Psychodynamic Psychotherapy Research Paper

There is still a passionate temperament or romanticintuitive world view embedded in psychoanalytic theories that inclines some of us to embrace them and others to disparage them (Messer & Winokur, 1980; Schneider, 1998). Mitchell and Black (1995) summarized the convictions held in common by diverse analytic thinkers as involving respect for “the complexity of the mind, the importance of unconscious mental processes, and the value of a sustained inquiry into subjective experience” (p. 206). Most psychodynamic thinking has emerged from clinical practice rather than from the research tradition of academic psychology. In this research paper we first cover developments in psychoanalytic clinical theory and then review empirical findings relevant to psychodynamic treatment. After more than a century of complicated, contentious evolution in psychodynamic metapsychology, practice, and research, we can hit only the high spots.

Historical Background of Contemporary Psychodynamic Psychotherapy

When Freud was formulating his early theories, diagnostic conventions reflected the work of Emil Kraepelin, whose nosology was descriptive. He divided psychological afflictions into neuroses and psychoses. In neuroses, the patient kept in touch with reality. Psychoses included dementia praecox (schizophrenia, considered organic and incurable) and manic-depressive psychosis (bipolar illness with psychotic features), viewed as having a complex etiology and as potentially treatable. Under neurosis in Kraepelin’s era were four syndromes: phobias, obsessive-compulsive disorders, nonpsychotic depressions, and the hysterias. The first three correspond roughly to the same categories in current taxonomies. The last included physical and mental disabilities with no physiological explanation—for example, inexplicable blindness, deafness, epileptiform seizures, anesthesia, paralysis, amnesia, and out-of-control acts at odds with a sufferer’s usual self.

Freud became fascinated by neurosis: How do human beings become terrified by an object they know not to be dangerous, become immobilized by anxiety if they cannot perform a ritual,believethemselvesunworthydespiteallevidencetothe contrary, or suffer a physical illness with no physical cause? Nineteenth-century doctors were exasperated by hysteria— improbable complaints voiced by people who often had self-dramatizing, provocative personalities. Freud’s determination to take (mostly female) sufferers of hysteria seriously atteststo both his relentless curiosity and his admiration for Jean Charcot, who was demonstrating that hysterical symptoms can be madeto disappear via hypnotic suggestion.

Classical Drive-Conflict Theory

Inspired by Charcot, Freud began experimenting with hypnosis and with entreaties to patients with hysterical problems to think out loud about the origins of their symptoms. His discovery of the superiority of free association over hypnosis is attributable to a talented patient of his collaborator Josef Breuer. Anna O. (the pseudonym given to Bertha Pappenheim) insisted that simply reporting her stream of consciousness led to relief from her suffering; she called it chimney sweeping. When this activity led to an emotionally charged memory of something deeply upsetting, specific symptoms would disappear. On the basis of this kind of work, Freud and Breuer postulated that hysterical symptoms express traumatic memories that need to be abreacted—that is, remembered and experienced in their original intensity.

Freud’s Topographic, Economic, and Dynamic Models

Freud began developing a model of the mind envisioned as containing a vast unconscious reservoir of primitive urges, affects, thoughts, and memories that—despite the Victorian conceit that civilized adults outgrow their childish preoccupations—continue to affect human impulses, emotions, thoughts, and reactions to stress. He argued that the psyche is like an iceberg: Most of it (the unconscious system) is submerged; a smaller part (the preconscious system) is potentially in awareness; the tiniest part (the conscious system) consists of what is at any time in mind. Freud’s earliest conception of therapy involved trying to connect with material in a patient’s unconscious life that was exerting a negative influence on her functioning. This formulation has been called the topographical model, as it involves progressively “deeper” layers of mentation.

From working with hysterical patients, Freud and Breuer concluded that people can keep disturbing, intolerable experiences out of consciousness—a process they termed repression. Much as contemporary psychologists feel defensive about the place of their field relative to the “hard sciences” and consequently convey ideas in terms of models from more prestigious disciplines, Freud tried to stress the scientific nature of his conclusions by expropriating concepts from seminal physicists such as Hermann Helmholtz and Gustav Fechner. Concepts like psychic energy, cathexis, dynamics, abreaction, and repression are all nineteenth-century physics terms.

Freud posited that although the mental effort required to achieve repression may have been necessary in childhood, its continued operation in adults is not warranted: Unlike children, adults can understand traumatic events, articulate reactions to them, and protect themselves from potential abusers. The energy required to keep their traumatic memories unconscious drains and depletes their general psychology. Hence, Freud inferred, treatment that undoes repression will free up the patient’s energy for use in positive directions. This idea of shifting quantities of psychic energy from one area to another has been called his economic model.

Hysterical symptoms were seen as products of a repressive process that did not entirely succeed; hints of the original trauma abide in the symptom. For example, an adult who had been traumatically shamed for masturbating as a child might develop a paralysis of the hand (glove anesthesia, a condition perhaps as common in Freud’s era and culture as anorexia is in ours). The symptom was believed to have the primary gain of ruling out masturbation, without the patient’s feeling either painful temptation or humiliating prohibition. It had the secondary gain of getting the now-disabled patient some loving attention. The site of the paralysis suggested that the trauma was related to an activity of the hand. Similarly, hysterical blindness or deafness implied that the patient had seen or heard something that had been too overwhelming to take in: The disability thus was seen as containing “the return of the repressed” (Freud, 1896, p. 169).

The term conversion was coined to refer to the mind’s capacity to transform traumatic experiences into bodily states that both resolve a painful conflict and symbolize its nature. Intolerably coexisting ideas are converted into a compromiseformation, the symptom.The construal of hysterical disorders as expressions of unconscious conflict was the origin of the general tendency in psychoanalysis to view psychological problems as expressing a subterranean tension and compromise between at least two contradictory aims: social respectability versus uninhibited expression, conscience versus impulse, and so on. Freud soon applied this model to other neuroses, including obsessive and compulsive syndromes, depressions, phobias, and some instances of paranoia. This emphasis on the dynamics of internal forces operating in opposition—and the consequent disposition to attribute psychological suffering to failed attempts to resolve unconscious conflicts—is the core of what is called the dynamic model in psychoanalytic theory.

Freud initially believed that neurotic symptoms result from sexual abuse or seduction of the young child. Like many discoverers of dissociation in the 1980s, he originally assumed that events recalled in therapy are veridical with early experiences. Readers who have seen clients relive a trauma with all its affect may appreciate how credulous a sympathetic observer can be about the historical accuracy of the memory; the emotional power of the description feels too authentic to be contrived. Later, however, Freud concluded that not all of what his patients “remembered” could have happened. Reluctantly (Masson, 1985, p. 264) he postulated that some of the recollections of hysterical patients stand for experiences even more disturbing than traumatic memories—experiences in which the patient felt not only like a victim but also like an actor in a perverse drama. To account for the prevalence of unsubstantiated convictions about childhood molestation, Freud had to devise a more complex theory.Therapy then evolved from the effort to remember and abreact into a more complex process; this process widened the explanatory power of psychoanalytic thinking about symptom formation and created possibilities for helping people with problems outside the hysterical realm, but it also contributed to minimizing the harm done by early sexual abuse. It disposed therapists toward skepticism about reportsofincestandmolestation,therebydoingagravedisservice to patients with trauma histories.

The Genetic Model: Psychoanalytic Developmental Theory

Eventually, Freud concluded that although beliefs in childhood sexual molestations are sometimes based on valid recollections, often they are screen memories—partial expressions, partial disguises—for children’s erotic longings. Screen memories were seen as condensations of wishes, fears, and experiences of some kind of sexual overstimulation. Freud began emphasizing (as pathogenic) certain outcomes of what he considered a universal Oedipus complex, the desire of children between about 3 and 6 years of age to possess one parent sexually and be rid of the other, combined with fears (magnified by projections of the child’s aggression) that the parent one wished to displace would retaliate by murder or mutilation. He postulated that it is the strength of these fears— along with the “civilized” person’s horror of acknowledging primitive incestuous wishes—that provide the impetus for repression.

This emphasis on children’s oedipal fantasies was grafted on to Freud’s existing ideas about infant development. His assumptions about child rearing betray both Platonic and Victorian tendencies to idealize self-knowledge and selfdiscipline (controlling one’s baser instincts, taming the beast within). He saw infants as insatiable, striving animals—and parenting as a balancing act between gratifying and thwarting the instinctual drives of offspring as they move through an invariant sequence of preoccupation with oral, anal, and genital satisfactions. According to Freud, a child can develop a fixation on the issues of a particular phase if he or she is either traumatically frustrated or seductively overgratified at that stage or if the constitutional intensity of that child’s oral, anal, or oedipal drives is particularly strong.

Following Darwin, Freud assumed that the essence of the primitive continues to exist in the form of the evolved. Applying this concept to individuals, he began to view neuroses as representing a stress-related regression to the passions of an early stage at which one is fixated unconsciously. For example, he argued that frugality, stubbornness, and fastidiousness—a triad of traits noted in people with obsessive and compulsive symptoms—betray a fixation on the anal phase of development, with its issues of expelling versus withholding, complying versus rebelling, and cleanliness versus mess. This idea of an orderly progression of conflicts organized around erogenous zones has been called the genetic model, meaning that the genesis of neurosis lies in normal maturational sequences and the drives and fantasies that accompany them.

This shift of emphasis from assumed seduction to infantile sexual striving and associated terrors led to substantial revisions in early psychoanalytic technique. Although Freud still aimed to make the unconscious conscious, the problematic contents of the unconscious mind were seen not so much as traumatic memories as they were unacceptable wishes and terrifying, primordial fears. Rather than urging his patients to have the courage to remember traumatic events, Freud began to lecture them about the normality of children’s erotic fantasies and about how they were behaving as if their natural sexual and competitive strivings were somehow dangerous. Instead of seeing them essentially as victims of incestuous perpetrators who needed to recount their ordeal, Freud began viewing his patients as agents coping with powerful sensual and aggressive urges—agents whose energies were being put into symptom formation rather than into achievements in love and work. Psychotherapy became an effort to put a person’s impeded development back on track rather than a mission to heal the unconscious scars of trauma.

The language of drive and energy in which Freud couched his economic, dynamic, and genetic models is referred to as drive theory. The Freudian term for the drive toward closeness, physical satisfaction in touch, and eventually adult sexuality is libido or libidinal energy. His early theories treated this energy as the wellspring of all human motivation. Later, possibly in reaction to World War I, he developed a dualistic theory, emphasizing the equivalent importance of the drive toward separateness, difference, antagonism, and ultimately death, usually referred to simply as aggression or the aggressive drive. Freud’s early notion of symptom formation is termed the drive-conflict model. This conceptualization originated when Freud was still thinking topographically, but it carried over into his structural model, explicated about 30 years later. Certain concepts from the early theory have been remarkably persistent: Practitioners still refer to secondary gain when they describe circumstances that reinforce a problematic condition, conversion disorder remains an official diagnosis in DSM-IV, and the term psychodynamic endures as the umbrella label under which psychoanalytically influenced ideas are categorized.

Although contemporary practitioners reject the nineteenthcentury drive models in which Freud’s first theories were grounded, clinical experience has so consistently noted the value of both free association and emotional expression that these early emphases persist. There are now substantial bodies of empirical literature attesting to the associative nature of unconscious cognition (see Westen, 1998) and to the value of expressing feelings (Frey, 1985; Pennebaker, 1997). Some widely repudiated drive-conflict concepts live on in psychoanalytic language, presumably because of a combination of familiarity and intuitive resonance. Even in nonprofessional conversation, one sometimes hears comments like What did you do with your anger?—as if anger contains a finite amount of energy that must be put somewhere to avoid some intrapsychic cost. Such is the legacy of Freud’s debt to the physics of his time.

Clinical Implications of Freud’s Early Theories

Freud wrote surprisingly little about therapeutic technique. His own was highly variable. Even after he gave up hypnosis and suggestion, he was hardly the stereotype of the silent, withholding analyst (Lipton, 1977). Over time, he made changes in how he worked, eventually adopting an approach that put more responsibility on the patient as a coinvestigator. In the second decade of the twentieth century (Freud, 1911, 1912a, 1912b, 1913, 1914, 1915), he laid out his ideas about how to conduct a psychoanalysis in quite nondogmatic language, comparing treatment to chess, in which opening and closing moves “admit of an exhaustive systematic presentation” (1912, p. 123), but everything else requires art and judgment. He explained practices such as using the couch and charging a fee for missed sessions as expressing his personal pBibliography: rather than as rigid rules. His main emphases included urging free expression, avoiding formulaic interpretations, expecting and respecting resistances to change, and not exploiting feelings (especially erotic ones) transferred from old love objects to the therapist. The use of free association and the analysis of transference and resistance in a relationship marked by abstinence and neutrality gradually became definitional of psychoanalytic treatment.

Transference was originally an unwelcome discovery. Freud found that although he was trying to come across as a benignly concerned doctor, he was instead being experienced as if he were a significant figure from a patient’s past.At first, he tried to talk people out of these attitudes with lectures about displacement (shifting the target of a drive from one object to a less disturbing one) and projection (attribution of one’s disowned strivings to others), but eventually he concluded that it was only in the context of a relationship dominated by transference that healing takes place. “It is impossible to destroy anyone in absentia or in effigie” (Freud, 1912a, p. 108), he commented, referring to how in analysis a person can have the experience of having a different outcome to a problematic early relationship. Resistance, the unconscious effort to cling to the familiar even when it is self-damaging, was also first subjected to frontal attack (Freud was not above complaining You’re resisting!) but later became understood as an inevitable process that must be respected and worked through. Abstinence referred to the avoidance of exploitation, especially when a patient’s transference was romantic or idealizing; neutrality referred to the commitment that the therapeutic role not be used in the pursuit of the analyst’s personal ambitions, goals, and values.

Freud saw people an hour a day, 5 or 6 days a week. When doctor and patient were together this often, with one party urged to say anything and the other saying rather little, patients had more than passing transference reactions; they tended to develop a transference neurosis, a set of attitudes, affects, and fantasies about the analyst expressing themes and conflicts from their individual childhoods. Eventually, psychoanalysis became defined as the process by which a transference neurosis is allowed to emerge and is then analyzed and resolved (Etchegoyen, 1991; Greenson, 1967). Resolution meant working through an understanding of the diverse effects of one’s core conflicts, ultimately substituting knowledge and agency for the unreflective, involuntary expressions of conflict that had required treatment. With some justification, intellectuals of the early Freudian era quipped that analysts create a disease in order to cure it.

Freud’s Structural Modeland the Development of Ego Psychology

In 1923, for complex reasons including a growing appreciation of the unconscious nature of defenses and the superego (Arlow & Brenner, 1964), Freud replaced his topographical model with a structural theory, the famous division of the mind into intrapsychic agencies. The id, roughly equivalent to the topographic unconscious, was envisioned as a seething cauldron of drives, impulses, primitive affects, and prelogical cognition (primary process thought); the ego, a term Freud often used synonymously with self, emerges as the child matures, to cope with reality and its limits on instant gratification. The id follows Fechner’s pleasure principle; the ego operates according to the reality principle. Ego processes were seen as involving such activities as language, problem solving, and logical cognition (secondary process thought). Eventually, as the child identifies with caregivers’ values, the superego arises from the ego as the voice of conscience and personal ideals. Freud described the id (it, in German) as entirely unconscious and the ego (I or me)and superego (above me) aspartly conscious and partly unconscious. Prophetically, Freud believed that these metaphorical concepts would eventually be replaced by an understanding of neurophysiological processes.

Unconscious aspects of the ego include habitual ways of functioning, such as reliance on defense mechanisms like repression. Unconscious superego functions were inferred from self-punishing behaviors that imply a sense of guilt. Anenduring literature—theoretical, clinical, and empirical—arose on ego processes and defense mechanisms (A. Freud, 1936; Hartmann, 1958; Laughlin, 1970/1979; Vaillant, 1992). Analysts began distinguishing between higher-order defenses and putatively more infantile processes such as withdrawal, denial, splitting of the ego, omnipotent control, projective identification (M. Klein, 1946), and primitive forms of idealization and devaluation. It was observed that patients with classically neurotic problems rely mainly on less global, less realitydistorting defenses such as repression, regression, reactionformation, isolation of affect, and reversal, whereas more disturbed clients depend heavily on less mature ways to handle anxiety and other negative states.

The tripartite image of the psyche ushered in the era of ego psychology. This term refers to the change from attention to the nature of the id to the study and treatment of the functions of the ego (and to a lesser extent, those of the superego). The ego psychology period saw important revisions of Freudian epistemologies. Erikson (1950), for example, recast Freud’s psychosexual stages in terms of the psychosocial tasks faced by the baby, restating Freud’s oral, anal, and oedipal sequence to describe the young child’s negotiation of trust, autonomy, and initiative, respectively. Later, Mahler (e.g., 1968) rethought the same phases in terms of symbiosis, separation-individuation, and object constancy. These contributions had wide-ranging consequences for the emerging discipline of psychotherapy (Blanck & Blanck, 1974, 1979).

Clinical Implications of Ego Psychology

Ego psychology concepts eventually changed the nature of therapists’ interventions. Instead of trying to expose the contents of the unconscious part of the mind (thoughts, feelings, fantasies, and impulses of the id), practitioners began to address the ego and superego processes that were keeping them out of consciousness. This clinical paradigm shift allowed patients to have more of a sense of discovery of their own dynamics. It translates into the difference between saying You desired your mother and I notice that every time we talk about your mother’s beauty, you get sleepy, or the difference between You’re obviously angry at me, and You seem to be disagreeing with everything I say today. What comes to mind about that?

The structural model ushered in a more collaborative version of therapy. Treatment was seen as requiring a therapeutic alliance (Zetzel, 1956) or working alliance (Greenson, 1967) between the clinician and the observing ego of the patient (the conscious parts of the person’s ego and superego that can describe feelings, thoughts, impulses, actions, and ideals). Together, both parties would examine the client’s experiencing ego, especially its defensive patterns. The goal of treatment became the modification of maladaptive, habitual defenses that manifest themselves as symptoms. Such defenses were understood as the residue of efforts to cope with a childhood situation for which they had been adaptive. Resistance was reconceptualized as an expression of the patient’s core defenses, as they manifest themselves in the therapy relationship.

The shift to the structural model also allowed practitioners to frame the therapeutic task differently depending on whether a patient was neurotic or psychotic, hysterical or obsessional or phobic or depressed, troubled by a sudden response to stress or burdened by a rigid character structure (Fenichel, 1945). For example, it became conventional clinical wisdom that one should undermine the defenses of people with neurotic-level problems (so that they would become less frightened of derivatives from their id), whereas one should support defenses of people with psychotic-level pathology (thus helping them recover from having been overwhelmed with material from their id). Types of psychopathology were associated with particular defenses (e.g., hysterical problems with regression, repression, and conversion; obsessive-compulsive problems with isolation of affect and undoing; phobic reactions with symbolization and displacement) that required different styles of therapeutic response. This emphasis gave clinicians a set of interventions that were much more powerful than simply relating symptoms to levels of psychosexual fixation.

A distinction arose between symptom neurosis and character neurosis, one still echoed in Axis I versus Axis II disorders, respectively, in recent editions of the DSM. People with symptom neuroses were described as able to remember not having their current problems and as feeling anxious about them and consequently motivated to change.Their difficulties were hence dubbed ego-alien or ego-dystonic. Because they could readily ally with a therapist and adopt mutual goals, patients with symptom neuroses could do brief, problemfocused work (some early analyses lasted only a few weeks). Clients with character pathology (personality disorders) were depicted as not notably anxious about what others saw as their psychological problems; their histories suggested they had “always” had what a therapist would see as maladaptive defenses. Their psychopathology was thus termed ego-syntonic. For these people, long-term work was required in order to develop a working alliance in which the patient gradually accepts the therapist’s idea of the problem and develops a vision of what it would be like not to have it.

Psychotherapy was conceived as a process that aims to strengthen the ego (including making defensive processes less automatic and more flexible), to modify the superego (making a person’s moral precepts more consistent with what is achievable instead of infantile fantasies of purity or perfection), and to put the energies of the id under the agency of the ego and superego (directing the powerful, primitive contents of the id into positive directions instead of self-defeating or socially destructive ones). By 1933, Freud was describing the ideal outcome of treatment with the aphorism “Where id was, there shall ego be” (p. 80).

Psychoanalysis and Psychodynamic Psychotherapy

The term psychoanalysis can refer, confusingly, to a theoretical position, a body of knowledge, or a type of psychotherapy. As to the therapy, some have followed Freud’s more catholic definition of psychoanalysis as any procedure that deals with transference and resistance. Others have reserved psychoanalytic for Bibliography: to classical, intensive treatment, preferring the term psychodynamic for any therapy or theoretical stance informed primarily by analytic theory (Westen, 1990). The ego psychology era inaugurated efforts to define psychoanalysis as a therapy and to stipulate its efficacy for various problems. The issue of who is analyzable became a hot topic theoretically and empirically (Erle, 1979; Erle & Goldberg, 1984). Distinctions were made between analysis proper (classical psychoanalysis) and more focused, analytically influenced therapies. For reasons of both expense (classical analysis is costly) and applicability (it is contraindicated for patients in whom it precipitates disorganization), analysts began developing definitions of the differences between—and the differential applications of—psychoanalysis and analytically oriented psychotherapy.

The critical difference between an analysis and a therapy is, of course, the content of what happens. Psychoanalysis is a comprehensive, open-ended effort to understand all of one’s central fantasies, desires, fears, defenses, identifications, and expectations; psychotherapy has the more modest goal of relieving a particular symptom or problem. Analysis was assumed to be ideal for resolving difficulties inhering in a person’s character, whereas therapy might adequately ameliorate a symptom neurosis. To accomplish the ambitious task of a full analysis, clinical experience suggested that patients must undergo a contained regression in the treatment, in which the analyst gradually attains the emotional power previously held by early caregivers—hence the centrality of a transference neurosis to both cure and prevention. Such a regression is more likely to happen under conditions of frequent contact between therapist and patient.

Freud had stressed that to help others explore their darkest places, the analyst must have been there. It quickly became an article of faith in the psychoanalytic community that the most important preparation for practice is to undergo a thoroughgoing personal analysis (see Fromm-Reichmann, 1950). Training institutes specified conditions, in the form of requirements, that would increase the probability that trainees would develop and analyze a transference neurosis. The question of how closely appointments must be spaced to ensure a full analytic process is still hotly debated. Most current analysts define analysis as requiring three to five sessions per week and psychodynamic therapy as requiring two or fewer.

An interesting controversy of the ego psychology period involved the mechanisms of therapeutic change. Alexander and French (1946) disquieted a community whose reigning gods were insight and interpretation with the proposition that what is therapeutic in analytic treatment is not so much acquired self-knowledge as a corrective emotional experience.

Accounting for therapeutic progress in learning theory terms, they recommended that clinicians deliberately aim to be experienced as different from pathogenic early influences. Most mainstream analysts found their departure from traditional norms of neutrality suspect, and yet much subsequent clinical and empirical work (reviewed later in this research paper) has supported their general position.

Psychoanalysis underwent a remarkable popularization during World War II, when Roy Grinker and John Spiegel treated posttraumatic conditions in combatants with a combination of sodium pentothal and cathartic psychoanalytic therapy. Public interest in getting soldiers back on the front lines—along with the dramatic nature of traumatic symptoms and recoveries—produced a spate of stories in the media about the new treatments for war trauma (Hale, 1995) along with ebullient claims for the efficacy of psychoanalysis. At the same time, films like Spellbound and Broadway shows like Lady in the Dark were fanning public fascination with unconscious processes. This idealistic period had both positive and negative effects—prompting an increase in resources to treat mental illness, yet spawning an uncritical overvaluation of analysis and an unseemly smugness among some analysts. Disillusionment predictably set in as grandiose claims were contrasted with the relatively modesteffects of psychodynamic therapies. The certainty of many analysts that the psychoanalytic movement had brought revolutionary, irreversible progress in mental health permittedan attitudeof indifferenceto effortsto evaluate their treatments scientifically—an indifference that has returned to haunt them in a more skeptical era.

The Object Relations and Interpersonal Contributions

As the ego psychology paradigm took shape, a different sensibility was stirring in several places. While keeping the Freudian emphasis on unconscious processes, this emerging paradigm replaced drive and conflict with relationship as a core construct, looked to preoedipal rather than oedipal origins of pathology, gave more weight to social and cultural contributors to individual dynamics, and attended to archaic modes of experiencing believed to predate the development of repression, conversion, displacement, and other defenses of interest to ego psychologists. Many analysts embodying these attitudes were influenced directly or indirectly by Freud’s Hungarian colleague Sandor Ferenczi, whose warmth and flexibility moved him to experiment with a more personally interrelated kind of therapy from very early on. In the United States, such analysts called their discipline interpersonal psychoanalysis (e.g.,Fromm,1941;Fromm-Reichmann,1950;Horney,1945; Sullivan, 1953); in Europe, a roughly comparable movement was becoming known as object relations theory (Fairbairn, 1952; Guntrip, 1971;Winnicott, 1958).

There are serious differences between and within these schools of thought, but for this review, we are stressing their shared thrust and similar divergences from drive-conflict theory and ego psychology, along with their joint contributions to the evolution of psychodynamic treatment. Together, they created the architecture of the relational movement in psychoanalysis (Aron, 1996; S. Mitchell, 1993, 1997, 2000). As individuals, the early relational theorists were more attuned than Freud was to mental processes that predate oedipal concerns. More critical to the nature of their thought, they were trying to help clients—children, impulsive and addicted people, schizophrenic and manic-depressive patients,and agroup that was eventually labeled borderline—for whom classical concepts seemed tangential to the central pathological issues.

By the second half of the twentieth century, some of the most vital clinical writing was coming from people with interpersonal and object-relational emphases. Many of these thinkers were deeply influenced by post-Freudian research on attachment. The work of Spitz (1965), Bowlby (1969, 1973, 1982), Mahler (1968; Mahler, Pine, & Bergmann, 1975), and others who conducted observational studies of babies and mothers was crucial to the maturation of psychodynamic theories and therapies. Winnicott’s ideas about infant mentation—shaped by his years of practice as a pediatrician—captured critical aspects of development about which drive theory was frustratingly silent. Because advocates of relational ideas lacked Freud’s need to root their theories in biological science and because they saw infants and mothers as fundamentally interrelated rather than as separate motivational units (Balint, 1968; Winnicott, 1965), they could consider ultimately psychological rather than biological explanations for psychopathology.

Meanwhile, the discipline of clinical psychology was maturing. When World War II created a pressing need for evaluations and treatment, academic psychology programs began contributing graduates to the effort—professionals who found the theories of the psychoanalytic movement highly relevant to their tasks. Some psychologists began to publish empirical research on analytic ideas. Medical analysts, too (Wallerstein, 1986), were conducting empirical investigations. The existence of a number of psychoanalytic journals with differing ideological and institutional orientations allowed clinicians to publish their experiences of applying analytic concepts and to share their knowledge across an international community of professionals.

All of these developments produced a creative ferment in psychoanalytic theory, practice, and scholarship. The appearance of new institutes with divergent theoretical biases reinforced the fissiparous tendency that Freud had inaugurated via his disposition to equate disagreement with heresy (Breger, 2000). At the same time, however, seminal thinkers like Otto Kernberg struggled to synthesize and integrate— combining object relations theory with ego psychology and relationship with drive. While analytic celebrities haggled over which approach was the most epistemologically defensible and therapeutically effective, ordinary clinicians tended to draw from different theorists depending on the specific psychologies of their clients and were grateful for any angle of vision that threw light on the suffering of someone they were trying to help.

Clinical Implications of the Object Relations and Interpersonal Traditions

One outcome of efforts to extend analytic help to previously untreatable conditions was the rejection of Kraepelin’s dichotomy between neurosis and psychosis—sanity and insanity. As Sullivan, Fromm-Reichmann, Bion, Milner, Searles, and others worked with psychotic patients, continuities between their experiences and those of putatively normal people emerged. The more therapists could feel their way into their deeply disturbing subjective worlds, the more Freud’s belief that human beings are all in some fundamental way psychotic became increasingly persuasive—until by the latter part of the twentieth century, psychoanalysts were referring to the psychotic core in all of us (Eigen, 1986). This conviction opened up possibilities for much deeper therapeutic work and contributed to a lengthening of psychodynamic therapies.

At the same time, awareness of a range of pathology lying between the psychotic and neurotic levels began to be noted by three different groups of professionals: those in outpatient practice, those in inpatient settings, and those with expertise in testing. Therapists in office practice reported that some people they took into analysis were unable to contain the regression fostered by standard approaches. Instead of settling into a relationship in which they could safely feel regressed, they would become regressed—swamped by intense feelings, impulsive behaviors, and transferences so unmitigated by reflection as to be considered psychotic. They tended to react to well-meaning interventions as if attacked, and they got worse rather than better in therapy. Their mental organization was not easily describable in terms of id, ego, and superego; they seemed to careen from one ego state to another, in which self and others were alternately seen as all good or all bad. In hospital and clinic settings, observers were describing patients admitted as schizophrenic who—once safely in the institution—no longer looked psychotic and began to pose dismaying management problems. Typically, some of the medical personnel had intense rescue fantasies toward such a person, whereas the rest found him or her manipulative and hateful (T. Main, 1957). Among psychological testers, it was observed that some individuals appear psychotic on relatively unstructured tests like the Rorschach or thematic apperception test (TAT), yet they appear neurotic on structured instruments like the Wechsler Adult Intelligence Scales (WAIS) and the Minnesota Multiphasic Personality Inventory (MMPI; see Edell, 1987).

From these converging observations came the notion that there is a type of person on the border between psychosis and neurosis, someone with a kind of stable instability (Grinker, Werble, & Drye, 1968). Thus arose the concept of borderline personality organization. Eventually, enough research was done with people with this kind of psychology (Gunderson, 1984; Stone, 1980) to justify including an operationalized version of borderline dynamics in the personality disorders section of DSM-III. Meanwhile, a sizable literature was appearing on how treatment of such clients should differ from therapy for either psychotic or neurotic individuals.

Practitioners had already followed Freud in noting that the uncovering, exploratory kind of work he had devised to help neurotic patients is unsuited to psychotic individuals, children, and people in crisis. Some clients respond better to educative interventions, judicious advice, explicit support of their self-esteem, concrete evidence of the therapist’s humanity, reinforcement of their most adaptive defenses, the involvement of external support services, and medication. This kind of work was eventually called supportive psychotherapy (Pinsker, 1997; Rockland, 1992). Conceptually, supportive therapy was described in ego psychology terms as an effort to strengthen a weak ego (as opposed to dismantling the defenses of a basically strong one to foster reconfiguration along healthier lines) and to encourage more adaptive behavior without trying to change the dynamics that had given rise to maladaptive responses.

As noted, the discovery of borderline pathology derived from clinical experience with clients for whom supportive therapy is infantilizing and uncovering therapy too disorganizing. It led to a flurry of efforts to devise appropriate treatments for people in this large group. The most visible early formulators of approaches for treating borderline clients were Masterson (1972, 1976) and Kernberg (1975, 1984), who hold somewhat different views but agree on the value of staying in the here and now (as opposed to dwelling on the client’s history), of establishing contingencies that support mature responses and discourage immature ones, and of addressing primitive defenses like splitting (the tendency to divide experience into all-good and all-bad categories) and projective identification (the tendency to ascribe disowned qualities to another person while behaving in ways that subtly induce that person to react with just those qualities).

One of Kernberg’s pivotal contributions was his argument that people in borderline states rely not on weak defenses against disorganization, as potentially psychotic people do, but rather on strong but primitive defenses. He originally called his approach expressive therapy but recently renamed his method transference focused psychotherapy (Clarkin, Kernberg, & Yeomans, 1998) to avoid its confusion with exploratory therapy. Thus, by the 1980s, three kinds of therapy had emerged from psychoanalytic theory and practice. Depending on the inferred character structure of the client, clinicians worked (a) in an exploratory way, letting transference reactions develop and become understood; (b) in a focused, expressive way, confronting the patient with defenses in the here and now; or (c) in a supportive way, behaving as an active mentor. For therapists learning to work psychodynamically with different kinds of people, the warm-up is the same, but the delivery is highly specific to the patient in question.

Not surprisingly, work with psychotic and borderline clients led dynamic therapists to a sensitivity to psychological processes that were seen as antedating oedipal conflicts and mature forms of identification and adaptation. Even less surprisingly, concepts relevant to the ways in which human beings symbolize and represent their preverbal experiences proved anything but irrelevant to higher functioning people. Attention to introjects—stark internalizations of comforting and persecutory images of others—supplemented efforts to understand ego defenses. If a client stated, for example, I’m terribly selfish, a therapist might respond, Who’s saying that? in an effort to identify the internal object and help the person stand apart from it—as opposed to simply noting that he or she tends to turn negative feelings against the self.

The object relations movement constituted a transformation in which therapists found themselves asking new questions. Instead of looking for fixation at a particular maturational stage, they looked for the nature of relationship across all phases of development. It was argued that a mother who is rigid about toilet training is apt to be equally rigid about feeding schedules, sleep arrangements, appropriate gender roles, and deference to authority. To understand the child of such a parent, the concept of maternal rigidity seemed to have more explanatory power than did that of anal fixation. Furthermore, clinicians reported more progress when they told clients that they may have had a certain kind of mother—one from whom they could now differentiate themselves—than when they told clients they were fixated at the anal stage and needed to pursue genitality.

An example of the clinical value of the shift toward relational thinking concerns how therapists respond to clients with an incest history. Freud viewed molestation as the premature gratification of a drive, thus emphasizing biological excitability and utterly missing the child’s experience of being used, scared by the incomprehensible phenomenon of adult sexual arousal, and made to feel confusing mixtures of intense pain and premature genital responsiveness. The language of drive gratification or frustration cannot capture the atmosphere of an incestuous enactment or appreciate why it can be so destructive. But when one talks in terms of what kind of relationship a child needs to feel safe, agentic, and understood, both the subjective world of the molested child and the damage to that child are much clearer (Davies & Frawley, 1993).

The Self Psychology Movement

As the twentieth century advanced, psychoanalytic therapy flourished. Yet experienced practitioners noted that the types of problems prevalent at midcentury—especially in Americans— differed from those that had intrigued the early European analysts. Many clients complained of emptiness, meaninglessness, and envy. They could not maintain a realistic, positively valued sense of themselves and found it hard to love others. They were perfectionistic, were consumed with how they were perceived, and were either grandiose and contemptuous or self-loathing and ashamed, depending on their perceptions of others’ reactions to them. In therapy, they did not develop familiar analyzable transferences, and they tended to perceive interpretation as criticism.

By the 1970s the effort to extend psychoanalytic help to people with these self-esteem problems had led to a vast literature on narcissism. A focus on how people come to understand and accept who they are had been foreshadowed by Erikson’s (1959) writing on identity and by observations of many previous analysts interested in how people develop a stable sense of self (Balint, 1968; Fairbairn, 1952; Guntrip, 1971; Jacobson, 1964, 1971; Mahler, 1968; Sullivan, 1953, 1956; Winnicott, 1958, 1965, 1971). But it was Heinz Kohut (1971, 1977) who radically reformulated psychoanalytic theories and therapies of narcissism; in the process, he created a movement that saw the formation of a positively valued sense of self as far more central to mental health than was the struggle with drive and conflict.

Clinical Implications of Self Psychology

Although Kohut originally wrote about the specific challenges of treating patients with narcissistic problems or disorders of the self, his ideas quickly grew into a general psychology that his successors consider universal (e.g., Basch, 1988; Goldberg, 1988; Shane, Shane, & Gales, 1997; Wolf, 1988). Contributions to the art of therapy from Kohut and his students are manifold, but the most important include his depiction of previously unidentified kinds of transferences, his elevation of empathy to a preeminent role, and his emphasis on and recommendations for dealing with the inadvertent injuries that therapists inevitably inflict on patients’self-esteem.

Psychodynamic clinicians trying to help clients with narcissistic problems had become frustrated with their inability to develop analyzable transferences. Efforts to show such patients that they were experiencing the therapist as an early object elicited not interest, but rather boredom and irritation. Queries like How are you feeling about me? would evoke only suspicions about the therapist’s insecurity or vanity. Then Kohut argued that although narcissistically preoccupied people do not generate transferences like those Freud wrote about, they do develop selfobject transferences: They unconsciously regard the analyst not as a separate object resembling someone from the past (an object transference); rather, the analyst is seen as a means to consolidate self-esteem. In other words, they need the therapist in the emotional role that an affirming parent plays in the years before a child appreciates the parent’s separate identity. Among the selfobject transferences, Kohut delineated idealizing, mirroring, and twinship or alter ego transferences.

Idealizing transferences handle self-esteem problems with the fantasy that the analyst is perfect and omnipotent; the client feels elevated by associating with this ideal figure. (Kernberg was more impressed with the tendency of narcissistic clients to develop devaluing transferences, in which the person gets self-esteem from feeling superior to the therapist.) Mirroring transferences refer to the experience of being seen and validated, allowing the client to feel deeply known and prized despite whatever shameful states of mind appear in therapy. Twinship or alter ego transferences occur when the patient sees the therapist as radically similar, aiding selfesteem because “there is someone basically like me out there.” Identification of these processes helped clinicians to appreciate divergent ways in which people experience the therapeutic relationship, to devise means of working with them, and to stop trying to push clients to find reactions that are alien to their most basic ways of organizing interpersonal information.

The promotion of empathic attunement from facilitating attitude to the sine qua non of therapy was a significant corrective to the privileged status of interpretation of defense in ego psychology. Whereas drive-conflict models emphasize the importance of frustrating a client’s wish for closeness or penchant to idealize so that such urges can be analyzed, self psychologists saw what classical analysts termed gratification as a prerequisite for healing. The acceptance by therapists of patients’ need to see them in self-esteem-restorative roles led to subtle but significant changes in intervention. Questions like Why do you suppose you need to see me as perfectly attuned? became comments like You feel deeply understood by me. The analysis of identification as a defense (I wonder why you selectively perceive us as so similar) became the appreciation of identification as a need (You take pleasure in noticing how we are alike).

Flexibility in practice was legitimated by self psychology. Whereas the classical analyst would avoid answering a question in order to explore the thoughts and feelings that had inspired it, a self psychologist would answer it when the patient might perceive failure to answer as a breach of empathy. Driveoriented analysts had been trained to reject small gifts from clients because gratification of the impulse to give would allow that impulse to remain unanalyzed; following Kohut, it became permissible to accept a gift if it would wound the patient not to do so. Many clinicians heaved sighs of relief to have a respected psychoanalytic theory that justified departures from standard technique—departures that they were already making on an intuitive basis.

Comparable changes had long been urged by Carl Rogers (1951), with arguments from a different metapsychology but based on similar clinical observations (Stolorow, 1976). Kohut went significantly beyond the nondirective therapists, however, in his belief that no matter how exquisitely empathic, genuine, and congruent a therapist tries to be, he or she will eventually be experienced as injurious. Just as a child is inevitably disappointed by the devoted parent who cannot always get it right, the therapy client will sometimes feel misunderstood by the most sensitive clinician. This insight ushered in a new way of handling mistakes. Instead of simply exploring how the client had experienced an error and associated it with early disappointments, Kohut (1984) and his followers advised therapists to express regret for their empathic failures. Such behavior, they argued, not only is realistic and humane, but it also models how to be an imperfect person who nonetheless maintains self-esteem, thereby demonstrating an alternative to the client’s doomed, self-defeating “narcissistic pursuit of perfection” (Rothstein, 1980).

Contemporary Relational and Intersubjective Views

Recently, there has been a shift in perspective that has become framed as the question of whether clinical psychoanalysis represents a one-person or a two-person psychology (Aron, 1996). Freud had labeled as countertransference any feelings toward clients that exceed ordinary professional concern. Strong emotional reactions to patients, he believed, reflect unresolved aspects of the analyst’s psychology and must be mastered in his or her own analysis, lest they unwittingly thwart the unfolding of the patient’s transference. Inherent in this stance was the ideal of scientific objectivity—the capacity to stand apart and see clients’ psychologies as created by their own temperament and personal history, uncontaminated by a therapist’s dynamics. Stolorow and Atwood (1992) call this position “the myth of the isolated mind” (p. 115). Freud (1912b) even urged colleagues to emulate the surgeon, “who puts aside all his feelings, even his human sympathy, and concentrates his mental forces on the single aim of performing the operation as skillfully as possible” (p. 115). His strikingly sterile analogy was doubtless meant to shame some of his colleagues into better behavior; by 1912 he was alarmed at the number of analysts who were acting out sexually with patients. Unfortunately, his metaphor was taken literally by many second-generation analysts who took pains to appear formal to the point of coldness with their analysands, lest they contaminate the transference (Gay, 1988).

Despite the master’s entreaty, when post-Freudian therapists spoke frankly, they admitted to intense countertransferences, regardless of how well analyzed they were (e. g., Searles, 1979; Winnicott, 1949). They noted that it is unrealistic to expect only mild, benign feelings toward unhappy, difficult people; more important, however, was that countertransferences contain valuable information (Ehrenberg, 1992; Gill & Hoffman, 1982; Maroda, 1991; Racker, 1968). It was not a big stretch to rethink the analytic relationship as involving two mutually influencing subjectivities.Appreciation of projective identification and similar types of emotional contagion (Bion, 1959; Ogden, 1982) led to efforts to describe the interpersonal field between therapist and patient (Langs, 1976; Ogden, 1994) rather than the dynamics of the patient as seen by a neutral onlooker. Joseph Sandler (1976) began writing about inevitable role-responsiveness; Irwin Hoffman (1983) spoke of the coconstruction of the transference.

This sea change emerged from many sources: heirs of Ferenczi’s work and of the American interpersonal and British object relations movements (Balint, 1953; Bollas, 1987; Greenberg & S. Mitchell, 1983; Joseph, 1989; Levenson, 1972, 1983); theorists in France (A. Green, 1999; Lacan,1977; McDougall, 1980); Gill and his Chicago group (Gill, 1982, 1994; Gill & Hoffman, 1982); Heidigger’s student, Hans Loewald (e.g., 1980); American feminists (e.g., Benjamin, 1988, 1995; Chodorow, 1978, 1989; Gilligan, 1982; J. Mitchell, 1974); developmental scholars (Beebe & Lachmann, 1988; Lichtenberg, 1983; Pine, 1985, 1990; D. Silverman, 1998; Stern, 1985, 1995); and writers drawing on George Klein (1976) and Kohut who stressed intersubjectivity and contextualism (Orange,Atwood, & Stolorow, 1997; Stolorow, Brandchaft, & Atwood, 1987). At the same time, research on therapy was generating relational explanations for its effectiveness, even when treatment was conducted classically (Weiss, Sampson, & The Mount Zion Psychotherapy Research Group, 1986). The intersubjective, two-person vision of therapy can be seen as a democratization of the more authoritarian Freudian model—an egalitarian, postmodern slant more suited to our era and culture.

Clinical Implications of a Relational-Intersubjective Orientation

For therapists who resonate to more intersubjective versions of psychoanalytic therapy, certain articles of faith of classical technique are called into question (Buirski & Hagland, 2001). Because objectivity is seen as impossible, authenticity replaces neutrality as a cardinal stance. The ideal that a therapist dispassionately interprets a patient’s acting out of transference feelings becomes the assumption that both parties will find themselves involved in enactments they must figure out together. Bion’s (1970) notion that the analyst becomes the container for disavowed contents of the patient’s psychology or Winnicott’s (1965) argument that substantial movement comes from the patient’s sense of therapy as a holding environment find expression in the therapist’s suspension of interpretation for more tentative ways of working. Rather than being assumed to represent distortion, the patient’s transferences may be seen as containing knowledge about the analyst’s psychology that the analyst would sometimes prefer to disown (Aron, 1991).

Tolerating not knowing becomes easier. Self-disclosure is not taboo, although a special discipline is required of relational therapists in deciding what and when to disclose (Aron, 1996; Maroda, 1991, 1999; Renik, 1995). Insight is regarded as the by-product of the internalization of a new relationship—not as the cause of change. Relational theorists often equate the work of therapy with Winnicott’s (1971) notion of play, carried out in the potential space (Ogden, 1986) generated by the analytic dyad. Sometimes the language of contemporary analysts becomes almost mystical in its effort to find metaphors that convey preverbal experience and the sense of intimate connection between therapist and client.

It is unclear how different actual behavior is between relationally oriented clinicians and therapists who think more traditionally. Some research suggests that effective treaters of different theoretical stripes—even markedly different stripes—do substantially similar things (Fiedler, 1950; Wachtel, 1977). Contemporary psychoanalytic practitioners may identify with the ego psychologists, the self psychologists, or the relational analysts—or they may synthesize several points of view. Many also integrate into their work the ideas of early psychoanalytic dissidents (especially Jung, Adler, and Rank), of systems theorists (Gerson, 1996; Leupnitz, 1988), and of more recent philosophers and scholars in other fields. Moreover, now that the behavioral movement has embraced cognition, there are myriad possibilities for integration between therapists trained in psychoanalytic theory and those who come from a learning theory or cognitive science background (Arkowitz & Messer, 1984; Frank, 1999; Wachtel, 1977, 1993).

Empirical Research on Psychodynamic Psychotherapy

Empirical research on psychodynamic psychotherapy is not nearly as plentiful or rich as is the theoretical work in this area. There are no studies comparing various psychoanalytic schools with one another, nor are there investigations comparing long-term dynamic therapy with the nondynamic short-term treatments currently in vogue. Without including interpersonal psychotherapy (e.g., Klerman, Weissman, Rounsaville, & Chevron, 1984), which is arguably psychodynamic, we must note the paucity of studies comparing dynamic therapies to nondynamic treatments. Studies relevant to dynamic therapy do exist, however. We begin with empirically identified factors that distinguish dynamic therapies— that is, with what makes psychodynamic therapy unique. We then cover research pertaining to the relevance of each factor in human functioning generally and in therapeutic efficacy specifically. Finally, we review research on the effects of long-term psychotherapy and psychoanalysis.

What Is Psychodynamic Psychotherapy Made Of?

Blagys and Hilsenroth (2000) reviewed the comparative psychotherapy process literature in order to identify those processes that distinguish psychodynamic and cognitivebehavioral therapies. To qualify as a distinguishing feature, a process had to differentiate a treatment in at least two studies, conducted in at least two different research venues. They identified seven such factors: (a) a focus on affect and expression of emotion; (b) exploration of the patient’s efforts to avoid certain topics or engage in activities that retard therapeutic progress (i.e., defense and resistance); (c) identification of patterns in the patient’s actions, thoughts, feelings, experiences, and relationships (object relations); (d) emphasis on past experiences; (e) focus on interpersonal experiences; (f) emphasis on the therapeutic relationship (transference and the therapeutic alliance); (g) explorations of wishes, dreams, and fantasies (intrapsychic dynamics). Missing from the list but implicit in all factors is the assumption of ubiquitous unconscious processes, the defining feature of psychoanalysis as described by Freud (e.g., 1926).Ablon and E. E. Jones (1998, 1999) and E. E. Jones and Pulos (1993) have shown that these factors in combination lead to successful psychotherapeutic outcome. In fact, they do so in cognitive-behavioral as well as in psychodynamic therapies. We next examine the evidence for each factor individually.

Focus on Affect

The best evidence that expression of affectively meaningful material is therapeutic has been supplied by Pennebaker (1995, 1997). In a typical experiment, his participants were asked to write or speak of upsetting incidents in their lives. Compared with members of a control group, they had fewer stressful physiological reactions (Pennebaker, 1997), healthier immune functioning (Petrie, Booth, & Pennebaker, 1998), and fewer health problems (Suedfeld & Pennebaker, 1997) months after this intervention. These results are all the more remarkable because the participants, who were not patients, were not seeking either emotional relief or health benefits. Unfortunately, there are as yet no studies relating such processes—as they specifically occur in dynamic psychotherapy—to outcome. Still, it is safe to say that emotional expression as it routinely occurs in the psychodynamic therapies is clearly good for people.

Focus on Defense

According to a model propounded by Weiss and Sampson (Weiss, 1971; Weiss et al., 1986), patients are troubled by unconscious pathogenic beliefs that interfere with their abilities to cope adaptively and that create psychological symptoms with their attendant guilt and shame. In order for treatment to work, patients must access warded-off (defended-against) material related to their pathogenic beliefs. After these beliefs become conscious, they can be disconfirmed. After they are disconfirmed, they lose their power. Patients come equipped with unconscious plans for achieving these ends; therapists must identify these plans and help each patient carry them out. This model was derived from a case-by-case examination of analytic treatments of numerous patients, after which Weiss and Sampson derived testable hypotheses and then subjected them to rigorous investigation. First, they assumed the existence of identifiable unconscious pathogenic beliefs. Second, the model proposed that a patient will test his or her pathogenic beliefs in relation to the analyst. Third, warded-off material ought to emerge so long as the therapist’s words and behavior do not confirm the pathogenic beliefs. Fourth, interventions that are compatible with a patient’s unconscious plan should further therapeutic progress, as evidenced by the emergence of previously warded-off material.

To test these hypotheses, Weiss and Sampson used transcribed audiotapes and process notes of psychoanalytic treatment, rated by clinicians blind as to hypotheses and critical aspects of the treatment. Scales measured analyst interventions for plan compatibility and patient verbalizations for warded-off material, insight, and therapeutic improvement. The units of analysis were analyst verbalizations and segments of patient speech. The most comprehensive research concerned the treatment of a patient dubbed Mrs. C. All hypotheses were strongly supported: Raters were able to agree about the nature of Mrs. C’s unconscious plan; without explicit interpretation, Mrs. C made use of her therapist to test her unconscious beliefs; she became conscious of previously warded-off material; and she showed favorable reactions and therapeutic improvement when the analyst’s interventions accorded with her unconscious plan.

There are also empirical data on repression, the conceptual grandparent of psychoanalytic notions of defense. Although experimental efforts to produce discrete incidents of repression have been largely unsuccessful (Eagle, 2000; Holmes, 1990), when repression is considered as a personality trait or style, there is a great deal of supporting data for this phenomenon. The most influential research of this sort is that of Daniel Weinberger’s group (D. Weinberger, 1990; D. Weinberger & Schwartz, 1990), who originally measured repressive style via two self-report scales assessing trait anxiety and social desirability (D. Weinberger, Schwartz, & Davidson, 1979). Individuals describing themselves as low in anxiety but high in social desirability were identified as repressors, on the assumption that they were being defensive about their anxiety.

Weinberger et al. (1979) found that repressors reported experiencing little reaction to a stressful task but were physiologically and behaviorally affected in a way that indicated considerable stress. Newton and Contrada (1992) reported that repressors claimed to experience little anxiety when askedtogiveatalk,yettheyevidencedsubstantiallyincreased heart rate. Derakshan and Eysenck (1997) had people rate videotapes of themselves giving a speech. Repressors claimed to have experienced and rated themselves as having exhibited little anxiety. Their high heart rate, however, told a different story. Moreover, independent judges viewing the videotapes rated the repressors as high in anxiety. Their defensiveness was further suggested by their response when informed of their elevated heart rate: They ascribed it to the excitement and challenge of giving the talk, not to anxiety.

Further evidence for the existence of a repressive or defensive kind of personality—and its costs—can be found in the work of Shedler and colleagues (Karliner, Westrich, Shedler, & Mayman, 1996; Shedler, Mayman, & Manis, 1993), Myers and Brewin (1994, 1995), and Davis and colleagues (Bonanno, Davis, Singer, & Schwartz, 1991; Davis, 1987; Davis & Schwartz, 1987). In summary, a group of people can be identified who manifest the sorts of defensive behaviors identified and ostensibly treated by psychodynamic clinicians. Such individuals tend to deny anxiety while physically displaying it and fail to recall negative events or stimuli. This style has been shown to have negative health consequences.

Identification of Patient Patterns

Surprisingly, there are no empirical data relating specifically to therapeutic interpretations in which patients are alerted to their recurrent patterns of thinking, feeling, perceiving, and acting. Insight has often been the stated goal of pointing out patterns to one’s clients. If this leads to insight and insight is associated with positive outcome, this factor would be supported. But there are no data directly linking the therapist’s identifying patterns to the patient’s achievement of insight. Because this connection is a central premise of classical psychoanalytic theory and case studies, this area would be fruitful for future research.

There is a vast literature, however, on devising treatment to fit patients’patterns. Individual personality dynamics and defenses are contained implicitly in diagnostic labels—especially those for the personality disorders (McWilliams, 1994; Millon, 1996); in the clinical literature on treating personality disorders and softening rigid character structure, one finds scattered Bibliography: to empirical research on psychodynamic therapy with individuals in the various categories. In the literature on depression, Blatt’s (2000) writing on the robust finding of a difference between introjective and anaclitic personality styles, who have different kinds of depressive dynamics and respond differentially to psychodynamic treatments, is notable.

Luborsky’s work, discussed later in this research paper, emphasizes a client-specific pattern of relationship, contributing to predictable feelings, thoughts, and behaviors. The working models concept of attachment theory, also discussed later in this research paper, has similar clinical implications. Weiss and Sampson, as noted previously, found support for the value of identifying patterns in order to determine a patient’s plan. Other empirically derived ways of understanding patients’ relational patterns for therapeutic purposes include concepts such as Henry, Schacht, and Strupp’s (1986) cyclical maladaptive pattern, Horowitz’s (1988) personal schemas, Dahl’s (1988) fundamental repetitive and maladaptive emotional structures, and Lachmann and Lichtenberg’s (1992) model scenes. Finally, there is research that addresses indirectly the question of identifying patient patterns with the purpose of conveying insight to the patient. Ablon and E. E. Jones (1998, 1999) and E. E. Jones and Pulos (1993) found that insight was related to positive outcome in both psychodynamic and cognitive-behavioral psychotherapy.

Emphasis on Past Experiences

The characteristic psychoanalytic emphasis on a mutual effort by therapist and patient to understand the patient’s personal history and its effects has also been largely unresearched. Although a focus on the past is usually carried out in the service of insight, there are no data currently linking exploration of an individual’s prior history to that person’s attainment of therapeutic insight. This area is another in which research is badly needed.

Focus on Interpersonal Experiences

The most comprehensive research enterprise examining interpersonal experiences from a psychoanalytic (as well as ethological and systems) perspective is the development and testing of attachment theory, inspired by Bowlby’s (1969, 1972, 1982) three-volume work on attachment and separation. Bowlby postulated an inborn need of the infant to maintain proximity to the mother or primary caregiver. How the caregiver responds and what environmental contingencies enhance or retard the fulfillment of this need are seen as having critical implications for the child’s attachment to the main caregiver and for his or her later relationships. Experiences and images of relationship arising from transactions between the infant and the mothering figure are internalized in what Bowlby called working models, which then influence how the person relates to others and respondsto the challenges of life.

Levy, Blatt, and Shaver (1998) found that attachment styles predicted parental representations. Thus, attachment style is closely akin to object representations. Ainsworth, who also related object representations to attachment, studied the effects of attachment on children (Ainsworth, 1969, 1978), whereas Mary Main and her associates expanded the domain of the theory to adults (M. Main, Kaplan, & Cassidy, 1985). Waters and his colleagues (Waters, Hamilton, & Weinfield, 2000; Waters, Weinfield, & Hamilton, 2000) have demonstrated the stability of attachment style—and therefore object representations—from early childhood through adolescence and young adulthood. Of 60 infants identified as having a particular attachment style, 72% showed the same style in early adulthood. Of those who had changed styles, most had suffered presumably traumatic events such as parental loss or abuse. This finding suggests that object representations tend to remain stable in the absence of outside forces that radically change relationships—exactly what psychoanalytic theory would predict.

Attachment and its associated object representations have also been shown to relate to diagnosed psychopathology in adults. Parkes, Stevenson-Hinde, and Marris (1991) have compiled a review of research relating childhood attachment patterns to adult psychopathology in general; Brennan and Shaver (1998) have related them to personality disorders. Slade and Aber (1992) and M. Main (1995, 1996) have reviewed much of this literature.

Emphasis on the Therapeutic Relationship

Research on the therapeutic relationship and its connection to outcome has focused on two areas: the therapeutic alliance and transference.

The Therapeutic Alliance. Data on the therapeutic alliance are clear and consistent. It has repeatedly been shown to be an important and positive factor in psychotherapy (Safran & Muran, 2000; J. Weinberger, 1995). Hovarth and Symonds (1991) conducted a meta-analysis of 24 studies examining the working alliance and found its effect to be reliably positive and not unique to psychodynamic psychotherapy. Gaston, Marmar, Gallagher, and Thompson (1991) reported a very large effect for the alliance even when controlling for initial symptomatology and symptom change.What we do not know from an empirical standpoint, however, is how best to foster the alliance or how it works. These questions await further empirical investigation.

Transference. The experimental study of transference has been spearheaded byAndersen (Andersen & Baum, 1994; Andersen & Berk, 1998; Anderson & Glassman, 1996; Andersen, Reznik, & Chen, 1997; Glassman & Andersen, 1999). Her conception of transference goes beyond representations of childhood parental figures as they manifest themselves in the relationship with a therapist; it involves representations of all significant others and applies to all interpersonal relationships in all settings. Andersen’s orientation is the empirical information-processing perspective of social cognition, which is closer to the kinds of internalizations described by object relations theory than it is to classical Freudian ideas of transference (see Westen, 1991, for a thorough comparison of social cognition and object relations theory, and Singer, 1985, for a translation of the concept of transference into information-processing terms).

Several studies (e.g., Andersen & Baum, 1994; Andersen, Reznik, & Manzella, 1996) have shown that people are more likely to remember information about a new or fictitious person that is consistent with significant-other representations. In fact, they will infer and claim to recall representation-consistent information that was never presented (Andersen & Baum, 1994; Andersen & Cole, 1990; Andersen, Glassman, Chen, & Cole, 1995; Andersen et al., 1996; Hinkley & Andersen, 1996). They will also respond affectively to new people in a manner consonant with their existing representation (Andersen & Baum, 1994)—that is, they find themselves feeling emotionally close to the new person (Andersen et al., 1996). Moreover, subjects’self-concepts shift so as to be more consistent with how they feel in the presence of the significant other whose representation has been activated (Hinkley & Andersen, 1996). Such effects can be obtained even when the significant-other representation is activated subliminally (Glassman & Andersen, 1998).

Andersen’s team has provided impressive evidence for the existence and operation of representations of significant others, representations that affect memory, emotions, and selfconcept and that operate even when we are unaware of their activation. Their findings give powerful support to Sullivan’s (1953) assertion that we have as many personalities as we do relationships with the important people in our lives. These data say nothing directly, however, about the operation of such representations in psychotherapy.

The work of Luborsky and his colleagues (Luborsky & Crits-Cristoph, 1990; Luborsky, Crits-Cristoph, & Mellon, 1986) does speak to the operation of transference representations in clinical practice. Their research with the Core Conflictual Relationship Theme (CCRT), designed to identify patterns of relationships as they appear in therapeutic sessions, shows that the frequency of unrealistic transference wishes diminishes in successful analytic treatment—as classical psychoanalytic theory would predict. In addition, selfand other-evaluations become less negatively toned and more three-dimensional (e.g., Crits-Christoph, Cooper, & Luborsky, 1988, 1990). Although there are some unresolved reliability problems with this research (Galatzer, Bachrach, Skolnikoff, & Waldron, 2000), the concept of transference has been shown to have validity and to relate to psychotherapeutic process and outcome.

Exploration of Wishes, Dreams, and Fantasies

An emphasis on inner subjective life—the intrapsychic factor of the psychoanalytic approach to therapy—has been studied in terms of unconscious dynamic conflicts and wish-fulfilling fantasies. Shevrin and his associates (Shevrin, Bond, Brakel, Hertel, & Williams, 1996) have for decades collected data showing that unconscious conflicts have unique effects on individuals. Their method has involved a rigorous combination of psychoanalytic assessment and modern electrophysiological measurement. Each person seeking treatment at the clinic associated with Shevrin’s laboratory underwent a thorough psychodynamic evaluation (three clinical interviews, the WAIS-R, the Rorschach, and the TAT). Clinical judges studied the material, inferred the person’s conscious description of relevant symptomatology, and specified the unconscious conflict presumably underlying it. Based on these formulations, the judges selected words that reflected, respectively, the patients’ conscious experience of their symptoms and the unconscious conflicts from which they were assumed to derive. These words were then presented both subliminally and supraliminally to the patients while event-related potentials (ERPs) were recorded from their brains. To control for affective valence of the words, pleasant and unpleasant words not chosen by the judges were also shown.

Results showed that unconscious-conflict words evidenced unique ERPs only when presented subliminally, whereas conscious-conflict words did so only when presented supraliminally. Participants did not respond differentially to control words, no matter how they were presented. These findings—that psychoanalytically oriented judges can identify relevant unconscious conflicts as confirmed by physiological (brain-wave) measures—demonstrate a clear connection between psychodynamic clinical judgment and brain functioning.

Research conducted by Silverman and his colleagues (L. Silverman, 1976, 1983; L. Silverman, Lachmann, & Milich, 1982; L. Silverman & J. Weinberger, 1985; J. Weinberger & L. Silverman, 1987) demonstrated a link between unconscious dynamic processes and behavior. Silverman termed his method subliminal psychodynamic activation (SPA). In an SPA experiment, one chooses a psychodynamic proposition and operationalizes it into a phrase. For example, Silverman operationalized the aggression that analytic theory posits as underlying depressive symptomatology in the phrase destroy mother. Then the chosen phrase or a control phrase is presented subliminally to individuals held to be susceptible to it.

Early SPA studies investigated the proposition that many behaviors are at least partly motivated by conflict over libidinal and aggressive wishes. They revealed that the relevant dynamic stimuli affected behaviors in the targeted populations in ways that control stimuli did not. Such effects were obtained only when the stimuli were presented subliminally. Populations tested by Silverman and his associates included schizophrenic, stuttering, and depressive individuals. Later SPA studies focused on the effects of stimuli designed to tap interpersonal fantasies. These were derived from Mahler’s notion of symbiosis and on the claim of some analysts (e.g., Limentani, 1956; Searles, 1965; Sechehaye, 1951) that therapy is more successful when symbiotic-like wishes are gratified. The stimulus used to test this assertion was mommy and I are one (MIO). To see whether subliminal MIO stimulation could enhance outcome, patients were given MIO or a control stimulus before they began treatment. Over a dozen studies using this strategy were conducted, with interventions ranging from systematic desensitization to counseling like that of Alcoholics Anonymous. Most found better outcomes in the MIO group than in controls (both groups improved, presumably as a result of the treatment). Meta-analyses have confirmed the reliability and strength of the MIO effects (Hardaway, 1990; J. Weinberger & Hardaway, 1990). The SPA studies show that there is validity to psychoanalytically posited unconscious intrapsychic dynamics and that these dynamics can be related to positive outcomes in therapy.

Joel Weinberger (e.g., 1992) has created a TAT measure of thefantasyassociatedwithMIO,termingittheonenessmotive (OM). Scores on OM have been found to predict outcome in a behavioral medicine study (Siegel & J.Weinberger, 1998) and in inpatient psychiatric treatment (J. Weinberger, Bonner, & Barra, 1999). This research shows that the types of unconscious fantasies posited by psychoanalytic theory can be operationalized and—in at least one case—predict outcome consistent with the theory’s assumptions.

Outcome in Psychoanalysis and Long-Term Psychodynamic Psychotherapy

Most of the work reviewed thus far has concerned short-term treatment. Some of it was purely experimental and involved no treatment whatsoever. Most psychodynamic therapy,however, is open-ended (decisions to continue or stop are within the client’s control) and thus typically of long duration, and all of psychoanalysis is long-term. We have taken psychodynamic therapy apart and looked at its components. Now let us move from process to outcome, putting it back together to see what empirical research says about its effectiveness.

Studies of psychoanalytic outcome began almost as soon as psychoanalytic clinics were established (Alexander, 1937; Coriat, 1917; E. Jones, 1936; Kessel & Hyman, 1933). Although Knight’s (1941) review of these early investigations paints a highly positive picture of outcome, all had employed a retrospective strategy using no control groups or independent observations; the sole arbiter of change was the treating analyst. Consequently, these findings are suspect. Later studies corrected for the flaws of retrospective report and independent observation but not for the lack of control groups. The first prospective and still the most impressive such study was the Menninger Foundation Psychotherapy Research Project (Appelbaum, 1977; Kernberg et al., 1972; Wallerstein, 1986). Initiated in 1954, this project tracked its participants for more than 30 years. Forty-two adult patients (22 in analysis and 20 in psychodynamic therapy) were studied. Psychotic, organically damaged, and mentally deficient patients were excluded. Nonetheless, many subjects were extremely troubled individuals with histories of unsuccessful treatment. Six had to be switched from psychoanalysis to psychodynamic psychotherapy because of unmanageable transferences. This research project generated a huge amount of data—hundreds of pages for each participant. Five books and 60 papers on this data set have appeared so far.

Overall, although the study reported substantial and equivalent general improvement for both psychoanalytic and dynamic psychotherapy patients, there was considerable variability. Treatment helped individuals to modify repetitive, long-standing, and characterological problems as well as to diminish their presenting symptoms. This finding was compelling because—as noted previously—many of the patients had not been helped by other treatments. Therapist support was the major curative factor identified by this study. Insight did not contribute to outcome—that is, improvement did not correlate with interpretive activity of the therapist or with the development of insight on the part of the patient. In contrast, the use of the positive dependent transference, corrective emotional experiences, assistance with reality testing, and other more supportive measures did correlate with outcome. Before one accepts these findings as representative of analytic treatment, a caveat applies: These patients were severely ill and may not have been suited for engaging in an exploratory, regression-promoting psychoanalytic process.

Another important study was conducted by the Columbia University Department of Psychiatry Center for Psychoanalytic Training and Research. Over 250 psychoanalytic patients (less disturbed than the Menninger clients), the largest sample ever examined in one research project, were studied from 1945 to 1961. A second wave of data collection involving about 90 patients ran from 1962 through 1971. Data included case records and reports of patients, analysts, and supervisors. Judges with adequate reliability evaluated these sources. Outcome was assessed through judge evaluation of circumstances of termination, clinical judgment of improvement by independent judges and treating therapists, and change scores based on judges’ evaluations of records at the beginning and end of treatment. Overall, patients benefited from treatment. Length of therapy and development of an analytic process were strongly related to the benefits obtained. Reviews and analyses of these data may be found in Bachrach, Weber, and Solomon (1985) and Weber, Bachrach, and Solomon (1985a, 1985b).

In later research at Columbia, Vaughan and her colleagues (Vaughan et al., 2000) investigated whether psychoanalysis and long-term analytic therapy could be feasibly subjected to the degree of methodological rigor necessary to establish their effectiveness. Methodology that has been used to study brief therapies and pharmacological studies—including self-report data, therapist data, and blind ratings at baseline, 6 months, and 1 year—was applied to nine patients in analysis and 15 in dynamic psychotherapy. Significant therapeutic effects on a variety of measures were seen at 1 year, despite the small sample, in both psychoanalysis and dynamic therapy. The authors did note, however, some resistance by clinicians to having their work studied—a problem if psychologists are to attain reliable data on outcome.

The Boston Psychoanalytic Institute conducted a retrospective study covering the years 1959 to 1966 (Sashin, Eldred, & Van Amerowgen, 1975) that showed positive effects of both treatment in general and treatment length in particular. A prospective and therefore less potentially biased study was undertaken at the same institute in 1972 (Kantrowitz, Katz, Paolitto, Sashin, & Solomon, 1987a, 1987b). Measures taken at the beginning and end of treatment included the Rorschach, TAT, Draw-a-Person Test, ColeAnimal Test, and WAIS verbal subtests. These were evaluated by two judges for reality testing, object relations, motivation for treatment, availability of affect, and affect tolerance. Both intake and termination interviewers also made these judgments, based on their respective experiences of each patient. A year after treatment, the therapist was interviewed, and his or her comments were rated for analytic process and for outcome. Therapeutic benefit was assessed in terms of changes in the tests (pre- to posttest) and in terms of therapist assessment. Again, patients showed improvement, and level of improvement was positively related to treatment length.

A follow-up on these patients, collected up to 10years after termination (Kantrowitz, Katz, & Paolitto, 1990a, 1990b, 1990c; Kantrowitz et al., 1989), showed that most had developed self-analytic capabilities and were maintaining their gains. Individual improvement was variable: Some kept improving, some maintained their gains, some had ups and downs, and a few got worse. Despite the variability, this result is impressive because 10-year follow-ups are extremely rare in the literature. That most patients had stayed better and acquired a lifelong skill of engaging in a self-analytic process is a remarkable finding.

The New York Psychoanalytic Institute collected data from 1967 to 1969 (Erle, 1979; Erle & Goldberg, 1984), showing that treatment length was strongly related to outcome and that most patients improved. Similar results were obtained with a retrospective study. Because all variables were collected from the treating therapists and were not confirmed through independent report or even by the patients involved, these data are not very reliable. Erle and Goldberg (1984) acknowledge the limitations of their findings, calling them preliminary.

A methodologically stronger study has recently been carried out in Sweden. Sandell and his colleagues (2000) collected data on 450 patients (a 66% response rate from a pool of 756), using normed interview and questionnaire data from patients and therapists, as well as absenteeism and health care utilization data. Patients were in a range of analytic therapies, including 74 in analysis three or more times per week. Findings were complex, but overall, patients in both analysis and therapy improved in treatment in direct proportion to its duration and frequency. Oddly, improvement was high on selfrating measures of symptom relief and general morale but not in the area of social relations.

Taken together, these studies support the efficacy of psychoanalysis and psychoanalytic therapy. They also demonstrate that deeply entrenched problems are amenable to psychoanalysis and psychodynamic treatment. Bachrach, Galatzer-Levy, Skolnikoff, and Waldron (1991); Doidge (1997); and Galatzer-Levy et al. (2000) provide excellent reviews of these and other psychoanalytic outcome studies.

A method for studying long-term psychotherapy that is popular in psychology today falls under the heading of “effectiveness” research. It was not designed with psychoanalytic principles in mind; rather, it was created as a counterpoint to rigorous, internally valid but somewhat artificial psychotherapy outcome studies termed efficacy research. In a nutshell, effectiveness studies are concerned with how actual patients fare in the real world. The goal of these naturalistic studies is ecological validity. Therapy investigated by effectiveness research includes long-term treatment, and longterm treatment as currently practiced is still overwhelmingly psychodynamic. We therefore review this area of research here.

The first effectiveness study was conducted by Consumer Reports magazine (Seligman, 1995, 1996), whose editors sent readers a questionnaire on their experiences in psychotherapy. More than 4,000 respondents reported having been in some kind of treatment; almost 3,000 had seen mental health professionals. Treatments were not standardized, diagnostic information was not obtained, and before and after measures were not taken. Data were obtained only from clients and were analyzed as to length and frequency of treatment and type of professional providing it. Results indicated that therapy was helpful. Psychiatrists, psychologists, and social workers obtained better results than did other professionals such as physicians and marriage counselors. Of particular relevance to our concerns is that greater improvement was associated with long-term as opposed to short-term treatment and with higher session frequency. Results were not limited to symptom relief; people reported that the quality of their lives had improved as well. These findings are controversial because they consist of self-report data, which are notoriously subject to bias, in a study that lacked a control group (see Vanden Bos, 1996).

For our purposes, a significant limitation of the Consumer Reports study is that although the treatments can be assumed to have been largely psychodynamic, this was not shown. Freedman, Hoffenberg, Vorus, and Frosch (1999) solved this problem by applying effectiveness methodology to psychoanalysis. Patients in their study were treated at a clinic associated with the Institute for Psychoanalytic Therapy and Research (IPTAR); thus, this study concerned itself specifically with psychoanalytic treatments. The investigators sent out 240 questionnaires, of which 99 were returned (41%). Treatment duration ranged from 1 month to 2 years, and session frequency from once a month to three times a week. Measures were the same as those used in the Consumer Reports study. Results from the IPTAR study replicated those of the Consumer Reports survey. Length of treatment was positively related to outcome, especially when therapies of under 6 months were compared with treatment lasting over a year. Frequency was also related to outcome: Both two- and threetimes-a-week appointments proved superior to once-weekly sessions, although they did not differ significantly from each other. Moreover, frequency and duration contributed separately to outcome—that is, each was related to outcome independently of the other (cf. Roth & Fonagy, 1996).

Taken together, these studies indicate that long-term psychoanalytic psychotherapy is effective. They also support the conclusion that duration and frequency of treatment are important variables. Prior to these findings, psychoanalytic clinicians had only personal and anecdotal experience to support their conviction that psychoanalysis and psychodynamic therapy are beneficial to their patients and that more is better. Currently, a collaborative analytic multisite program, spearheaded by the American Psychoanalytic Association, is gathering process and outcome data from numerous research groups in the United States and elsewhere, in which a common database of audiotaped and transcribed psychoanalytic sessions will be analyzed in methodologically sophisticated ways that correct for design flaws in the earlier studies. Regrettably, costs of implementing this project are high enough—and funding dicey enough—that Wallerstein (2001) has wryly referred to the fulfillment of the aim to integrate these process and outcome studies as “music for the future” (p. 263). We look forward to hearing this music.

Current Directions in Psychodynamic Psychotherapy

Changes in health care financing have required psychoanalytically oriented therapists to confront treatment exigencies radically at odds with their sensibilities. One positive effect of the managed care movement has been to stimulate research on psychoanalytic therapies. Meanwhile, more and more psychodynamic clinicians are practicing on a fee-for-service basis outside health maintenance plans because the values and goals of analytic work are hard to graft on a symptomfocused, limited-session model in which drug treatment is privileged (cf. McWilliams, 1999).

Peripheral to managed care and its political context, there are some areas of current psychoanalytic exploration that have significant implications for therapy. For example, there is an impressive clinical and empirical literature about infancy that permits preventive interventions of a precise nature (e.g., Greenspan, 1992; Stern, 1995). Psychoanalytic therapy with children has matured into a sophisticated discipline with empirical as well as theoretical underpinnings (Chethik, 2000; Heineman, 1998). There is a growing body of psychoanalytic work that illuminates the psychologies and the treatment needs of previously ill-served populations such as people in sexualminorities(e.g.,Glassgold&Iasenza,1995;Isay,1989, 1994), in cultures of poverty (Altman, 1995), and in racial and ethnic subgroups (e.g., Foster, Moskowitz, & Javier, 1996; Jackson & Greene, 2000).

Psychoanalytically influenced feminists have been contributing to an increasingly sophisticated interdisciplinary conversation on gender (e.g., Young-Breuhl, 2000). Connections between psychoanalytic theory and diverse religious and spiritual traditions are being forged (e.g., Epstein, 1998; Suler, 1993). Philosophical explorations of psychoanalysis are enjoying a recrudescence, in the contemporary context of hermeneutic, postmodernism, and social constructivist ideas (e.g., Hoffman, 1991, 1992; Messer, Sass, & Woolfolk, 1994). Other scholars are integrating analytic theory and cognitive neuroscience (e.g., Schore, 1994).

We hope that we have conveyed the richness and diversity of the psychodynamic tradition. In the new millennium, when the talking cure has been subject to unforgiving scrutiny and penetrating criticism, the need for well-controlled research on psychoanalytic therapies—and on conventional long-term treatment in particular—is especially pressing.

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