Foundation for Codependent Therapeutic Relationships
by Sandy Sela-Smith, Ph.D.
This literature review reveals two perspectives of resistance in psychotherapy. The first concerns the patient’s internal process of avoiding painful information and the second pertains to an attitude in the patient/therapist relationship. When Freud (1900) focused attention on the therapeutic relationship instead of the internal process of resistance, I propose that he collapsed the two resistances into one by equating the patient’s internal process to the external process of resistance as expressed in the therapeutic relationship. This has laid the foundation for the formation of codependent therapeutic relationships that fail to address internal resistance.
A number of therapeutic methods have evolved from Freudian psychoanalysis or had connections to it, each attempting to correct what theorists saw as misconceptions of classical psychoanalytic theory. I contend, however, that those who opposed Freud such as Adler and Jung, as well as the new theorists such as the Neo-Freudians, the object relations therapists, the self psychologists, and others have inadvertently followed in Freud’s (1900, 1913, 1933) footsteps. Like he, they developed theories that interpret what the patient experiences and contain the potential for codependency. I offer a nontraditional perspective that refocuses attention on the internal process and redefines the responsibilities of participants related to problem solving and dealing with resistance in psychotherapy.
Traditional Views of Resistance
Weaving in and out of the psychological literature over the last century are two explanations of the word resistance as applied to psychotherapy. The first identifies resistance as the internal process of preventing painful information that has been pushed out of conscious awareness from coming back into awareness (Brewer & Freud, 1895; Freud, 1900, 1905, 1915a, b, c, 1923, 1933; Horney, 1939; Janet, 1907, 1925; Jones, 1911; Stark, 1994). Priests, mesmerists, and hypnotists who were the practitioners of early dynamic psychiatry traditions from which psychoanalysis evolved, presented evidence of their patients’ resistance to knowledge of painful information in the waking-state that was only available in altered states of consciousness (Ellenberger, 1970, Hilgard, 1987). Though the intention of this internal resistance is self-protection, the long-term result is a mental disturbance that may present itself as hysterical illness, mental distress, and / or abnormal behavior (Brewer & Freud, 1895; Janet, 1907, 1929).
A second explanation of resistance was written in the Psychological Bulletin II, (1905) which identified resistance as being simply “something hindering inquiry” (p. 256). Around this same time, Freud (1895, 1900) made reference to the struggle between analyst and patient that hindered psychoanalysis. I propose that Freud (1900, 1913, 1923, 1933) subtly collapsed the two definitions into one when he concluded that the internal resistance of painful information is the cause of the patient’s resistance to the therapist. In doing so, the patient’s heuristic investigation of his or her internal process is abandoned while the therapist’s interpretation of the patient behavior based on theory determines what is occurring within the patient. I hold the opinion that for nearly a century, the generally accepted meaning of the word “resistance,” as applied to psychotherapy has come from this collapsed definition originating in Freudian Psychoanalysis. Therapeutic practices that appear to focus on the patient’s internal experience still define that internal resistance based on the theoretic perspective, leaving the therapist in charge of defining the problem and providing the solution. I submit that this practice creates the elements necessary for the development of a codependent therapeutic relationship.
Codependent Relationship Literature
Codependent literature came to the forefront in the1970s and 1980s popular press in the form of self-help literature based on clinical experience rather than from rigorous research (Messner, 1996, Subby, 1986; Subby & Friel, 1988). Professionals who treated chemical dependency needed to find ways to work with the spouses and children-of- alcoholics. These specialists found that family members exhibited symptoms similar to alcoholics. The examination of this concern became the foundation of the codependency literature (Beattie, 1986; Betz, 1987; Black, 1981; Bradshaw, 1990, Miller, 1981, 1983; Whitefield, 1986).
The relationship styles exhibited by persons in codependency with alcoholics were recognized in many other relationships between persons facing addiction issues. Anecdotal reports rather than research documentation indicated that there were common characteristics of relationships in which addiction is a factor. According to Loughead, Spurlock, and Ting, (1998) popular literature of the 1970s and 1980s identified a number of these features. They suggest that codependents bind their self-esteem to the ability to control other people and they suffer from distorted understanding of will power. Codependents invest inordinate amounts of energy in efforts to improve other people in their search for a semblance of self-worth. They also tend to assume responsibility for meeting others’ needs. Codependent persons feel anxiety and boundary distortions around intimacy and separation and become enmeshed in relationships with personality disordered, chemically dependent, other codependent and/or impulse disordered individuals. Cermak (1991) pointed out that codependent persons are likely to have “three or more of the following: constriction of emotions, depression, hyper-vigilance, compulsions, anxiety, substance abuse, excessive denial, recurrent physical or sexual abuse, stress-related medical illness, and/or a primary relationship with an active substance abuser for at least 2 years” (pp. 64-76).
Because these findings were not based on empirical research, these DSM-like descriptives (Cermak, 1991; Irwin, 1995; Loughead, et al., 1998) and the assumptions made by writers such as Beattie (1986); Miller, (1981, 1983); Norwood (1986); and Whitfield (1987) were rejected in academic literature as unfounded. However, by the 1990s, empirical research began to support what earlier anecdotal reports had purported (Clark & Stoffel, 1992; Donat, Walters, & Hume (1991); Loughead, Spurlock & Ting, 1998; Springerk, Britt, & Schlenker, 1998; Wells, Glickauf-Hughes & Jones, 1999). In these studies, the features of codependency as identified by the popular literature were positively correlated with shame-proneness, low self-esteem, and parentification (parent/child relationship identified as one in which the child feels responsible for the parent and expresses a need to take care of parental needs at the cost of their own needs.) High codependency scores were also significantly correlated to high external locus of control, high anxious/ambivalent attachment and avoidant attachment.
Earlier popular literature indicated that codependent systems create a unique way of forming relationships that correlates with research of the 1990’s (Clark and Stoffel, 1992; Donat, Walters, & Hume (1991); Loughead, Spurlock & Ting, 1998; Springerk Britt, & Schlenker, 1998; Wells, Glickauf-Hughes & Jones, 1999). The Karpman (1968) codependent “drama triangle” depicts a relationship between two or more participants in codependency. Each person takes one of three positions: the victim, the rescuer, or the persecutor. Each position fulfills a role-relationship with the other roles in problem-oriented interactions. The “rescuer” role takes the responsibility of supplying the solution for the one that is experiencing the problem. The one who suffers from the effects of the problem takes the “victim” role. The persecutor in abusive relationships may be dominant most of the time, using ongoing passive-aggressive behaviors or outright aggression. However, when the victim or rescuer becomes disturbed by the control of the other, an inherent characteristic of codependency, either may shift positions and become a persecutor.
A B Figure 1: A= The Karpman drama triangle
B= The Quigley shadow triangle
Problem Solver Victim
Quigley (1989) pointed out that the unseen side of the rescuer is a shadow victim who believes he or she must rescue someone in order to feel valued. He suggests that hidden in the persecutor is also a shadow victim whose vulnerability is defended by aggressive acts; in the victim is a shadow aspect of self that is capable of solving the problem. All roles have a victim aspect that struggles to use the relationship for relief.
According to Weinhold and Weinhold (1989) the role participants take in the “drama triangle” may shift a multitude of times during a single incident. Whenever one party becomes dissatisfied with the dynamics of the codependent relationship, he or she shifts from one position and takes on one of the other two roles in an attempt to force the non-compliant party back into compliance. Relationship is based on the tension between the roles rather than on connection and cooperation to find solutions. Problems tend not to get solved because the codependent relationship needs problems to exist. The relationship is characterized by struggle that is exhibited in ongoing attempts to control the other, as well as, resist the attempts of the other to control.
Codependence in the Therapeutic Relationship
In psychotherapy, the therapeutic relationship exists because a patient is experiencing a problem. When there is an assumption that the therapeutic perspective together with the therapist’s intervention holds the solution to the patient’s problem, I contend that the establishment of a codependent relationship begins. If control is an aspect of the relationship, resistance becomes the new problem and, now, the therapist may suffer because he or she cannot be a successful rescuer of the patient if the patient resists. As the two shift positions, the patient can become the rescuer of the therapist by becoming compliant and accepting the therapeutic interpretation. Perhaps the patient may become the persecutor of the therapist by refusing to cooperate. The focus has shifted from the patient’s presenting problem (caused by whatever is being internally resisted) to the therapist’s problem (the need to overcome the patient’s iatrogenic resistance in the relationship.) I contend that whenever the therapist is in the rescuer position, there is hidden victim in the therapist’s shadow that is being projected onto the patient. Both therapist and patient struggle in an attempt to control the behavior of the other. Control replaces authentic relationship and resistance to control becomes the focus. This becomes a potential petri-dish situation for creating the characteristics identified in codependency (Cermak, 1991, Loughead, et al., 1998).
Understanding of codependent relationships appeared in psychotherapeutic literature regarding neurosis before the popular version became known in the 1970s and 1980’s, though in these early references theorists assumed that it was the patient who was neurotic. Ellenberger (1970) pointed out that:
Jung defines neurosis as a “sick system of social relationships,” a definition that is well in accord with the concepts of Janet as well as Adler. Because of this projection the neurotic unconsciously manipulates the persons around him (spouse, parents, children, and friends) and plays them against each other so that he is soon enmeshed in a web of intrigues of which both he and the other are victims. (p. 719)
I propose that any rescuing therapist is neurotic and codependent. The rescuing role might be played out as one of Jung’s (1934b, 1936, 1939) archetypes within the masculine, feminine, or androgynous images. Examples of the masculine roles that either male or female therapists might assume include the benevolent ruler or dictatorial tyrant, the authoritarian father figure, wise old man, coach, or guide. Examples of feminine roles that might be taken include the good mother, the caretaker of the innocent, the protector of the lost, the weak and the broken, or the wise old woman.
The role counterpart of the rescuing therapist in codependency is the victim patient who may be an obedient or unruly subject, a cooperative or difficult student, or a willing or resistive apprentice in relationship with the one in authority. The patient in relationship with the rescuing mother figure is one who may be helpless, broken, weak, or lost. The patient in relationship with a guiding or coaching therapist may be seen as one who is in training to break free (even from the therapeutic relationship) to become whole.
I speculate that therapists who identify with the codependent role of the masculine archetype do not work well with helpless, broken, weak , or lost patients where resistance is hidden. Therapists who identify with the feminine archetypal images may not work well with the unruly, difficult or resistive patients with visible resistance. This speculation is based on the consideration that therapists who assume therapeutic roles are themselves playing out codependent relationships reflective of their resistance to becoming aware of what has been pushed away just as their patients do. A therapist who feels inferior may seek to be superior in a therapeutic relationship; perhaps, a therapist who avoids the painful information held in his or her own unconscious may select a therapy method that focuses on the present and future and dismisses the value of delving into the past.
I submit that many of the current psychotherapies can be shown to have the potential to foster codependent relationships in which the roles taken on by both the therapist and the patient play out prescribed ways of relating. The focus of codependent psychotherapeutic relationships is on the external resistance as in the case of authoritative-resistive relationships or external chaos of the patient’s life as in nurturing- distressed relationships. Both create a distraction to internal resistance.
Jung (1965) suggested that the complex, which is the totality of the components that make up a disturbance experienced by a patient, contains important clues that both hide and reveal the patient’s secret (p. 117). If a theorist creates a psychotherapeutic process that contains codependency, a codependent therapeutic complex might both hide and reveal the therapeutic secret. A patient’s resistance to the therapist interpretation may be, as many theorists suggest, resistance to awareness to what has been hidden; however, it might be a legitimate struggle against an inappropriate interpretation projected onto the patient by a neurotic therapist.
The Codependent Authoritarian Paternalistic Relationship: The Role of the Despot or Benevolent Director Over the Compliant or Rebellious Subject
Paternalism, derived from paternal or fatherly, is a word that describes a relationship in which the one in authority takes care and control of the needs of those who are subject by providing for their needs without giving the subjects responsibility (American Heritage Dictionary, 1983). The superiority of the therapist is acknowledged by texts on professional ethics, by APA ethical standards, (APA, 1982), and by many state laws (e.g. F.S.S. 490 and 491, 1999) that regulate the relationship within, outside, and beyond the therapeutic setting. These standards assume the vulnerability and dependency of the patient years after the relationship has ended and in some cases in perpetuity. I contend that Freud’s psychoanalysis and Adler’s individual psychology are examples of authoritarian paternalism.
Freud and psychoanalysis: The therapist as ruler over the subject with patient’s
resistance identified as interference with psychoanalysis.
A review of classical Freudian psychoanalytic literature from 1895 to 1940, in my opinion, reveals that psychoanalysis has codependent characteristics at its foundation. Psychoanalytic theory identifies what causes patients’ problems and what has to be done for those problems to be solved. Though Freud’s conception regarding original cause of the patient’s problem shifted from actual trauma, as he proposed in 1895, to unrequited wishes and drives as presented in 1900, Freud’s explication of the solution remained the same, an explication, I contend, that has embedded in it, codependency.
Freud, (1985, 1900) like many of his counterparts at the end of the 19th century, searched for causes and cures of hysterical illness, whereby patients experienced blindness, amnesia, paralysis, and other diseases without any known physical cause (Freud, 1895, 1900; Janet, 1907, 1929). Freud (1985) used a mechanistic-organistic positivism that reduced psychological processes to physiological laws and physiological processes to physical and chemical laws. He developed a model, as reflected in a document called the Project for a Scientific Psychology (Ellenberger, 1970), that he never published, but it contained the foundation for what became his psychoanalytic theory. In this document he explained a complicated system of neurological functions of excitation and inhibition later to be identified as resistance. When he worked with people in those beginning years, Freud interpreted these patients behavior from this physiological perspective.
In Studies in Hysteria, Breuer and Freud (1895) proposed a theory that painful memories that have become dissociated convert into bodily symptoms that are relieved when the memories are brought into consciousness. The explanation for the loss of awareness from Breuer’s (1895) perspective is that the painful events in childhood cause the child to enter a hypnoid state, a state called somnambulism by hypnotists a century earlier, where memories held in that state are not available to ordinary consciousness. Breuer believed that traumatic memories could be retrieved only when that state is re-entered. Freud (1896) later rejected the hypnoid state theory and proposed that memories exist on a chain from the present to the past. He believed that the therapist must trace the chain of events from current hysteria to some incident in puberty when less traumatic sexual incidents occur but are connected to the original painful memories unavailable to normal waking awareness. In therapy, as the doctor probes into the patient’s past, the safety of the psychotherapeutic relationship allows the patient to reconnect with memories of the buried events; however, it is also possible for the patient to resist the probes, fight the doctor, and resist the memory. (Freud, 1913, 1933)
Early in his work, Freud (1895, 1896) concluded that childhood sexual trauma causes repression, resistance, and hysterical illness. Two years later he shifted to a view that unresolved sexual drives in early stages of development rather than actual traumas cause disturbance, pain, repression, and resistance. Instead of the patient resisting the probing for an actual memory, Freud (1900, 1915c) determined that the patient resists becoming aware of hidden sexual fantasies toward the opposite sex parent, a feeling the patient may later project on the therapist.
With the embrace of this new perspective, Freud (1900) withdrew therapeutic attention from seeking deeply buried childhood trauma and rejected using hypnosis as an access tool to the patient’s unconscious. Instead, he began to focus on patient’s dreams and free association. He interpreted the meaning based on psychoanalytic theory rather than permitting the patient to discover his or her own meaning. With this shift, Freud proposed that dreams, uncensored slips of the tongue, and uncensored talk available in free association during psychoanalysis, provide access to what is repressed and resisted in the unconscious.
Freud (1933) concluded that: “the defense mechanisms directed against former dangers recur in the treatment as resistances against memory. It follows from this that the ego treats recovery itself as a new danger” (p. 238). This defense that is ongoing in every aspect of therapy is what the therapist must continually point out to the patient as the therapist interprets the meaning of the dreams, slips of the tongue, and talk (Freud, 1913, 1920, 1923, 1925).
Freud (1924) reviewing what he had proposed earlier in his work, defined resistance as an ongoing part of every aspect of analysis whereby the patient attempts to block therapy as he “clings to his disease and fights the psychoanalyst against his own recovery” (p. 254). That fight can show up as resistance to the therapists probing, to interpretation, and to the analyst (Freud, 1925) or as refusal to keep what occurs in therapy between the analyst and patient (1913). He argued that patients who discuss their analysis outside the confines of the therapeutic relationship want to remain in control of the process instead of working it through with the therapist. The patient may enter a power struggle with the therapist by refusing to participate in free association and by resisting the procedures of analysis to recall, to insight, and to change (Eagle & Wolitzky, 1992). There may be attempts to cover thoughts with filling in silence out of fear of the analyst’s criticism, which is subtle resistance in the form of compliance. Freud also indicated that patients may attempt to take control of the therapy process by planning everything they say in sessions (1913) or that they attempt to take control by falling in love with the therapist (1912). These acts of resistance become the focus of analysis (Freud, 1925).
Much like the conflict inherent in codependency, psychoanalytic theory sees conflict as the major descriptor of many relationships (Corsini & Wedding, 1995). The three parts of self (id, ego, and superego) struggle with each other (1923), not unlike an internalized victim, rescuer, and persecutor. The self and civilization are in continuous strife (1930), and of course, the patient and the analyst are in contention for control. In 1914, Freud wrote Wolf Man, not published until 1918, in which he used an analogy of an enemy army making its way across a stretch of country to describe the therapeutic struggle (p. 403). Freud (1925) insists that resistance is a part of every step in treatment; he states that “every single association, every act of the person under treatment must reckon with the resistance and represents a compromise between the forces that are striving towards recovery and the opposing ones” (p.103). The psychoanalytic relationship experiences tension and resistance just as exhibited in codependent relationships.
The student who trains to be an analyst must go through psychoanalysis as a patient not only to learn how to identify and interpret resistance, but also, to learn how to use psychoanalytic methodology to duplicate the analytical relationship that Freud had with his patients. In the therapeutic relationship the therapist is in the dominant position and the patient is submissive. The patient is not only in a vulnerable position physically, but is also required to be emotionally vulnerable to someone who is not sharing that vulnerability. During the analysis, the patient relaxes on a couch and tells whatever comes to mind no matter how futile, absurd, embarrassing, or even offensive it may seem (Freud 1925). While saying anything that comes to mind, the patient feels moments of inhibition and other inner difficulties that interrupt the flow of the process. Freud (1925) termed this interruption resistance. Wolitzki (1995) pointed out that as a patient freely associates, the analyst offers interpretations of the fixations that are exhibited in the talking. The patient will eventually begin resisting what the therapist interprets as forcing awareness into mental content that the patient has warded-off in an attempt to prevent behavior and attitudinal changes.
Wolitzki (1995) points out that anxiety and/or depression, which may arise from accessing the repressed knowledge or conflicted wish, often results in humiliation, shame, guilt, or fear. This can create a sense in the patient of feeling victimized by the process, which in turn causes more resistance to therapeutic interpretation. The patient’s resistance eventually is projected onto the analyst in transference and this becomes the focus of the therapy. From a codependent perspective this transference and resistance can be interpreted as the “victim” becoming angry at the control of the therapist and shifting to the “persecutor” or unruly subject position. The patient then uses passive aggressive behaviors to force the therapist, seen as despot, to stop what the patient experiences as persecution from the therapist.
Freud (1937) identified the underlying sources of clinical manifestations of resistance as including the constitutional strength of the instinctual drives, rigid defenses, and powerful, repetitive attempts of the patient to seek familiar forms of gratification. (I interpret these to be the defenses of the patient who feels control and moves into the persecutor role to relieve what is perceived as persecution coming from the therapist.) Resistance, Freud (1937) concluded, is a natural tendency to defend against painful memory and to avoid becoming aware. He contended that the patient’s free association coupled with the therapist’s interpretation provides new information as a counter to resistance. With this new information there is an expansion of awareness that calls for new behaviors and creates the cure.
Freud (1918) acknowledged that the therapist’s self-esteem is enhanced when favorable conclusions to therapy are achieved. He proposed that therapists who succeed in difficult, long-term treatments are the ones who renounce short-term therapeutic ambition and are to be commended since lengthy work produces results “attained by the therapist” (p. 402). I interpret these statements as reflecting the belief that it is the therapist who does the work and the patient who resists what the therapist is doing. This fits the sentiments associated with the rescuer in codependent relationships, attempting to rescue the uncooperative victim. The paternalistic relationship exists, perhaps at the expense of accessing hidden, painful information that first created the disturbance. I submit that the psychotherapeutic method, as well as, the therapeutic relationship may be an expression of the therapist’s unaddressed resistance that is projected into both the method and the relationship.
Adler and individual psychology: The therapist as authority figure and patient as the student with resistance as an iatrogenic artifact.
In the last decade of the 1800s, Adler began treating private patients who were suffering from neither organic neurological problems nor difficulties that required hospital psychiatry as did Freud (Ellenberger, 1970). Adler’s patients were people experiencing failures, frustrations, and unfulfilled fantasies. Instead of “Freudian-Couch-Psychoanalysis” that holds embedded messages of dominance and submission, Adler sat across from and faced his patients in chairs similar in height, shape, and size. He conducted talk therapy regarding present concerns rather than depth psychology dealing with a search for unconscious, repressed information and resistance to such exploration (Ellenberger, 1970; Lake, 1987; Lande, 1976; Mosak, 1995). He did not encourage transference or dependence of patients on the therapist. From external appearances, the process seems to operate without dominance or submission, a practice much different from psychoanalysis.
Both Freud (1900) and Adler (1926) determined that neuroses are formed as a result of the interaction between the individual and society; however, their perspectives were in opposition. Freud (1915) focused on the individual and internal dynamics. He stressed the unconscious conflict regarding opposing psychosexual needs, repression of drives that are not socially acceptable, and the resistance to reconnecting with traumatic memories from the past associated with that repression. Adler (1929, 1935), on the other hand, focused on society and on the social factors that cause the individual to feel inferior and to strive for superiority. His focus was on the present and how the patient attempts to overcome a sense of inferiority in the external world.
While Freud (1900,1925) gave resistance a central position in his theory and practice, Adler (1935) dismissed resistance as an iatrogenic artifact of psychotherapy. Adler (1917) did not accept the psychoanalytic concept of inner conflict between separated aspects of self, repression, and resistance as the norms that must be overcome to attain mental health. Instead he believed in the unity of the individual that causes all parts to cooperate towards a common goal, just as individuals cooperate toward the common goal of society. When the individual is seen as internally undivided, there can be no internal resistance of one part of self to awareness held by another part. The only resistance that may occur would take place if the patient attempts to fight for superiority in a relationship with therapist. Therefore, the therapist eliminates resistance by a refusal to participate in the struggle. By accepting Freud’s “collapsed” interpretation of resistance and then dismissing it as an artifact, I propose that Adler made the same decision as Freud, which was to focus on the external relationship, the former involving the patients’ interaction with the “world” and the latter, the patient’s interaction with the therapist. Both disconnected from the patients’ internal process of resistance. In his comparison of the “whole” individual as counterpart to the whole society and then acknowledging conflict within society but not within the individual, I believe Adler may have exposed his own resistance to addressing internal conflict.
While resistance was a central concern of psychoanalysis, inferiority was a major concern of individual psychology. Adler (1917) theorized that an individual who believes him or herself to be inferior creates a goal of self-assertion to become superior which follows that others must be made inferior. This sets the individual’s goal above the whole; a condition that Adler (1917) contends is naturally opposed to the greater social good and in opposition to the concept of the absolute logic of society. According to Adler (1917), conflict between this personal goal of superiority and societal goal of advancement of the whole is the cause of neuroses. Neuroses can show up as self-focus, as striving for superiority, or fearing that someone will be better.
The neurotic creates a false image of superiority and attempts to make it real by living what Adler identifies as a fictitious life; a fantasy made to allow the patient to feel superior in a social system that has causes him to feel inferior. This fantasy is the person’s attempt to create substantiation, or proof of his superiority while disproving inferiority, results in experienced everything in opposites: high or low, win or lose, best or worst. He easily loses the feeling of superiority within moments after a high or a win, and returns to a fear of being inferior. Instead of experiencing authentic life, the patient lives in fear avoiding awareness of inferiority and avoiding success which contains the seeds of inferiority, comparable to Freud’s concept of resistance to repressed information.
The irony is that while the individual pushes to substantiate the fiction of superiority, he also creates behaviors to prevent the fiction from meeting reality. The push to attain a goal of superiority results in ambition, arrogance, jealousy, and hatred, but the opposite may also occur when the neurotic person becomes shy, anxious, weak, or withdrawn, creating what Mosak (1995) identified as a “tyranny of the victim”. Adler (1917) suggests that anyone seeking to be superior will experience failure even in success. This sets up self-sabotage to prevent the self from having to face what he calls “substantiated fiction.” Sabotage may take the form of releasing the goal just as it is about to be attained, becoming sick while striving for success, having accidents at critical moments, or perhaps, by experiencing a debilitating neurosis that can be blamed for the failure instead of having to discover the falsity of the goal.
In the practice of Adlerian individual psychology, the therapist has the job of determining if the actual life goal and life style of the patient is contrary to the social goal. If the patients’ life goal and life style are not socially acceptable, psychological disorder will result, while the law of social interest leads to fulfillment of what he considered the 3 main tasks of life: occupation, love and family, and community. The therapist points out to the patient how the fictitious life goal and life style are in opposition to “the reality of life and the law of social interest” (Ellenberger, 1970 p. 620).
I propose that Adler (1917, 1925) set up a codependent system by determining what the patient is experiencing. The theory creates a superior position for the therapist who interprets the patient’s behavior and experience based on that theory, which is the rescuer role in codependency. In spite of the outward appearances of equality between therapist and patient, and the contention that the patient’s choice is paramount, I propose individual psychology is another expression of a relationship of masculine dominance. While Freud seems, in my opinion, to fulfill the dictator role, I submit that Adler fits the image of the superior masculine authority figure role and the patient is the inferior student. Ellenberger’s (1970) comment that “Adler equated resistance with a form of masculine protest, which had to be immediately pointed out to the patient as undesirable” (p.621). This indicates an assumption of therapist domination over the patient. In order for the cure to take place, the patient must submit to the theory and the therapist’s interpretation of the patient’s experience without resistance.
In his theory, Adler (1917) attaches significance to family dynamics related to birth order and the problem of inferiority. He described the position of the second child in a large family as being always under pressure and trying hard to compete with the older sibling (Bottome, 1939). It would not be difficult to see how a theorist, a second born son who felt inferior to his elder brother his entire life (Ellenberger, 1970 p. 577), would propose a theory that emphasized the problem of inferiority while elevating the theorist to a superior position, even while attempting to appear to create equality. His experience with feeling inferior may have allowed him to understand inferiority (Adler, 1917). However, his particular struggle might not be what all patients encounter. It may be that Adler’s painful experience of being a second child was repressed and pushed away only to have it projected into a theory of inferiority and projected onto patient behavior as a struggle for superiority. If the patient gets better, the therapist hopes to substantiate his superiority, and free himself from the unaddressed inferiority from his childhood. Embedded in the therapeutic process is a hidden agenda, the substantiation of the therapist. The therapeutic relationship, as well as the theory, both hide and reveal what is resisted and are expressions of resisted experience in the therapist. Whatever the patient had actually experienced, repressed, and is resisting, represented in the problem that brought him or her to therapy may remain unattended, especially if it is not related to inferiority issues, when therapy is focused on fitting the patient into the theory.
Though Freud and Adler were fundamentally different in their therapeutic models, it was Adler’s individual psychology that most influenced psychoanalytic theory as it evolved into object-relations psychotherapy. These Neo Freudian theorists incorporated an “almost imperceptible assimilation of individual psychological concepts” into their theories, (Ellenberger, 1970, p. 637) including Adler’s interpretation of resistance and the role of the therapist.
Codependent Nurturing Maternalism: The Role of the Care Giving Protector
With the next generation of therapists, the rising feminine consciousness, and the increase in the number of women becoming practitioners, I propose that the role of therapist expanded beyond the predominantly paternalistic authoritarianism as characterized by Freud and Adler to what I call nurturing maternalism. These women include Ainsworth (1962, 1967, 1972, 1973, 1982), A. Freud (1937, 1972), Gilligan (1988, 1993, 1997), Horney (1937, 1939), Klein (1935, 1946), and many others. (Though the English language has the word paternalism that describes a masculine role of domination, there is no equivalent word suggesting a relationship where the one who nurtures takes care by controlling the one nurtured. In order to create equivocation in the masculine and feminine roles in what I propose to be the codependent rescuing therapeutic relationship, I have will use the word maternalistic to identify this kind of care giving.) Maternalistic psychotherapies include therapies such as ego psychology, object relations psychology, self psychology, existentialism, and humanistic psychology. I contend that though the characteristics of the role changed, the potential for codependency did not. Instead of focusing on the theory to instruct the patient to fit into a prescribed mold of psychological health, the new therapies focus on the patient’s feelings to encourage him or her to accept a healthy mold. In both cases, health, as well as the problems that block health, are still identified by the therapist. The therapeutic rescuer in the role of the authoritarian father simply expanded to include the rescuer in a feminine form as maternalistic care-giving mother, both claiming to know what is best for the disturbed and dependent patient-child.
Ego Psychology: The wise old woman and the child in need of direction with patient’s resistance identified as defense of the ego.
Freud had both supporters and detractors as his theories unfolded. Some, such as Adler and Jung parted ways to develop their own theories while others remained committed to his theories and were identified as classical psychoanalysts. Still others began to challenge a few of the premises without completely rejecting Freud’s (1900) basic theory, and finally some changed enough of the foundational precepts of psychoanalysis and incorporated other perspectives that they became new psychotherapies. Perhaps, it was evolution within Freud’s own thought that led to what later became known as neo-Freudian psychoanalysis, which included ego-psychology and object-relations psychotherapy.
Gregory (1987) identified Freud’s youngest daughter, Anna, as the leading proponent of ego-psychology that concentrates on the ego instead of the id. She concluded that ego-weakness, rather than wishes and drives of the id, was the result of unsuccessful defense against instinct and inability to adapt to social realities. Hilgard (1987) suggested that Freud’s (1900) theory gave a pessimistic view of human nature by preoccupation with anxiety and guilt, while the new theorists saw human nature in a more positive light preoccupied with a need to defend against outside threat. I suggest this indicates the shift from a paternalistic therapeutic perspective to a maternalistic one. Hartmann’s Ego Psychology and the Problem of Adaptation (1939) introduced the concept of a “conflict-free ego” sphere, in which problems could be solved in an open and adaptive manner without regard to unconscious residues from infantile experiences (p. 373). It might be valuable to ask what unconscious residues may be hidden.
Those identified as ego psychologists (Cooper, 1987, 1989, 1992; A. Freud, 1937; Hartmann, Kris, & Loewenstein, 1946; Schafer, 1969; Sullivan, 1953) concluded that defense and coping mechanisms due to conflicted wishes are responsible for behavior and mental life disturbance rather than Freud’s (1915c) explanation of drive repression. These conclusions were seen as alternative formulations of theory rather than complementary structures. The analysis of the content of the unconscious and resistance to making the content conscious was replaced by analysis of defense mechanisms “as to whether they were adequate to the patient’s age, and to the external and internal conflicts he had to withstand” (Ellenberger, 1970, p. 860).
Neo-Freudian therapists point out the resistance just as their predecessor did, but with the purpose of making the patient aware of dysfunctional ego defenses instead of repressed drives. Neo-Freudians see transference as just another form of resistance, something to be pointed out, but neither focused upon nor searched out to discover its origins. The emotional dimension and meaning of resisted material to the patient’s psyche is downgraded. In the evolved version of psychoanalysis, rational problem solving takes the place of looking into conflicts and pain in the unconscious. The inner process of resistance that was first acknowledged by Freud (1895) and then by-passed with the collapse of the two definitions into one, became even more removed in Neo-Freudian psychoanalysis. Therapeutic resistance to the internal resistance of the patient, and perhaps the therapist, appears to be a parallel process in this new psychotherapy, somehow matching what may still be unaddressed within the patient.
Object Relations: The therapist as rescuer and patient as the broken child with resistance interpreted as the patient’s avoidance of painful relationship.
Object-relations oriented analysts contributed to major rethinking regarding psychoanalysis. Believing that Freud’s theory was based on too narrow a population that could not account for problems encountered by those patients with whom they worked, relational psychologists determined that the historical and present environment had to be considered in the cause of the disorder and the treatment. Instead of searching deeply into the individual to observe resistances, the focus turned to interaction between individuals and resistance to that interaction (Abraham 1924; Ainsworth, 1962, 1967, 1972, 1973, 1982; Bowlby, 1969, 1973, 1980, 1988; Erikson, 1963, 1982; Fairbairn 1952; Fromm, 1941; Greenberg & Mitchell, 1983; Horney, 1937, 1939; Klein, 1935, 1946; Winnicott, 1965).
From the object-relations perspective behavioral and psychological patterns are created from the interaction of three sources. The first is the complex of mental representation of objects; the second is comprised by the relationship that one’s self has to the world of inner objects, and the third is the condition that requires repetitive reenactment of this inner world in the context of the outer world. Object-relations therapists do not focus on repressed drives and wishes of the patient, with the therapist poised to point out the repressions and the resistances to becoming aware. Instead these analysts acknowledge that resistance provides insight into what constitutes the three sources of the behavioral and psychological patterns. The therapist can discover characteristics of early relationships that negatively impact present relationships and work to correct what was poorly formed (Greenberg & Cheselka, 1995).
Abraham (1924) wrote a significant paper regarding depression and obsession related to unpredictable changes of patients’ “objects.” Klein and Fairbairn were both influenced by this presentation but in very different ways. Klein (1935, 1946) emphasized the original relationship, with mother as the one who feeds the infant, as foundational to child development. She contended that the infant goes through two major shifts while in this original relationship and that later relationships are dependent upon the degree to which this first relationship was a success or failure. She identified the first shift as having to do with the paranoid schizoid position, as the infant becomes aware of its separation and deals with a struggle between its wish for survival (as separate) and its death wish (to be rejoined with mother). The defenses in this struggle are psychical splitting, idealization, projection, and introjection. The second shift takes place in what she referenced as the depressive position when the child realizes that mother is a separate whole person. This awareness drives the child to restore connection for survival. Within this struggle are ambivalent feelings regarding love. The infant yearns for connection but is also angry for being dependent. These conflicts, left unresolved in infancy affect future relationships. The therapist’s job is to assist the patient in resolving the conflicts by joining the patient in a two-person relationship in order to model what the patient missed in the earlier one between mother and child. I propose that when the therapist becomes the care-giving rescuer who interprets the patient’s problem within a theory, he or she has created the potential for a codependent relationship.
Fairbairn (1952) looked at the relationships that are formed as a result of the original relationship and identified them as closed or open. Current closed relationships, based on mother-infant relations that did not successfully transit survival-dependency conflicts, result in what he considers to be crippling division in the self. The part of self that is driven to reconnect is highly sexualized and the part that is driven to independence rejects sexuality. This conflict is repressed, yet is recapitulated, and any attempt to become aware of the division is resisted.
Bowlby (1969, 1973, 1980) and Ainsworth (1962, 1967, 1973, 1982) extended Fairbairn’s (1952) Neo-Freudian, object-relations theory by adding attachment theory, which introduced ethological concepts into psychoanalytic thought. Though not psychotherapeutic, per se, attachment theory provides therapists with ways to investigate relational behavior in the therapeutic relationship as a reflection of the original attachment with mother to determine if that attachment was secure based, insecure, or avoidant.
In this new relational psychotherapy, the patient comes to discuss a particular, concrete problem in the present that could expand to deeper or more general concerns. Instead of the therapist being the interpreter of the patient’s unconscious as in classical Freudian psychoanalysis, this new “relational-psychoanalysis” appears to be patient- oriented. The patient presents the material that will be the subject of the therapist-patient work, and the therapist is a guide, in the direction the patient already has chosen to go by pointing out resistances that inhibit the process. From this perspective, the patient’s unconscious is seen as a safe place for feelings and thoughts or “internalized objects” that would be anxiety provoking, if not debilitating, were they to be conscious (Greenberg & Cheselka, 1995). Resistance is interpreted as simply a protective facet of the unconscious and needs to be understood from a relational viewpoint. The therapeutic relationship, acting as a healthy model, can facilitate the transcending of unhealthy childhood relationships (Buckley, 1996; Fairbairn, 1952).
According to Fairbairn (1952), “the psychotherapist is the true successor to the exorcist. His business is not to pronounce the forgiveness of sins, but to cast out devils” (p.59), those devils being bad object relations. Fairbairn (1952) continued:
There is no doubt in my mind that the greatest source of resistance is the fear of the release of bad objects from the unconscious for, when such bad objects are released, the world around the patient becomes peopled with devils which are too terrifying for him to face. (p. 59)
The good object that takes the place of the bad object is the therapist. There is an assumption that this healthy relationship with the therapist stimulates the growth and strengthening of the arrested ego, thus allowing for the disclosure of inhibiting information that would have been destructive in the less developed ego-self.
Greenberg and Cheselka (1995) suggest that these “relational” psychoanalysts have a belief that conflict permeates all mental processes. “When the thought of exploring a particular issue becomes anxiety producing, aspects of the personality that are security seeking will come into play, and the person may avoid dealing with the very issue for which he/she came into treatment. (p. 66) It becomes the therapist’s job to notice the opposing forces and guide the patient back to the patient’s stated goal. The therapist’s responsibility is to help the patient fight against the resistance to discussing a subject by redirecting the conversation, by asking if the patient is trying to avoid something, perhaps some “bad object” or by drawing attention to something that is missing in the conversation. From this perspective, resistance is respected but also seen as something necessary to point out and remove.
Stark (1994) comes from a similar object relations perspective as Buckley (1996); Fairbairn (1952); Kohut (1959, 1968 a, 1968 b, 1971 1977, 1979, 1981,1984); Rowe (1982, 1993, 1994, a & b, 1996; Rowe & MacIsaac, 1989). She stated that patients are people who protect themselves from the pain of truly knowing their past and present objects. In order to avoid grief, they hold on to misconceptions. Stark (1994) noted that the patient must learn to accept the objects as they are and give up the illusions held of the objects to which they have maintained infantile attachment. She suggested that surviving the pain inherent in the illusion permits the patient to release infantile hope and embrace mature hope. The patient’s work in therapy, according to Stark (1994), is to work with 27 therapeutic tasks, such as arriving on time, talking about childhood events (reminiscent of Freud’s requirement that patients not hold back anything that comes to mind in free association), and getting angry without getting abusive. If patients resist working with the “tasks” the therapist must “articulate the intrapsychic conflict behind the patient’s distress in plain language” (Winer, 1995). Stark’s (1994) method, as in psychoanalytically based therapies, interprets the therapeutic relationship with what is seen as inherent transference characteristics. The relationship becomes the center of therapy, a substitute arena where qualities of the old relationships are worked through by confronting the resistance to the therapeutic relationship.
Horney (1937), who had been an instructor in psychoanalysis, was influenced by the work of anthropologists Ruth Benedict and Margaret Mead and adapted their findings to psychoanalysis. She rejected the tenets of penis envy and libido theory, which resulted in her dismissal from the New York Psychoanalytic Society. Horney (1937) expressed shock by the emphasis placed on success in America, a concept that she believed inevitably would cause a majority of people to feel they had “failed” in life. She saw human relationships that are contaminated by rivalry, as unable to possess genuine warmth and security. Horney (1937) saw this condition as disastrous for the development of a healthy, free personality since the need for security in a hostile world would become the basic dynamic in the formation of character.
Horney (1937) and Adler (1917) had similar interpretations regarding the drive to superiority but differed regarding the etiology of the drive. Adler attributed it to the external social conditions, and Horney interpreted it as coming from the mind attempting to create an artificial, but acceptable self, as if they are mutually exclusive rather than necessarily complementary. Resistance comes into play, according to this neo-Freudian’s perspective, as a means to not feel the pain when the pride system, or idealized self-image begins to be stripped away in psychoanalytic psychotherapy. The stripping occurs to replace the pride system with realization of the true self. Her contribution to psychoanalysis was the proposition that “tensions generated by a culture could be the cause of neurosis” (Lande, 1976).
In ego-psychology and object-relations therapy, I conclude that the maternalistic mother has overshadowed the paternalistic father in the role of therapist. Though it appears that attention is centered on the patient instead of the theory, the therapist still interprets what is occurring within the patient and the therapist’s responsibility is to become the person upon whom the patient is dependent to heal. As long as the therapist continues to define the interiority of the patient, what is really occurring within remains hidden as the relationship and the interpretation overshadow the internal process.
Self Psychology: The therapist as defender of the patient who is weak with resistance used by the patient to create safety.
A more recent change in psychoanalysis came with Kohut (1984) who proposed self psychology, a perspective that interprets the individual’s primary aim as the creation of a cohesive and fulfilled self. To him, the fulfillment of drives, the defense against conflicting wishes, or longing to absorb the objects to which one is attracted are objectives that are contradictory to individual needs. Objects with which someone is in relationship, or selfobjects as Kohut dubbed them, are important for their function in forming and fulfilling self, and not important for their intrinsic essence. Self psychology, as formed by Kohut (1959, 1968, 1977, 1981, 1984), and implemented most notably by Rowe (1982, 1989, 1993, 1994, 1996), moved from a theory-and-analyst based therapy to what was believed to be a more patient-centered approach. Self psychologists believe the patient’s experience, rather than psychoanalytic drive therory, has become the focus of psychotherapy. However, one might notice that theory continues to identify what the patient experiences. The patient who is now in front and center is one who relates to the world and everything in it from a personal utilitarian perspective, unable to experience a “thou” in “I and thou.”
In self psychology theory, the process of mirroring, whereby the caregiver reflects back to the infant what the infant is projecting outward, is seen as a fundamental need in the formation and development of the self. If mirroring is not satisfactorily achieved in the development process, the individual will have an enfeebled sense of self, and development will be arrested, since what is not reflected back is not identified or developed. Resistance to accessing the self is then formed to protect that frailty. Therefore, the therapist does not seek to overcome resistance because resistance is interpreted as necessary in preserving an undeveloped part of the individual. Instead, the therapist provides the function of mirroring to allow the arrested development to be re-stimulated toward completion. (Kohut, 1984, p. 615) “Self psychology’s focus on selfobject as the experience of a function provided is clearly different from that of object relations theory where the focus is on the object per se and not on the functions provided by the object” (Rowe, 1996, p.68). Strean (1996) a leading self psychologist explained that patients are able to move forward in the treatment when their need to maintain their developmental position is respected and resist forward movement when they feel misunderstood. This contrasts with to the classical Freudian view of resistance as “treatment interferences that must be overcome as they defend against awareness of impulses and allow for unconscious instinctual gratification. (Strean, 1996, p. 29)
Transference is still central to Kohut’s self psychology, but the focus is on the patient’s needs related to the developmental stage the patient is experiencing as he or she moves toward mature forms of selfobject transference. Rowe (1996) points out that patients who were seriously disillusioned as children will resist emerging needs to idealize for fear of further disillusionment. “Patients who have suffered humiliation will resist sharing unique thoughts and ideas that could be the target of critics” (p. 86).
Resistances to the development of the selfobject transferences in psychotherapy are, therefore, attempts to protect against being re-traumatized.
Rowe indicated that severely traumatized patients, who have serious defects in the structure of the self, return to these protective patterns of experiencing others during the “working through” process, as well as in times of development of new forms of selfobject transferences. He suggested that this is not a compulsion to repeat, which is the repeating of patterns of behavior that provide instinctual pleasure or unpleasure, as an effort to master and bind excitation. Returning to old patterns is simply going back to the known instead of risking unknown dangers in some new pattern. When the patient-in-resistance feels as if he or she is understood, a mirroring has taken place and the self is strengthened, causing the need for the resistance to disappear. The patient then continues to move up the developmental line toward maturity. The therapist remains in control and identifies the patient’s problems. The potential for codependency remains.
Existentialism: The therapist as companion of the lost patient with resistance as a defense of self-and-world construct.
The person-centered perspective of existential-humanistic psychotherapy grew spontaneously first in Europe in the 1940’s and in America in the 1950’s from psychiatrists and psychologists who believed that earlier theories did not deal with the actual, immediate person to whom things were happening. These therapists were aware that we are living in an age of transition that is experienced by almost every human being as a time of alienation from fellow humans, of threat by nuclear war and economic upsets, and of confusion from the radical changes. They note that we are all beset by anxiety. With the need to deal with this anxiety at its base, existential psychotherapy does not offer answers as much as it “asks deep questions about the nature of the human being and the nature of anxiety, despair, grief, loneliness, isolation, and anomie. It also deals centrally with the questions of creativity and love” (May & Yalom, 1995, p. 262-263).
Existential-humanistic interpretation of the psychodynamics of the human condition sees conflict as central to human experience. This conflict is not like that of the Freudian perspective that sees the individual as an instinctively driven being at war within the self and with the world. It is also not like the Neo-Freudian model that believes the conflict is relational with a struggle between growth toward autonomy and the need for security. The existential-humanist sees the conflict in terms of struggle between the individual and the “givens” of existence that ultimately concern each person. These are “death, freedom, isolation, and meaninglessness” (May & Yalom, 1995). The individual constructs defenses against awareness of these four fears and these constructs become the ground for experience. The resistance to awareness forms not only the world the individual constructs to block that awareness, but also creates the very discontent experienced within that world. This construction is intended to resist experiencing the pain of knowing that death is inevitable, that the self is responsible for what he or she makes of life, that each of us is ultimately alone, and that one must find his or her own meaning in a meaningless universe.
The existential-humanistic perspective recognizes that each person has a self-and-world construct that is, in fact, the life as experienced by that person. (Bugental, 1976, 1986, 1990, 1992; Bugental & Sterling, 1995) When an individual is experiencing life as not satisfactory, it is necessary to change the way of being and the view of the world that is held. The problem is that the subject matter that is being investigated in order to make the changes is the very ground from which the examination takes place. To dismantle the ground is tantamount to the destruction of the self-and-world construct, which is experienced as destruction of the self and life. But to not change the self-and–world construct is to continue to live unsatisfactorily, which too, may seem like self-destruction. Bugental and Sterling (1995) have pointed out that “a person’s self-and-world construct system is that person’s life—or at least the plan or pattern for that person’s life” (p. 234). If that system has been able to evolve in such a way that it provides reasonably dependable outcomes and prevents excessive stresses, it will be strongly defended and will resist any attempt to change it. What may be less obvious is that even if the system does not work so well, the person is still likely to defend it. This is what creates the task of existential-humanistic depth psychotherapy that seeks to assist the patient in making lasting life changes. When the experience of life is too overwhelming, he or she may be willing to consider changing the construct, but the closer to the change, the more overwhelming the fear of the loss of the current construct and self destruction.
This perspective suggests that resistance and defense are two aspects of the same process: the preservation of the self-and-world construct system that the patient feels is necessary to his or her life and yet is destroying life. There is a struggle between the maintenance of the system and dismantling it, which places the patient in a catch-22 situation. It is a gamble of current benefit/costs against hypothetically greater future benefits without any assurance that giving up the former will produce the latter.
If the therapist is to be useful, he or she must be an ally who can remain with the person as a supportive companion while the patient finds his or her own way out of the seemingly impossible trap. However, if the therapist conceives resistance as being in opposition to therapeutic intervention instead of an understandable defense of the only way the patient knows how to live in the world, the therapist becomes an adversary instead of an ally. The patient may now have to resist the therapist’s pressure to change the self-and-world construct as well as their own inner conflict about the change. Instead of facilitating change, the therapist interferes with the transformation process that is being called into existence by the challenge. When the therapist is seen as an adversary the patient may resist the direction toward which he or she believes that the therapist is trying to push (Bugental, 1976; Bugental & Sterling, 1995; Gilligan, Rogers, & Tolman, 1997).
Bugental (1976) differs from therapists who interpret resistance to be the patient’s defense against the interpretations of behavior made by therapists. Instead he defines resistance as:
…the impulse to protect one’s familiar identity and known world against perceived threat. In depth psychotherapy, resistance is those ways in which the patient avoids being truly subjectively present—accessible and expressive—in the therapeutic work. The conscious or unconscious threat is that immersion will bring challenges to the patient’s being in her world. (p. 175)
Bugental (1976) suggests that resistance, outside of therapy, as well as in therapy, results in inauthentic being. The person has removed him or her self from subjective experience and avoids presence in life by objectifying the self. May (1991) in The Cry for Myth, uses the Oedipus myth (Freud, 1924) itself to point out that it is not just fantasy that is significant in human nature (and, therefore, in any therapy process that deals with human nature). The resistance to knowing the truth of the fantasy for which one wishes is also central to our natures and to therapy (p.73).
Bugental and Sterling (1995) identify what he calls two capacities of human beings. One capacity holds the “learning” that has been incorporated into a person’s personal knowledge. This is what we call on when we encounter something that is familiar. These authors contend that “searching,” the second process, is complementary to learning and is called on:
When we do not have a satisfactory pre-established path for dealing with a situation of importance to us. Searching involves risking openness to the unknown, exploring possibilities, experimenting with some that seem likely, using alternative paths when blocked, and eventually resolving the situation. (p. 235)
This searching capacity has been given greater attention in psychotherapy and has been named “free association” in psychoanalysis, “unfolding” by Buber (1970) and “focusing” by Gendlin (1978), all similar ways of tapping into the same human power.
By assisting the patient in his or her internal investigation through seeking, an understanding and reorganization of information can occur. The expanding, deepening, and transforming of self-and-world structures can take place. In order for this transformation to occur, the therapist reflects back to the patient old defensive patterns that have been part of the old self-and-world structures that protect, but also stand in the way of changes the patient wants to make. The resistance must be “worked through” at the time it occurs by continually pointing it out and asking the patient to become conscious of the patterns and their ill consequences.
It is highly desirable for the therapeutic relationship to become strong enough to support the patient as he or she begins to call into question self-definition and world-view. This level of work is with character structures and arises “from experience that actually began at the preverbal level and then…(became)…extended and modified by the patient’s life and inner promptings” (Bugental & Sterling, 1995). Once this level is reached in the patient, the relationship with the therapist (as in Fairbairn, 1952; Klein, 1935, 1946; Kohut, 1959, 1968, 1977, 1981, 1984) becomes a part of the self-and-world construct, then major self-and-world structures can be reconstructed.
Bugental and Sterling (1995) identify three distinguishing aspects of existential-humanistic psychotherapy. The first is that the therapist does not attempt to account for the patient’s symptoms in terms of the patient’s history. “Purpose, rather than cause, is the decisive dynamic” (Raskin & Rogers, 1995). Causal thinking, they suggest, objectifies the patient and loses genuine presence needed for productive searching. According to Bugental and Sterling (1995) instead of looking into the patient’s history, the therapist must focus on how the patient is in the world and how the patient is attempting to make his or her life more pleasant in the present. The second characteristic, like most of the other methods, is that the therapist’s job is to assist the patient in fostering inner awareness, by identifying the resistances. Finally, the therapist, as Adler insisted, is an educator, facilitating the enlargement and change of the patient’s way of being in the world. This is not a medical, curative, or healing process, it is educational. (p. 249). One might question the need to make these therapeutic outcomes oppositional or exclusive.
As person-centered as this approach appears to be, the therapist remains the one who maintains focus on the present and uses the past only to identify character structures. The therapist identifies the resistance and has determined the patient’s interior experience based on a theory. The therapist’s objective remains in that the focus is on how the patient is in the world and how the patient is attempting to make his or her life more pleasant in the present, instead of encouraging the patient to go inward to discover resistance, repression, experience, and meaning.
Other Therapeutic Relationships
Otto Rank (1929) proposed that birth created suffering, and was the greatest trauma of all. He suggested that there is an unconscious longing to return to the womb, similar to Klein’s (1935, 1946) paranoid schizoid shift. He proposed that all of a person’s life experience is formed by the birth experience. Transference is interpreted as reenactment of the infant’s mother fixation. Healing occurs after abreaction to the birth trauma, and successful separation from the analyst has occurred. In this relationship, the therapist is the coach and resistance is evidence of a patient’s will to independence, and therefore a positive factor. Rank focused on the immediate analytic situation rather than on the past. He emphasized ‘experiencing’ rather than learning, and becoming aware of the patterns of reaction rather than analyzing individual experiences. The will to self-determination and the creative aspects of the patients behavior received attention. Rank (1929) determined that instead of wearing down resistance, as a Freudian analyst would likely attempt, resistance should be used to direct self-discovery and development. While there may be truth here for some patients, someone who experienced abandonment and resists reconnecting with the debilitating pain of separation by non-attachment may not identify with a therapist who can only see a need for independence.
Wilhelm Reich (1933), a psychoanalyst, shifted the Freudian focus on sexual energy, from the drive perspective, to a biological-energetic perspective. He proposed that social inhibitions against sexual expression and resistance to those inhibitions created not only psychological disturbance but also muscular tension and eventually, physical illness. While Freud and Adler applauded the constraints of society, Reich, like Horney, believed that society is the cause of the tension and illness. Reich contended that dissolving of the psychic resistance is parallel to that of the “muscle armour” that relaxes in the release of sexual tension. The idea that the body could hold psychological tension became a component in the explosion of body therapies in the decades that followed (Bing et al, 1999). Like Freud who limited the libido to sexuality without including will and striving, Reich limits his theory to sexual tension when it is possible that others may suffer from tensions caused by other issues. A narrow understanding of body tension may distract the patient from searching for unconscious psychophysiological response to the other forms of trauma that remain hidden and resisted.
Perhaps the two theories that came closest to being interior-oriented were Rogerian Psychotherapy and Jungian Analytical Psychology. Yet they, too, created forms that contain the potential for missing the information the client resists. Roger’s (1951, 1961) perspective appears to be person-centered. He presented a method whereby resistance is circumvented by not engaging it. The job of the therapist as in self psychology is simply to mirror back to the patient what the patient presents. However, to focus fully on the patient as if the therapist and the relationship do not exist other than as a mirror of the patient, is to assume that the “mirror” reflects only the patient, rather than the therapist’s image of the patient. I propose that to resist resistance by entering the therapeutic relationship in a way that does not engage resistance may lead to a possible dismissal, denial, diminishing, or dissociating of what is deeply buried and resisted. A therapy that has created a method that makes the therapist invisible, perhaps is a metaphor for a theorist, as well as a therapist, who cannot see him or her self.
Jung (1934, 1936,1939) was a seasoned veteran of the inner-journey, having spent six years on his own quest that led beyond the personal unconscious into the collective unconscious. He believed that the journey inward opened to “the reservoir of thoughts and images of all mankind, a sort of agglomeration of the archetypes…(that are)…preexisting forms that seem to be the inherited structure of the psyche” (Lande, 1976, p. 39). Corsini and Wedding (1995), editors of Current Psychotherapies, described Jungian psychology as especially inclusive in that it embraces concepts from Janet, Freud, and Adler. However, Jung added wholeness, completion, and individuation. The editors point out that this perspective allows for the “depths of the collective unconscious and width of humanity’s collective history, art, and culture while grounding itself solidly in the particular individual at a particular time and moment” (p. 125). What is significant about Jung’s experience toward individuation and wholeness is that he took the journey by himself. After having had his own experience, he outlined the journey for others, recommended that all analysts go through analysis and advised anyone seeking individuation to then take their inner quest in analysis only with a seasoned veteran. Regarding that journey, Jung pointed out: “the dread and resistance which every natural human being experiences when it comes to delving too deeply into himself, is, at bottom, the fear of the journey into Hades” (1953, V. 12. p. 336).
In detailing the domain of the personal and collective unconscious, and identifying all the internal and archetypal players, Jung created a path for others to follow. However, by detailing that path, it is possible that the apprentice may not be able to discover his own individuation because a master-in-the-making must create his own path by surrendering to the journey, not to his master’s path. I propose that Jung created a system that has the potential to produce technicians rather than masters, and they may find what Jung found rather than discover their own resistances, their own Hades.
Ellenberger (1970) made a summation of the inner journeys of Freud and Jung by noting that:
Those who undertake a Freudian analysis will soon develop intensive transference neurosis, have Freudian dreams, and discover their Oedipus complex, child sexuality, and castration anxiety. Those who undertake a Jungian analysis will have Jungian dreams, confront their shadow, their anima, their archetypes and pursue individuation. (p. 737)
I propose that the same observation can be applied to of any of the therapies reviewed in this study. Those patients who identify with the world-view of their therapists or those who have a need to be compliant in a codependent relationship may organize their therapeutic experience around the therapy presented. Those patients who follow the therapist out of codependency will likely find what the therapist expects them to find. Those who do not identify with the therapeutic world-view or have a codependent need to challenge the control of the therapist will be resistant and may, together with the therapist, focus on the external relationship instead of search for what information is being resisted. It would be possible for the compliant or resistive patient to miss what is hidden within the self as the patient focuses on working with or against the therapist. If the relationship is the focus of therapy, the very resistance experienced within the interiority of the patient is duplicated in the relationship. If the therapist is also using his or her therapeutic perspective as a means to resist his or her internally repressed information, not only is a codependent relationship established with the patient, but an unconscious complicity may be established. Therapy may parallel the resistance of the patient as well as the therapist and the theory.
After reviewing psychoanalysis and the major theories that have been influenced by or evolved from psychoanalysis, I have noticed a pattern that I propose creates the codependent therapeutic relationship. Psychotherapists with pre-conceptions regarding what causes neuroses are confronted with patients who have psychological disturbance. The patients reveal their neuroses and what the therapists interprets, the patients may resist. The job of therapists is to continue to interpret the problems and confront the resistance until the patients accept the interpretation and release the neuroses. What may not be as obvious in this pattern, I believe, is that theorists bring their personal experiences as well as their resistances into the observations, the formation of the theories, and the interpretation of patients. (Freud’s struggle with his father can be seen in the Oedipal theory and Adler’s competition with his older brother seems to have made its way into the theory of inferiority.) Another part of the pattern that may not be noticed is that, too often, the theory rather than the person is what is seen. Theories based on the observation of patients as in the case of person-centered therapies, those founded on some application of natural science as in psychoanalysis, or the ones growing out of medical discovery as in individual psychology, get in the way of the persons who sit in front of therapists. Without the patient experiencing his or her interiority, the internal process of resistance remains unaddressed.
Jung (1954) proposed that the outside world can only be known through a person’s internal images of the outside world. The images and the organization of them into meaning are largely unconscious. Therefore, what each of us perceives is largely determined by who we are. What each theorist concluded about others is likely more a reflection of his or her interiority than about anyone who might be sitting in the patient’s chair or lying on the couch. The assumption that the theory is correct, focuses attention on the assumption rather than on the patient’s internal experience and the patient is not seen.
Conclusions and a Non-Traditional Interpretation of Resistance
I propose that Freud’s shift in focus from the internal experience of the patient, to the external therapeutic relationship and to the theory regarding interiority and resistance, became the prototype for major psychotherapeutic theories, in spite of the fact that some are considered to be patient-centered. Historically, the theoretic stance, rather than the patient experiencing his or her interiority, is what identifies and interprets the internal experience of the patient. That stance also defines internal resistance in terms of patient resistance to therapy.
From this review I conclude that underneath resistance there is pain (e.g., Breuer & Freud, 1995; Buckley, 1996; Freud, 1933; Horney, 1939; Jung, 1953; Stark, 1994) related to unresolved, unexpressed and, therefore, unintegrated experience. This review supports the conclusion that underneath the pain there is fear (Freud , Adler, Jung, Fairbairn, Rowe, Bugental). Dissociation from pain and fear related information regarding painful experiences creates internal disturbance, which in turn creates neuroses. Current psychotherapies have evolved from early attempts to address these debilitating neuroses. However external observation rather than internal exploration of the pain and fear has produced therapeutic methods that have inherent limitations at best and are complicit in the unconscious conspiracy to resist awareness of interiority at worst.
I submit that neuroses are healed when the patient garners the courage to feel the pain, and surrender to the fear of what the pain means. Without a therapist or a theory deciding ahead of time what is painful or feared, the patient is able to discover what has been repressed and resisted. This can only be done by rejecting Freud’s (1900) collapsed definition of resistance and giving credence to the patients’ experience of his or her own interiority. In so doing, the patient has the responsibility to discover the cause of the problem and the therapist becomes a facilitator for the patient’s self-search. The unaddressed resistance may be related to sexual abuse or sexual fantasy; resistance may be covering the fear of inferiority or the lack of a loving relationship with mother. It may be an existential struggle regarding death, or related to the shock of being born. It may be the pain of having choice removed or the fear of making a wrong choice when given freedom to choose or any of the experiences we have in being human. But this is for the patient to discover, not for the therapist to determine based on a theory. There is no need control the self-search, and no need to prove or disprove any particular theory.
The more that the therapist has done his or her own self-searching to overcome pain and face fear, the more effectively the therapist can be a facilitator for the patient’s investigation rather than a role player in a codependent relationship. The patient can know that another human being has plunged into Hades, and made it out to the other side. Both Freud and Jung recommended that analysts go through analysis to know how to direct the patient on the journey. I propose that the value of the therapist taking the journey inward is that theory, therapy, and the patient do not receive projections of the therapist’s resistance, which frees therapist and patient to focus on the disturbance that caused the patient to begin the therapeutic process. I contend that the truly effective therapist is one who has taken his or her own inner journey and has discovered and overcome resistances that hide the pain. After experiencing a successful journey, the therapist no longer needs to use relationships, including therapeutic relationships to enhance self-esteem, to feel empowered in life, and to be assured of self-worth and worthiness. The therapist can authentically enter a therapeutic relationship that acknowledges the esteem, the power, and the worthiness of the patient to discover his or her own interiority and take responsibility for self-healing.
I became interested in resistance in psychotherapy as a result of my own struggle with internal resistance in a particular area of my life. I wanted to review what theorists had discovered about the interior process that would allow me to better access my own resistance. However, as I reviewed each of the therapeutic positions included in this study, I found a myriad of observational explanations regarding the cause of resistance and how it plays out in the therapeutic setting, but found little about the internal confrontation of one’s own resistance from the experiential perspective. It would be a useful contribution to the literature to conduct heuristic self-search inquiry (Moustakas, 1990, Sela-Smith, 2001) from a researcher-as-participant perspective into overcoming resistance.
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