Therapy and Cure II: The Relational Psychologies

“To love oneself is the beginning of a lifelong romance.”

—Oscar Wilde

Drive and ego psychologies are essentially one-person systems and conceptualize therapy as the correction of errors or the repair of injuries within that self-contained system. The relational theories, i.e., the object relations schools and self psychology, view development and psychopathology as creations of an interpersonal environment. It follows that they would have very different philosophies about the curative process of psychotherapy, and the types of interventions that are mandated.

OBJECT RELATIONS

As noted in Chapter 5, although the object relations theories are best known for their differences, they have more in common. While the specifics of intervention and therapeutic style vary across object relations theories, many fundamentals of therapeutic philosophy and the curative process are shared by all of them. Therapeutic principles common to all object relations theories include these:

Since the patient’s problems are relational in origin and nature, cure comes through rectification of perceptions of, and relationships with, others.
Identification, elaboration, and understanding of emotional states are necessary for the therapeutic process.
Interventions, especially interpretations, not only convey information, but also convey an interpersonal message and influence the dyadic exchange.
▪ The patient brings his or her relational patterns into the therapy and these are mobilized in the transference. The transference is also substantially and specifically influenced by the therapist’s conduct and communication.
The patient-therapist interaction has therapeutic potential that transcends the power of interpretations alone.
Cure is achieved when the patient is released from irresistible repetition of old and maladaptive patterns of perceiving and relating and is free to choose modes fitting to his or her current circumstances.

Comparisons with the one-person psychologies of the drive and ego models highlight the tenets that characterize object relations therapies. The therapeutic implications of the different models are outlined in Table 9-1. Like the preceding models, object relations therapies use interpretation as a central element, but the focus is different. Instead of looking at Oedipal-phase conflicts based in drives, and in the defenses mobilized against them, object relations therapy pays attention to pre-Oedipal relations, particularly maternal ones. Where objects are incidental to one-person models, the internal object world is the primary target of investigation by therapists of the relational schools. Drive and ego psychologies presume that once the conflicts are resolved and/or the defenses improved, then relations will follow suit. Object relations psychologies maintain that correction of distorted object perceptions is the primary focus and that conflicts and symptoms will improve in due course.

TABLE 9-1 Comparison of Therapy from the Major Perspectives

	*Drive*	*Ego*	*Object Relations*	*Self*
Origin of pathology	Id impulses seek expression and gratification. Defenses mounted by ego and superego yield pathologic behavior and emotions.	Symptoms are produced by ego in a misplaced attempt at adaptation.	Symptoms reflect distorted object relations and/or attempts to substitute for them.	Symptoms are breakdown products of noncohesive self. Self-pathology is result of imbalance of mirroring and idealizing poles; a matter of deficit, not conflict.
Goals	– Real improvement in mental functioning – Acquisition of insight – Development of tolerance of drives – Ability to assess and accept oneself objectively – Freedom from tensions and inhibitions – Realignment of aggressive energies for self-preservation and achievement – Improved reality adjustment – Consistent and loyal interpersonal relations with well-chosen objects – Free function of abilities in productive work – Improved sublimation in recreation and avocation – Full heterosexual function	– Relief of affective symptoms – Conscious control over symptomatic behaviors – Recognition of defensive operations – Deliberate choice of defense mechanisms – Maturation of defenses to age-appropriate level – Improved interpersonal relations	– Perceptions of others grounded in reality – Conscious choices of objects based on current affective needs and ability of others to provide – Affective stability – Productive channeling of aggressive energies – Minimization of splitting (as defined by respective object relations theories)	– Removal of inhibitions to inherent push toward healthy development – Consistent self-identity – Selfobject needs appropriate to current maturity and environment – Affective stability – Capacity for self-soothing – Capacities for empathy, creativity, humor, wisdom, and acceptance of mortality
Questions	– What drive urge is being expressed? – What unconscious ideas are forcing the drive wishes to be repressed? – What defenses is the ego using to deal with the urges? – How do the defenses themselves reflect the id’s drives? – What compromise is ego maintaining among drive wish, defense, and reality?	– What defenses are operating against the drives? – How adaptive are they? – What affects are provoking them? – What tools of adaptation have failed to develop abnormally or at all? – What areas of the conflict-free sphere are inadequately developed? – What factors in the environment shaped the maladaptive or inadequate development of the ego?	– What is the nature of current object relations (as defined by respective object relations theories)? – At what developmental stage were object relations disrupted? – What injury, trauma, or deficit derailed normal object relations development? – What is the patient seeking from current relations?	– What is the nature of selfobject needs? – What is the balance between mirroring and idealizing poles of development? – What injuries or deficiencies in the past prevented healthy development?
Nature and content of interventions	– Encouragement of free association and recollection of repressed ideas and emotions – Identification of id impulses and drive derivatives – Interpretation of conflicts that result in pathological phenomena	– Identification of affects – Identification of defense mechanisms at work – Elaboration of intended adaptive purpose of defenses – Identification of relevant life-stage issues in development – Assessment of adaptive value of perceptions and responses	– Identification of distorted perceptions of and wishes from others – Identification of affective context of behaviors – Identification of splitting of affects and/or objects – Clarification of consequences of relational distortions – Exploration of alternative perceptions and relations – Strong emphasis on object relations in transference – Countertransference is diagnostic of object relations pathology	– Identification of selfobject needs, particularly in transference – Effects of disruptions in selfobject matrix by failings of therapist – Healing effects of therapist’s empathy – Specific avoidance of expectation of change
Transference	– Therapist is blank screen onto whom patient projects ongoing wishes, fears, and distortions – Analysis of transference is most productive realm for understanding drive impulses and defenses against them	– Therapist brings personal characteristics and behavior into the dyad; patient responds in attempts to adapt – Transference is most productive venue for understanding and changing patterns of maladaptive response	– Therapist is a specific individual who serves as the object of transference projections and brings his or her own character and behaviors into the dyad – Transference is inherently dyadic – Transference is necessary target of analysis and interpretation – Transference has curative potential (depending on specific object relations theory)	– Therapist is participant in selfobject matrix – Therapist is an individual who makes specific contributions to the transference dyad – Disruption by therapist’s perceived failings is inevitable and serves a basis for disruption-restoration cycle of therapy

Since drive theory holds that pathology results from material that was improperly repressed, then cure requires that it be recovered, claimed, and appropriately internalized into the ego under conscious control. Object relations theory attributes pathology to wrongly internalized objects, and therefore successful therapy requires that those pathogenic objects be disowned and externalized in order to be replaced with more realistic ones.

Transference in drive and ego psychology is a projection of the patient’s unconscious expectations onto the relatively neutral screen of the therapist. In the relational model, the patient still brings in his or her habitual patterns of perception, hope, and fear; but the therapist is no longer considered a blank slate. The transference instead is inherently dyadic. There are two very real human beings involved in a prolonged emotional encounter. The specifics of the therapist’s appearance, demeanor, communication, and behavior all have particular reference in the patient’s object world. The therapist is also affected, as the patient’s emotions and projections influence his or her own feelings and fantasies. The object relations therapist is obliged to examine his or her particular responses to the patient, understand the contributions of his or her own unresolved issues, and assess what the patient has contributed to the interaction. Countertransference becomes not an impediment or complication, as it is in one-person psychologies, but an opportunity for emotionally based diagnostic scrutiny.

This perspective adds a dimension to the nature of interpretation. In the drive and ego models, interpretations convey information that uncovers unconscious motivations and brings them under conscious control of the ego. In the relational models, interpretation is also an interaction. Every communication from the therapist is conveyed in an affective context. Every action or intervention is an interpersonal event perceived through the template of the patient’s mode of object relations. The patient is not only informed by an interpretation, he or she is also changed by the process of sharing it with the therapist. The therapist pays attention to the context of the interpretation, and to the patient’s responses to it, and may use that observation as the focus of further interpretation.

Since pathology can all be traced to disturbed object relations, since those pathogenic patterns are predictably reenacted in the specific dyad of the transference, and since cure depends on correction of those relational distortions, it follows necessarily that the transference is a vehicle not only of diagnosis but also of
therapy. To varying degrees, each of the object-relational schools views the therapeutic relationship as an opportunity for direct change in the maladaptive patterns of perception and response in which the patient’s suffering is based. Through interpretation at least, and in some models by direct intervention, the therapist uses the transference as a corrective experience for the patient.

Guided by their respective models of normal human development and its vulnerabilities to maladjustment, the theories differ in other dimensions:

The emphasis placed on the drives and their manifestations
The focus on the self as an object of attention
The degree of directive activity required of the therapist
The degree to which the therapist attempts to become a corrective object in the patient’s world

Each of the major object relations theorists owns a model of human development. Just as each model paints a different picture of how misdirected development produces pathological results, each points the therapist in a particular direction toward effecting change.

Melanie Klein

Klein’s models pay particular attention to the object-based nature of the drives, to the primary role of fantasy in the object world, to the intensity of aggression as a driving force in normality and pathology, to the centrality of the conflict between love and hate, and to the persistence of the depressive position through adult life. In the domain of therapy, she dealt primarily with children and is perhaps best known for introducing play therapy as a technique. Her successors have adapted her models for psychotherapy with adults (mainly for psychoanalysis).

Kleinian therapy searches actively for the prevailing fantasies, since these elements are at the root of all relational experiences. Dreams, daydreams, and spontaneous elaborations are mined for their fantastic content. Stories of real-life events are reformulated around the presumptive fantasies at their center, as are reactions to the therapist. Presuming the presence of hidden aggressive impulses, and of love-hate conflicts, the therapist quite actively makes direct interpretations of the hypothesized meaning of the images in the fantasies. These explications often center on sadistic intentions and consequent guilt.

When MS. GRAY announced her desire to drive her car into a telephone pole, the therapist noted, “That seems like a very angry thing to do.” Ms. Gray confirmed her anger and, with some facilitation by the therapist, she listed some of the many objects of her anger: Michael, her parents, her unpredictable moods. “And me?” queried the therapist. “I’m going to be leaving you in a few weeks. What are your ideas about that?” With that invitation, Ms. Gray elaborated her fantasies that the therapist was unable to tolerate Ms. Gray’s emotions and that he was leaving her with Michael just as her mother had failed to protect her against her father. As she spoke, her hostility toward the therapist grew and she expressed her wish that his plane would crash on his vacation. When prompted for her feelings in the event that were actually to happen, she acknowledged she would feel avenged but terribly guilty. The therapist suggested that her own violent suicidal fantasy was an expression of self-punishment for her wish to kill the therapist.