Excerpts from Must Read Books & Articles on Mental Health
Articles- Part V
The Evocative Power of Enactments
Judith Fingert Chused, M.D.
The inevitability of analytic enactments, defined as symbolic interactions between
patient and analyst, is discussed. Clinical material from the psychoanalysis of a
latency-age child is presented to illustrate the role of enactments and to demonstrate
their usefulness in furthering the analytic work.
Although we think of words as the primary modality of communication in analysis,
patients do more than talk to us. They also communicate with other forms of behavior--with
actions, attempts at actualizations (Boesky, 1982), and with enactments. The role of these
behaviors during an analysis, in particular the role of enactments, has provoked much
discussion, most recently at a panel presentation (1989). Most of the analysts who
participated in that discussion, both panelists and members of the audience, agreed that
enactments in analysis are inevitable. What remained unsettled was the question of whether
and how enactments could beneficially contribute to the analytic process.
Enactments are symbolic interactions between analyst and patient which
have unconscious meaning to both. During an analysis, they are usually initiated by
the patient's actions or by the covert communication in his words (Poland, 1988).
Enactments also may originate with the analyst (Jacobs, 1986), although in these
instances, it is often the analyst's countertransference response to the patient's
material that leads to the enactment.
Throughout an analysis, patients engage in symbolic action (both verbal
and nonverbal) which generates a corresponding impulse for action in the analyst. In the
best of all possible worlds, an analyst is sensitive to his patient's transference, as
expressed in either words or action, but does not act. Sympathetic with a patient's
pitiful state, he does not nurture; temporarily aroused by a patient's seductive attacks,
he does not counterattack. An analyst contains his impulses, examines them, and uses the
information gained to enrich his interpretive work.
This best of all possible worlds is the ideal, something we strive for,
but often fail to achieve. In the second best possible world, where most of us dwell, an
analyst reacts to his patient--but catches himself in the act, so to speak, regains his
analytic stance, and in observing himself and the patient, increases his understanding of
the unconscious fantasies and conflicts in the patient and himself which have prompted him
to action. As Sandler (1976) notes, the analyst will "tend to comply with the role
demanded of him [but] may only become aware of it through observing his own behavior,
responses, and attitudes, after these have been carried over into action" (p.
It is written into our job description that in "doing
analysis" we must contain ourselves yet still experience the impulse to action. But
when actions are forbidden, often the experiencing of the impulse also feels forbidden. I
believe at times it may be more useful for an analyst to act on an impulse, catch himself,
and thereby learn about the impulse and its stimulus, than to be so constricted that he is
never stimulated or so defended that he is not aware of his behavior. I do not think that
enactments are therapeutic in themselves, and I do not advocate consciously gratifying a
patient's wish for mutual enactment. However, unconsciously determined enactments, if
observed, can inform the analyst in a new way. Enactments have been used in support of
various clinical theories. For example, Alexander (1950) presented a clinical vignette
containing an enactment to support the therapeutic value of the "corrective emotional
experience." He described a patient who unconsciously provoked his analyst into
disliking him in order to reinforce a defensively distorted memory of his relationship
with his father. In the discussion, Alexander noted, "The analyst's reaction was not
calculated to be different from that of the patient's father. He simply lost, for a
moment, the type of control which we consider so important in psychoanalytic therapy"
(p. 491). In essence, Alexander unconsciously participated in an enactment of a
defensively distorted object relationship. He makes clear that it was his subsequent
awareness and articulation of this that enabled the patient to gain from the experience.
Nonetheless, based on this observation, Alexander made a recommendation for a consciously
manipulated experience for his patients. Enactments provide information as to the content
of the fantasy, memory, or impulse that is being enacted, and lead to affects that can
enrich the analytic process. The value lies not in the enactments themselves, but in the
observation, description, and eventual understanding of their transferential meaning.
The potential for enactments is omnipresent throughout an analysis; as
soon as there are transference distortions of the analyst and the process, any exchange
within the relationship may lead to an enactment. A patient who "imagines" that
the analyst is critical or seductive has some distance from his experience--which permits
the analyst to have distance from the experience. There is no such distance during an
enactment. During an enactment, the patient has a conviction about the accuracy of his
perceptions and behaves so as to induce behavior in the analyst which supports his
conviction. Even if an analyst is neither angry nor critical, a patient's accusations can
still induce guilt, defense, and retaliative anger. This is one aspect of the evocative
power of enactments.
In addition, all object-related wishes and fantasies (including the
wishes and fantasies of the analyst) are evocative of relationships with the primary
objects. Both gratification and frustration contain a potential for regression which
exposes the individual to dormant internal conflicts and the possibility of maladaptive
compromise formations. Every time a person has a wish within an object relationship--in
this case, the therapist's wish to be of help to his patient--he exposes himself to the
possibility that the interaction will evoke an earlier object relationship, that is, will
become laden with transference. To want anything from patients, to want to cure, to help,
even to be listened to or understood accurately, is to be vulnerable to the experience of
one's own transference and thus be susceptible to an enactment.
Communication is always a two-person procedure; what is intended to be
said is altered by the person and the context in which the information is received. When
patient or analyst speak, the meaning and intent of the words is altered by how the other
hears him, altered for the speaker as well as for the listener.
If an analyst accepts the inevitability of his contribution to
enactments and analyzes them to separate his participation from the patient's
understanding of his participation, to distinguish the determinants based on his
psychology from those arising from the patient's, the work can only be enhanced. As
illustration, I shall present material from the analysis of Debra, a latency-age girl.
Much of the work with Debra can be related to work with adults; I find it useful to focus
on her analysis because so much of a child's communication is through action--and so many
of Debra's actions led to enactments.
Debra was eight years old when she was referred for treatment. She was an exceptionally
intelligent child who was working at that time with an educational consultant regarding
school placement. Debra had already attended three private elementary schools but had been
unhappy at each, ostensibly because they "failed to stimulate" her. She had
applied to and was accepted at a fourth school, one of the best available in the city, but
the consultant feared that without psychological help Debra would continue to be unhappy.
Before I had even seen her, the parents' pride-filled description of
Debra created an image in my mind of a very talented, somewhat vulnerable child whose
environment continually reinforced whatever grandiosity already existed. My expectation
proved correct--as far as it went--for Debra was very talented and very grandiose. What I
was not prepared for was the intensity of her rage, the totality of her isolation, and her
utter contempt and lack of empathy for others.
Debra, on first meeting, was a physically beautiful, totally
self-absorbed, angry, sullen child. She had taken gymnastics since age four, and as she
posed gracefully and motionless in the chair opposite me, with no evidence of discomfort
or anxious chatter, I felt as if I were part of the stage set for a movie of "Debra's
visit to a psychiatrist's office." There was no apprehension in the gaze of this
incredibly self-possessed child as she communicated that I, not she, was expected to
perform. She did say she had no idea why her parents had wanted her to see me and that, as
far as she was concerned, the whole idea of talking to someone about her private life was
ridiculous--"After all, it's private, isn't it?" As I struggled to find some
subject with which to engage her, I was impressed with the difficulty of my task and a
sense of not wishing to expose myself or my thoughts to any more of her contempt than was
absolutely necessary. This concern with self-protection set the stage for my participation
in the first enactment: a guardedness in approaching Debra.
Debra was the oldest of three children. She had two younger brothers
who were good athletes, on whom the father spent a great deal of time as coach for their
soccer teams. Her parents were upper-class, concerned about social form and status, yet
quite invested in all their children. The father was well-meaning, insecure, and totally
dominated by his wife. She was an imposing woman whose enormous energies were devoted to
furthering peace and fellowship in the world and to achieving an atmosphere of total
psychological and physical sharing in her family. She also was given to emotional storms,
which were made more dramatic by their unpredictability. During my weekly meetings with
the parents I often found the mother intimidating, and I was more than relieved when,
after a year of Debra's analysis, the mother accepted a recommendation for therapy for
Debra's development during infancy was normal. However, from early on
her precocious intellectual achievements were an important focus of her parents' lives,
and she was subject to constant cognitive, physical, and psychological overstimulation. By
the time Debra came to analysis her mother was sharing intimate details of her own
emotional, sexual, and excretory functioning with her daughter, and expected Debra to do
likewise. In contrast, the father's wish to shut the door when he toileted was considered
peculiar and prudish, and. his "selfishness" was a family joke.
I made the recommendation for analysis reluctantly, although I believed
that only an analytic experience could enable Debra to emerge from her narcissistic
isolation and expose her conflictual impulses and unhappiness. Nonetheless, I felt that to
engage Debra would be no easy task.
My reluctance proved fully justified. Debra began the work with her
self-esteem further reduced by the recommendation for treatment, and she was enraged at me
for "belittling" her. She made it clear that it was inconceivable that there
would be any benefit from the treatment.
During the first hours Debra sat silently, noting only when I took a
deep breath or seemed as if I wanted to speak. That was her signal that I was open to
criticism and that it was time for her to begin an attack on my appearance, my smell, or
my "rudeness." Rudeness was her name for my interest in talking with her, and
for my curiosity about her irritation, her anger, and her desire to be left alone. It was
not lost on Debra that I made a deliberate effort not to ask too many questions and
restricted my interventions to responses to her or clarifications of what I perceived to
be happening between us. She said, with some satisfaction, that she knew she made it hard
for me to speak. Debra's awareness of this first enactment--my self-esteem preserving
caution in response to her message that I was persona non grata--made the situation all
the more uncomfortable. I felt ridiculous trying to make myself inoffensive to an
Although my "self-esteem preserving caution" and
"guardedness" in approaching Debra was ". . . a compromise between [my] own
tendencies and the role-relationship which the patient is unconsciously seeking to
establish" (Sandler, 1976, p. 47), I found no evidence that the elements in my life
that gave rise to my participation in the enactment were relevant in understanding the
significance of the enactment for her. The affect evoked in me did seem to complement
hers, and that I used as a clue to her current experience within the transference.
However, the genetic determinants for our participation in the enactment were quite
different. I believe this is important, for had I assumed that the unconscious meaning
of the enactment was the same for Debra and for me, it might have led to inaccurate
interpretations, which would have further confused an already difficult situation.
I noted, in the midst of this first enactment, that I had ceased being
neutral or abstinent, and instead was engaging in a counter-enactment; that is, I was
using clarifications as disguised directives. This realization, that through my words I
was covertly trying to control Debra's behavior, led me to a beginning understanding of
what was being enacted. And so, in the midst of her protests that I was a prying busybody,
intent on sticking my nose into her business, I said she had told me that she knew her
complaints and criticisms made it hard for me to speak. I wondered whether this made her
feel more powerful than me, as if she could control me, and whether she had ever
felt controlled. Much to my surprise (for I had begun to question whether there would ever
be a non-adversarial exchange between us), Debra responded spontaneously that the kids
"picked on" her at school, but she didn't care, she just ignored them. I then
asked, "Are you trying to get me to ignore you?" To this she responded, "It
probably won't work; my mother never ignores me when I want her to leave me alone."
My understanding and clarifying her use of complaints to try to control
me seemed useful. For a brief period, Debra was less "up-tight," and a
comfortable silence, alternating with talk about her mother and school (both of which
displeased her), took over the sessions. Then the next set of enactments began.
Debra became very curious about me. At first she expressed her interest
through casual questions about the sweaters I wore and whether I made them. But soon the
questions escalated to a belligerent inquisition of relentless intensity. She quizzed me
about my taste in clothing, perfume, hairstyles and lipstick colors. She told me my
furniture wasn't "fine," my toys were old-fashioned, and my waiting-room
magazines were dull and, she was sorry to say, rather tacky. But worst of all were my
other patients--they were disgusting. She was particularly interested in and censorial of
the bathroom manners of the five-year-old girl whose hour preceded hers. She talked at
length about the smell, dirtiness, and habits of this other patient, watching carefully
for my reaction. From my protective feelings for the other child, it was clear Debra's
comments had gotten to me. However, I said nothing until she began to attack me directly.
Focusing on my failure to join in her criticism, she said it was proof that I was as
disgusting as the other child. I asked her, as she was shouting at me for being
disgusting, whether she expected me to defend myself and shout back at her. She stopped
short, then, smiling rather sheepishly, she said, "No, I guess I'm not giving you a
chance. Do you think I sound like my mother when I yell?"
Debra's remarks and her finicky behavior when describing the disgusting
habits of others were related to conflictual anal fantasies. Her haughty self-isolation
expressed both a compromise between the wish and fear of intrusion and a defense against
an awareness of this. Her anal fantasies had contributed to her low self-esteem, and
during the course of the analysis, as they became less forbidden, she projected less and
became able to speak about them more directly. The problem was, as with other children
(and some adults) at this early stage of the treatment, evidence of her unconscious
conflicts and fantasies was clear long before she had any conscious awareness of them.
This made it hard to talk about her internal world in a non-threatening, non-intrusive way
that did not bypass defense, was experience--near, understandable, and at the same time
therapeutically useful. I found that with Debra enactments provided a ready, albeit not
always welcome or comfortable vehicle for this, for they enabled the analytic process to
be a joint venture. Her awareness that I could be "touched" by our interaction
seemed to make me more available to her as an object for transference projections and
In analysis (particularly in child analysis), the inequality of the
doctor-patient (or adult-child) relationship often functions as a resistance to an
integration of the analyst's words with the analytic experience--the words become encrusted
with authority because of the source and are discredited at the same time they are
ostensibly accepted. Recognition of the potential for and occurrence of enactments, a
shared experience, diminishes the authoritarian image of the doctor and the tendency of
patients, particularly child patients, to fall into a (iatrogenically induced) submissive
relationship with him. It is not that the analyst "confesses" his participations
in enactments, but his and his patient's awareness that the process has engaged them both
enhances the sense of a collaborative effort and, to the extent the analyst is
non-defensive, permits the patient greater freedom to give voice to his transference-based
perceptions of the analyst.
In the beginning phase, all my attempts to explore the projection in
Debra's comments had led to a heated denial and further isolation. However, Debra could
talk about her behavior toward me and the interaction it produced. Her initial success in
inhibiting me was clarified in a way that "felt right" to her and made Debra
curious about herself in a new way. To be sure, everything that was condensed in the
enactment, that contributed to it, was not explored. But from our talk she began to
understand how her reaction to her peers was similar to her reaction to me, how
anticipating discomfort in the contact with her classmates, she retreated from any real
engagement and "turned them off" just as she tried to turn me off.
When Debra first quizzed and criticized me I had worked hard not to
withdraw or counterattack, but I had felt inhibited from commenting on the
sadistic, intrusive aspect of her questioning. In my apprehension about stimulating rage
in Debra, I had participated in the enactment of her fantasy that she could control me.
Again, although it was my own early life experience that made me particularly vulnerable
to the threat of her anger, I did not think the specifics of my experience informed me
about hers. However, becoming aware of my over-determined reaction and its origin enabled
me to talk more easily about Debra's interaction with me, which led, in turn, to her first
attempts to understand herself. Debra's self-scrutiny yielded only the explanation that
her wish to control me was justified by my crudeness, my curiosity about things
scatological. Nonetheless, her willingness to think about herself, even if only for a
moment, did permit us to extend the area we talked about. Initially, in response to,
"Oh, Dr. Chused, that dark-haired girl got pee on the floor again; you must be crazy
to let her use your bathroom," I would simply say, "Debra, you're telling me
that girl does disgusting things; are you also telling me that if she does
something disgusting, we shouldn't have anything to do with her?" Now, I was able to
make more exploratory comments such as, "You've said I'm interested in sex and
bathroom stuff and that's disgusting, but it's not clear what it is about having sex or
getting pee on the floor that's so awful." Sometimes she could follow me into this
type of dialogue, but more often than not, as we began to approach her own impulses or
defensive reaction formation, she would project, with remarks such as, "You're a
strange grownup, always wanting to talk about sex with a kid." For a long time, no
matter what I said, Debra heard guilt, defensiveness, or seduction in my response.
It was not that Debra could not understand the words, for, as Katan
(1961, p. 185) has said, with analysis, "verbalization increases the possibility of
distinguishing between wishes and fantasies on the one hand, and reality on the
other," but rather that my speaking had accrued symbolic meaning. I thought I was
trying hard to "say it right" because I was so invested in the work. Debra
thought I was self-motivated and intrusive. My efforts to verbalize our interaction
became, for a while, an enactment of her transference perception of me as intrusive. But
here, too, the clarification of our differing perceptions of my talking was part of the
"working through" and permitted us to better understand her attempts to control
me as she had wanted to control both her mother and her own arousal.
Although Debra was engaged at this point, and her isolation had given
way to greater responsiveness, the anal erotic fantasies that preoccupied her had not yet
entered the sessions in a usable fashion. Then, after about 18 months of analysis, Debra
began to come into my office with her school uniform unbuttoned at the waist. She also
started to wear her sweater under her skirt, with a leg in each sleeve and the neck hole
over her perineum. She stated her legs were cold and it was important for a gymnast to
wear warmers, but since her family was poor, she had to make do with her sweater. I
resisted making any comment about the sweater until it became obvious, through her
unbuttoned uniform and requests for safety pins, that she wanted me to notice the hole.
When I stated this, she told me that she liked to have her body noticed, and described, in
rather vivid detail, the ticklely perineal sensations she had when she thought someone was
looking at her. She went on to volunteer the fantasy she had of intercourse, of two Ferris
wheels that rose up from a horizontal position on the ground to join together vertically,
like two wheels fusing. But just as the holes in her clothing, her showing and my seeing
her body, were to lead to an enactment, the telling of her fantasies also became part of
an enactment. The fantasies were not communicated to me as evidence of her inner life,
shared so that together we could understand them better. Instead they were presented, like
the hole over her perineum, to excite me and titillate her with the thought of my
excitement. Speech serves many functions; affective appeal (Loewenstein, 1956) rather than
the communication of ideas was often the motive force behind Debra's words.
Debra's fantasies did indeed interest me. Having spent many hours with
her, listening (as one must) to recitation of daily events, school activities, stuck-up
friends, and mean parents, I was pleased when she began to reveal her inner life more
directly. Trying to ferret out the significance of material expressed in displacement or
through play is a difficult task--direct verbal communication of a fantasy, wish, or fear
always appeals. However, this was not the only reason for my heightened interest. My
curiosity was also a response to the covert communication of excitement, a communication
that contained critical information about Debra. I did not recognize this at first, but it
soon became apparent (from the increased pressure in her speech and the associated
gestures) that Debra's understanding of my increased attentiveness was not entirely the
same as mine. It was through my self-scrutiny, the recognition and integration of what was
stimulated in me with what I knew of Debra, that I began to understand what we had just
enacted. And it was to this I directed our attention. I stated rather simply that my
listening to her seemed to make her excited. With some pride and a bit of a giggle, she
agreed she wanted to see how I would respond to her story about the Ferris wheels she
liked to think about it while she was in the bathroom. She went on to say, "I could
tell you were interested. My mom also likes to hear me tell what I think about sex, about
getting breasts and hair and all that stuff." She then asked, "Did you know I
don't use the bathroom in school, only at home and now in here, while I wait for
you?" Actually, during the past several months I had noted that she was always in the
bathroom when I came into the waiting room to get her, but I had refrained from commenting
on it (another enactment), apprehensive that a direct comment would anger her and lead to
an attack. Now I said, "Was I supposed to notice? Maybe notice but not say
anything?" Again she smiled slyly, then said, rather irritatedly, "But you
always ruin things by talking about them." As if to prove her point, I went on to say
that I thought not using the bathroom at school was like not playing with the kids--it was
as if they would find out something private about her, something she wanted them to know
and not know, something she wanted them to like but was afraid they would not, just as she
did not like the little girl's pee on the floor. She made no response immediately, but
then said, "In my family we all like to stay on the pot a long time--and we all fart a
lot too; my father has the smelliest. We always talk and joke about it, but my father
doesn't like that. He also doesn't like to kiss me on the lips--only on the cheek and the
forehead. My mother always kisses me on the lips ... and she talks about
The enactment of her transference perception that I, like the mother,
was sexually interested and aroused by her, but like her father, retreated from
stimulating interactions, followed from my attentive silence. As we explored her
understanding of my interest in her erotic fantasy and my noticing yet not saying anything
about her exhibiting herself, she began to talk of her experiences with her mother (who,
in regular baths with her daughter, intently examined Debra's body for evidence of
pubertal development) as well as her disappointment that her father was not more involved
with her physically.
There was an additional enactment that preceded Debra's acceptance of
her disappointment in her father's unavailability. As Debra was explaining how she saw me,
she said that even when I was silent, she knew I wanted to ask questions, that is, pursue
her and intrude into her. In part Debra's perception was correct, for when she had begun
to describe her interaction with her mother, I had reacted with a silence that was far
from neutral. The extent of the overstimulation she described had made me uncomfortable,
and I had withdrawn from the analytic process. This enactment, though initiated by Debra's
attempt at transference gratification, was created by the interaction of her behavior and
my response. My withdrawal, a countertransference response, appeared to Debra to parallel
her father's, and she elaborated it into the same secret arousal she wanted to see in him.
I do not know if the reaction formation of dismay which Debra's experiences aroused in me
was similar to the father's reaction. I do know, however, that Debra chose to deny my
withdrawal just as she denied her father's discomfort--and her own. It was the defensive
denial that I addressed.
Debra's connection to her mother had been in yielding to her mother's
persistent questioning about sexual and excretory functioning. This became part of the
transference as did her denial of disappointment in the exciting yet unavailable father
who kissed her on the forehead rather than the lips and had the poor manners and
selfishness to close the door when he was using the bathroom. Though she initially saw me
as intrusive as her mother was and as she wished her father to be, the exploration of our
enactments and her transference misperceptions enabled her to see both her parents more
clearly, to separate her wishes from theirs, and to begin to behave more autonomously. In
addition, her gradual awareness of her disappointment and sadness over her father's
unavailability (which she had initially talked about only as a joke) marked the beginning
appreciation of the extent of her longing for him.
Before I say more of Debra, I would like to elaborate on my
understanding of enactments and how I differentiate them from "acting out" or
"repetitions." Terms such as acting out and repetition refer only to the
patient's behavior; they imply that the analyst is an observer of the experience, not a
participant in it. Even the term "projective identification," while recognizing
the analyst's responsiveness to the patient, does not acknowledge the contribution to the
analytic experience which is determined by the analyst's own psychology (Sandler, 1976;
Enactments, distinguished by the unconsciously determined affective and
behavioral involvement of the analyst, result from the patient's attempt to create an
interactional representation of a wished-for object relationship. Through getting the
analyst to enact with him, the patient achieves a measure of reality for his transference
fantasies. Enactments occur when an attempt to actualize a transference fantasy
elicits a countertransference reaction.
Many analysts today recognize that they are both observers and participants
(to a greater or lesser extent) in the analytic process; however, this was not always true
(McLaughlin, 199 1). Even now, while there is general agreement that threats or overtly
seductive gestures stimulate responses in the analyst which affect his analyzing capacity,
there is still a failure to attend to the more subtle behavior, more ambiguous expressions
of a patient's affective state, which can wreak havoc with analytic abstinence and
neutrality and lead to enactments.
There are several possible scenarios when a patient attempts unsuccessfully
to evoke an enactment. The analyst may recognize what is transpiring and be able to
usefully interpret the process to the patient. Or, with no reaction from the analyst, the
unconscious intent of the patient's behavior may be lost, to reemerge later in another
form. If the patient has sufficient self-observing capacities, he may become aware of his
frustrated wishes and begin to speak of them, rather than enact them. Or he may continue
to provoke until he has roused the analyst to action. So it was with Debra.
After disclosing a wish that her mother were less intrusive and her
father (and I) more involved, Debra stopped talking about her excitement with me, and
instead turned to the play materials. Within several weeks, she had begun a repetitive
game that continued for six months. Debra's pattern was not unique; many latency children
(Debra was then ten) dramatize their conflicts and wishes in play rather than speaking
about them directly. What made Debra's activity interesting was that not only were her
conflicts expressed through the content of the play, but she also "played" to an
audience (me) and the manner in which she "played" was determined by the
response she wished to elicit from me.
It began with a "confession" of masturbation, which occurred
while Debra was decorating a lamp in my office that is in the shape of a glass ball. She
and other children I analyze have discovered that this ball (lit by an interior light
bulb) melts any crayon pressed to its surface, and it has become a means for them to draw,
mess, and play out conflicts. The crayon melting for Debra began as a distraction,
intended, I believe, to draw off some of the motor tension she was feeling as she told me
of her masturbation. This had come in the midst of discussing my prurient interests, and
though she initiated the "confession," she began by saying there was something
she did that she guessed I might be interested in since I was so nosey. Her tone made it
clear she was being "forced" to talk. Somewhat defiantly, then, as she melted a
crayon, she said she sometimes stuck her finger "in there" to see if she was
At this point she became aware of a design left by another child, and
with competitive vigor, wiped off the other child's work and took over the lamp. The next
hour she returned to the lamp as soon as she entered the office, and by the end of the
week crayon melting was her only activity (other than speech). Within two weeks her crayon
melting had assumed the characteristics of a ritual. It was performed in an identical
manner each day; her absorption was total, her movements sensual and slow. At first she
pretended that the melting crayons were men trying to cross over a barrier she had to keep
clean. If they dribbled across the barrier before she could wipe them away, they would do
evil. If she kept the barrier clean (and destroyed the dribbles), evil would be overcome.
While her total absorption in the melting crayons made it appear she did not want me to
"cross the barrier" surrounding her, her comments seemed designed to provoke me
to penetrate her reserve. She spoke angrily of the other children who "dared" to
touch the lamp. She also said she thought I was angry that she messed up the lamp and did
not talk much (though I kept it hidden, she said, because I was supposed to
"act" like a "good doctor"). Gradually her transference misperceptions
and preoccupying sexual daydreams became interwoven, and she developed an erotic fantasy
of my punishing her, spanking her again and again on her bottom for messing. She imagined
that I would act in anger but claim, "it's for your own good."
Over time, as Debra began talking more directly of her fantasy, her
interest in melting crayons decreased. Its function shifted from being a symbolic playing
out within the transference of sadomasochistic anal fantasies (not only did she create an
incredible mess on and around the lamp, but regardless of the colors other children used,
after Debra's hour the lamp was always yellow-brown) to once again being a means to
release enough of the affective tension associated with her aggressive and erotic
fantasies to tolerate talking about them.
Of note is that during the "lamp game," when I had expressed
concern for the crayon splatters on the wall, Debra did not hear me as particularly angry.
Her belief that I was angry or disgusted or aroused seemed to have no relation to my
behavior or affect. During this time Debra was so caught up in the analysis that within
her psychic reality I was a full participant in the transference, even when I was
abstinent (Bird, 1972). Though our interaction during much of the lamp game does not fit
my definition of enactments, it served the same function. The major difference was that
when I was not "enacting" I was able to understand the determinants of Debra's
However, not long after the lamp game stopped, another enactment
ensued. Debra by now had become more comfortable in school and had begun to take pleasure
in describing her activities there. Nonetheless, talking about friends soon became
conflictual (I believe because she felt that 1, like the mother, would be jealous of her
relationships with others), and she gradually slipped into her "actress mode,"
over-dramatizing scenes and events. Once again I felt excluded and began to over-talk,
chasing Debra with words. When I became aware of how insistent I had become, I asked Debra
if she noticed that the more I talked, the less she seemed to hear. Her response was,
"You sound like me trying to talk to my mother," and she went on to speak of her
helplessness in challenging her mother's opinions. Later this was elaborated into her
feeling of being helpless yet excited by her mother's sexual intrusion and the sensations
There was one final enactment that heralded the onset of termination.
Debra began to not understand my interpretations and clarifications. During the lamp game
she had acknowledged that her withdrawal was motivated by a wish to have me ask questions,
and together we had connected my questions with her genital "tickles" and her
confused and troubled experiences with her parents. Now, over a year later, she again
withdrew, ostensibly without any understanding of "why." I began once more to
work hard at teasing out the determinants of her behavior, as Debra, sensitive to my
desire to be helpful, unconsciously manipulated me into "playing analyst." When
I regained my self-observing capacity and asked her about this, she said, "Don't you
like helping me understand myself ?" I replied that I did, but then asked whether she
was worried that I would not like her being able to understand without me. She nodded her
head in agreement.
That enactment (our joint participation in the fantasy that she still
needed me) was followed by a change in her behavior, not an enactment, but a clear
nonverbal communication. Debra insisted that we play card games. She knew from past
experience that I generally do not play card and board games (because of their tendency to
degenerate into ritualized resistance), and over the years we had been together, she had
grown to accept this, with some reluctance and irritation, but with eventual tolerance for
my limitations. Now there was a new insistence, and when I would not join her, she played
solitaire. I tried to clarify her behavior--she did not ignore my words, nor did she
disagree, but she kept on playing cards. She then brought in yarn and began knitting in
the chair opposite mine (she knew that I sometimes knit while listening to patients).
Again I felt frustrated--not angry, but somewhat useless. It took me a while to recognize
that Debra was telling me I was useless to her now, that it was time for our work
to be over. Why did she tell me this way? I asked her that. Her reply was, "I don't
know; I wasn't sure it was time to leave. I know I feel good, that I like school and the
kids, but I also like coming here. And maybe I didn't want to hurt your feelings."
Thus began Debra's termination. This initially very vulnerable,
defensively isolated child was experiencing what she had avoided for so long, that once
you are engaged, it hurts to become disengaged. That she saw it in terms of my being hurt
was not a bad beginning. We had lived with our joint participation in the analytic
process, through enactments and other analytic interactions, for a long time. I was
certain that if she thought I had feelings, she was aware she had them too.
Debra's analysis contained many enactments, not only because she was a
child, but because she was a chronically overstimulated child whose capacity to organize
and contain her impulses was less than other children, and I was susceptible to the
primitive, dramatic quality of her behavior. In addition, her isolation and hunger, as
well as her previous discomfort and feeling of vulnerability in relationships, had
intensified my importance to her and her susceptibility to transference misperceptions.
Like other patients in analysis, when stimulated by significant regression, she attempted
to actualize the transference through enactments.
Given that enactments are inevitable during an analysis, the question remains, how can
they be most effectively utilized? Words that name can reduce anxiety by organizing
conflictual emotions. Enactments, in creating experience beyond words, engage the
participants in a regressive experience which often increases anxiety and decreases
ego mastery. Yet this regression can lead to a new depth of understanding of conflict,
fantasy, and memory. Enactments also link current and past experiences with a vividness of
affect and inter-subjective relatedness that imparts enormous conviction. They are a
concrete shared experience in which the opportunity for defensive denial,
intellectualization, and distortion is diminished. If an analyst finds that he is
unintentionally enacting with a patient, withdraws from the enactment, and then subjects
his behavior and subjective sensations to analytic self-scrutiny, he often has additional
information that was not available when he was not so fully engaged.
I believe enactments result from a communication via unconscious clues
(Sandler, 1976) that relies on an affective signaling similar to that used by (and with)
very young children, before the capacity for abstraction and symbolization takes place.
Both Stern (1985) and Emde et al. (1976), in their work on the affective mode of
communication that antedates language, have demonstrated the appeal, clarity, and
universality of such signals. However, that repressed conflictual fantasies and wishes
find expression via a developmentally early mode of communication does not mean that the
conflicts expressed are from a preverbal period of life--only that a more primitive
channel of communication, reliant on affectively laden signals, is being called into play.
Throughout our lives we all are attuned to the subtle clues contained in gesture, tone,
facial expression, and rhythm. What makes analysis unique is not the analyst's reception
of the clues, but his examination of them, and his effort to find the words to describe
In any analytic search to understand the intrapsychic domain, much of
the initial data come from the observation of interpersonal behavior; the problem during
an enactment is that the analyst's power of observation is clouded. In addition, as
unconscious conflicts lead to his participation in the enactment, even after he becomes
aware of the enactment, the analyst's resistance to full understanding will continue.
There were times during my analysis of Debra when all I was aware of was my discomfort and
a feeling that the work was nonproductive. Occasionally it required taking verbatim notes
immediately after the session, or discussing the process with a colleague for me to
recognize when I was enacting.
Enactments do not necessarily offer an easier road to the unconscious
determinants of behavior or a better way to communicate with patients. But as they occur,
repeatedly, in the course of every analysis, an objectivity about them, a capacity to deal
with them just as we deal with the associations or memories that are called forth by our
patients' verbal communications, can only increase our technical armamentarium. To
continue to track is the work of analysis, whatever the mode of communication.
Even after one enactment is recognized and interpreted, others may
ensue. When a defense or resistance, impulse or fantasy, is revealed in a patient's
associations and interpreted, his psychic equilibrium will shift, often with new
compromise formations and the expression of the conflict in a new form. Similarly, when an
enactment is interpreted, the arena of enactment may also shift, with the patient's
conflicts expressed in new behavior, which again tests the analyst's vulnerabilities.
For example, after an analyst has withdrawn from participation in an
enactment, integrated the experience with his cognitive understanding of the patient and
the analytic process, he often wants to share his understanding of the enactment and its
determinants with the patient. However, to a patient enmeshed in transference, the very
act of intervening can become a vehicle for an enactment. Interpretations, heard as
meaning that the analyst understands something which the patient does not, are denied. If
the analyst tries harder to clarify the experience, he is heard as defensive or irritated,
and his words become evidence of his authoritarian stance.
Or, after the analyst first interprets, the patient may begin to speak
in such a way as to manipulate him to continue to interpret the seemingly unconscious connections.
This too is an enactment. And though quite common, this use of words to stimulate the
analyst to "act like an analyst" can be quite difficult to detect.
In the Panel on enactments (1989), Boesky said, "just about
everything the patient feels, says, thinks, or does during the session is influenced by
wishful tendencies which press for actualization." When we as analysts are conscious
of this "press for actualization," we are able to interpret and, through our
interpretations, increase our patients' awareness of their motivating impulses and
fantasies. When we are not so aware, we enact. Enactments are often the first sign of a
shift in a patient's transference, a shift that caught the analyst by surprise and made
him a participant in an emerging transference paradigm he is not yet able to objectify and
observe. The analyst does not consciously "choose" to enact; he enacts and then
thinks, "Why did I say (do) that?" It is his scrutiny of the enactment, not the
enactment itself, which will lead to a new understanding of the transference.
In analysis we interpret more than words; we also explore and
articulate the unconscious links between what is said at one moment and what is said at
the next. That these links are revealed through the process of speaking has misled many of
us into assuming that the content of verbal communications is the focus of our work. This
is not true. Not that the content of the patient's material is not valuable. It is, for it
leads to an awareness of unconscious connections and enriches the analyst's
interpretations and makes them immediate, specific, and therefore real to the patient. But
in the work of making the unconscious conscious, it is the determinants of the words and
their sequence, rather than the conscious thought, that we attend to.
The same process of looking for unconscious determinants is at work
when we examine enactments. We look beyond the conscious intent of behavior (both ours and
the patient's) and examine it within the context of the analytic situation, hoping to
uncover its relation, via the transference, to unconscious processes. Jacobs (in Panel,
1989) has suggested that enactments in analysis often reflect specific identifications and
are essentially memories put into action-memories of actual events or events defensively
distorted by the patient but retained in memory as enacted. This has not been my
experience. I think that enactments, being a resultant of unconscious forces in both the
analyst and the patient, are rarely so specific. However, I do agree with Jacobs that
external behavior can sometimes communicate what thoughts and feelings do not quite
capture. The determinants for the analyst's participation in an enactment will not be the
same as for the patient, but the intrapsychic conflicts being stimulated may prove similar
enough to provide a new source of empathically derived information which, when "made
consonant with the patient's material according to disciplined, cognitive criteria"
(Arlow, 1979, pp. 204-205), can lead to an understanding that was not accessible through
Nonetheless, enactments are still seen as deterrents to analysis. Is
this just because of the potential for gratification in enactments, or because they are
tenacious resistances? Or is it also because our participation in enactments leads us, the
analysts, to behave in ways that feel unanalytic?
Enactments will convey, from patient to analyst, knowledge of impulses
and affect that may be impossible to communicate through verbal description. But
enactments will also convey to the patient the analyst's participation in the process.
Unlike repetitions, in which it is the patient who repeats and the analyst who witnesses,
in an enactment both analyst and patient are participants.
The communication of the analyst's involvement and his vulnerability to
involvement, inadvertent though it be, will have important ramifications for the course of
treatment. It is different from a deliberate act by the analyst, for the latter, be it
classical abstinence or Kohutian mirroring, is under the control of the analyst and
carries with it a sense of his authority. There are times during an analysis when the
analyst's involvement can be an important fuel, motivating the patient to continue the
work. At other times, even with the same patient, it can be a significant source of
resistance, or a threat to the patient's comfort with the relationship. But all reactions
to enactments, including these, are information to be explored and analyzed. Not to do so
is to collude with the patient's resistance.
In summary, an enactment is a nonverbal communication (often cloaked in
words) so subtly presented and so attuned to the receiver that it leads to his responding
inadvertently in a manner that is experienced by the patient as an actualization of a
transference perception, a realization of his fantasies. Although not therapeutic in
itself, an enactment can provide invaluable information and an immediacy of experience
that enrich the work. Viewed as yet another source of information, greeted with curiosity
and not guilt, enactments can become part of the analytic process from which we all learn.
Arlow, J. A. (1979). The genesis of an interpretation. Journal of the American
Psychological Association, 27(Suppl.): 193-207.
Alexander, F. (1950). Analysis of the therapeutic factors in psychoanalytic treatment. Psychoanaytic
Bird, B. (1972). Note on transference: universal phenomenon and hardest part of analysis.
Journal of the American Psychological Association, 20:267-301.
Boesky, D. (1982). Acting out: a reconsideration of the concept. International Journal
of Psychoanalysis, 63:39-55.
Emde, R., Gaensbauer, T. J. & Harmon, R. J. (1976). Emotional Expression in Infancy. Psychological
Issues, Monograph 37. New York: International University Press.
Jacobs, T. (1986). Countertransference enactments. Journal of the American
Psychological Association, 34:289-308.
Katan, A. (1961). Some thoughts about the role of verbalization in early childhood. Psychoanalytic
Study of the Child, 16:184-188.
Loewenstein, R. M. (1956). Some remarks on the role of speech in psychoanalytic technique.
International Journal of Psychoanalysis, 37:460-468.
McLaughlin, J. (1991). Clinical and theoretical aspects of enactment. Journal of the
American Psychological Association, 39:595-614.
Panel (1989). Enactments in psychoanalysis. Morton Johan, reporter. Journal of the
American Psychological Association, in press.
Poland, W. (1988). Insight and the analytic dyad. Psychoanalytic Quarterly,
Sandler, J. (1976). Countertransference and role-responsiveness. International Journal
of Psychoanalysis, 3:43-48.
Stern, D. (1985). The Interpersonal World of the Infant. New York: Basic Books.
Why Not Long-Term Therapy?
It is curious how few meetings and training programs there are on how to do long-ten-n
therapy. Most of the announcements one sees are for seminars and workshops on brief
therapy. The implication is that everyone knows how to engage clients in therapy for
months or years. Yet long-term therapists are made, not born. Therapists do not have
innate skills in committing clients to long-term contracts. Without training, they must
learn by trial and error to do interminable therapy when they get into practice.
Often it is thought that long-term therapy occurs because the therapist
does not know how to cure a person faster. A more respectful view is that it is a special
ability. After all, many people do brief therapy because they lack the skill to keep
clients coming for a long time. Little is written about long-ten-n therapy techniques.
One of the few therapists with the courage to discuss how to keep a
client in therapy and block him or her from going to someone else was Milton H. Erickson.
For example, he proposed that a technique for preventing a client going elsewhere was to
listen to him and respond, "I know how difficult it is for you to talk about this. If
you bad to go over it again with someone else, that would be even more painful."
Erickson reported that such simple comments prevent clients from going to other
therapists. More complicated techniques developed by Erickson to keep clients in therapy
still remain secret.
The length of therapy is one of the most important issues in the field,
and insurance companies now set the limits. Clinicians have some voice in this matter and
should consider the issues. The first issue involves the needs of the therapist, and the
second the needs of the client.
The Issue for the Therapist
Because therapy is both a calling and a business, the topic of how to keep
someone in therapy can be embarrassing. The implication can be that the therapist wants to
make money by seeing the client longer. It is best if we face facts. A therapist does make
more money from a client who stays in therapy for years compared with a client who stays
in therapy only a short time. The fact that more money is made should not be a reason to
avoid workshops or instruction in long-term techniques.
If we accept the financial problem as something we must live with, what
are the merits of long-term therapy for the therapist? Even if some therapists would
rather not think about the positive side of interminable therapy, it should be discussed.
Like having romantic affairs, many people would rather do it than talk about it at a
At one time short-term therapists were on the defensive. Long-term
therapists thought of themselves as "deep" and were confident, even arrogant
They liked to imply that brief therapy was a shallow, superficial endeavor. Brief
therapists had to quote scientific outcome results to prove their success, pointing out
that research did not show any correlation between length of therapy and successful
outcome. Long-term therapists easily rejected such data as irrelevant. They pointed out
that outcome results do not cause changes in therapy approaches in the field, which change
only on the basis of fashion. Short-term therapy was simply condemned as not fashionable
and not elegant in practice or theory. Now, with changes in insurance and HMO contracts
setting limits on therapy length, the situation is reversed; long-term therapists are
becoming defensive and brief therapists are bragging. One day we might even see long-term
therapists desperately trying to bring science into the issue.
Young therapists won't recall the Golden Age of long-term therapy and
might appreciate an example of a personal encounter to illustrate bow it was in those
days. I was once dining in a restaurant in Paris and began talking with an American couple
who were sitting at the next table. When they asked what I did, I said I directed a
therapy institute. 'Me couple knew a lot about therapy since they were from New York. They
were pleased to find we had something in common. The husband said he had been in therapy
for 12 years, considering psychoanalysis to be therapy, and his wife had been in therapy
for 8 years. Both of them had several sessions a week. I asked if therapy had solved their
problems. They looked surprised at the question. "Of course not," said the
gentleman, as if thinking the matter over for the first time. "We wouldn't still be
going if it had." I asked them if they would recommend therapy to someone else. They
said, "Of course we would. Everyone should be in therapy." I could see they had
a therapist who knew his business.
In the discussion, I mentioned that 12 years seemed a long time to be
in therapy. Rather defensively, the man asked me how long we did therapy at our Institute.
I said, "We average about six interviews. With student therapists the average is
about nine interviews." The couple looked at me, shocked, as if regretting they had
begun this conversation. I found myself saying apologetically, "Well, that's only an
average, we see some people a long time." I even added, to fill the silence,
"Sometimes people come once a month, and so six sessions can take as long as six
months." The couple became rather condescending and polite. The gentleman said that I
must see a different class of clients than be was familiar with. I said defensively that
we treated every wretch who knocked on our door. He said that I certainly could not be
doing therapy with advertising executives like him and his wife. They are required to be
in therapy for a long time because they feel so guilty about their work that they have to
pay a lot of money to an analyst for years as a kind of penance. I had to agree that our
therapy did not meet that special need because we did not have that size advertising
industry in our area. The couple lost interest in me and began to look for an Italian to
I found myself defensive about doing effective therapy even though the
people were saying their long-term therapy had not produced results. I also realized that
I did not know how the therapists of this couple had kept them coming so many years
without any improvement. There are thousands of therapists with that skill in the large
cities. If they teach it, they do not do so in public workshops where all of us can learn.
Perhaps it is secretly taught during personal therapy. I understand a training analysis in
New York now averages seven years. That is quite a bit longer than the few months that
Freud recommended. Perhaps the analysands are more obtuse these days and so require a
longer analysis, but it might also be that they are being taught more secrets about how to
contain people in therapy.
Now that fashions, and funding for therapy, have changed, people are
beginning to be defensive about doing long-term therapy. The pendulum is swinging. As we
examine therapy today, there have been remarkable changes in the last two decades. No
longer do a few therapists deal with a few clients in distress. Therapy has become a major
industry. just as photocopying machines are flooding the world with paper, the
universities are pouring out therapists of every species. There are psychologists,
psychiatrists, social workers, educational psychologists, industrial psychologists,
hypnotherapists, rational therapists, drug counselors, hospital therapists, marital
therapists, family therapists of a dozen schools, and so on. These therapists rush out
into offices and agencies everywhere. Part of the reason for this deluge is the publicity
given to therapy in the mass media. In TV dramas the characters are in therapy and discuss
it as part of life. Talk show hosts discuss their therapy, setting examples for the
audience. Women I s magazines have columns on the subject. TV and radio psychologists
advise everyone to rush off and get therapy' "If only your husband will go into
counseling, all will he well" is the cry of the radio psychologist heard by millions.
With therapy such a way of life, is it proper for a therapist to talk
about how briefly it can be done? Isn't that like General Motors bragging about how
quickly they can build a Cadillac? Or surgeons bragging about how short a time it takes
them to do bypass heart surgery? In the early days of therapy when people were less
affluent and there was no insurance, it seemed appropriate to be brief. Now with what it
costs to become a therapist, obviously it is only fair to get a return on the investment.
Not only is an expensive undergraduate degree necessary, and an expensive graduate degree,
but there is postgraduate training. There is also typically the personal therapy expense.
It is hoped that a personal therapy will somehow make a therapist more successful. (It is
also a way to provide clients for the training staff who might not otherwise have them.
Four analysands and four guilty businessmen seen several days a week is all a long-term
therapist needs to avoid having to get more referrals for several years.) Besides academic
costs, therapists must go to private institutes to learn the therapy skills they were not
taught in the university. Seminars and workshops are required to keep up with the
continuing education requirements. A therapy practice these days represents a large
financial investment, and we must accept that and count it in the fee.
The therapist is not the only person who is being supported by the
therapy fee. Just as there are 40 or 50 backup persons to support every soldier who is
actually in combat, so the therapist is at the tip of a pyramid of support personnel.
There are administrators of training institutes, supervisors, protective service personnel
and judges, hospital and prison staffs, public agency case workers, teachers of abnormal
psychology, systems theorists, journal editors, publishers, professional organization
staff, licensing authorities, constructivists, and so on. Obviously, a therapy case must
provide enough money to support not only the therapist and his family, but all the
auxiliary personnel employed in the field.
Can the same income be made with short-term therapy as with lengthy
therapy? Some brief therapists argue that it can be done but only if the therapist is
willing to seek financial salvation through suffering. The effort required to keep the
hours of the brief therapist filled is considerable. I once had a brief therapy private
practice, and to equal the income of the long-term therapist required from three to four
times as many referrals. A constant supply of clients is necessary because they are
constantly changing. I can recall envying the long-term therapists who could schedule
their hours a year in advance with confidence that the rent would be paid. In short-term
therapy one recesses as soon as there is an improvement, and so a client is shifted to
appointments every two weeks or once a month. What happens to that hour next week that
must be filled? Perhaps a new referral will come in time, but perhaps it will not. Another
talk to a PTA meeting might be necessary. Each decision about whether to have an interview
becomes a moral decision, not a routine matter.
The style of short-term therapy is also more exhausting. A day is long,
rather than leisurely. As an example, in a first interview the therapist must make the
effort to clarify what is wrong and think of something relevant to do, all in an hour. He
or she typically formulates a problem and gives a directive. The second interview reveals
the response to the directive, which is then modified. By the third interview a positive
improvement is taking place and sessions can be spaced more widely apart. The search for
new clients begins. What a contrast that is to a(long-term approach, where it takes three
sessions to complete a history and three more to finish the genogram before one begins to
think about what to do to solve the problem. How much easier it is to lean back and say,
"Tell me more about that" or "Have you wondered why it upset you that I was
Long-term therapy can be leisurely because it lacks a goal, but brief
therapy requires that something be done to achieve some end. One cannot create a method
and try to fit everyone into it. The therapist must innovate a special directive for each
person. The long-term therapist needs to learn only one method and apply it. The therapist
does what he did with the last person. If the client does not fit the method, another one
will. How much more demanding it is to come up with an innovation or a variation in each
case. Some brief therapists try to use a method for all cases, such as always telling the
clients to stay the same, but such simplicity only works with a few cases.
The long-term therapists have all the best theories to rationalize
their techniques and the length of their therapy. Not only has there been a hundred years
of talking and writing about psychodynamic theory, but new fashions in philosophy are
always available. One can easily step from theorizing about the unconscious to turgid
discussions of epistemology, aesthetics, constructivism, chaos, and so on. If the theory
is heavy, the therapy can be light, particularly when the theories are about what is wrong
with people rather than what to do about changing them. Brief therapists are usually stuck
with talking about what to do, which does not lead to profound ideological discussions.
There is also not much literature on brief therapy compared with the 70,000 books and
articles written about psychodynamic theory.
As another issue, brief therapists tend not to have a theory of
resistance. They believe one gets what one expects, and such a theory interferes with
gaining cooperation from a client. Long-term therapy has a theory of resistance, which
excuses therapy being done forever to overcome that resistance. They also have the potent
theory that if the client wants to terminate, he is resisting change and has not really
improved, obviously needing more therapy. Long-term ideology has the therapist be the one
who decides when therapy is over, not the client, so the length of therapy is in safe
hands. Therapy does not end until the therapist is satisfied that the client is as near
perfect as can be achieved in one lifetime.
One must also not overlook the importance of the therapist's self-image
when choosing the type of therapy to be done. The brief therapist tends to have an image
of himself or herself as harried and under stress. The long-term therapist has a look of
boredom at times, listening so much to so few people. Not even the marital contract
requires that much togetherness. Yet the long-term therapist also has a positive image as
a wise philosopher, one who could offer the best advice if he chose to, but clients must
decide for themselves. In a comfortable chair in a well decorated office, preferably with
a fireplace, the therapist patiently listens like a good friend to the clients who come to
him for many years. Sometimes confrontation is necessary, but if so it is gently done, so
the person will continue in therapy. The long-term therapist is loved by his clients.
Usually the short-term therapist is not There is not enough time for a romance. This
kindly, loving, philosophical image is particularly appealing as a target image for young
people coming out of school. Graduates hope for a private practice, though more and more
of them must settle for a salary in an agency or hospital where they must do brief
The Issue for the Client
Besides the merits of long-term therapy for the therapist, there is the question
whether the client benefits most from long- or short-term therapy. We must also consider
not only the client but also his or her support personnel in the family network. A
scientific case report might clarify the matter.
I recall a woman who became upset when she married. She went into
therapy as a result. Eighteen years later she is still in therapy. At that point, she
divorced her husband. She also divorced her therapist. The last time I saw her she was
considering marriage to another man. She was also thinking of going back into therapy. Can
we say that the two decades of therapy bad a positive or a negative effect? Would short
term therapy have been preferable in her case? Only intensive research can resolve this
question. However, a few ideas are evident On one side, the woman never had a marriage
that was a dyad. She was in a triangle with her husband and her therapist all during her
marriage, as many men and women in individual therapy are today. What did the therapy cost
her husband? Not only is the expense of therapy over the years a steady drain on a
household budget, but what of the personal cost? This husband had a wife whose experiences
and ideas, even her intimate thoughts, were more likely to be communicated to another man
rather than to him. If communicated to him, it was often after she had spoken to her
therapist about it and so it was a twice-told tale with second-hand emotion. Each major
event in her life, including childbirth and crises with the children, was shared with her
therapist The husband was labeled as secondary as an advisor to his wife and a parent to
the children, while the therapist was the authority and expert on human relations whom she
For a different perspective on this triangle, we can consider the fact
that the husband lived 18 years with a wife while paying another man to listen to her
complain. This relieved the husband of that task, which some husbands might consider a
positive result and others might not. There was also the agreement, confirmed with each
therapy visit, that the wife was defective and the husband was not, since he did not go to
a therapist. Therefore, their relationship was defined by an expert as one where the
husband was superior and took care of a wife who was not quite adequate. The long-term
therapist was, of course, thinking of the wife as fragile and needing his support or he
would not have continued with the therapy for so many years. By the act of seeing the wife
in therapy, he communicated to the marital couple that the wife was not normal like other
How difficult it is to choose brief or long-term therapy in such a
case. A positive aspect is that the therapist helped the marriage continue for those many
years. An 18-year marriage is an accomplishment in this age of easy divorce. Many wives
who get upset after marriage and have brief therapy rather than long-term might break up
with their husbands. If the marriage was stabilized by therapy, should that not be
considered a positive effect? One must also consider the fact that some wives and husbands
do not seek therapy because they wish to change, but for consolation. Often they feel they
must stay married for financial reasons, or for the children. They ask of the therapist
only that a miserable marriage be made more tolerable by refraining aspects of it and
offering suggestions. Perhaps it is wrong to help people stay in an unhappy marriage, but
often they ask for that service. A brief intervention to make a change will not satisfy
The Stigma Issue
One important factor about long-term therapy is that the practitioners do not
consider being in therapy a stigma. They consider therapy good for everyone and the fact
of being in therapy does not mean one is defective, or inadequate, in the eyes of others.
In this framework are the growth therapists, or those who seek to increase human
potential. They do not find anything wrong with a client except the human condition, and
all human beings can grow and improve. Yet the growth therapist might be aware that the
client in therapy should not try to run for president. It is still the popular assumption
that "therapy" means that a person is defective and unable to deal with life's
problems like normal people, particularly if therapy goes on and on for years.
Long-term therapy is usually defended with the argument that the client
is fragile and needs support in meeting life's problems. In contrast, the brief therapist
tends to have the view that all the person needs to become normal like other people is a
few sessions to straighten out some problems. The underlying premise of brief therapy is
fundamentally different from the long-term therapy view of the human condition and how
people cope with it. A brief therapist, for example, might turn down someone for therapy
because the person does not need it. Long-term therapists consider therapy valuable for
everyone and no one should be rejected if he or she can afford it.
Only recently has the social context of a client been emphasized by therapists.
The effect of the family organization is now more taken for granted. For example, suppose
a kindly family member dies and the family becomes unstable. If a family member enters
therapy with a kindly therapist, the family is stabilized. A problem only occurs when
termination is considered. At that point the family will have to reorganize to adapt to
the loss that they had not adjusted to. As the family becomes unstable, it is the client
who will appear agitated, and the therapist will conclude he still has problems and must
continue longer in therapy. As the years pass, the therapy has the function of stabilizing
the family. Sometimes the same goal is achieved by regularly hospitalizing a family
member, usually an expendable adolescent. The auxiliary personnel of the therapist, the
hospital staff, and the auxiliary personnel of the client, the family, all benefit from
the therapeutic arrangement. The family benefits by stability, the therapist and his
auxiliary personnel benefit from the fee. Can we say that is not a proper function of
therapy? Short term therapy does not offer that function. In fact, short-term therapy
tends to destabilize a family as part of inducing change. Long-term therapists tend to
stabilize the organization the way it is.
There is another aspect of stabilization that involves symmetry in
human relations. just as human beings and other animals are symmetrical, having one eye
above each side of the nose, one ear on each side of the head, and so on, there seems to
be the same pattern in human interaction. This is called the 4th law of human relations.
With a marred couple, for example, if one spouse becomes attached to someone outside the
family, the other may seek an attachment. That is, if one spouse begins an affair, the
other spouse often seeks one also. Or the spouse might become over-involved with people at
work, or goes into therapy and attaches to a therapist. Similarly, if a spouse enters
therapy, the other one can become attached to someone else as a way of balancing the
symmetry of the family.
Within the family, if a mother becomes attached to her son, the husband
is likely to become attached elsewhere, perhaps to his mother or a therapist. Obviously,
if families need to balance symmetrically in this way, there must be therapists available
to be paid to help correct the symmetry of the family. If the involvement of the family
member with someone else is long-term, the spouse must have a long-term therapist to
provide the needed stability for the system.
The Needs of the Individual
Besides stabilizing an organization, what of the needs of the individual? Does
long-term therapy meet those needs better than short-term therapy? Let us consider a basic
human need: the need to hypothesize. Social psychologists have proposed for many years,
and brain researchers are now suggesting, that a basic need of a person is to make
hypotheses about himself and other people. One cannot not hypothesize. Whatever someone
does, we must make a hypothesis about why the person did that. As this comment
illustrates, we must even make hypotheses about why we hypothesize. In all our waking
hours, if not in our dreams, we explain.
Does short-term therapy help with this need? Obviously it does not
because it is not assumed that conversation about a problem will change the problem.
Action must be taken. I recall years ago concluding that insight comes after a therapeutic
change. When I did a brief intervention and got someone over a symptom, he or she wanted
to tell me insightfully about all the functions of the symptom in the past and present.
Even if I was not interested, the insight was imposed on me. I now realize that the person
was fulfilling the need to hypothesize. People have to have an explanation of why they got
over a symptom and so must rethink why they had it. Unaware of the hypothesizing need, I
was impatient with them since the problem was over and they should go about their
When we examine long-term therapy from this view, obviously its
greatest contribution is in the hypothesizing area. Hour after hour, week after week,
month after month, year after year, the client has a therapist willing to sit and
hypothesize. "I wonder why you are puzzled over what you did?" "Let us
examine where that idea came from" or "Isn't it interesting that you... "
Every hypothesis about the past and present is explored. The two people enjoy
hypothesizing together, and each has needs satisfied. The therapist finds support for a
theory that has as its foundation the need to hypothesize and explain. The clients must
hypothesize to try to explain why their lives are always such a mess.
The Interpretation Versus the Directive
Long-term therapy primarily focuses on the interpretation, which is the tool of
hypothesis making. Short-term therapy focuses on the directive, which is the tool for
producing a change. Long-term therapy tends to be educative. Rather than focus on
resolving a problem, the task is to help the person understand. With that emphasis,
outcome research is not appropriate. There is nothing for the person to get over. In
contrast, brief therapy usually focuses on a problem that is to be changed by the
interventions. Whether the change occurs or not can more easily be determined. To put the
matter in another way, long-term therapy tends to create an elite who have specialized
knowledge about themselves that the average person does not have. The client learns to
monitor himself and hypothesize why he does what he does within an ideological framework
that is only learned in therapy. The short-ten-n client tends to get over a problem and
get back to being like other people rather than being special.
Long-term therapy ideas are easier to learn because they are part of
the intellectual climate of the time and available in both professional and popular
literature. Giving brief interventions, such as arranging an ordeal or a paradox, is more
difficult to learn since the specialized techniques are largely confined to the
practitioners of therapy and are unknown to intellectuals generally. Perhaps that is why
few long-term therapy workshops are needed and many are necessary to learn brief therapy
techniques. They cannot be learned merely by living in an intellectual culture.
Special Problems Requiring Long-Term Therapy
Rather than create an either/or situation for long-term or brief therapy, one
might suggest that there are times for long-term therapy and other times for brief
interventions. Let us consider some of the situations where long-term therapy seems
Besides the need to stabilize a married couple or a family over time,
there are special problems. One serious problem is that of sexual or physical abuse where
therapy is usually mandated by the court A brief intervention might stop those illegal or
immoral acts. However, how can one be sure the acts have really stopped? The possibility
of a relapse is not an academic matter but means a victim will be harmed. There is a need
to monitor these clients over time to be sure the positive effect of therapy continues. If
one follows the person in a serious way, it becomes long-term therapy and is compelled by
the nature of the problems.
Another type of problem usually requiring long-term therapy is the
chronic psychotic and his family. With a first episode of psychosis, therapy can be brief
since it is focused on getting the person back to normal functioning as quickly as
possible. A crisis therapy with the family is designed to get a young person diagnosed
schizophrenic off medication and back to work or school. This can be accomplished
relatively quickly. However, if a therapist is dealing with a case where the person has
been hospitalized a half-dozen times, the need for long-term therapy is apparent. The
client is chronic, the family is chronic in that it expects the person to be incurable,
and the professionals dealing with the client are in a chronic expectation that medication
will be needed forever and custody regularly. To change all the auxiliary personnel in
such a situation is obviously not a short-term task.
Another special problem is the long-term therapy that is done
reluctantly when a therapist wants to terminate a person and cannot So the therapy goes on
without enthusiasm and even with resentment. In the same way the client can wish to
terminate and receives such a reaction from the therapist that he or she is unable to do
so. One analogy in such a case is the addiction framework. just as a person can become
addicted to a lover, this can happen in therapy. The person might be hooked on a
particular therapist or just on being in therapy with someone. A therapeutic goal is to
successfully get the person free.
Perhaps it is in the nature of therapy that addiction occurs because of
the kinds of sequences involved. In a typical addiction pattern there is a promise of
feeling good and of intimacy, and this is followed by a rejection, which takes the form of
not fulfilling the intimate promise. Yet it might still happen. It is like a mother
encouraging her child to seek her out and then not responding because she is too busy. She
invites the child and complains if he hangs on her. By the nature of the therapy contract,
the situation is a relationship of an intimate nature. Yet the relationship cannot be
consummated as an intimate relationship, and rejection is inevitable. The intimate rapport
also lasts only as long as the person pays the bill; thus it is a paid friendship and so a
rejection of intimacy while implicitly promising that. Often long-term therapists are
caught up in such addictive relationships and cannot escape until a third party, such as a
supervisor, helps detach them.
There are, of course, situations where long-term therapy is not
appropriate and the therapist must work briefly. Therapy that is limited by an insurance
company to a certain number of interviews is obviously not long-term, unless client or
therapist decides to make a financial sacrifice and to continue the therapy. Another
limited situation is the short-term hospitalization paid by insurance companies. The
person is hospitalized for a few weeks and discharge will occur when the insurance runs
out, no matter what. Usually the therapist who briefly sees the client inside the hospital
cannot carry him or her outside and so continue the therapy.
Future Financial Arrangements
As we look over the field today and consider the long and the short of therapy,
there are trends for which we must prepare. Obviously therapy is going to become shorter
because of the ways it is financed. just as it was discovered that hospitalization could
be more brief when the insurance companies decided that, so therapy will become briefer as
insurance companies limit the length of therapy. Certain changes are going to come in the
basic financing of the therapy enterprise and so new opportunities arise.
When we look at the history of therapy, the most important decision
ever made was to charge for therapy by the hour. Historians will someday reveal who
thought of this idea. The ideology and practice of therapy was largely determined when
therapists chose to sit with a client and be paid for durations of time rather than by
When one realizes that charging by the hour was an arbitrary decision,
there is no reason why other ways of financing therapy could not be developed. Long-term
therapists might continue to use the hourly charge for clients who can personally finance
that, but other therapists can consider alternate ways of charging.
Charging by the Relief of the Symptom
Of the many ways to set a fee, the most obvious is to charge for the cure of a
symptom rather than the number of hours sitting in the presence of the client. Each
problem can have a designated fee. There is a precedent for this in medicine, where a
surgeon charges by an action, in contrast to a pediatrician, who charges by the hour or
any portion thereof as an office visit.
In the field of therapy there are also precedents. Masters and Johnson
charge a flat fee for sexual problems, with consultation for a period of time afterward.
Milton Erickson was known to say to parents who brought in a problem child, "I'll
send you a bill when he is over the problem."
There are also people charging a fee per phobia rather than charging by
the hour. I understand a group is charging $300.00 to cure any phobia. Anticipating quick
results, they will continue to see a person for that fee until the phobia is gone. Another
way we are already charging by this method is when we accept time-limited therapy by
insurance companies. To see a client for only 20 interviews at a set fee is to charge a
set price for the relief of a symptom. The difference is that if the therapist resolves
the symptom in only three sessions, he or she cannot collect for the remaining 17 hours,
as might be done with a flat fee.
What are the problems in setting a fee for the successful relief of a
symptom? First, the therapist has to be able to resolve the problem. That is what everyone
attending brief therapy workshops is learning to do. If brief therapy can be successfully
taught, as the teachers claim, there is no reason that payment cannot be made on the basis
of success. There will also be the need to protect both client and therapist with any
price arrangement. The client might be offered a choice: payment by the hour into an
uncertain future, or a flat fee for getting over a specific problem. The contract would
have to be precise in problem and goal. What if there is an ambiguous outcome? One way to
protect therapist and client would be to have an escrow account. The fee could be put into
it until the problem is over. On those occasions when client and therapist disagree, an
arbitrator can be available.
Such procedures can be worked out since they are simply part of setting
up a new system. A more important issue is setting the fee. How much for relieving a
depression, if that category is used? How much for solving school avoidance? What is the
price to stop an alcoholic from drinking? If a person has several problems, can priorities
be listed? There might also be contingency fees for relapses. These are important issues,
and resolving them will bring more precision into the therapy field. There will need to be
a therapy manual rather different from the current DSM, which is irrelevant to therapy.
Such a manual would essentially be a price-per-problem listing. One can hope that this
arrangement will not lead to price cutting to compete for the insurance dollar. Obviously,
the arrangement of payment per symptom will be met with enthusiasm by therapy contractors.
As this pricing system develops, most therapists will first think of
correlating outcome with the number of hours to achieve the goal. In time it will be
recognized that the issue is types of intervention rather than time. An example is the
medication interview of a psychiatrist. Once they charged by the hour, sometimes
regretting that they could not see more patients per hour, like other doctors. Then they
discovered they could charge the same hourly fee for a medication interview and yet see
clients for only 10 minutes. This increased their fee to six times the previous income per
hour. Then the medication interview was set for a fee independent of hours. I know of one
practitioner who has 60 medication interviews per day, charging what would once have been
the fee for 60 hours. This can be a model for brief therapists. They might not achieve
that large a number of clients per hour, but they can see clients for 10 or 15 minutes
rather than an hour and so increase their incomes by several times.
Obviously there are a variety of ways of charging fees. The problem is
complex, but it is solvable. A positive thought is that spontaneous remission is not
uncommon and can be as high as 40% to 50%, according to waiting list studies. If that is
so, therapists can be rather incompetent and still get a fee in almost half their cases,
as they do now. Once a few therapists have the confidence to charge on the basis of
outcome, others will have to follow to stay in business. One important effect will occur
in training programs as therapy requires more skill and becomes more brief and precise. It
might ultimately be that teachers will he paid by particular therapy techniques
successfully taught instead of being paid by the hour or the semester. just as client fees
can be determined by results, so can the fees for training.
At the moment it is the client who risks money and time by going to a
therapist with no guarantee of change, with no limit on the length of time of therapy, and
no way of knowing the ultimate cost. When a fee is charged for the successful resolution
of a problem, it will be the therapist who takes that risk. The therapist must either
change someone or continue to see him or her for unpaid interviews while more lucrative
clients are waiting. With the past arrangement of pay by the hour, it was the client who
could go broke or waste hours, months, or years of his or her time in therapy. With the
fee-for-a-problem arrangement, it is the therapist who can go broke or waste time. Is that
not something we are willing to risk rather than impose it on clients, since we therapists
are kindly and helpful people?