the fantasies that lend force to the transference.

In its contributions to psychotherapy research, client-centered therapy

has been outstanding. Rogers and his followers were the first to record and
review transcripts of sessions, the first to document the process of
treatment, and the first to do follow-up studies of results. They developed
such innovations as the q-sort and scales to objectify the Rorschach test.
They showed that, in successful therapy, negative attitudes about the self
are replaced by positive attitudes, that acceptance of others occurs in
parallel, that psychological tension decreases, and that plans take the place
of old complaints. Although initial claims about success in treating
schizophrenia patients had to be dropped, and although Rogers and his
colleagues did not do controlled comparisons of their method with others,
they were able to document that client-centered therapy is effective. By
clearly delineating that a successful outcome is associated with genuine
acceptance and an empathic congruence that facilitates the recognition and
expression of emotion, they recognized two of the features that empower
psychotherapy of whatever stripe. Perhaps most importantly, their
emphasis on progressive clarification of the client’s feelings sounds an
insistent cautionary note about the need for clear understanding, rather
than facile interpretation based on the assumptions of one’s theory.

TRANSACTIONAL PSYCHOTHERAPY
History
Transactional analysis or psychotherapy was the creation of Eric Berne, a
psychiatrist with psychoanalytic training who parted with the Freudian
movement to focus on social interaction as the unit of analysis.
Transactional Analysis in Psychotherapy was published in 1961, and
Games People Play was published in 1964; Games People Play became a
record bestseller, with sales of more than 2.5 million copies. Berne’s thesis
was that, in social interactions, people seek intimacy, comfort, or
recognition, which they get through a series of mutual exchanges or
strokes. If the ego states of the participants are adult and appropriate, the
transaction is harmonious and realistic. Ulterior motives, sponsored by
other than an adult ego state, cause discomfort in the transaction, and
transactions habitually colored by such motives may become ritualized and
predictable.
Written with wit and humor, Berne’s books inspired considerable
controversy. Some accused them of facile psychologizing better left to
cocktail parties, rather than true contributions to psychotherapeutic theory
and practice. The fact that the movement has endured, inspiring a journal,
an accrediting body, and an occasional article in the psychiatric literature,
suggests that a number of its ideas have merit.
Theoretical Issues
Transactional analysis rests first on the principle that human beings have a
hunger for stimulation and contact in the infantile style. When such
strivings are blocked, efforts are made to regain the intimate contact.
Compromises and sublimations are made in that pursuit, so that a hint of
the original intimacy may suffice, and the stimulus hunger may be satisfied
symbolically. Thus, the original physical strokes of caress and comfort are
replaceable by metaphorical stroking by which the person is recognized,
flattered, or supported and even by acknowledgments that may appear to
bring discomfort. A stroke is a fundamental unit of interaction. An
exchange of strokes is a transaction, the unit of social intercourse; a
stimulus from one person produces a corresponding response in another
person. Because social stroking satisfies the original infantile need, it
follows that any social intercourse is better than none.
In addition, social interactions fill time, provide structure, and help
avoid boredom. Interactional programs, all of which contain stroking
opportunities, may be material (dealing with reality issues); social (the
norms and manners of a social order); or individual (incidents sneaked
into the other programs to get extra, personalized strokes). The sequences
of a person’s program are developed in line with that person’s life script, a
set of overall goals and patterns, and these sequences are the individual
games. The games range from harmless and pleasantly satisfying to
dangerous and destructive. What develops in a game is assumed to be the
purpose of the game, and what eventuates as its end result are the strokes
that constitute the aim and the satisfaction.
To understand and to diagram the interactions in a game, the theory
posits three ego states, the parent, the child, and the adult. In the parental
ego state, the person reacts as the parent or as the parent would have
directed. In the child state, one may be adaptively compliant or whiny and
withdrawing or, as the natural child, rebellious, creative, or impulsive. The
adult state appraises reality and acts in tune with it; the adult also
moderates between the parent and the child. All three states are present
and potentially active at all times.
When the adult in one person addresses the adult in another and is
responded to in adult terms, the stimulus and the response are
complementary, and the transaction is smooth. The same is true if the child
addresses the parent, and the parent responds appropriately—for example,
when a child (to parent) demands “Water!” and the parent (to child)
responds “Here, baby.” Such transactions are normal, two-stroke
harmonious social interactions.
However, if one partner in a couple asks, “Where are my cuff links?”
and the other responds, “You’re always losing things!” the lines of
communication are crossed; the query may be adult to adult, but the
response is parent to child, and the situation gets sticky. A comparable
child-to-parent cross in response to an adult-to-adult stimulus may occur
when one notes to a person driving, “You missed the turnoff,” and the
driver responds, “You’re always criticizing me!”
Such ulterior transactions are the basis of games, which are ongoing
series of complementary ulterior transactions progressing to a predictable
defined outcome that satisfies some aspect of the person’s life-script
strivings. On the surface, the interactions may appear plausible, but their
recurrent nature, concealed snares, and predictable payoffs define them as
parts of a neurotic game.
The test of a game is that a respondent’s refusal to play causes
increasingly intense efforts to force its continuation; continued refusal may
elicit despair or bewilderment. The cure for a game is recognition of its
presence, its rules of play, and its motivation. A cure is signified when the
initiator can note with a laugh, “There I go again,” and can desist
volitionally.

Techniques
Because games generally involve at least two parties, they reveal themselves
and are best treated in couples or groups. Transactional analysis has
therefore had its most widespread application in couples and group
therapies, although it has also been seen as useful in individual treatment.
The techniques aim to illustrate the game, dissect the transactions, and
frustrate players in their pursuit of strokes. In doing so, the players may
learn a considerable amount about their life scripts and how they evolved,
although that is not necessarily the goal of treatment.
Games are named for convenience of recognition, with the name usually
connoting something about the ends sought. Thus, in “if it weren’t for you,”
a woman (usually) picks a domineering man to marry, who then forbids her
to do things she allegedly wants. She blames him for her unhappiness, they
quarrel, their sex life deteriorates, he gives her gifts to make up, and the
cycle goes on. In reality, the woman fears the activities for which she says
she longs, has a sexual inhibition (which the husband may share), and is
pleased by the opportunity to prove that men are tyrannical. In the game of
“schlemiel,” a man (usually) messes up or breaks things to be castigated
and then forgiven.
Other life games include “debtor,” “alcoholic,” and “see what you made
me do.” The aim of each is to obtain one or several ulterior satisfactions
without accepting conscious responsibility. In “alcoholic,” the players may
include the alcoholic, a persecutor (usually, a spouse), a rescuer (often, a
health professional), a patsy (who gives money or sympathy), and,
sometimes, a connection (who may tempt the alcoholic to drink). Each
player may also be in the game for idiosyncratic reasons, games, or strokes.
For the alcoholic person, the payoff is the hangover and its chance to
indulge in psychological torment and suffering; for the rescuer, it is an
opportunity to play “I’m only trying to help you”; for the persecutor, it is an
opportunity to play “Look what you’ve done to me.” The antithesis, the goal
of treatment, is to have each one recognize the role played and frustrate the
primary player (and the other persons addressed as well) by giving up the
role assigned.
Groups may be randomly selected or homogeneous. In treatment
sessions, the theory of transactional analysis is taught assiduously; with
blackboard illustrations, the aims of treatment are outlined in operational
terms; and contracts are made about individual large goals and are
redrawn for small, particular steps in the course of therapy. The therapist’s
role is active and confrontational but egalitarian.

Research and Ethical Issues

Interest in transactional analysis peaked long before the advent of
criterion-based diagnosis and controlled clinical trials, and little research
on it can stand up to today’s critical scrutiny. It was claimed to be effective
for persons with neuroses, psychoses, personality disorders, sexual
disorders, and mental retardation; for individuals and groups; and as a
means of self-help for young children and teenagers. Like most therapies,
however, its usefulness rests on clinical lore and a certain common-sense
validity. What seems sensible includes an emphasis that is typical of later
cognitive-based treatments—namely, identifying elements of behavior that
reflect neurotic problems, so that their maladaptation can be
acknowledged, their driving emotions and underlying assumptions can be
recognized, and the pattern of behavior can be altered. Psychoanalytic
therapies share the same aims but include the additional goal of genetic
uncovering. Transactional analysis’ emphases on confrontation, contracts,
homework, active diagramming of conflict, and teaching about behavior are
also more like cognitive therapies.
The weakness in the system and the potential it has for abuse in work
with patients lie in its theoretical assumptions. Neurotic behavior, by
definition, is not realistically aimed and is often maladaptive. To assume
that all bad consequences are deliberately sought is incorrect and unfair. To
the extent that such a view is held, important motivations may be missed,
and therapy may be tainted by a tendency to level accusations. If this
position is avoided, and complaints are not trivialized by being seen
routinely as goals, the dissection of social transactions and the focus on
personal responsibility offered by transactional therapy conform to what is
generally considered to be of therapeutic value.

EXISTENTIAL PSYCHOTHERAPIES
History