (see Compton 1983. 1996).2:1-19. From a developmental perspective. countertransference. Although the foregoing explanation defines the typical role of the unconscious. unconsciously withholding important information from the therapist and deflect- ing attention to less painful topics. The unconscious. resulting in a psychological struggle to block the emotional discomfort from awareness. identification. interpretations (including the accuracy of interpretations). When the defenses break down and can no longer effectively block the distress from awareness. This tension is influenced not only by internal strivings (motiva- tion) but also by environmental or experiential factors acting upon the individual. Fisher and Greenberg (1996) also offer an excellent summary of psychoanalytic studies and their usefulness in validating key analytic concepts. experiences occur that are thought to trigger an early. and control. Rev. drives. Rec- ognizing distress. Kernberg 2001) center on the general notion of a need for pleasure (sex and hunger) and the instinctual response that occurs when that need is blocked (aggression and control). sex. a person may work to avoid underlying pain by consciously or by BOSTON COLLEGE on 02/03/10. neurosis or even psychosis results. Fisher & Greenberg 1985. and resistance.annualreviews. The original drive concepts included hunger. a drive or instinctual urge has been defined as an internal force or tension that propels an individual to act in ways that reduce tension. and intellectualization). which then sets off myriad efforts to block it. Historically. drives. Downloaded from arjournals. the manner in which an infant’s need for comfort is met by a signif- icant other (object) influences the way in which future relationships are defined 2 Several books highlight quite nicely the concept of the unconscious and the characteristic ways in which it is evident (see Davanloo 1990. projection. 1996). parent-infant and parent-child relationships (object rela- tions). to name a few. internal conflicts are theorized to result from poorly resolved developmental issues. aggression. Clin.

From an understanding of cause and effect. affects are the prime motivators of behavior and influence communication in the infant/caregiver relationship such that positive and negative affects combine to form the drives or motivational systems of plea- sure and aggression. Downloaded from arjournals. an intervention or treatment can be developed to block or change the causative agent with resulting changes in effects or symptomatic outcome. More recently. Parent-Infant and Parent-Child Relationships In much of the psychological literature.tex XMLPublishSM (2004/02/24) P1: OKZ 4 LUBORSKY  BARRETT (internalized object relations). has made a similar to others.. Moreover. that intimate relationship was shared between mother and father. such as “early patterns influence later patterns” or “a child who is ad- vanced early will be a child who is advanced later. The horse was simply an acceptable conscious representation of the unacceptable unconscious conflict with the father. the young boy sought his mother’s love but feared retribution from his father through castration. Because of the early physical connection with mother (through breast-feeding). affect can be modified and elaborated by internal object relations. he described a child who was afraid to walk along the streets for fear of being bitten by a horse.2:1-19. For personal use only. 2006. drive.annualreviews. Unfortunately. theorists have described these early developmental patterns in terms of how individuals relate to a central object (person or thing) in their life. Clin. For instance. and object relations. According to Kernberg’s (2001) integrated model of affect. Freud interpreted this behavior as representative of the close yet fearful relation between a child and his father. the importance of early parent-child re- lationships (object relations) was referred to in terms of generalizing explanatory sentences. who not only suggested that affects are the prime factors of human motivation but also saw affect as a neurophysiologically based factor. What is most striking about this example (even more than the illustration of parent-child relationship patterns) is that the information was obtained through regular observation of the child for many months.” Freud (1909/1955) offered more specific explanations of developmental patterns using case examples. Psychol. Al- though Freud did not present these data as a scientific study. In contrast to the motivating force of drives. by BOSTON COLLEGE on 02/03/10. observational data formed the foundation for early verification of many psychoanalytic concepts as well as stimulating new ideas about human development.e. 17 Feb 2006 8:1 AR ANRV271-CP02-01. Freud theorized that children sought an intimate emotional relationship with mother. that is. thus putting the child in competition with father for mother’s love. resulting in changes in the drives or in motivation. Thus. he argued that the nonverbal behavior and communication of parents (or caregivers) elicited certain affect in the child that resulted in personality development and defense structure. Such observation represents a major tenet of most medical and psychological inquiry. Schwartz (1987). facial features) that communicated emotions and empathy Annu. It was the neurologically generated affect evident in motor behavior (i. object relations theorists focus on the . In this example. a critical event causes a particular course of action (an effect). Rev.

The self (or ego) will utilize whatever is available to defend against this anxiety and decrease the perceived threat (i. In other words. By projecting her unaccept- able wishes or impulses onto another. Downloaded from arjournals. (a) a wish to eliminate the father and take his place in a sexual relationship with the mother and (b) a wish to eliminate the mother and take her place with the father (Brenner 1955).annualreviews. also among Freud’s earliest list of defenses. Repression. the individual is able to criticize that which is discomforting about her without experiencing the associated pain. represent the mechanisms by which we keep anxiety. Defenses. 2006. Once unique to psychoanalytic theory. a somewhat similar yet better-known defense. For personal use only. Psychol. occurs when one sees into another person but what one sees really comes from the self. and they occur in response to and are the effect of distress brought about by an internal unconscious psychological event. an assumption of analytic theory is that anxiety results from an internal perception of danger or threat to the self. Most Annu. . is a defensive strategy that keeps from consciousness unpleasant or unacceptable memo- ries. These objects and the way in which a developing child relates to them form the basis for the sense of self or individual personality. and we review a few of the more long-standing defenses for which there is empirical support (Perry 1993). or discomfort out of conscious awareness. The frequency and types of defenses are determined by the strength of the ego (self). between the competing dynamic theorists today accept a broader interpretation of the Oedipus complex encompassing the idea that there is an active competition between two people for the affection of a third person. He concluded that any child (boy or girl) had a twofold attitude toward the parents. 17 Feb 2006 8:1 AR ANRV271-CP02-01. 1. one of the earliest defenses described by Freud. Fear of retaliation is often embedded in the dynamic by BOSTON COLLEGE on 02/03/10. Rev. fear. Clin. Projection.tex XMLPublishSM (2004/02/24) P1: OKZ IMPACT OF PSYCHOANALYTIC CONCEPTS 5 role of interpersonal relationships as the motivation for human behavior. The concept involves the act of pushing down memories and restricting their access to awareness. in an effort to avoid discomfort or anxiety as a result of personal wishes or impulses. therefore. or wishes. Oedipus Complex Freud’s original Oedipus concept developed from his observations of interactions between parent and child (see example above). a move to make it unconscious). A repressed mem- ory is one that is forgotten from the subjective perspective of the person in whom the repression occurs. that is. Defenses As discussed in the section on the unconscious.2:1-19. emotions. involves the act of keeping from conscious awareness an unacceptable behavior or idea. 3.e. an individual will unconsciously see in an- other that which she is unable to see in herself. 2.. desires. Denial. the concept of defenses has now been examined in other areas (Caspar 1995).

transference. aloof manner. The only way in which the conscious mind can deal with the unacceptable feelings toward another person is to identify with that person and strike out against one’s self as if one’s self was the other. Frequently by BOSTON COLLEGE on 02/03/10. much like a waking dream.tex XMLPublishSM (2004/02/24) P1: OKZ 6 LUBORSKY  BARRETT For example. a defense later identified by object-theory psychoanalysts (Drapeau et al. Thus. better reflect the process of psychodynamic therapy than developmental concepts of psychoanalytic theory. For personal use only. 6. i. about personally important people. involves the avoidance of disturbing feelings or conflicts through a pseudo-objective stance. 2003).annualreviews.2:1-19. they are included in this discussion because of their acceptance through- out psychology.. Annu. in which conscious memories and wishes. Such distancing from discomforting sit- uations relies on abstract thinking and results in a somewhat cold. Within treatment. The resulting fantasy is a “makeover” of personally important people in terms of the individual’s conscious or unconscious wish. However. and associated disciplines as well as in literature and the media. Klein (Drapeau et al. Transference Transference was described in Freud’s early writings (Freud 1912/1958) and rep- resents the process by which the patient is not satisfied with seeing the therapist as a helper and adviser. Although having its historical basis in dream analysis. “I am not angry. one person may re- spond to another. 2006. psychiatry. Fantasy is a state of mind. a more recently articulated defense and one considered of higher order. resistance. Freud and M. Rev. Psychol. Downloaded from arjournals. Intellectualization. Rather. involves the development of a self-identity that is based on a copying by the self of the other person’s qualities. 2003). PSYCHOANALYTIC CONCEPTS IN THERAPY The concepts that follow. Clin. and interpretation (including accuracy of interpretation).org 5. transference can be critically important because it embodies both .e. Such memories and wishes become less threatening due to a decreasing need for being exact. are reexamined in a less threatening way. Identification. 17 Feb 2006 8:1 AR ANRV271-CP02-01. because the therapist and some important past figure in the patient’s life are seen by the patient as sim- ilar. the therapist comes to represent some important figure out of the patient’s past such that all feelings and reactions related to this person are consequently transferred to the therapist. after a particularly stressful discussion. identification has been viewed as a turning against the self because the ob- ject of the identification is often seen as the aggressor. you are!” 4. countertransference. the patient relates to the therapist as if the therapist was the significant other. fantasy was first discussed as a defense mechanism in the work of A.

interpretation involves an explanation of the transference and of how it relates to other patterns of relating in the client’s life. Downloaded from arjournals. Until recently.2:1-19. 17 Feb 2006 8:1 AR ANRV271-CP02-01. Countertransference Annu. Callahan 2000. the client continually shifts between movement toward change and resistance to issues that would lead to change.annualreviews. countertrans- ference is now seen as inevitable in the treatment process and is embraced as a way to recognize and better understand the patient’s transference. In other words. The concept involves a search for the essence of the client’s statements. Psychol. For personal use only. interpretation is a means by which the therapist offers an explanation of cause and effect for events in the patient’s life. countertransference is a pattern of miscommunication in which the client’s responses—which are based on other relationships in the client’s life—are responded to by the therapist from the per- by BOSTON COLLEGE on 02/03/10. However. Interpretation Interpretation describes the types of messages within the therapist’s statements that are shared with the client. distorting the therapist’s understanding of the transference. coun- tertransference was to be avoided because it meant that the therapist’s personal experiences were entering into the treatment of the client. Resistance Resistance is an in-therapy behavior in which the patient can slow the rate of change. Cho & Lee 1997. It is through interpretation that the patient is made aware of previously unrecognized patterns of behavior that are negatively affecting their interpersonal In its basic form. Rennie 1994). resistance involves the conscious (and sometimes unconscious) act of avoiding the emergence of repressed feelings. Rev. Recently. . One aspect of negative transference that is essential to keep in mind is that a patient can behave in ways that stimulate the therapist to respond in a manner consistent with the patient’s negative transference expectations. Clin. 2006. countertransference represents the therapist’s personal and gen- eral responses to the patient’s transference. Konzelmann 1995. Rather than repressing uncomfortable feelings or anxiety through the use of defenses. 1999. theorists and researchers have argued that the movement toward and away from change is representative of the dynamic between resistance and alliance such that resistance blocks the formation of a good working alliance (Berg 2000. By wanting change yet desiring to do so without emotional discomfort. spective of the therapist’s experience with significant others. Often.tex XMLPublishSM (2004/02/24) P1: OKZ IMPACT OF PSYCHOANALYTIC CONCEPTS 7 positive (affectionate) as well as negative (hostile) attitudes toward the therapist and can be examined for recurring interpersonal themes. This concept involves recognition of two competing processes: the move toward change and the move to block change. Such patient-stimulated countertransference can then serve to reinforce the negative transference pattern with which the patient is familiar. Piper et al. That is.

EVIDENCE FOR THE EXISTENCE OF PSYCHOANALYTIC CONCEPTS If we listen to current opinions about psychodynamic theory. In their method. However. symptoms were reduced.annualreviews. These diagnoses were selected because the authors believed they were clearly in the neurotic range and represented discrete distress. Psychol. (1998) offers the only systematic method for estimating the degree of accuracy for therapist’s interpretations. The therapist’s most accurate interpretations. formulation of the unconscious conflict. unconscious conflict. and is. and words generally considered to be pleasant or unpleasant. For example. Downloaded from arjournals. defined as by BOSTON COLLEGE on 02/03/10. Judgments concerning . Freud’s reliance on observational study of critical concepts was. and future behavior could be pre- dicted. accuracy is determined by the level of Annu. or behaviors that are congruent with the CCRT. Unfortunately. 2006. the measure by Crits-Christoph et al. Although some measures assess the amount or usefulness of interpretations (see Ogrodniczuk & Piper 1999. (1996). Although many therapists are loath to appreciate the scientific basis to dynamic theory. Each subject completed a battery of tests and four interviews from which the following were obtained: diagnosis. a scientifically sound avenue for theory development. Prior to undertaking their study of the unconscious. even from some psy- choanalysts. tend to be followed by the patient’s presentation of increased understanding. For personal use only. a systematic assessment of interpersonal patterns of relating to others) and observer ratings of therapist agreement between the Core Conflictual Relationship Theme (CCRT. Shevrin and colleagues interviewed 11 patients who suffered from phobias or pathological grief reactions. 17 Feb 2006 8:1 AR ANRV271-CP02-01. reasons for the patient’s thoughts.tex XMLPublishSM (2004/02/24) P1: OKZ 8 LUBORSKY  BARRETT Accuracy of Interpretation The degree to which interpretations are accurate depends upon the extent to which the client agrees with the cause-effect relationship articulated by the therapist as drawn from client behavior or statements. this is not a true representation of psychodynamic theory (see Holt 2000). it would appear that psychoanalysis has no scientific support or even that it is not in need of such validation. Sachs 1983). Kubie (1952) stated that the accuracy of an interpretation would be evident if the patient’s associations to it confirmed the content. and 32 key words used by the subject that best described the conscious symptoms. We would like to dispel this perception and offer empirical evidence in support of these concepts. description of the conscious symptoms of distress. Evidence for the Unconscious Our understanding of the unconscious was advanced considerably by the empirical work of Shevrin et al. feelings. and possibly of the scientific basis for the therapy. Clin.2:1-19. criticism of these early methods. has limited more rigorous investigations of analytic concepts and fostered a disinterest in and ignorance of current research findings. Rev.

dur- ing which brain activity and time to response were recorded. Research on self-stimulation in animals has implicated an area of the brain associated with the dopaminergic system as a factor in determining drives and motivation (see review by Gaillard 1992). Whereas some individuals will show apathy. the theoretical model of Schwartz (1987) offers one of the best explanations in support of drives or internal motivational forces. He believed that the development of object relations and patterns of interpersonal defenses resulted from the presence of affect evident in motor behavior (i.e. In contrast. conflicts with others and with self are de- fined by early patterns of relating to others. Moreover. Ordinary unpleasant words were equally Annu. Subjects were shown the selected words first subliminally (1 msec). emotions have been linked to subcortical areas of the brain. Downloaded from arjournals. neurological factors or changes in brain chemistry can result in altered motivational forces and underlying drives. the construct is one that is difficult to operationalize for investigation. The central research question was to determine whether evidence for the un- conscious could be demonstrated by showing differing patterns of brain activity in response to conscious and unconscious stimuli. Psychol. Clin.. and hyperactivity (i. Evidence for Drives Because drives are internal motivational forces. That likely to be correctly classified regardless of exposure duration.tex XMLPublishSM (2004/02/24) P1: OKZ IMPACT OF PSYCHOANALYTIC CONCEPTS 9 the unconscious conflict or word selections were discussed among participating clinicians until a consensus was reached. by BOSTON COLLEGE on 02/03/10. conscious words were classified correctly more often when presented supraliminally. facial features) arising from internal motivation (see also Kernberg 2001).2:1-19. studies on attachment and . subjects relying on repression more often correctly classified unconscious symptomatic or unconscious conflict words. Research on affect and neurological functioning has provided evidence sup- porting the notion of internal drives. these findings suggest that dynamic unconscious processes exist and are confirmed by brain activity. Taken together. For personal use only. Despite these concerns. excess motivation). In fact. Compton (1983) suggested that a more useful conception of drives needed to be developed. elevation of mood. Schwartz not only viewed affect as the prime factor of human motivation but saw it in neurophysiological terms. Resulting analyses showed that subjects correctly classified unconscious words more often when pre- sented subliminally. 2006.annualreviews. 17 Feb 2006 8:1 AR ANRV271-CP02-01. Evidence for Parent-Infant and Parent-Child Relationships According to object relations theory. Rev. others evidence disinhi- bition. six times. a significant correlation was found between a measure of repression and response to unconscious words.e. a lack of initiative..e. Therefore. Thus. or blunting of affect (i. then supraliminally (30–40 msec). no internal motivation) when there is frontal lobe damage. Furthermore. and damage to the frontal lobe has repeatedly been shown to cause disturbances in affect and emotions (see Fuster 1989). the subjective judgment of the clinician regarding these conflicts is supported by objective measures of unconscious processes. For instance.

these initial CCRT findings coupled with those on attachment patterns and neurological development suggest the stability of interpersonal patterns across development. dependable). Based on early patterns of interactions.e. the infant will show altered physiological functioning (changes in body pattern than are infants who not maltreated (Cicchetti & Barnett 1991). a number of theoretical articles . 2003).2:1-19. Of course. Rev. Still others have found that the quality of attachment at one year of age is related to a child’s by BOSTON COLLEGE on 02/03/10. as described by Bowlby (1988). Although additional research is needed to document consistency of the CCRT from early childhood into adulthood. object relations). The CCRT method. For instance. Schore (2002) found a link between growth of the right hemisphere and attachment experiences. an internal model for relating to people is laid down in the brain. In addition to studies on attachment.e. The more a person has good attachment experiences in childhood (i. non- verbal signals in adult relationships can trigger biobehavioral responses that are accompanied by distress. Attachment theory. the central relationship pattern derived from therapeutic sessions has been found to be con- sistent across different narratives (Barber et al. feelings of security at six years of age (Main et al. research has shown a connection between emotional experience and brain development that is distinct from genetic influ- ences (see Bokhorst et al. heart rate. is another way in which early patterns of relating to people can be shown to affect later patterns. 1985).. 17 Feb 2006 8:1 AR ANRV271-CP02-01. Evidence for the Oedipus Complex The Oedipus complex embodies the libidinal wishes of a child toward one parent and against the other. close. the issue of poor attachment experiences is the focus of most research. secure. he states that attachment is a necessary mechanism for survival (see also Ainsworth 1989). Similar CCRTs were found in a group of children from ages 3 to 5 (Luborsky et al. Psychol. argues that individuals form an internal working model of relationships based on their emo- tional connections with significant others. it is currently regarded as representing any compe- tition between two individuals for the affection of a third. the more secure the person is in adulthood (see Feeney 1999). For instance. For example. In research with rhesus monkeys. Because the infant comes to associate these physio- logical changes with presence or absence of mother. Suomi (1999) found significant differences in attachment between monkeys raised by peers and those raised by their mothers. mal- treated infants are much more likely to show an insecure. Although data directly assessing such competition for affection are absent.annualreviews. disorganized attachment Annu. 2006. Clin. However. etc. because it identifies the central relationship pattern evident in patient’s narratives about their lives.tex XMLPublishSM (2004/02/24) P1: OKZ 10 LUBORSKY  BARRETT neurological development as well as on the CCRT method offer solid empirical evidence for the importance of parent-infant and parent-child relationships (i.). 2002). 1995) and throughout childhood.. Furthermore. For personal use only. Hofer (1996) has demonstrated a biological link between mother and child such that in the absence of mother. Downloaded from arjournals. 1996) and in an adolescent sample from ages 14 to 18 (Waldinger et al.

One of the first studies to examine this connection found significant as- sociations between defenses and the CCRT (Luborsky et al. . the patient sees the therapist and some important past figure in the patient’s life as similar and thus relates to the therapist as if the therapist were the significant other. 1996). the concept of defenses and a defensive mechanism in response to anxiety has solid empirical support. Research on interpersonal patterns of relating has also examined the existence of defenses. Freni et al. In a study by Crits-Christoph & Luborsky (1998). Evidence for Transference In transference. Rev. Downloaded from Evidence for Defenses Considerable research is available to demonstrate the accurate and reliable identifi- by BOSTON COLLEGE on 02/03/10. 2003). Because the CCRT reflects an underlying schema of the patient’s experience in relationships. Perry & Cooper 1992). cation of one of the best-supported psychoanalytic concepts. it has been postulated that the defensive structure of an individual would relate to the CCRT.tex XMLPublishSM (2004/02/24) P1: OKZ IMPACT OF PSYCHOANALYTIC CONCEPTS 11 and single case studies continue to address this issue (see van Dam 1991). Moreover. Perry & Cooper 1989. Nearly all of the transference components described by Freud (1912/1958) corresponded with the components of the CCRT. 2006. 2003). For personal use only. Clin. and defense structures appear to be mod- erately stable over time (Perry 2001. (2004) also found correlations between high. Moreover.2:1-19. parallels between Freud’s description of transference and the CCRT were examined. Annu. Given that the Oedipus complex is considered an unconscious phenomenon. De Roten et al. it might be inferred from research on dreams using the CCRT method. Thus. defense structures have been shown to differentiate various Axis I and II disorders as well as severe psychopathology (Drapeau et al. neurotic defenses increased when responses from others were not rejecting. Psychol.e. (1998) found that borderline defenses were higher when there was little desire to help others. Because the CCRT method examines general patterns of relating. 17 Feb 2006 8:1 AR ANRV271-CP02-01. Despite the connection of content between dreams and therapy. In addition. Vaillant 1992). Recall that the central relationship pattern is determined from the wishes and interpersonal behaviors (de- fined in affective terms) evident in patient narratives about relationships. it can be studied as evidence for trans- ference (i. 1990). and narcissistic defenses were more evident when closeness was desired but feelings of being mis- understood were high.. defense mechanisms (Perry 2001. changes in defense utilization have been identified over a four-session brief treatment (Drapeau et al.and low-level defenses and CCRT as well as overall defensive functioning.annualreviews. a general pattern for relationships). Research on the CCRT has shown that the wishes and interpersonal responses obtained in therapy are reliably similar to the wishes and affective responses obtained from dreams (Popp et al. specific evidence for recurring relationship patterns involving an Oedipal triangulation have not been forthcoming. obsessive defenses were more likely when self-control and self-assurance were minimal.

it has broadened in scope to include any mental activity or behavior that interferes with treatment (see Greenson 1967). Fried et al. countertransference represents the therapist’s responses to the patient based on significant patterns of relating in the therapist’s life. Despite this difficulty. Evidence for Countertransference In contrast to transference. Gelso and colleagues (Gelso et al. its usefulness in treatment. although a mitigating factor was the quality of the patient’s patterns of relating (Ogrodniczuk et al. Downloaded from arjournals. Rosenberger & Hayes 2002). 2002) found that a su- pervisor rating of trainees’ ability to manage countertransference was positively related to therapist and supervisor ratings of outcome (see also Hayes et al. the CCRT for the relationship with therapist was significantly similar to the CCRT with other people.annualreviews. In order to examine countertransfer- ence directly. 1999). Thus. 17 Feb 2006 8:1 AR ANRV271-CP02-01.tex XMLPublishSM (2004/02/24) P1: OKZ 12 LUBORSKY  BARRETT the CCRT demonstrated similar patterns of relating with the therapist.2:1-19. For instance. and significant others in a person’s life. For personal use only. and the self. for transference to be successful there needs to be a supportive environment and strong therapeutic alliance (Ogrodniczuk & Piper 1999). Psychol. Rev. For instance. the results suggest that countertransference is a phenomenon that does occur in treatment and that the ability to manage it is likely to be related to better outcomes. In an attempt to better define the current conceptualization of resistance. Singer & Luborsky (1977) found that accurate inter- pretations via CCRT formulations tend to limit the countertransference expressed in the interpretations. The CCRT has also found similar patterns of relating to people described prior to treatment as that found early in therapy (Barber et al. resistance represents the conscious (or unconscious) block- ing of therapeutic progress. several researchers have conducted quantitative analyses of therapy transcripts. (1992) found that in a sample of 35 patients. 2006. (1991) examined the sessions from 20 patients and found good reliability for four . For instance. An examination of the CCRT in various populations has found that within each person’s narratives a pattern appears across relationships with different other people. researchers would need to identify significant interpersonal patterns evident in the therapist’s experience and then compare these patterns with coun- tertransference responses made in treatment. 1997. Schuller et al. In addition to evidence for the presence of transference in the therapy relation- ship. a few studies have examined the management of countertransference and situations in which it is reduced. As may be expected. and the stability of interpersonal patterns across time. there is consider- by BOSTON COLLEGE on 02/03/10. others. research in this area is extremely difficult since treatment is not focused on therapist interpersonal patterns. Moreover. populations. Evidence for Resistance In its most basic form. Clin. Although the studies are few. able evidence for the concept of transference. 1998). research has also found that a better outcome and more positive alliance are related to fewer transference interpretations.

research strongly supports the notion of resistance and its importance in psychotherapy. Resistance has also shown a relation to treatment dropout such that high levels of resistance are as- by BOSTON COLLEGE on 02/03/10. One explanation for the connection between resistance. whereas more recent research has shown an inverse relationship between interpretation and . (b) the therapist. Callahan (2000) found positive outcomes were related not only to positive alliance but negatively related to resistance. research supports the contention that therapeutic resistance is related to the development of alliance. Although there continues to be debate about the appropriate definition of resistance. Despite attention to the concept of interpretation. (d ) recollection of material. As such. resistance decreased. (2002). But does resistance relate to alliance. For example. alliance. (c) insight. Quantifying recurrent symptoms and preceding events in therapy. the Symptom- Context Method is based on Freud’s observations of patient symptoms within various contextual settings (Freud 1926/1959).2:1-19. Downloaded from arjournals. and therapists’ efforts to intervene were met with immediate resistant behaviors. and outcome is that more directive ap- proaches increase patient resistance for change. They found that parent pathology was as- sociated with higher levels of resistance. These included opposition to (a) change. Rev.annualreviews. Psychol. Thus. For personal use only. and (e) expression of painful affect. he was able to identify eight contexts in which specific psychological and somatic symptoms followed the pattern. oppositional. which then negatively affects the working alliance. the Symptom-Context Method seeks to draw connections between the emergence of a symptom and the context in which it occurs. Using patient dialogue from psy- chotherapy. ferent perspective. From a slightly dif- Annu. Evidence for Interpretation Interpretation is the therapist’s explanation for events and symptoms in the pa- tient’s life. For instance. Luborsky (1996) offered evidence for the use of interpretation by applying the Symptom-Context Method to seven psychodynamic therapy cases. Patterson & Chamberlain (1994) examined studies of resistance in parent training therapy. as some have suggested? Indeed. flat or halting.tex XMLPublishSM (2004/02/24) P1: OKZ IMPACT OF PSYCHOANALYTIC CONCEPTS 13 subtypes of resistance behavior: abrupt or shifting. and vague or doubting. Clin. These findings have been corroborated in a number of studies reviewed by Beutler et al. 1997) examined resistance and alliance across several sessions of treatment. Marziali & Sullivan 1980). Whereas the working alliance increased over the course of therapy. 17 Feb 2006 8:1 AR ANRV271-CP02-01. sociated with higher rates of dropout (Piper et al. Mahalik (1994) found evidence for five subtypes of resis- tance similar to those described theoretically by Greenson (1967). there appears to be good evidence for the concept of resistance. Patton and colleagues (Patton et al. 1999). research on the Symptom-Context Method for understanding formation of symptoms represents one of the best avenues for documenting inter- pretation as a viable concept. Early studies examining the role of interpretation in outcome showed a positive association (Malan 1976. the vast majority of research in this area has focused on the connection between use of interpretations and treatment outcome. First developed in the early 1950s.

interpretation clearly has an important place in psychodynamic treatment. recognition). and the methods for reducing its effects without negatively affecting the therapeutic alliance (Leahy 2001. Puhl 2003)..b). 1991). Piper et al. 17 Feb 2006 8:1 AR ANRV271-CP02-01.e. 1999. 2006. Kandel . THE IMPACT OF PSYCHOANALYTIC CONCEPTS Evidence of the continuing impact of psychoanalytic concepts throughout psy- chology can be seen in a number of areas. Cognitive models have now begun to address the phe- nomenon of resistance to change. the underlying motivations for resistance. it was shown that the accuracy of in- terpretations predicted outcome (see also Crits-Christoph et al. Defining accuracy as the level of agreement between the CCRT and observer ratings of therapist inter- pretations. However. Evidence for the Accuracy of Interpretation According to Kubie (1952). Downloaded from arjournals. 63% (24/38) of findings showed that interpretation was associated with a positive therapy outcome (Orlinsky et al. 1993). the accuracy of an interpretation is evident when the Annu. and personality traits. However. Blatt (1998) found that higher accuracy in interpretations was associated with a better treatment outcome except in highly perfectionist patients. attention. and discriminability of such an axis have been found for seven defenses and three levels of defensive structure (Perry et al. attachment. 1998. 1998). prefrontal cortex activity (inhibition. Although there was considerable variability in the scientific and methodological rigor of these studies. (1988) found comparability between the CCRT and in-session interpretations. For instance.annualreviews. Fisher & Greenberg 1996. Clin. In an examination of the interplay between interpretations. amygdala and hippocampus (emotion). Crits- Christoph et patient’s associations or connections to the interpretation confirm the content of the interpretation and future behavior can be predicted (i.2:1-19. reliability. Skodol & Perry 1993). Psychol. Crits-Christoph et al. Despite these caveats.tex XMLPublishSM (2004/02/24) P1: OKZ 14 LUBORSKY  BARRETT outcome (Piper et al. several researchers have argued in favor of a sixth diagnostic axis listing defense mechanisms (Perry et al. Rev. and there remains concern about the impact of high-frequency interpre- tations (see Connolly et al. the temporal lobe (memory).g. In fact. Ogrodniczuk & Piper 1999). in a review of studies assessing psychother- apy process and outcome. 1993b.. 1994). motivation. it is not always easy to assess this effect since research has by BOSTON COLLEGE on 02/03/10. and neurochem- istry (emotional experiences. outcome. Furthermore. 1993a. Even more striking is the link between neurophysiology and psychoanalytic concepts. For personal use only. the feasibility. shown that individuals will accept bogus interpretations as accurate descriptions of themselves (Fisher & Greenberg 1985). conscience). Human psychological functioning can be linked to neurological struc- ture and functioning by means of information processing (perception. several quite useful measures exist for assessing the accuracy of interpretations (e. object relations) (Hadley 1983. the cause-effect con- nection).

A Secure Base: Parent-Child fancy. chotherapy and during early sessions. An Elementary Textbook flictual Relationship Themes before psy.tex XMLPublishSM (2004/02/24) P1: OKZ IMPACT OF PSYCHOANALYTIC CONCEPTS 15 1999. London: Oxford Univ. eds. and working alliance. The relationship be- 129–43. including the defenses. Fearon RMP. 290 pp. 1995. Clin. Stability of the CCRT from change in breaks in eye contact during anxi- before psychotherapy starts to the early ses. Crits-Christoph P. 253–60 Optimizing Psychotherapy. 219 pp. Dev. Korean J. Psychother. 2003. tween client resistance and client psychologi- Blatt SJ. 9:101–27 52 Cicchetti D. 3:397–411 Schuengel C. object relations. J. Taken together. In Psychotherapy Relationships That Clinical Applications. LITERATURE CITED Ainsworth MS. Ashland.annualreviews. classification. sult. The internalizing transference. For personal use only. cal reactance. Moleiro CM. Diguer L. current efforts have increased our understand- ing of personality and encouraged the use of more rigorous experimental designs to test quantitatively the usefulness and accuracy of these qualitatively generated concepts. J. Con. Am. 44:709–16 Attachment and Healthy Human Develop- Barber JP. ment. Moreover. Child Dev. transference. Bowlby J. Research. Indexing resistance in Barber JP. Assoc. siveness to Patients. pression. Plan Analysis: Toward pp. The importance of shared Compton A. OH: Berg M. Brenner C. Lee CH. 2000. Hand- Beutler LE. 1988.2:1-19. 1998. Psychoanal. Psychoanal. ety (BECAs). Univ. Cho SH. van IJzendoorn MH. tervention. Psychoanal. The current status of the environment in mother-infant attachment se. UK: Int. Talebi H. A comparison of Core Con. Q. I. Fonagy P. and tance. psychoanalytic theory of instinctual drives: curity: a behavioral genetic study. Psychopathol. Can. Clin. And research has begun to demonstrate neurophysiological correlates of several psychoanalytic concepts. Oxford. and drives (see review by Kandel 1999). Luborsky L. Press. 925 pp. 1995. Psychol. 1997. 17 Feb 2006 8:1 AR ANRV271-CP02-01. Bakermans-Kranenburg MJ. 52:364–401 . Res. Work: Therapist Contributions and Respon. these data offer strong empirical evidence for several key psy- choanalytic concepts. 1998. Hogrefe & Huber. Attachment or- Bokhorst CL. ed. Caspar F. Drive concept. and develop- 74:1769–82 ment. 46:723– Counsel. characteristics of counselor in- sis to the understanding and treatment of de. 1955. 2002. book of Attachment: Theory. Am. 8:167–80 Cassidy J. 1999. The Annual Review of Clinical Psychology is online at http://clinpsy. by BOSTON COLLEGE on 02/03/10. 205 pp. Resis. Psychol. JC Norcross. Attachments beyond in. Psychother. Barnett of dynamic treatments (Fisher & Greenberg 1996). 2000. Shaver PR. Rev. 1989. Crits-Christoph P. Press. Psychol. 1983. short-term dynamic psychotherapy (STDP): Diguer L. Though steeped in a tradition of observation as the key mechanism for scientific validation. these efforts have begun to bring about empirically validated assessments of treatment that are producing evidence for the general effectiveness Annu. See Luborsky & Crits-Christoph 1998. Luborsky L. Contributions of psychoanaly. pp. Downloaded from arjournals.annualreviews. New York: Basic Books. J. 452 pp. 10:87–99 sions. 1991. New York: Guilford. resistance. of Psychoanalysis. 63:145–48 Callahan PE. Semenza 2001). ganization in maltreated preschoolers.

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Taft 161 THE PSYCHOPATHOLOGY AND TREATMENT OF BIPOLAR DISORDER. and A. Tyrone D. Markon 111 WOMEN’S MENTAL HEALTH RESEARCH: THE EMERGENCE OF A BIOMEDICAL FIELD. Brown and Lisa T. Spence. Fabricatore and Thomas A. Amy D. Clin.2:1-19. Albert and Deborah Blacker 379 vii . David J. Adrian Raine 291 AUTISM FROM DEVELOPMENTAL AND NEUROPSYCHOLOGICAL PERSPECTIVES. Mary C. Lorna Smith Benjamin. Marilyn S. Critchfield 83 REINTERPRETING COMORBIDITY: A MODEL-BASED APPROACH TO UNDERSTANDING AND CLASSIFYING PSYCHOPATHOLOGY. Eyler 51 THE USE OF STRUCTURAL ANALYSIS OF SOCIAL BEHAVIOR (SASB) AS AN ASSESSMENT TOOL. and Kenneth L. and Casey T. Marshall. Cannon and Matthew C. Anthony Spirito and Christianne Esposito-Smythers 237 ENDOPHENOTYPES IN THE GENETIC ANALYSES OF MENTAL DISORDERS. For personal use only. Anthony N. Jeffrey Conrad Rothweiler. Sarah J. Keane.annualreviews. Psychol. Krueger and Kristian E. 2006 CONTENTS THE HISTORY AND EMPIRICAL STATUS OF KEY PSYCHOANALYTIC CONCEPTS. Johnson 199 ATTEMPTED AND COMPLETED SUICIDE IN ADOLESCENCE. Barrett 1 Annu. SCHIZOPHRENIA RESEARCH. Downloaded from arjournals. McFall 21 METHODOLOGICAL AND CONCEPTUAL ISSUES IN FUNCTIONAL MAGNETIC RESONANCE IMAGING: APPLICATIONS TO by BOSTON COLLEGE on 02/03/10. 2006. Ting Wang 327 OBESITY. 2006 16:34 Annual Reviews AR271-FM Annual Review of Clinical Psychology Volume 2. Blehar 135 POSTTRAUMATIC STRESS DISORDER: ETIOLOGY. AND TREATMENT OUTCOME.P1: JRX February 24. Wadden 357 MILD COGNITIVE IMPAIRMENT AND DEMENTIA. Miklowitz and Sheri L. Richard DOCTORAL TRAINING IN CLINICAL PSYCHOLOGY. Lester Luborsky and Marna S. Keller 267 SCHIZOTYPAL PERSONALITY: NEURODEVELOPMENTAL AND PSYCHOSOCIAL TRAJECTORIES. Gregory G. Rev. Marian Sigman. Robert F. Terence M. EPIDEMIOLOGY. INDEX Subject Index 499 ERRATA by BOSTON COLLEGE on 02/03/10. 2006 16:34 Annual Reviews AR271-FM viii CONTENTS COGNITION AND AGING IN PSYCHOPATHOLOGY: FOCUS ON SCHIZOPHRENIA AND DEPRESSION. An online log of corrections to Annual Review of Clinical Psychology chapters (if any) may be found at http://www. Downloaded from arjournals. Philip View publication stats . Harvey. and Christopher R. Timothy W. 2006. Clin.annualreviews. Maxine Stitzer and Nancy Petry 411 PERSONALITY AND RISK OF PHYSICAL ILLNESS.AnnualReviews.2:1-19. Loftus and Deborah Davis 469 Annu. Abraham Reichenberg. P1: JRX February 24. Smith and Justin MacKenzie 435 RECOVERED MEMORIES. For personal use only. Rev. Bowie 389 CONTINGENCY MANAGEMENT FOR TREATMENT OF SUBSTANCE ABUSE. Elizabeth F.