03 - 4.3 Other Psychodynamic Schools

4.3 Other Psychodynamic Schools

Aging Hum Dev. 2004;58:29–48. Wulff D. Freud and Freudians on religion: A reader. Int J Psychol and Rel. 2003;13:223. 4.3 Other Psychodynamic Schools The men and women discussed in this chapter contributed to psychiatric thought and practice in the early and middle years of the 20th century. Many of these theories of psychopathology evolved as direct offshoots of Freudian psychoanalysis. This, however, derived from various aspects of psychology, such as learning theory and quantitative methods of personality assessment. The theories selected for the discussion in this section have stood the test of time and are most relevant for psychiatry. Brief synopses of the theories that exert the greatest influence on current psychiatric thought are listed below in alphabetical order of their proponent. Each of these theories contains insights that merit consideration because they enhance our understanding of the complexities of human behavior. They also illustrate the diversity of theoretical orientation that characterizes psychiatry today. KARL ABRAHAM (1877–1925) Karl Abraham, one of Sigmund Freud’s earliest disciples, was the first psychoanalyst in Germany. He is best known for his explication of depression from a psychoanalytic perspective and for his elaboration of Freud’s stages of psychosexual development. Abraham divided the oral stage into a biting phase and a sucking phase; the anal stage into a destructive-expulsive (anal-sadistic) phase and a mastering-retentive (anal-erotic) phase; and the phallic stage into an early phase of partial genital love (true phallic phase) and a later mature genital phase. Abraham also linked the psychosexual stages to specific syndromes. For example, he postulated that obsessional neurosis resulted from fixation at the anal-sadistic phase and depression from fixation at the oral stage. ALFRED ADLER (1870–1937) Alfred Adler (Fig. 4.3-1) was born in Vienna, Austria, where he spent most of his life. A general physician, he became one of the original four members of Freud’s circle in 1902. Adler never accepted the primacy of the libido theory, the sexual origin of neurosis, or the importance of infantile wishes. Adler thought that aggression was far more important, specifically in its manifestation as a striving for power, which he believed to be a masculine trait. He introduced the term masculine protest to describe the tendency to move from a passive, feminine role to a masculine, active role. Adler’s theories are collectively known as individual psychology.

FIGURE 4.3-1 Alfred Adler. (print includes signature). (Courtesy of Alexandra Adler.) Adler saw individuals as unique, unified biological entities whose psychological processes fit together into an individual lifestyle. He also postulated a principle of dynamism, in which every individual is future-directed and moves toward a goal. Adler also emphasized the interface between individuals and their social environment: the primacy of action in the real work over fantasy. Adler coined the term inferiority complex to refer to a sense of inadequacy and weakness that is universal and inborn. A developing child’s self-esteem is compromised by a physical defect, and Adler referred to this phenomenon as organ inferiority. He also thought that a basic inferiority tied to children’s oedipal longings could never be gratified. Adler was one of the first developmental theorists to recognize the importance of children’s birth order in their families of origin. The firstborn child reacts with anger to the birth of siblings and struggles against giving up the powerful position of only child. They tend not to share and become conservative. The second-born child must constantly strive to compete with the firstborn. Youngest children feel secure because they have never been displaced. Adler thought that a child’s sibling position results in lifelong influences on character and lifestyle. The primary therapeutic approach in adlerian therapy is encouragement, through which Adler believed his patients could overcome feelings of inferiority. Consistent human relatedness, in his view, leads to greater hope, less isolation, and greater affiliation with society. He believed that patients needed to develop a greater sense of their own dignity and worth

and renewed appreciation of their abilities and strengths. FRANZ ALEXANDER (1891–1964) Franz Alexander (Fig. 4.3-2) emigrated from his native Germany to the United States, where he settled in Chicago and founded the Chicago Institute for Psychoanalysis. He wrote extensively about the association between specific personality traits and certain psychosomatic ailments, a point of view that came to be known as the specificity hypothesis. Alexander fell out of favor with classic analysts for advocating the corrective emotional experience as part of analytic technique. In this approach, Alexander suggested that an analyst must deliberately adopt a particular mode of relatedness with a patient to counteract noxious childhood influences from the patient’s parents. He believed that the trusting, supportive relationship between patient and analyst enabled the patient to master childhood traumas and to grow from the experience. FIGURE 4.3-2 Franz Alexander. (Courtesy of Franz Alexander.) GORDON ALLPORT (1897–1967) Gordon Allport (Fig. 4.3-3), a psychologist in the United States, is known as the founder of the humanistic school of psychology, which holds that each person has an inherent potential for autonomous function and growth. At Harvard University, he taught the first course in the psychology of personality offered at a college in the United States.

FIGURE 4.3-3 Gordon Allport. (© Bettmann/Corbis.) Allport believed that a person’s only real guarantee of personal existence is a sense of self. Selfhood develops through a series of stages, from awareness of the body to self-identity. Allport used the term propriem to describe strivings related to maintenance of self-identity and self-esteem. He used the term traits to refer to the chief units of personality structure. Personal dispositions are individual traits that represent the essence of an individual’s unique personality. Maturity is characterized by a capacity to relate to others with warmth and intimacy and an expanded sense of self. In Allport’s view, mature persons have security, humor, insight, enthusiasm, and zest. Psychotherapy is geared to helping patients realize these characteristics. MICHAEL BALINT (1896–1970) Michael Balint was considered a member of the independent or middle group of object relations theorists in the United Kingdom. Balint believed that the urge for the primary love object underlies virtually all psychological phenomena. Infants wish to be loved totally and unconditionally, and when a mother is not forthcoming with appropriate nurturance, a child devotes his or her life to a search for the love missed in childhood. According to Balint, the basic fault is the feeling of many patients that something is missing. As with Ronald Fairbairn and Donald W. Winnicott, Balint understood this deficit in internal structure to result from maternal failures. He viewed all psychological motivations as stemming from the failure to receive adequate maternal love. Unlike Fairbairn, however, Balint did not entirely abandon drive theory. He suggested that libido, for example, is both pleasure seeking and object seeking. He also worked with seriously disturbed patients, and like Winnicott, he thought that certain aspects of psychoanalytic treatment occur at a more profound level than that of the ordinary verbal explanatory

interpretations. Although some material involving genital psychosexual stages of development can be interpreted from the perspective of intrapsychic conflict, Balint believed that certain preverbal phenomena are reexperienced in analysis and that the relationship itself is decisive in dealing with this realm of early experience. ERIC BERNE (1910–1970) Eric Berne (Fig. 4.3-4) began his professional life as a training and supervising analyst in classic psychoanalytic theory and technique, but ultimately developed his own school, known as transactional analysis. A transaction is a stimulus presented by one person that evokes a corresponding response in another. Berne defined psychological games as stereotyped and predictable transactions that persons learn in childhood and continue to play throughout their lives. Strokes, the basic motivating factors of human behavior, consist of specific rewards, such as approval and love. All persons have three ego states that exist within them: the child, which represents primitive elements that become fixed in early childhood; the adult, which is the part of the personality capable of objective appraisals of reality; and the parent, which is an introject of the values of a person’s actual parents. The therapeutic process is geared toward helping patients understand whether they are functioning in the child, adult, or parent mode in their interactions with others. As patients learn to recognize characteristic games played again and again throughout life, they can ultimately function in the adult mode as much as possible in interpersonal relationships. FIGURE 4.3-4 Eric Berne. (Courtesy of Wide World Photos.) WILFRED BION (1897–1979)

Wilfred Bion expanded Melanie Klein’s concept of projective identification to include an interpersonal process in which a therapist feels coerced by a patient into playing a particular role in the patient’s internal world. He also developed the notion that the therapist must contain what the patient has projected so that it is processed and returned to the patient in modified form. Bion believed that a similar process occurs between mother and infant. He also observed that “psychotic” and “nonpsychotic” aspects of the mind function simultaneously as suborganizations. Bion is probably best known for his application of psychoanalytic ideas to groups. Whenever a group gets derailed from its task, it deteriorates into one of three basic states: dependency, pairing, or fight-flight. JOHN BOWLBY (1907–1990) John Bowlby is generally considered the founder of attachment theory. He formed his ideas about attachment in the 1950s while he was consulting with the World Health Organization (WHO) on the problems of homelessness in children. He stressed that the essence of attachment is proximity (i.e., the tendency of a child to stay close to the mother or caregiver). His theory of the mother–infant bond was firmly rooted in biology and drew extensively from ethology and evolutionary theory. A basic sense of security and safety is derived from a continuous and close relationship with a caregiver, according to Bowlby. This readiness for attachment is biologically driven, and Bowlby stressed that attachment is reciprocal. Maternal bonding and care giving are always intertwined with the child’s attachment behavior. Bowlby felt that without this early proximity to the mother or caregiver, the child does not develop a secure base, which he considered a launching pad for independence. In the absence of a secure base, the child feels frightened or threatened, and development is severely compromised. Bowlby and attachment theory are discussed in detail in Section 2.2. RAYMOND CATTELL (1905–1998) Raymond Cattell obtained his Ph.D. in England before moving to the United States. He introduced the use of multivariate analysis and factor analysis—statistical procedures that simultaneously examine the relations among multiple variables and factors—to the study of personality. By examining a person’s life record objectively, using personal interviewing and questionnaire data, Cattell described a variety of traits that represent the building blocks of personality. Traits are both biologically based and environmentally determined or learned. Biological traits include sex, gregariousness, aggression, and parental protectiveness. Environmentally learned traits include cultural ideas, such as work, religion, intimacy, romance, and identity. An important concept is the law of coercion to the biosocial mean, which holds that society exerts pressure on genetically different persons to conform to social norms. For example, a person with a strong genetic tendency toward dominance is likely to receive social encouragement for restraint, whereas the naturally submissive person will be encouraged toward self-assertion.

RONALD FAIRBAIRN (1889–1964) Ronald Fairbairn, a Scottish analyst who worked most of his life in relative isolation, was one of the major psychoanalytic theorists in the British school of object relations. He suggested that infants are not primarily motivated by the drives of libido and aggression but are by an object-seeking instinct. Fairbairn replaced the Freudian ideas of energy, ego, and id with the notion of dynamic structures. When an infant encounters frustration, a portion of the ego is defensively split off in the course of development and functions as an entity in relation to internal objects and to other subdivisions of the ego. He also stressed that both an object and an object relationship are internalized during development, so that a self is always in relationship to an object, and the two are connected with an affect. SÁNDOR FERENCZI (1873–1933) Although Sándor Ferenczi, a Hungarian analyst, had been analyzed by Freud and was influenced by him, he later discarded Freud’s techniques and introduced his own method of analysis. He understood the symptoms of his patients as related to sexual and physical abuse in childhood and proposed that analysts need to love their patients in a way that compensates for the love they did not receive as children. He developed a procedure known as active therapy, in which he encouraged patients to develop an awareness of reality through active confrontation by the therapist. He also experimented with mutual analysis, in which he would analyze his patient for a session and then allow the patient to analyze him for a session. VIKTOR FRANKL (1905–1997) An Austrian neurologist and philosopher, Viktor Frankl’s distinctive view of human nature and psychopathology was profoundly shaped by his experience in Nazi concentration camps. There he came to the conclusion that even the most appalling circumstances could be endured if one found a way of making them meaningful. He described his experience in Man’s Search for Meaning, a book that has been read by millions around the world. Frankl was both a humanist and an existentialist. He believed that human beings shared with other animals somatic and psychological dimensions, but that humans alone also had a spiritual dimension that confers both freedom and responsibility. People find meaning in their lives through creative and productive work, through an appreciation of the world and others, and by freely adopting positive attitudes even in the face of suffering. Those who fail to find meaning face alienation, despair, and existential neuroses. Traditional societies provided a framework of meaning in religion and shared cultural values; in modern society, people must find their own sources of meaning, and Frankl attributed many social problems, such as drug abuse and suicide, to their failures to do so. Because of the spiritual dimension, human beings show self-transcendence and self-distancing. The former refers to the capacity to put other values (for example, the well-being of a loved one) above self-interest. The latter is the ability to take an external perspective, as seen in a sense of humor. These capacities form the basis for therapeutic interventions in

Frankl’s version of psychotherapy known as logotherapy. Logo therapy is derived from the Greek word logos, which means thought or reason and Frankl believed that man instinctively attempts to find universal understanding and harmony in life experiences. ANNA FREUD (1895–1982) Anna Freud (Fig. 4.3-5), the daughter of Sigmund Freud, ultimately made her own set of unique contributions to psychoanalysis. Although her father focused primarily on repression as the central defense mechanism, Anna Freud greatly elaborated on individual defense mechanisms, including reaction formation, regression, undoing, introjection, identification, projection, turning against the self, reversal, and sublimation. She was also a key figure in the development of modern ego psychology in that she emphasized that there was “depth in the surface.” The defenses marshaled by the ego to avoid unacceptable wishes from the id were in and of themselves complex and worthy of attention. Up to that point, the primary focus had been on uncovering unconscious sexual and aggressive wishes. She also made seminal contributions to the field of child psychoanalysis and studied the function of the ego in personality development. She founded the Hampstead child therapy course and clinic in London in 1947 and served as its director. FIGURE 4.3-5 Anna Freud. (Courtesy of the National Library of Medicine.)

ERICH FROMM (1900–1980) Erich Fromm (Fig. 4.3-6) came to the United States in 1933 from Germany, where he had received his Ph.D. He was instrumental in founding the William Alanson White Institute for Psychiatry in New York. Fromm identified five character types that are common to, and determined by, Western culture; each person may possess qualities from one or more types. The types are (1) the receptive personality is passive; (2) the exploitative personality is manipulative; (3) the marketing personality is opportunistic and changeable; (4) the hoarding personality saves and stores; and (5) the productive personality is mature and enjoys love and work. The therapeutic process involves strengthening the person’s sense of ethical behavior toward others and developing productive love, which is characterized by care, responsibility, and respect for other persons. FIGURE 4.3-6 Erich Fromm. (© Bettmann/Corbis.) KURT GOLDSTEIN (1878–1965) Kurt Goldstein (Fig. 4.3-7) was born in Germany and received his M.D. from the University of Breslau. He was influenced by existentialism and Gestalt psychology— every organism has dynamic properties, which are energy supplies that are relatively constant and evenly distributed. When states of tension-disequilibrium occur, an

organism automatically attempts to return to its normal state. What happens in one part of the organism affects every other part, a phenomenon known as holocoenosis. FIGURE 4.3-7 Kurt Goldstein. (Courtesy of New York Academy of Medicine, New York.) Self-actualization was a concept Goldstein used to describe persons’ creative powers to fulfill their potentialities. Because each person has a different set of innate potentialities, persons strive for self-actualization along different paths. Sickness severely disrupts self-actualization. Responses to disruption of an organism’s integrity may be rigid and compulsive; regression to more primitive modes of behavior is characteristic. One of Goldstein’s major contributions was his identification of the catastrophic reaction to brain damage, in which a person becomes fearful and agitated and refuses to perform simple tasks because of the fear of possible failure. KAREN HORNEY (1885–1952) German born physician-psychoanalyst Karen Horney (Fig. 4.3-8), who emphasized the preeminence of social and cultural influences on psychosexual development, focused her attention on the differing psychology of men and women and explored the vicissitudes of martial relationships. She taught at the Institute of Psychoanalysis in Berlin before immigrating to the United States. Horney believed that a person’s current personality attributes result from the interaction between the person and the environment and are

not solely based on infantile libidinal strivings carried over from childhood. Her theory, known as holistic psychology, maintains that a person needs to be seen as a unitary whole who influences, and is influenced by, the environment. She thought that the Oedipus complex was overvalued in terms of its contribution to adult psychopathology, but she also believed that rigid parental attitudes about sexuality led to excessive concern with the genitals. FIGURE 4.3-8 Karen Horney. (Courtesy of the Association for the Advancement of Psychoanalysis, New York.) She proposed three separate concepts of the self: the actual self, the sum total of a person’s experience; the real self, the harmonious, healthy person; and the idealized self, the neurotic expectation or glorified image that a person feels he or she should be. A person’s pride system alienates him or her from the real self by overemphasizing prestige, intellect, power, strength, appearance, sexual prowess, and other qualities that can lead to self-effacement and self-hatred. Horney also established the concepts of basic anxiety and basic trust. The therapeutic process, in her view, aims for self-realization by exploring distorting influences that prevent the personality from growing. EDITH JACOBSON (1897–1978) Edith Jacobson, a psychiatrist in the United States, believed that the structural model

and an emphasis on object relations are not fundamentally incompatible. She thought that the ego, self-images, and object images exert reciprocal influences on one another’s development. She also stressed that the infant’s disappointment with the maternal object is not necessarily related to the mother’s actual failure. In Jacobson’s view, disappointment is related to a specific, drive-determined demand, rather than to a global striving for contact or engagement. She viewed an infant’s experience of pleasure or “unpleasure” as the core of the early mother–infant relationship. Satisfactory experiences lead to the formation of good or gratifying images, whereas unsatisfactory experiences create bad or frustrating images. Normal and pathological development is based on the evolution of these self-images and object images. Jacobson believed that the concept of fixation refers to modes of object relatedness, rather than to modes of gratification. CARL GUSTAV JUNG (1875–1961) Carl Gustav Jung (Fig. 4.3-9), a Swiss psychiatrist, formed a psychoanalytic school known as analytic psychology, which includes basic ideas related to, but going beyond, Freud’s theories. After initially being Freud’s disciple, Jung broke with Freud over the latter’s emphasis on infantile sexuality. He expanded on Freud’s concept of the unconscious by describing the collective unconscious as consisting of all humankind’s common, shared mythological and symbolic past. The collective unconscious includes archetypes—representational images and configurations with universal symbolic meanings. Archetypal figures exist for the mother, father, child, and hero, among others. Archetypes contribute to complexes, feeling-toned ideas that develop as a result of personal experience interacting with archetypal imagery. Thus, a mother complex is determined not only by the mother–child interaction but also by the conflict between archetypal expectation and actual experience with the real woman who functions in a motherly role.

FIGURE 4.3-9 Carl Gustav Jung (print includes signature). (Courtesy of National Library of Medicine, Bethesda, MD.) Jung noted that there are two types of personality organizations: introversion and extroversion. Introverts focus on their inner world of thoughts, intuitions, emotions, and sensations; extroverts are more oriented toward the outer world, other persons, and material goods. Each person has a mixture of both components. The persona, the mask covering the personality, is the face a person presents to the outside world. The persona may become fixed, and the real person hidden from himself or herself. Anima and animus are unconscious traits possessed by men and women, respectively, and are contrasted with the persona. Anima refers to a man’s undeveloped femininity, whereas animus refers to a woman’s undeveloped masculinity. The aim of jungian treatment is to bring about an adequate adaptation to reality, which involves a person fulfilling his or her creative potentialities. The ultimate goal is to achieve individuation, a process continuing throughout life whereby persons develop a unique sense of their own identity. This developmental process may lead them down new paths away from their previous directions in life. OTTO KERNBERG (1928–PRESENT) Otto Kernberg is perhaps the most influential object relations theorist in the United States. Influenced by both Klein and Jacobson, much of his theory is derived from his clinical work with patients who have borderline personality disorder. Kernberg places great emphasis on the splitting of the ego and the elaboration of good and bad selfconfigurations and object configurations. Although he has continued to use the structural model, he views the id as composed of self-images, object images, and their associated

affects. Drives appear to manifest themselves only in the context of internalized interpersonal experience. Good and bad self-representations and object relations become associated, respectively, with libido and aggression. Object relations constitute the building blocks of both structure and drives. Goodness and badness in relational experiences precede drive cathexis. The dual instincts of libido and aggression arise from object-directed affective states of love and hate. Kernberg proposed the term borderline personality organization for a broad spectrum of patients characterized by a lack of an integrated sense of identity, ego weakness, absence of superego integration, reliance on primitive defense mechanisms such as splitting and projective identification, and a tendency to shift into primary process thinking. He suggested a specific type of psychoanalytic psychotherapy for such patients in which transference issues are interpreted early in the process. MELANIE KLEIN (1882–1960) Melanie Klein (Fig. 4.3-10) was born in Vienna, worked with Abraham and Ferenczi, and later moved to London. Klein evolved a theory of internal object relations that was intimately linked to drives. Her unique perspective grew largely from her psychoanalytic work with children, in which she became impressed with the role of unconscious intrapsychic fantasy. She postulated that the ego undergoes a splitting process to deal with the terror of annihilation. She also thought that Freud’s concept of the death instinct was central to understanding aggression, hatred, sadism, and other forms of “badness,” all of which she viewed as derivatives of the death instinct. FIGURE 4.3-10 Melanie Klein. (Courtesy of Melanie Klein and Douglas Glass.)

Klein viewed projection and introjection as the primary defensive operations in the first months of life. Infants project derivatives of the death instinct into the mother and then fear attack from the “bad mother,” a phenomenon that Klein referred to as persecutory anxiety. This anxiety is intimately associated with the paranoid-schizoid position, infants’ mode of organizing experience in which all aspects of infant and mother are split into good and bad elements. As the disparate views are integrated, infants become concerned that they may have harmed or destroyed the mother through the hostile and sadistic fantasies directed toward her. At this developmental point, children have arrived at the depressive position, in which the mother is viewed ambivalently as having both positive and negative aspects and as the target of a mixture of loving and hateful feelings. Klein was also instrumental in the development of child analysis, which evolved from an analytic play technique in which children used toys and played in a symbolic fashion that allowed analysts to interpret the play. HEINZ KOHUT (1913–1981) Heinz Kohut (Fig. 4.3-11) is best known for his writings on narcissism and the development of self-psychology. He viewed the development and maintenance of selfesteem and self-cohesion as more important than sexuality or aggression. Kohut described Freud’s concept of narcissism as judgmental, in that development was supposed to proceed toward object relatedness and away from narcissism. He conceived of two separate lines of development, one moving in the direction of object relatedness and the other in the direction of greater enhancement of the self.

FIGURE 4.3-11 Heinz Kohut. (Courtesy of New York Academy of Medicine, New York.) In infancy, children fear losing the protection of the early mother–infant bliss and resort to one of three pathways to save the lost perfection: the grandiose self, the alter ego or twinship, and the idealized parental image. These three poles of the self manifest themselves in psychoanalytic treatment in terms of characteristic transferences, known as self-object transferences. The grandiose self leads to a mirror transference, in which patients attempt to capture the gleam in the analyst’s eye through exhibitionistic self-display. The alter ego leads to the twinship transference, in which patients perceive the analyst as a twin. The idealized parental image leads to an idealizing transference, in which patients feel enhanced self-esteem by being in the presence of the exalted figure of the analyst. Kohut suggested that empathic failures in the mother lead to a developmental arrest at a particular stage when children need to use others to perform self-object functions. Although Kohut originally applied this formulation to narcissistic personality disorder, he later expanded it to apply to all psychopathology. JACQUES LACAN (1901–1981) Born in Paris and trained as a psychiatrist, Jacques Lacan founded his own institute, the Freudian School of Paris. He attempted to integrate the intrapsychic concepts of Freud with concepts related to linguistics and semiotics (the study of language and symbols). Whereas Freud saw the unconscious as a seething cauldron of needs, wishes, and instincts, Lacan saw it as a sort of language that helps to structure the world. His two principal concepts are that the unconscious is structured as a language and the unconscious is a discourse. Primary process thoughts are actually uncontrolled freeflowing sequences of meaning. Symptoms are signs or symbols of underlying processes. The role of the therapist is to interpret the semiotic text of the personality structure. Lacan’s most basic phase is the mirror stage; it is here that infants learn to recognize themselves by taking the perspective of others. In that sense, the ego is not part of the self but, rather, is something outside of, and viewed by, the self. The ego comes to represent parents and society more than it represents the actual self of the person. Lacan’s therapeutic approach involves the need to become less alienated from the self and more involved with others. Relationships are often fantasized, which distorts reality and must be corrected. Among his most controversial beliefs was that the resistance to understanding the real relationship with the therapist can be reduced by shortening the length of the therapy session and that psychoanalytic sessions need to be standardized not to time but, rather, to content and process. KURT LEWIN (1890–1947) Kurt Lewin received his Ph.D. in Berlin, came to the United States in the 1930s, and taught at Cornell, Harvard, and the Massachusetts Institute of Technology. He adapted the field approach of physics to a concept called field theory. A field is the totality of coexisting, mutually interdependent parts. Behavior becomes a function of persons and their environment, which together make up the life space. The life space represents a field in constant flux, with valences or needs that require satisfaction. A hungry person is

more aware of restaurants than someone who has just eaten, and a person who wants to mail a letter is aware of mailboxes. Lewin applied field theory to groups. Group dynamics refers to the interaction among members of a group, each of whom depends on the others. The group can exert pressure on a person to change behavior, but the person also influences the group when change occurs. ABRAHAM MASLOW (1908–1970) Abraham Maslow (Fig. 4.3-12) was born in Brooklyn, New York, and completed both his undergraduate and graduate work at the University of Wisconsin. Along with Goldstein, Maslow believed in self-actualization theory—the need to understand the totality of a person. A leader in humanistic psychology, Maslow described a hierarchical organization of needs present in everyone. As the more primitive needs, such as hunger and thirst, are satisfied, more advanced psychological needs, such as affection and selfesteem, become the primary motivators. Self-actualization is the highest need. FIGURE 4.3-12 Abraham H. Maslow. (© Bettmann/Corbis.) A peak experience, frequently occurring in self-actualizers, is an episodic, brief occurrence in which a person suddenly experiences a powerful transcendental state of consciousness—a sense of heightened understanding, an intense euphoria, an integrated nature, unity with the universe, and an altered perception of time and space. This powerful experience tends to occur most often in the psychologically healthy and can produce long-lasting beneficial effects.

KARL A. MENNINGER (1893–1990) Karl A. Menninger was one of the first physicians in the United States to receive psychiatric training. With his brother, Will, he pioneered the concept of a psychiatric hospital based on psychoanalytic principles and founded the Menninger Clinic in Topeka, Kansas. He also was a prolific writer; The Human Mind, one of his most popular books, brought psychoanalytic understanding to the lay public. He made a compelling case for the validity of Freud’s death instinct in Man Against Himself. In The Vital Balance, his magnum opus, he formulated a unique theory of psychopathology. Menninger maintained a lifelong interest in the criminal justice system and argued in The Crime of Punishment that many convicted criminals needed treatment rather than punishment. Finally, his volume titled Theory of Psychoanalytic Technique was one of the few books to examine the theoretical underpinnings of psychoanalysts’ interventions. ADOLF MEYER (1866–1950) Adolf Meyer (Fig. 4.3-13) came to the United States from Switzerland in 1892 and eventually became director of the psychiatric Henry Phipps Clinic of the Johns Hopkins Medical School. Not interested in metapsychology, he espoused a commonsense psychobiological methodology for the study of mental disorders, emphasizing the interrelationship of symptoms and individual psychological and biological functioning. His approach to the study of personality was biographical; he attempted to bring psychiatric patients and their treatment out of isolated state hospitals and into communities and was also a strong advocate of social action for mental health. Meyer introduced the concept of common sense psychiatry and focused on ways in which a patient’s current life situation could be realistically improved. He coined the concept of ergasia, the action of the total organism. His goal in therapy was to aid patients’ adjustment by helping them modify unhealthy adaptations. One of Meyer’s tools was an autobiographical life chart constructed by the patient during therapy.

FIGURE 4.3-13 Adolf Meyer. (From the National Library of Medicine, Bethesda, MD.) GARDNER MURPHY (1895–1979) Gardner Murphy (Fig. 4.3-14) was born in Ohio and received his Ph.D. from Columbia University. He was among the first to publish a comprehensive history of psychology and made major contributions to social, general, and educational psychology. According to Murphy, three essential stages of personality development are the stage of undifferentiated wholeness, the stage of differentiation, and the stage of integration. This development is frequently uneven, with both regression and progression occurring along the way. The four inborn human needs are visceral, motor, sensory, and emergency-related. These needs become increasingly specific in time as they are molded by a person’s experiences in various social and environmental contexts. Canalization brings about these changes by establishing a connection between a need and a specific way of satisfying the need.

FIGURE 4.3-14 Gardner Murphy. (Courtesy of New York Academy of Medicine, New York.) Murphy was interested in parapsychology. States such as sleep, drowsiness, certain drug and toxic conditions, hypnosis, and delirium tend to be favorable to paranormal experiences. Impediments to paranormal awareness include various intrapsychic barriers, conditions in the general social environment, and a heavy investment in ordinary sensory experiences. HENRY MURRAY (1893–1988) Henry Murray (Fig. 4.3-15) was born in New York City, attended medical school at Columbia University, and was a founder of the Boston Psychoanalytic Institute. He proposed the term personology to describe the study of human behavior. He focused on motivation, a need that is aroused by internal or external stimulation; once aroused, motivation produces continued activity until the need is reduced or satisfied. He developed the Thematic Apperception Test (TAT), a projective technique used to reveal both unconscious and conscious mental processes and problem areas.

FIGURE 4.3-15 Henry Murray. (Courtesy of New York Academy of Medicine, New York.) FREDERICK S. PERLS (1893–1970) Gestalt theory developed in Germany under the influence of several men: Max Wertheimer (1880–1943), Wolfgang Köhler (1887–1967), and Lewin. Frederick “Fritz” Perls (Fig. 4.3-16) applied Gestalt theory to a therapy that emphasizes the current experiences of the patient in the here and now, as contrasted to the there and then of psychoanalytic schools. In terms of motivation, patients learn to recognize their needs at any given time and the ways that the drive to satisfy these needs may influence their current behavior. According to the Gestalt point of view, behavior represents more than the sum of its parts. A gestalt, or a whole, both includes, and goes beyond, the sum of smaller, independent events; it deals with essential characteristics of actual experience, such as value, meaning, and form.

FIGURE 4.3-16 Fritz Perls. (Courtesy of the National Library of Medicine.) SANDOR RADO (1890–1972) Sandor Rado (Fig. 4.3-17) came to the United States from Hungary in 1945 and founded the Columbia Psychoanalytic Institute in New York. His theories of adaptational dynamics hold that the organism is a biological system operating under hedonic control, which is somewhat similar to Freud’s pleasure principle. Cultural factors often cause excessive hedonic control and disordered behavior by interfering with the organism’s ability for self-regulation. In therapy, the patient needs to relearn how to experience pleasurable feelings.

FIGURE 4.3-17 Sandor Rado. (Courtesy of New York Academy of Medicine.) OTTO RANK (1884–1939) An Austrian psychologist and a protégé of Sigmund Freud, Otto Rank (Fig. 4.3-18) broke with Freud in his 1924 publication, The Trauma of the Birth, and developed a new theory, which he called birth trauma. Anxiety is correlated with separation from the mother— specifically, with separation from the womb, the source of effortless gratification. This painful experience results in primal anxiety. Sleep and dreams symbolize the return to the womb.

FIGURE 4.3-18 Otto Rank. (Courtesy of New York Academy of Medicine.) The personality is divided into impulses, emotions, and will. Children’s impulses seek immediate discharge and gratification. As impulses are mastered, as in toilet training, children begin the process of will development. If will is carried too far, pathological traits (e.g., stubbornness, disobedience, and inhibitions) may develop. WILHELM REICH (1897–1957) Wilhelm Reich (Fig. 4.3-19), an Austrian psychoanalyst, made major contributions to psychoanalysis in the area of character formation and character types. The term character armor refers to the personality’s defenses that serve as resistance to selfunderstanding and change. The four major character types are as follows: the hysterical character is sexually seductive, anxious, and fixated at the phallic phase of libido development; the compulsive character is controlled, distrustful, indecisive, and fixated at the anal phase; the narcissistic character is fixated at the phallic state of development, and if the person is male, he has contempt for women; and the masochistic character is long-suffering, complaining, and self-deprecatory, with an excessive demand for love.

FIGURE 4.3-19 Wilhelm Reich. (Courtesy of New York Academy of Medicine.) The therapeutic process, called will therapy, emphasizes the relationship between patient and therapist; the goal of treatment is to help patients accept their separateness. A definite termination date for therapy is used to protect against excessive dependence on the therapist. CARL ROGERS (1902–1987) Carl Rogers (Fig. 4.3-20) received his Ph.D. in psychology from Columbia University. After attending Union Theological Seminary in New York, Rogers studied for the ministry. His name is most clearly associated with the person-centered theory of personality and psychotherapy, in which the major concepts are self-actualization and self-direction. Specifically, persons are born with a capacity to direct themselves in the healthiest way toward a level of completeness called self-actualization. From his personcentered approach, Rogers viewed personality not as a static entity composed of traits and patterns but as a dynamic phenomenon involving ever-changing communications, relationships, and self-concepts.

FIGURE 4.3-20 Carl Rogers. (Courtesy of the National Library of Medicine.) Rogers developed a treatment program called client-centered psychotherapy. Therapists attempt to produce an atmosphere in which clients can reconstruct their strivings for self-actualization. Therapists hold clients in unconditional positive regard, which is the total nonjudgmental acceptance of clients as they are. Other therapeutic practices include attention to the present, focus on clients’ feelings, emphasis on process, trust in the potential and self-responsibility of clients, and a philosophy grounded in a positive attitude toward them, rather than a preconceived structure of treatment. JEAN-PAUL SARTRE (1905–1980) Born in Paris, Jean-Paul Sartre wrote plays and novels before turning to psychology. He was a German prisoner of war from 1940 to 1941 during World War II. Influenced by the ideas of Martin Heidegger, he developed what he called existential psychoanalysis. The reflective self was a key concept in Sartre’s psychology. He recognized that humans alone could reflect on themselves as objects, so that the experience of “being” in humans is unique in the natural world. This capacity to reflect leads humans to impose a meaning on existence. For Sartre, this meaning allows a human being to create his or her own essence. Sartre denied the realm of the unconscious; he thought that human beings were condemned to be free and to face the fundamental existential dilemma—their aloneness without a god to provide meaning. As a result, each individual creates values and meanings. Neurosis is an escape from freedom, which is the key to maintaining psychological health. Sartre made no distinction between philosophy and psychology. Psychologists, as with philosophers, search for the truth about

the world. Part of this truth, in Sartre’s view, was the dialectic between consciousness and being. Consciousness introduces nothingness and is a negation of being-in-itself. Ideals are revealed in actions, not in professed beliefs. B. F. SKINNER (1904–1990) Burrhus Frederic Skinner (Fig. 4.3-21), commonly known as B. F. Skinner, received his Ph.D. in psychology from Harvard University, where he taught for many years. Skinner’s seminal work in operant learning laid much of the groundwork for many current methods of behavior modification, programmed instruction, and general education. His global beliefs about the nature of behavior have been applied more widely, it can be argued, than those of any other theorist except, perhaps, Freud. His impact has been impressive in scope and magnitude. FIGURE 4.3-21 B. F. Skinner. (Courtesy of New York Academy of Medicine, New York.) Skinner’s approach to personality was derived more from his basic beliefs about behavior than from a specific theory of personality per se. To Skinner, personality did not differ from other behaviors or sets of behaviors; it is acquired, maintained, and strengthened or weakened according to the same rules of reward and punishment that alter any other form of behavior. Behaviorism, as Skinner’s basic theory is most commonly known, is concerned only with observable, measurable behavior that can be operationalized. Many abstract and mentalistic hallmarks of other dominant personality theories have little place in Skinner’s framework. Concepts such as self, ideas, and ego are considered unnecessary for understanding behavior and are shunned. Through the process of operant conditioning and the application of basic principles of learning, persons are believed to develop sets of behavior that characterize their responses to the world of stimuli that they face in their lives. Such a set of responses is called personality.

HARRY STACK SULLIVAN (1892–1949) Harry Stack Sullivan (Fig. 4.3-22) is generally acknowledged as the most original and distinctive American-born theorist in dynamic psychiatry. When psychiatrists use the term parataxic distortion, apply the concept of self-esteem, consider the importance of preadolescent peer groups in development, or view a patient’s behavior as an interpersonal manipulation, they are applying concepts Sullivan first proposed. FIGURE 4.3-22 Harry Stack Sullivan. (Courtesy of the National Library of Medicine.) Sullivan described three modes of experiencing and thinking about the world. The prototaxic mode is undifferentiated thought that cannot separate the whole into parts or use symbols. It occurs normally in infancy and also appears in patients with schizophrenia. In the parataxic mode, events are causally related because of temporal or serial connections. Logical relationships, however, are not perceived. The syntaxic mode is the logical, rational, and most mature type of cognitive functioning of which a person is capable. These three types of thinking and experiencing occur side by side in all persons; it is the rare person who functions exclusively in the syntaxic mode. The total configuration of personality traits is known as the self-system, which develops in various stages and is the outgrowth of interpersonal experiences, rather than an unfolding of intrapsychic forces. During infancy, anxiety occurs for

the first time when infants’ primary needs are not satisfied. During childhood, from 2 to 5 years, a child’s main tasks are to learn the requirements of the culture and how to deal with powerful adults. As a juvenile, from 5 to 8 years, a child has a need for peers and must learn how to deal with them. In preadolescence, from 8 to 12 years, the capacity for love and for collaboration with another person of the same sex develops. This so-called chum period is the prototype for a sense of intimacy. In the history of patients with schizophrenia, this experience of chums is often missing. During adolescence, major tasks include the separation from the family, the development of standards and values, and the transition to heterosexuality. The therapy process requires the active participation of the therapist, who is known as a participant observer. Modes of experience, particularly the parataxic, need to be clarified, and new patterns of behavior need to be implemented. Ultimately, persons need to see themselves as they really are, instead of as they think they are or as they want others to think they are. Sullivan is best known for his creative psychotherapeutic work with severely disturbed patients. He believed that even the most psychotic patients with schizophrenia could be reached through the human relationship of psychotherapy. DONALD W. WINNICOTT (1896–1971) Donald W. Winnicott (Fig. 4.3-23) was one of the central figures in the British school of object relations theory. His theory of multiple self-organizations included a true self, which develops in the context of a responsive holding environment provided by a good-enough mother. When infants experience a traumatic disruption of their developing sense of self, however, a false self emerges and monitors and adapts to the conscious and unconscious needs of the mother; it thus provides a protected exterior behind which the true self is afforded a privacy that it requires to maintain its integrity.

FIGURE 4.3-23 Donald Winnicott. (Courtesy of New York Academy of Medicine, New York.) Winnicott also developed the notion of the transitional object. Ordinarily a pacifier, blanket, or teddy bear, this object serves as a substitute for the mother during infants’ efforts to separate and become independent. It provides a soothing sense of security in the absence of the mother. The case history below illustrates how the different psychodynamic schools discussed in this chapter can be applied to the clinical observations of a patient. Mr. A was a 26-year-old white man who had a history of bipolar I disorder. He was brought in for treatment after not completing the last required course for his advanced degree and being arrested for disturbing the peace. He had consistently lied to his family about where he stood with his coursework and about having skipped an examination that would have qualified him to use his professional degree. He had also not told them that he had been using marijuana almost daily for a number of years and occasionally used hallucinogens. His arrest for disorderly conduct was for swimming naked in an apartment complex in the middle of the night while under the influence of hallucinogens. Mr. A’s use of marijuana began early in college but became daily during graduate

school. He was diagnosed as having bipolar I disorder early in his senior year at college after a clear episode of mania. His mood disorder was well controlled on lithium (Eskalith). During graduate school, he was episodically compliant with medications, preferring to try to maintain a state of hypomania. He saw a psychiatrist every 3 to 6 months for medication checks. During his 4 years in graduate school, he had two clear episodes of depression and began taking sertraline (Zoloft), 100 mg per day, with questionable benefit. Mr. A believed that he could be a great writer. He spent most of his time reading and trying to write. He dreamed of going to New York and becoming part of a group of avant-garde writers that would parallel the Algonquin Club of the 1930s or the Beat poets of the late 1940s. This aspiration and his marijuana abuse predated his development of bipolar I disorder. He attended class episodically, nonetheless performing adequately. His last class had no final examination but required a paper. He planned to write this paper in the form of a play, involving a dialogue between two thinkers from different times and cultures. His professor was very excited about this idea, but Mr. A kept postponing the task until he was forced to extend his schooling by a year. His other major interest during this time involved growing and photographing flowers. Mr. A was born and raised in a large city. His father had been very successful in commercial real estate, and his mother, after raising the children, used the substantial real estate holdings she inherited from her father to set up a business to manage them. Most of the money was placed in a trust for the patient and his siblings. His mother had total financial control of the trusts and doled out the proceeds to the children as they needed them. There was no family history of any psychiatric disorders. The patient described his mother as very loving and caring but to the point of being intrusive and controlling. For example, the mother arranged the initial treatment but then was angry that the psychiatrist had not called her regularly to report on her adult son’s progress. She was also critical of various aspects of the treatment as reported to her by her son. The patient’s two older siblings had attended prestigious colleges and graduate schools but had returned home to work in the mother’s real estate management company. The 30-year-old sister was living in the parents’ home. The 35-year-old brother had lived at home for a time but then moved out to a location a few blocks away. There was a younger brother, still in college, who also smoked marijuana excessively. He tried to minimize the patient’s problems to the family and tried to protect the patient, who desperately had not wanted to return home. Of note is that none of the children were married, although the two older ones had each had a couple of serious relationships. The children seemed to regard the mother with affectionate amusement and bemusement. The father was seen as a very caring but undemonstrative man who put much energy into keeping the mother from becoming too upset and encouraged the children to do the same. The children often wanted to provoke the mother for her judgmental, detail-oriented intrusiveness. The father discouraged them but occasionally found their provocations amusing. The family viewed itself as very close, with strong values oriented toward

community service and family loyalty. The family belonged to a religious community but expressed their involvement primarily in social service and social action volunteer work, accompanied by very generous financial contributions. The patient had been a very successful debater in high school and recalled his development as very positive but provided few details. He tended to place himself in the role of the outsider, an observer of humanity, which he saw as consonant with the role of a writer. He was proud to have bipolar I disorder and tried to regulate his medications so that he would be hypomanic much of the time, seeing this as enhancing his creativity. He viewed his use of marijuana in the same vein. One of the most distressing aspects to him of his depressive episodes was that marijuana no longer created a feeling of well-being but made him feel worse. His current depressive episode involved no neurovegetative symptoms. Rather, he presented as flat, numb, apathetic, ashamed, anhedonic, and anergic. He was particularly ashamed of being back in his hometown and of living with his parents. The patient ostensibly understood and accepted his illness well and had read much about it. However, the family had responded to the information “with proper treatment, bipolars can live normal lives” as meaning that the information should be kept secret so that he should be treated normally. Mr. A, on the other hand, was very open with friends at graduate school about his illness and his pride in it and the creativity he associated with it. The patient had two long-standing recurrent dreams. One involved him flying. The narrative line varied, but the flying theme recurred. Often, he had other magical powers in his dreams such as the ability to heal, to not be killed by bullets, to save the world or some group of people from mortal danger, and so on. The other recurrent dream was of a hotel lobby. These dreams regularly began with him entering a hotel lobby to meet a group of people, accompanied by a feeling of dread. REFERENCES Caldwell L, Joyce A, eds. Reading Winnicott. New York: Routledge; 2011. DeRobertis EM. Deriving a third force approach to child development from the works of Alfred Adler. J Hum Psychol. 2011;51:492. DeRobertis EM. Winnicott, Kohut, and the developmental context of well-being. Hum Psychol. 2010;38(4):336. Funk R, ed. The Clinical Erich Fromm: Personal Accounts and Papers on Therapeutic Technique. New York: Editions Rodopi B.V.; 2009. Guasto G. Welcome, trauma, and introjection: A tribute to Sandor Ferenczi. J Am Acad Psychoanal Dynam Psych. 2011;39(2):337. Kernberg O. Narcissistic personality disorder. In: Clarkin JF, Fonagy P, Gabbard GO, eds. Psychodynamic Psychotherapy for Personality Disorders: A Clinical Handbook. Arlington, VA: American Psychiatric Publishing; 2010:257. Kirshner LA, ed. Between Winnicott and Lacan: A Clinical Engagement. New York: Routledge; 2011. Kiselica AM, Ruscio J. Scientific communication in clinical psychology: examining patterns of citations and references. Clin Psychol Psychother . 2014;21:13–20. Lachman G. Jung the Mystic: The Esoteric Dimensions of Carl Jung’s Life and Teachings: A New Biography. New York: