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SYMPOSIUM:

T H E DYNAMICS O F CHANGE IN P S Y C H O T H E R A P Y *
W . H . COONS, Ph.D. 1

The primary concern of this paper equating the acquisition of insight with
will be with the conditions under which changes in his patients' adjustment.
change occurs during psychotherapy; a Freud's system of psychoanalysis was
concern which stems from the difficulty designed to provide an experience which
encountered by all major schools of psy­ would foster insight. T o him, insight
chotherapy in explaining bow and why meant an awareness and understanding
therapeutic changes come about. of the relationship between contempor­
Since Freud's development of psycho­ ary behaviour and repressed infantile
analysis, the primary stress in all syste­ sexuality (6). Initially, he placed pri­
matic psychotherapies has been on mary emphasis on the intellectual aspects
insight as the core of adjustment. of the process. The assumption was that
However, no unequivocal relationship when the patient was made aware of the
between degree of insight and level of forgotten incidents in his life, the im­
adjustment has yet been demonstrated. pact of the new knowledge would re­
When insight is considered to be a cog­ sult in immediate amelioration of the
nitive act by which we grasp the signi­ maladjustment. However, this expecta­
ficance of some pattern of relations tion was not confirmed. In Freud's
(13), clinical experience does not wholly words:
support its use as an explanatory con­
"We accounted it specially fortunate if it
cept. Improved adjustment occurs in were possible to obtain information of the
persons who have not shown evidence forgotten traumas of childhood from external
of increased insight; other persons who sources, from parents or nurses, for instance,
are thought to 'have gained insight re­ or from the seducer himself, as occurred
occasionally, and we hastened to convey the
main seriously maladjusted.
information and proofs of its correctness to
Attempts to explain this discrepancy the patient, in the expectation of bringing
between theoretical expectation and the neurosis and the treatment to a rapid
clinical experience have resulted in the end by this means. It was a bitter disappoint­
ment when the expected success was not
postulation of two types of insight: forthcoming" (<5, p. 362).
intellectual and emotional. However,
specifying the difference between them Freud attributed to 'resistance' the
has been difficult. In practice, differen­ reluctance of patients to accept as fact,
tiation is usually based on the presence incidents from their past. Resistance was
or absence of improvement in adjust­ assumed to be due to the repression from
ment; if the patient with insight im­ consciousness, as a result of unconscious
proves, he has emotional insight; if he psychic activity, of incidents which were
does not improve, he has intellectual in­ painful, disagreeable, frightful, or ob­
sight only. This is essentially a circular noxious, to the ego of the patient. The
definition and suggests that some more belief was and is, that resistance to the
basic factor is at work. recall of ego-deflating incidents mani­
fests itself in psychoanalysis in the form
Assumptions of Psychotherapists of transference; the patient transfers to
Freud the analyst those feelings and attitudes
Early in his experience in psychother­ which he holds toward important figures
apy, Freud encountered difficulty in in his past experience — usually parents.
^Manuscript received August, 1965. Successful analysis requires that the pa-
Department of Psychology, York University, Toronto.
3

Canad. Psychiat. Ass. J . Vol. 12 (1967)


239
240 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL Vol. 12, No. 3

tient recognize the existence of the contents of the mind as have hitherto
transference before progress is possible. remained unconscious. Insight is the pri­
However, Freud was forced to re­ mary objective which can be best
cognize that 'uncovering' the transfer­ achieved within a warm, personal rela­
ence is only the beginning of the tionship between the patient and the
analysis; a process which he called authoritarian therapist.
'working through' must follow if the
analyst's efforts are to be successful. Rankian Psychotherapy
Here is how he described it: The work of another of Freud's re­
"One must allow the patient to get to know calcitrant students, Otto Rank (12),
this resistance of which he is ignorant, to merits special consideration. In my view,
'work through it', to overcome it, by con­ his contribution to the evolution of psy­
tinuing to work according to the analytic
chotherapy has not received the recog­
rule in defiance of it. Only when it has come
to its height can one, with the patient's co­ nition it deserves. Perhaps it is because
operation, discover the repressed instinctual of the difficulty in formulating a defini­
trends which are feeding the resistance; and tive statement of the actual technique
only by living them through in this way of therapy employed by Rank. Theore­
will the patient be convinced of their pow­
er." "This 'working through' of the resis­
tically at least, he introduced a new
tance may in practice amount to an arduous emphasis to the conduct of psychothera­
task for the patient and a trial of patience peutic interviews.
for the analyst." "Nevertheless", Freud goes
on, "it is the part of the work that effects
T o him, relationship and will are the
the greatest changes in the patient and dis­ primary components, and, if we accept
tinguishes analytic treatment from every kind his statements literally, the patient
of suggestive treatment" (6, p. 375-376). rather than the therapist is the central
figure in the therapeutic process. He
The 'working through', Freud held
believes that the patient has within him­
must always occur in an understanding,
self the 'forces of self-creation' as well
non-moralizing atmosphere. He emphas­
as of 'self-destruction'. The former
ized that the analyst must carefully re­
forces, those of self-creation, can be
frain, even in the later stages of analysis,
brought into play if the therapist will
from making interpretations to the pa­
play the non-authoritarian role of 'ego-
tient "until the patient is already close
helper' or 'assistant ego'. The goals of
upon it, so that he has only a short step
therapy are achieved by the patient
to take in order to grasp the explana­
through the experiencing of the present
tion himself" (6, p. 361).
rather than through an explanation of
Adler and Jung the past. In the close relationship with
the therapist the patient reacts in terms
The conditions which are basic to
of all his earlier reaction-patterns, plus
Freud's psychoanalysis are characteristic
those of the present. This experience,
also of the techniques of others who do
Rank believes, is the most direct means
not subscribe to his theory of personal­
of bringing the patient to feel the will
ity. Thus, Adler (1927) rejects Freud's
conflict present in his total life situation
emphasis on repressed infantile sexuality.
and his denial of the will for indepen­
He favours a concern for the patient's
dence and self-reliance.
neurotic life-plan which is determined
by compensation for feelings of infer­ The dynamic of change is inferred to
iority. T o Jung (16), individuation is be the experiencing, through the thera­
the goal of analysis, individuation being peutic relationship, of the present mal­
denned as the utmost widening and adaptive modes of adjustment. There
deepening of consciousness. But, while appears to be no place for interpretation
the content of 'insight' differs they both, (which would imply, of course, an
like Freud, seek to make conscious such authoritarian relationship), nor is insight
June, 1967 PSYCHOTHERAPY 241

introduced as a goal. This is an impor­ aspect of self which he exposes is equally


tant innovation. Like others, however, accepted, equally valued" (14, p. 192);
and again: "In this atmosphere of safety,
Rank cannot completely accept his basic protection, and acceptance, the firm boun­
premise. Here are a few samples of state­ daries of self-organization relax. There is
ments he makes which are contrary to no longer the firm, tight Gestalt which is
his general thesis: characteristic of every organization under
threat, but a looser, more uncertain confi­
"I unmask all the reactions of the patient guration. He begins to explore his perceptual
even if they apparently refer to the analyst, field more and more fully. He discovers
as projections of his own inner conflict and faulty generalizations, but his self-structure
bring him back to his own ego" (12, p. 6); is now sufficiently relaxed so that he can
or, (the therapeutic situation) "is the place consider the complex and contradictory ex­
to show him how he tries to destroy the periences of which he has never been aware,
connections with this experience just as he which are deeply contradictory to the per­
does with the past" (12, p, 37); and again, ception he has had of himself, and this is
"He (the patient) may arrive finally at self- threatening indeed. He retreats temporarily
understanding, which is the true therapeutic to the former comfortable Gestalt, but then
goal, only by identification with the analyst slowly and cautiously moves out to assimi­
who understands him" (12, p. 21-22, italics late this contradictory experience into a new
mine). and revised pattern. Essentially this is a pro­
So, although Rank professes to be cess of disorganization and re-organization
. . . As the process continues, a new or re­
non-authoritarian with his patients, there
vised configuration of self is being construc­
is substantial evidence to indicate that, ted. It contains perceptions which were
in actual practice, interpretation and previously denied. It involves more accurate
insight are important components of his symbolization of a much wider range of
approach. Theoretically, he apparently sensory and visceral experience. It involves
a reorganization of values, with the organ­
thinks that the intense interpersonal ex­
ism's own experience clearly recognized as
perience during therapy is responsible providing the evidence for the valuation.
for the personality change; in actual There slowly begins to emerge a new self,
practice, it appears that he is unable to which to the client, seems to be much more
reject completely the psychoanalytic a 'real self, because it is based to a much
greater extent upon all of his experience,
technique in which he was originally perceived without distortion" (14, p. 193).
trained.
Rogers assumes that the nature of the
Client-centered Psy chotherapy
self-organization determines the level
Rogers' technique in therapy owes and mode of adjustment. Changes in
more to Otto Rank than to Freud, Jung self-organization occur as a result of a
or Adler, but the rationale for the tech­
cognitive re-orientation based on a more
niques of all of them has much in com­
adequate awareness of the relationship
mon. Rogers (14) has formalized Rank's
of the 'self to its true environment. Yet,
concept of client-as-therapist, and devel­
this appears to be an incomplete repre­
oped a systematic technique of therapy
sentation of Rogers' thinking on the
which is consistent with this therapeu­
genesis of therapeutic change; it omits
tic philosophy. He rejects the use of
his concern for the role of the emotional
interpretation. He strives for a non-
relationship as the dynamic of change.
authoritarian relationship with the client
On occasion he implies that the emotion­
which is designed to promote in him a
feeling of complete understanding and al relationship in therapy might be more
acceptance. This type of therapeutic than the medium through which insight
atmosphere is held to facilitate the devel­ may be achieved most effectively. Like
opment of insight by the client. In Rank, he strives to develop insight but
Rogers' words: has doubts about its primacy. His argu­
ment here is that many of the verbal,
(In client-centered therapy, the client) "gra­
dually experiences a freedom from threat
attitudinal, and perceptual, changes are
which is decidedly new to him . . . every simply by-products of a basic emotional
242 CANADIAN PSYCHIATRIC ASSOCIATION J O U R N A L Vol. 12, No. 3

experience between two human beings. concern itself with rationalizing post-mor­
tems and fitting into some cognitive struc­
He says: ture in which the person can have faith,
"One of the arguments for this point of view what actually did happen, or what is wished
is that in play therapy, particularly, many for, or anticipated in interpersonal inter­
of the processes we have discussed either do course."
not occur, or occur only in unverbalized
form, and yet constructive changes take Here, Bach is quite obviously exclud­
place. What are we to regard as essential to ing, or at least minimizing, the role of
psychotherapy if success occurs in dealing
the conscious, cognitive 'insightful',
with a child, when there have been no ver­
balized insights, little expression of attitudes control of social behaviour. In essence,
toward the self, no certain expression of he is saying that we behave without
denied experiences, and only a fresh and thinking. After we have acted, we try
vital experiencing of self?" (14, p. 158). to rationalize what we have done; we
It seems that, while Rogers' client- try to make our behaviour appear 'logi­
centered technique of therapy is designed cal'. But elsewhere (2, p. 235) he says:
to facilitate the development of insight, "Then gradually through identification with
he has reservations about according it the group, the patient can accept with rela­
the primary role in the production of tively little resistance, the meaning of his
behavioural improvement. patterns of set-up operations, and this spells
the beginning for deep therapeutic effects.
Now with the recognition of his inner
Group Psychotherapy
enemy, of his neurotic patterns, the immense
The practice of group psychotherapy motivation of the human organism for prob­
has depended primarily upon the modi­ lem-solving begins to shift and applies itself
fication of theories and techniques of to the relevant aspects of his life: his in­
effectual contact operations and his patholo­
individual psychotherapy for use with
gical need structure" (Italics mine).
groups of patients. Generally, the same
assumptions are used with one exception: Bach then, experiences the same dif­
most group psychotherapists believe ficulty in reconciling his biases regard­
that, at least with some patients, the ing the necessity of cognitive under­
group provides a more effective medium standing with his clearly expressed
for the 'working through' required for belief in the practical efficacy of a par­
the development of insight. Generally ticular type of interpersonal experience.
too, group psychotherapists share with The self is inconsequential in the volun­
individual psychotherapists the dilemma tary direction of social behaviour, but
resulting from discrepancy between motivation for problem solving is im­
practice and theory. portant in therapy.
Thus, Bach (2) questions the effec­ Bach's position epitomizes that of
tiveness in behaviour of conscious, cog­ individual and group therapists alike:
nitive, control. He argues that behaviour practice has impressed upon them the
occurs spontaneously in the absence of
inadequacy of techniques which • aim at
voluntary direction. In discussing the
relationship of the self to social behav­ imparting insight in the absence of
iour be says (p. 227-228): interaction, but for some reason they
"The self concept is not a central integrative cannot quite accept the evidence which
or even selective organ in the sense of con­ points to interpersonal interaction with­
trolling or directing contact. The ego inter­ in the therapeutic situation as the origin
prets dead issues only, past experiences, and/ of the change which results.
or lapses in fantasies about the future. It
This has been a veiy brief survey of
does not direct the contemporary spon­
taneous life. Upon contact, the social instinct
some of the psychotherapists who have
life (mutuality), rather than the self, governs most profoundly influenced the thera­
unconsciously and spontaneously what a per­ peutic assumptions and techniques most
son will do with, to, or for another. The commonly used today. There are gross
'self has little to say about it. It can only differences in many aspects of their ap-
June, 1967 PSYCHOTHERAPY 243

proaChes to the problem of psychother­ Regardless of the type of insight ex­


apy; but there are also numerous simi­ perienced, all these patients had one
larities. It is the similarities with which experience in common: a warm, person­
we are concerned here. al, relationship with a sympathetic, em-
Throughout the range of psychother- pathic person (the therapist). This sug­
apies, whether the approach has gests that it is the interaction within a
been consciously authoritarian (as was non-threatening social atmosphere which
Freud's) or has striven to be non- produces therapeutic change and that
authoritarian in the style of Rogers, the insight per se, is unimportant. Support
emphasis has been on an understanding, for such a contention is provided by
accepting, non-moralizing attitude, to­ those theorists who consider personality
ward the patient. This common concern development as being largely a response
of all techniques was dictated apparently to the individual's social matrix.
by the resistance of clients to any other Personality Theories
initial approach. Thus, Freud used a long
Since the time of George Herbert
period of free association during which
Mead, personality theorists have been
a strong relationship (transference) be­
placing increasing emphasis on the role
tween patient and therapist was develop­
of social factors in the development of
ed, before he introduced interpretation
personality. Behaviour at any point in
or any other threatening behaviour. The
time is held to be a reciprocal interac­
recognition of the importance of a non-
tion between personality and the social
threatening atmosphere has culminated
matrix within which the personality is
in the Rogerian technique which strives
acting. This view emphasizes the man­
to be completely acceptant of the client.
ner in which the historical antecedents
Whatever the technique, however, it has
of contemporary personality structure
been designed to facilitate the develop­
influence the current reactions, particu­
ment of insight in the patient. Explicitly
larly the social reactions, of the organ­
or implicitly, insight has-been considered
ism. Perception and meaning, which are
to be the process by which the cognitive
held to be based on past experience, are
processes of perceiving, identifying, and
considered to be crucial factors in deter­
remembering, are related and organized
mining behaviour. The theory of Par­
so that some new and significant rela­
sons and Shils (9) may be considered to
tionship is clearly understood.
represent, in a general way, this point
But the nature of the insight develop­ of view.
ed differs with different therapeutic They assume that the essence of inte­
orientations. Freud's patients developed grated behaviour is the role each behav­
insight into the influence on current ing individual (referred to as the 'actor')
behaviour, of repressed infantile sexual­ assigns to himself. Role is a product of
ity. Adler's patients developed insight others' responses to the individual in all
into the influence of unconscious feel­ prior social interaction. As they describe
ings of inferiority. Rank's patients devel­ it, role is that
oped insight into the dynamics of their "organized sector of an actor's orientation
current interpersonal behaviour. Rogers' which constitutes and defines his participa­
patients developed insight into the na­ tion in an interactive process. It involves a
set of complementary expectations concern­
ture of their distorted perceptions of
ing his own actions and those of others with
self in relation to others. BaCh's patients whom he interacts. Both the actor and those
developed insight into the meaning of with whom he interacts possess these expect­
their patterns of social expectancies. ations" (p. 23).
Yet, presumably, patients of each of In any contemporary social situation an
these therapies showed improvement in individual's behaviour is determined by
their behaviour patterns. his perception of the role assigned to
244 CANADIAN PSYCHIATRIC ASSOCIATION JOURNAL Vol. 12, No. 3

him by those with whom he is inter­ of distortion and yet be unable to mod­
acting. The nature of his behaviour is a ify his behaviour in terms of that under­
product of his perception of the role standing. Apparently we act in strict
assigned to him, and of his system of accord with our perceptions even though
need-dispositions. Non-conformity we recognize that the results of our
(which includes maladaptive behaviour) behaviour are ineffective or unsatisfying.
may result from inaccuracy of his per­ Intellectually understanding the trouble
ception of the role expected of him does not help. In the distorted room
(presumably because of discrepancies experiment it is reported (15), that what
between his perception of past exper­ did belp to modify the subjects' percep­
ience and the reality of the present situa­ tions and subsequent behaviour, was
tion), or from needs which predispose continued practice in hitting the rat or
him to antagonistic behaviour. striking the marked spots on the wall.
Parsons and Shils appear to feel that The continued striking in this experi­
most individuals are aware, most of the ment appears to be analagous to the
time, of the forces which determine their continuous interaction characteristic of
behaviour. However, they do acknowl­ psychotherapy. T o make the analogy
edge that some indeterminate proportion complete it is necessary to assume that
of behaviour springs from factors about the therapist (and possibly the physical
which the behaving individual is un­ attributes of the therapeutic setting) is
aware. Numerous other authors (Mc- consistent in his reactions to the pa­
Ginnies ( 7 ) , Postman and Brunei- (10), tient, just as the oblique room is always
Postman, Brunei- and McGinnies (11), oblique.
Bruner (3), Miller ( 8 ) , Cameron (4)
This is not easily accomplished. Dif­
describe the manner in which the be­
ficulties of the type encountered by the
haviour of both 'adjusted' and 'malad­
subjects in Ames' experiment must be
justed' persons is influenced by these
magnified tremendously in interpersonal
'unconscious' factors.
situations in which reality (in the form
An experiment by Ames (one of the of the persons with whom interaction
Hanover experiments), demonstrates occurs) can manifest itself in such com­
quite explicitly how these unconscious plex and nebulous form. However, a
factors may result in maladaptive be­ study by Coons (5) suggests that the
haviour. The experimental setting was a analogy is basically valid. Groups of
miniature distorted room of oblique patients who were involved in a form of
shape which, when viewed monocularly, group psychotherapy which facilitated
seemed to 'have the shape of an ordinary social interaction in the absence of the
rectangular room. The behaviour of usual insight-producing techniques pro­
subjects asked to react to phenomena duced significantly more change than did
occurring within the room, was maladap­ insight group psychotherapy with mini­
tive even though they understood the mal social interactions. In fact, the latter
nature of the subterfuge; the subjects groups did not differ significantly from
behaved as if the room were normally control groups which received no psy­
shaped. Because they were using un­ chotherapy.
realistic cues, based on their previous It seems then, that there is substantial
experience with rooms, they were un­ basis in both research and theory for
able to perform simple tasks like hitting the assumption that social behaviour is
a rat, or striking marked spots on a wall determined by the expectancies or anti­
(15). Their performances give striking cipations which the behaving individual
testimony to the manner in which a has built up on the basis of prior exper­
person may understand intellectually the ience. A4aladaptive social behaviour may
nature and the perceptual consequences be assumed to result from the develop-
June, 1967 PSYCHOTHERAPY 245

ment of expectancies about the reactions 8. Miller, J . G . : Unconscious processes and


of other persons which are not in ac­ perception. In Blake, R . R . , & Ramsey, G .
V . , eds. Perception: An Approach to Per­
cord with the reactions actually being-
sonality. N e w Y o r k : Ronald Press, 1951.
encountered; or from the development
9, Parsons, R . , and Shils, E . A . , (eds.):
by the individual of needs, the satisfac­ Toward a General Theory of Action. C a m ­
tion of which is denied by the current bridge, Mass.: Harvard. University Press,
situation. There is at least some evidence 1951.
to suggest that the process of bringing 10. Postman, L e o and Bruner, Jerome S.: Per­
expectancies into line with the reality ception under stress. Psychol. R e v . 1948,
55, 6: 314-323.
situation is not primarily an intellectual
11. Postman, L e o , Bruner, Jerome, and M c ­
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T w o separate lines of evidence con­ Psychol. 1948, 43, 2: 142-154.
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in a consistently warm and accepting


social environment. Resume
Deux series distinctes d'indices con­
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