THE PATIENT’S CONTRIBUTION TO THETHERAPEUTIC PROCESS:

A Rogerian-psychodynamic Perspective

Sidney J. Blatt, PhDYale University

This article considers the importance of focusing on the patient’s experientialworld in the treatment process. It also presents an evidence-based conceptualmodel of personality development and psychopathology that enabled investiga-tors to introduce aspects of patients into research designs so they could explorepatient-treatment and patient-outcome interactions—interactions that addresscomplex questions such as what kinds of treatments are most effective withwhat types of patients and that suggest that different, but equally desirable,therapeutic outcomes occur through differing mechanisms of therapeutic action.Consistent with clinical experiences discussed in the earlier sections of thisarticle, results from three studies of long-term, psychodynamically orientedtreatment, and from a randomized clinical trial investigating several briefmanual-directed treatments for depression, demonstrate the importance of fo-cusing on the contributions of patients to the treatment process in both clinicalpractice and research.

Keywords: therapeutic process, patient’s contributions, empathy, countertrans-ference, two polarities model

The emphasis in much of contemporary psychotherapy research and practice is on thetechniques and tactics of therapy. We develop manuals specifying therapist’s interventionsand conduct seemingly endless trials comparing different types of intervention with thehope of identifying evidence-based treatments. Relatively little attention, however, isdevoted to examining the contributions of the patient to the treatment process in order tounderstand more fully the mechanisms or processes that lead to sustained therapeuticchange. In contrast to the emphasis on the therapist and the techniques and tactics of

I am grateful to John S. Auerbach, Rachel B. Blass, Deborah Fried, Patrick Luyten, Sherwin Nuland,Paul Wachtel, Joan Wexler, and David C. Zuroff for their constructive comments on an earlier draftof this article.

Correspondence concerning this article should be addressed to Sidney J. Blatt, Department ofPsychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT05511. E-mail: sidney.blatt@yale.edu

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Psychoanalytic Psychology © 2013 American Psychological Association2013, Vol. 30, No. 2, 139–166 0736-9735/13/$12.00 DOI: 10.1037/a0032034

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various treatments in contemporary psychotherapy research, this article is devoted tounderstanding the contributions the patient makes to the treatment process.

Initially, I address the importance of focusing on the patient’s experiential world, bothwithin and outside the treatment process. I then consider the processes that occur withinthe patient that led to sustained therapeutic change. Then I summarize a theoretical modelof personality development and psychopathology (e.g., Blatt, 2008) that can facilitate theintroduction of central aspects of the patient into research designs, thereby allowinginvestigators to address more complex questions, such as what kinds of treatments aremost effective with what kinds of patients, and that lead to different types of therapeuticaction, possibly through different processes or mechanisms of therapeutic change. Isummarize the results of four studies (three of long-term intensive treatment, and arandomized controlled trial of several brief, manual-directed treatments) that demonstratethe importance of differentiating between patients in psychotherapy research.

Early Influences on My Development as a Therapist

I began my career as a psychotherapist and psychoanalyst with training primarily in theclient-centered tradition. As a beginning graduate student at The Pennsylvania StateUniversity with Dr. William U. Snyder, a predominant figure in client-centered therapy inthe early 1950s, I first learned the importance of assuming the client’s frame of referenceand the importance of “clarifying” the client’s feelings. In our psychotherapy seminars andpracticum, Dr. Snyder relentlessly evaluated typescripts of our treatment hours, assidu-ously and authoritatively scoring each of the comments we made to our clients accordingto his definition of whether the comment was, on one hand, only a restatement of what theclient had said, or an “interpretation,” on the other hand, or the highly sought-after“clarification of feelings” that Dr. Snyder believed was the essence of good psychother-apy—the core intervention of the client-centered approach. If at least 75% of yourcomments in the therapeutic hour were considered by Dr. Snyder to be “clarifications offeelings,” it was deemed an acceptable hour, provided, of course, your hour contained nomore than 5% of interpretations—what Dr. Snyder considered an antitherapeutic inter-vention.

Being somewhat inquisitive and rebellious in the early years of my graduate training,I commented, rather provocatively, in seminar with Dr. Snyder, that it seemed to me thatthere was very little difference between a clarification of feelings and an appropriateinterpretation. Using Carl Rogers’s terms, I went on to comment that both types ofinterventions, if done appropriately, should result in what Rogers called “catching theedge of awareness.” Dr. Snyder, as you might imagine, was dismayed, probably evenappalled, by my lack of appreciation of this very important distinction and by my inabilityor unwillingness to repudiate the role of interpretation.

Through a complex and most fortunate series of events (see Blatt, 2006a), Isubsequently enrolled as a doctoral candidate in the psychology department at theUniversity of Chicago, where The Counseling Center was directed by none other thanDr. Carl Rogers, who also taught the graduate psychotherapy seminars. Naturally, Ienrolled in Carl’s seminar, and, as the semester progressed, I decided to test fate onceagain and asked Dr. Rogers whether a good clarification of feelings was really verydifferent from a good interpretation, in that both sought to capture the edge of theclient’s awareness. Typical of Carl’s openness and thoughtfulness, he responded, “Ofcourse not!”

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In my 2 years of internship at the Counseling Center with Carl Rogers and hiscolleagues, I learned a great deal about psychotherapy and about myself, and much ofwhat I learned in those early years is still central to my capacities as a therapist andanalyst. First and foremost, I learned the importance of assuming the patient’s frame ofreference—of seeking to give voice to the thoughts and feelings that the client wasexperiencing but was unable or unwilling to articulate. Still today, this emphasis oncapturing and communicating the experiences of the patient is my cardinal goal as atherapist and psychoanalyst—to give voice to the subtle personal experiences that thepatient is struggling to articulate. As a therapist and analyst, I therefore maintain thisempathic immersion so that I can help the patient to discover something that is just outsidehis or her conscious experience—something that might be called, in older psychoanalyticterminology, preconscious (Freud, 1915) or, in more current thinking, unformulated(Stern, 1983). This emphasis on understanding the patient’s experiences has been aguiding principle not only in my clinical work but also in my research as well.

Heinz Kohut was also at the University of Chicago in the mid- to late 1950s, primarilyat the medical school, which was located just a few blocks from Roger’s CounselingCenter. Kohut gave a series of eight evening lectures from 1958 to 1959 on basicpsychoanalytic theory. Those lectures greatly enriched my understanding of fundamentalpsychodynamic thought, so much so that my notes of these lectures were the basis of mylectures on psychoanalytic concepts early in my career at Yale. But as I recall, Kohut didnot discuss the role of empathy in the treatment process in these lectures. But Kohut’sseminal 1959 paper on introspection and empathy had a profound impact on my emergingunderstanding of the treatment process, especially his opening lines in that article that weunderstand the physical world through our physical senses and the psychological worldthrough our psychological senses—through introspection and empathy (Kohut, 1959; seealso Kohut, 1982). In a detailed discussion of the contributions of Rogers and Kohut onempathy in the treatment process, Kahn and Rachman (2000) noted that Ferenczi was thefirst to discuss the role of empathy in psychoanalysis.

The Patient’s Experiential World in the Treatment Process

Based on my experiences with Rogers and influenced by Kohut’s (1959) article, I seek toview patients not from an external perspective from which I would make judgments aboutthe nature of their pathology, the quality of their relationships, or their life more generally.Rather, I seek to be sensitive to patients’ struggles and try to capture conscious andunconscious aspects of their experiences, and to place these experiences into words thatpatients could hear and use effectively in their internal dialogue or exploration. I try toavoid, for example, commenting about a therapeutic impasse that the patient is “resistant”to dealing with a particular issue. Such an intervention, from an external perspective,primarily expresses the therapist’s judgment rather than capturing an aspect of thepatient’s feelings and thoughts. Rather, I prefer to note how difficult it seems to thinkabout or discuss a particular topic, with the hope that such an intervention recognizes andappreciates the patient’s struggles to express the thoughts and feelings he or she is seekingto articulate and communicate. Such an intervention identifies the particular issues centralin the patient’s current concerns, as well as some of the experiential modes currentlyactive around these issues. Similarly, to comment to a patient about his or her difficultcurrent or past life circumstances could be experienced by the patient as sympathy (orpity), but articulating that the patient feels (or felt) overwhelmed by certain life circum-

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141PATIENT’S CONTRIBUTIONS TO THERAPEUTIC PROCESS

stances could be experienced as empathic, as the therapist has given voice to the patient’ssubjective experiences around particular events. Such an intervention from an internalperspective gives voice to aspects of the patient’s conscious and unconscious experiences,rather than objectively noting a realistic fact from an external perspective.

Interventions that give voice to the patient’s experiences facilitate the therapeuticprocess because they enable the patient to feel understood rather than judged or criticized.Accurate interventions from an internal perspective, a “clarification of feelings,” if youlike, also enable patients to experience their thoughts and feelings as having a coherenceand logic that can be understood and accepted by another person (Atwood & Stolorow,1980; Blatt & Erlich, 1982; Rycroft, 1956). The goal of such interventions is to facilitatethe patient’s internal dialogue or exploration. It is the facilitation of the internal dialoguethat should be the criteria of the effectiveness of any intervention and of the progress ofthe therapeutic process more generally (Freud, 1937).

Placing partially articulated experiences into words enables patients to establish asense of greater control over their experiences by providing a structure that enables themto think about and understand previously unarticulated experiences. Placing experiencesinto words sharpens the delineation between self and other, helps clarify cause-and-effectsequences, and enhances the sense of self as an active and effective agent (Horowitz,1977). By placing partially conscious experiences and enactive modes into verbal form,the therapist provides organization and structure to experiences. Giving voice to partiallyconscious longings and fears facilitates the integration of these thoughts and feelings withcurrent experiences. This organizing, restructuring interaction between patient and ther-apist, which occurs predominantly on the level of language, facilitates the differentiation,articulation, and integration of self and object representations so that these representationsare no longer primarily linked to earlier unconscious experiences and repetitive enact-ments but are now more open to environmental input and modification (Horowitz, 1977,1991, 1998).

In other words, the therapist participates in and facilitates the patient’s internaldialogue by empathically identifying with the patient and by constructing representationsof the patient and of his or her world—representations that approximate the patient’sexperiential world (Buie, 1981; Greenson, 1960, p. 423; Schafer, 1959). By articulatingexperiences that were just outside of the patient’s conscious experience (Sandler &Rosenblatt, 1962), both patient and therapist make increasingly subtle differentiations anddistinctions of aspects of the patient’s intrapsychic and interpersonal world (Jacobson,1964; Kernberg, 1966, 1976). The therapist’s parallel construction of an approximation ofthe patient’s experiences enables the therapist to understand the subtleties of the patient’scommunications. It also enables the therapist to contrast the nuances of his or herconstructions with what the patient reports, thereby enabling the therapist to questionhimself or herself and the patient when aspects of their representations are incongruent.The therapist can consider whether this incongruity was the result of the patient beingunable or unwilling to consider certain possibly relevant aspects of a particular issue, orwhether the therapist has an inaccurate construction that needs to be revised because ofinsufficient information or because of a countertransference distortion that interfered withthe therapist accurately hearing the patient, or an expression of subtle defensive processesin the patient that the therapist has identified by noting the inconsistencies between his orher constructions and the patient’s experiences. In this sense, countertransference is anatural and inevitable part of the therapeutic process—one that can produce considerableinsight into the patient’s experiential world. The therapist’s representations of the patient’sexperiential world are constantly revised and reworked throughout treatment, eventually

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becoming highly differentiated, rich, and diverse concepts and images of the patient’spast, present, and wished-for (and feared) future life. The continual refinement of theserepresentations enables the therapist to more fully appreciate nuances of the patient’ssubjective world.

The Experiential World of Patient and Therapist in the Treatment Process

The therapist’s understanding of the patient’s experiential world is often based on thetherapist’s own experiences, especially early life experiences. We, like our patients, havegone through similar fundamental developmental sequences and challenges as we prog-ress through life, though everyone’s life journey is always, in some way, unique. Despiteindividual and cultural differences, we all have struggled with two fundamental psycho-logical developmental tasks: (a) a struggle for individuation, separation, and the devel-opment of an essentially positive and realistic sense of self or an identity; and (b) theestablishment and maintenance of meaningful, reciprocal, mutually satisfying, interper-sonal relationships (Blatt, 1990, 2006b, 2008; Blatt & Blass, 1990, 1996; Blatt &Shichman, 1983). Shared experiences and commonalities at various levels in these twofundamental developmental tasks enable therapists to understand the experiences of theirpatients, even though we may have approached these developmental tasks somewhatdifferently because of unique life circumstances and experiences (e.g., differences in sex,race, religion, and social class, as well as differences in personal events, especially withprimary caretakers). The therapist, having dealt reasonably successfully with these devel-opmental tasks in his or her own life and therapy, has a structure and organization forunderstanding the patient’s difficulties with these tasks and for finding ways to facilitatethe patient’s dealing with them in the treatment process. The commonalities we share withour patients in dealing with the same fundamental developmental tasks enable us toconstruct increasingly accurate approximations of patients’ experiential world and, espe-cially, to appreciate the patient’s experiences in the therapeutic process (see also Bowlby,1988; Fromm-Reichman, 1951; Racker, 1957).

This transactional interpersonal process in the therapeutic situation involves a constantand subtle reciprocal influence between patient and therapist, each affecting and influ-encing the other in a myriad of complex ways. It is this transactional interpersonal processthat makes therapy such an emotional experience, not just for the patient but for thetherapist as well. We experience and reexperience important aspects of our own lives witheach of our patients, and we use these usually brief and temporary reexperiences of ourown fundamental life issues to understand the subtleties and nuances of our patient’sexperiences. We use our own past and current life experiences, in direct and indirect ways,in the treatment process. Our experiences guide our thoughts and associations about thepatient’s experiences. Thus, it is essential that we have examined in detail, and haveresolved as fully as possible, our own needs and conflicts so that they do not distort ourability to listen to our patients and limit our capacity to respond primarily from thepatient’s point of view. One’s own therapy, therefore, is a central part of becoming atherapist—not so much to become a paragon of mental health but, as research indicates(e.g., Geller, Orlinsky & Norcross, 2005; Macran, Stiles, & Smith, 1999; Orlinsky &Geller, 2011; Rizq & Target, 2008a, 2008b), to be reasonably certain that our basic toolsin the therapeutic process—our empathic thoughts, feelings, and associations—are rela-tively objective and conflict free, and do not intrude upon and distort our capacity to useour past and current life experiences to understand the experiences of our patients. When

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143PATIENT’S CONTRIBUTIONS TO THERAPEUTIC PROCESS

the therapist has an inaccurate construction of the patient’s experiential world, because ofinsufficient information or because of countertransference distortions, these inaccuraciesreflect difficulties in establishing the shared understanding of therapist and patient that isessential in the treatment process.

Empathy in the Treatment Process

Rogers (1975, p. 4) defined empathy as a

complex, demanding, strong, yet subtle and gentle . . . process . . . [of] entering the privateperceptual world of the other and becoming thoroughly at home with it. It involves beingsensitive, moment to moment, to the changing felt meanings which flow in this other person.. . . It means temporarily living in his or her life . . . without making judgments, sensingmeanings of which he or she is scarcely aware, but not trying to uncover feelings of which theperson is totally unaware, since this would be too threatening. It includes communicating yoursensing’s of his or her world as you look with fresh and unfrightened eyes at elements ofwhich the individual is fearful. . . . To be with another in this way means that for the timebeing you lay aside the views and values you hold for yourself in order to enter another’sworld without prejudice.

We are drawn into our patient’s life not only by the patient’s reenactment of his or herearly conflictual experiences in the transference relationship but also by our temporaryempathic identification with the patient in each therapeutic hour. This temporary empathicidentification is usually relatively limited, ending with the close of each hour, to bereactivated once again on the patient’s return for the next session. On occasion, however,this empathic identification can be more intense and extend beyond the confines of thetherapeutic hour. This can occur, on occasion, in a problematic way when countertrans-ference reactions are no longer in the service of understanding the patient but begin toinvolve more personal needs of the therapist. The patient’s admiration for the therapist, forexample, can become a source of narcissistic gratification for the therapist, and thepatient’s anger might involve the therapist in enactments of his or her own experienceswith things like punishment or rejection or humiliation. But these more intense counter-transference reactions can also occur in more subtle ways and be a vital part of thetreatment process.

I have noted occasions when my empathic identification with the patient is moreintense and extends beyond the treatment hour, but is still in the service of the therapeuticprocess. Therapists often review or even dwell on a particularly difficult or significanttherapeutic hour after the patient has left, as we consciously try to think through and sortout what the patient was trying to communicate or what was happening in the hour. Thisprocess of working through an hour, however, can also occur in much more subtle andunconscious ways. After a particularly compelling or perplexing hour, when I consciouslyor unconsciously feel troubled or puzzled by certain aspects of the session, I subsequentlyfind myself doing, saying, thinking, or feeling—in a word, enacting (see also Aron, 1996,and Bromberg, 1998)—something that feels strange and ego alien. I may say somethingabrupt to my wife or children, or may have a set of thoughts, fantasies, or feelings thatseem strange and incongruent. These thoughts, feelings, or enactments simply do not feellike me. On reflection, after such an experience, I have realized that I, unconsciously, havebeen carrying an issue within me that is directly relevant to something that had occurredin a perplexing or troubling therapeutic hour but that I did not, or could not, articulate atthe time. The compelling nature of the issue and its centrality in the treatment processbecame apparent to me only upon reflection about my incongruent action, thought, or

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feeling, and only through this reflection did I gain an awareness of aspects of an hour thatwas previously unavailable to me. That an enactment was necessary to bring this materialto my awareness also alerts me to more fully consider the special nature of this materialfor either the patient or myself. Intensive therapy, working several hours each week overextended periods of time with an individual, places considerable emotional demand onboth patient and therapist. We balance our involvement through empathic identificationwith our capacity to disengage emotionally and to evaluate the therapeutic processrelatively realistically and objectively. This balance of empathic engagement and disen-gagement is essential to maintain because our therapeutic efficacy requires us to also standoutside or apart from our patients’ struggles, but it is our capacities for empathicidentification with the patient’s conscious and unconscious experiences that make it at allpossible for us to help our patients in the first place.

The Impact of the Patient on the Therapist

We rarely consider the patient’s impact on us as therapists and the gratifications we gainfrom participating in the therapeutic process. Conducting a relatively successful treatment,for example, enables the therapist to grow in the sense of being an effective therapist. Butparticipating in the therapeutic process through empathic identification—using one’s ownpersonal life experiences as guides to understand aspects of the life experiences of thepatient—often stimulates, in subtle ways, the therapist’s further clarification of his or herown personal issues. Certainly, the significance and intensity that the therapeutic processhas for the therapist is different from the depth of meaning it can have for the patient. Butthe issues that patients raise and struggle with in intensive therapy, and the infinite waysthey can relate to the therapist, require the therapist’s continual self-analysis (Blatt &Behrends, 1987). Allowing access to our own current and past personal experiences inorder to elaborate our understanding of our patient’s experiences requires that we partic-ipate, more or less vicariously, in the patient’s explorations and resolution of conflicts.This participation in our patients’ dealing with important developmental processes andchallenges forces us to reconsider, usually in very subtle ways, some of these issues forourselves. This is why the therapist’s empathic participation in the therapeutic process,while contributing to the patient’s growth at the same time, albeit much more microscop-ically, can both directly and indirectly result in a subtle reworking and consolidation of thetherapist’s personal issues as well.

Let me illustrate this point with a somewhat vivid clinical example. A young profes-sional, in his early 30s, was referred to me by a colleague for psychoanalysis. The patienthad worked with him in psychotherapy but was now interested in a more intensivetherapeutic experience. Among his complex personal issues was his experiencing aprogressively serious hearing loss because of increasing deterioration of his auditorynerves. He was, however, able to maintain adequate auditory discrimination with the useof hearing aids. Thus, I was able to conduct the analysis in the traditional way, using thecouch, by speaking loudly and enunciating each word clearly and slowly. I also tried tostate my interventions as briefly and succinctly as possible. Initially, it was difficult for meto adjust to speaking loudly and emphatically in the analysis—an earlier patient hadcommented in the closing hour of a 4-year analysis that she would always remember meas the “gentle voice”—but I soon became accustomed to these changes in my therapeuticstyle. I also decided at the outset of the analysis that I would never directly interpret hisoccasional misperception of what I had said, though I felt free to interpret his slips oftongue or his use of unique phrases or verbal constructions. In my interventions I avoided,

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145PATIENT’S CONTRIBUTIONS TO THERAPEUTIC PROCESS

however, directly using any of his possible misperceptions that might have been causedby his hearing loss.

In the closing hour of a lengthy and relatively successful analysis, he thanked me formy thoughtfulness and sensitivity, especially my attention to articulating my commentscarefully and slowly so that he could always hear me clearly. He was also very appre-ciative of my willingness to repeat things he might not have heard clearly and myoccasional seeking alternate ways of stating comments that he had been unable to hearprecisely. He then abruptly stopped and thoughtfully began to wonder why I had been sounusually sensitive and attentive to his hearing loss. I suddenly realized that my atten-tiveness was, in part, a consequence of my attempts to compensate for my lack of patiencewith my father’s serious and progressive hearing loss that began when I was in earlyadolescence. The patient’s question enabled me, for the first time, to realize explicitly thatthroughout this analysis I had been unconsciously working through important issues withmy father. As Freud (1897, 1954, p. 234) noted, one’s own self-analysis can proceed byway of analyzing others.

Separation, Loss, and the Construction of Representational Structures

Termination is a complex process for both patient and therapist. Classically, terminationis indicated when the patient has achieved a growing sense of autonomy, independenceand mature relatedness, and has acquired a self-analytic or self-interpretive function, afunction which he or she had previously depended on the therapist to provide. The patient,however, internalizes not only the interpretative function but also the therapist’s sensi-tivity, compassion, and acceptance as well. With these internalizations, the patient has alsodeveloped an increased capacity to tolerate painful experiences and affects. Hopefully andideally, at termination, the patient can conduct the process of self-inquiry with the concernand empathy originally experienced with a caring parent or therapist, so that self-inquiryand examination is conducted with acknowledgment and acceptance of both one’slimitations and strengths (Blatt & Behrends, 1987). In addition, the experience of feelingaccepted, understood, and cared for by another should enable the patient to feel, in turn,more capable of understanding and caring for others (Blatt & Behrends, 1987; Nacht,1962). Much as a child learns to love by being loved by his or her parents, the patient cancome to regard others with dignity and respect by having had such experiences in thetherapeutic relationship—in sum, to develop mature reciprocal caring relationships. Theanalyst’s recognition of the patient’s subjectivity enables the patient, through experiencinga meeting of minds, to recognize and value his or her own subjectivity as well as thesubjectivity of others (Aron, 1996; Auerbach & Blatt, 2001, 2002; J. Benjamin, 1995;Winnicott, 1971).

But there is always a fundamental indeterminacy for both patient and therapist intermination—both remain somewhat uncertain about whether the patient can now con-tinue the exploration without the assistance of the therapist. Termination is not only a lossfor the patient but also a loss for the therapist, and therefore a challenge to the therapist’sability to bear painful experiences and emotions. The therapist feels confident abouttermination, however, when he or she has established a well-consolidated representationof the patient as being able to conduct the therapeutic exploration with skill, sensitivity,and compassion (Blatt & Behrends, 1987). In other words, successful termination requiresnot only the patient’s consolidation of his or her own self-representation, and his or herrepresentation of the therapist, but also the consolidation of the therapist’s representationof the patient. The loss of the therapist at termination is a major factor in the patient’s

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internalizations that consolidate the therapeutic gains achieved in the treatment process.As Freud (1923, 1925) noted in his conceptualization of the formation of the superego—the threat (or experience) of loss precipitates an attempt at recovery or restitution of theloss through identification with, or internalization of, the lost object. If loss is a majorfactor in the internalizations that occur at termination, then the experience or anticipationof loss should also play an important role throughout the treatment process. Therapeuticgains should be most manifest at separations—before, during, or after planned, as well asunplanned, interruptions of the treatment process.

I first became aware of the importance of separation and loss leading to the formationof representational structures in the treatment process early in my career, during theanalysis of a very talented, physically attractive graduate student who sought analysisprimarily because of interpersonal difficulties. She had been sexually abused when shewas about 5 years old and again in early adolescence. More recently, she also had to dealwith sexual advances by a member of the clergy in the religious institution with which shewas affiliated and by the psychotherapist who she was seeing shortly before she soughtanalysis. Understandably, given the violations by people whom she should have been ableto trust, the first year of analysis was filled with long periods of silence and a sense ofapprehension. She spontaneously reported that she never dreamed.

Early in the second year of analysis, she requested a change in the time of our Fridaymorning appointment so she could attend a lecture that was relevant to her graduatestudies. I, trying to maintain a “classic” approach to the psychoanalytic process early inmy career, told her that the hour was hers and she could decide how she wanted to use it.She decided to attend the lecture. On her return to analysis on Monday morning, shereported, for the first time, that she had a dream. She could not recall any details of thedream other than that, though she did not see me in it, she sensed my presence. Thissequence of events was a major turning point in a relatively successful 5-year psychoan-alytic process.

It seemed that my presence in her mind and thoughts in her dream was a way of hercoping with the loss she experienced in missing her usual Friday morning appointment. Inaddition, allowing her to make the decision about how to use the hour may have given hera sense of safety in my maintaining boundaries and in her having some control over howthe analysis would proceed. But this experience dramatically called my attention to theimportance of separations and loss in the treatment process.

Once the therapeutic alliance has been reasonably well established, patients seem todemonstrate therapeutic progress primarily around interruptions of the treatment process(see Jiménez, Kächele & Pokorny, 2006). Therapeutic progress early in treatment seemsto occur primarily during or after an interruption (e.g., vacations, absences because ofillness, absences over weekends, or even at the end of an hour). Much as a child developsobject constancy to deal with the mother’s absence (e.g., Mahler, 1968), patients begin toestablish, revise, and consolidate representations of self, the therapist, and of the thera-peutic relationship, primarily when there is a disruption of the usual cadence of therapeuticsessions. Alternatively, changes in patients’ internal working models of the therapeuticrelationship, and of relationships more generally, are more likely to occur when there arechanges in the therapist’s provision of a secure base (Bowlby, 1988). Later in treatment,progress more often occurs in anticipation of separation, as the patient and therapist dealwith anticipated loss in symbolic and verbal form rather than through its enactment.Throughout treatment, therapeutic gains appear to occur as a consequence of the resolu-tion of a complex series of attachments and separations between patient and therapist(Blatt & Behrends, 1987), events similar to the sequence of affect matching, mismatching,

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147PATIENT’S CONTRIBUTIONS TO THERAPEUTIC PROCESS

and repair that is central to the mother–infant dyad (e.g., Beebe & Lachmann, 1988, 1994;Gergely, 2002), although, of course, carried out in analysis at a much more mature levelof symbolization and of mutual emotional need. But both attachment and separation arecrucial therapeutic experiences in the internalization process that results in the progressivedevelopment of representations of self and of actual and potential relationships withsignificant others.

In considering the nature of therapeutic action in both clinical practice and research,we therefore must be attentive not only to the quality of the therapeutic alliance but alsoto the processes through which patients attempt to cope with separation and loss. Theexperience and anticipation of loss are crucial moments in the therapeutic process (Blatt,Auerbach, & Behrends, 2008). They are the moments at which both patient and therapistdevelop, revise, extend, and consolidate their representational structures. And it is theserevised representational structures that are crucial elements of therapeutic change.

Adaptive Processes in the Transference

Many formulations of the mutative effects of the therapeutic process consider ways inwhich patients internalize “aspects of the analyst’s way of looking at things . . . [whichbecome] a self-analytic function and probably a permanent new intrapsychic representa-tion” (McLaughlin, 1981, p. 653). McLaughlin, for example, argues that analysis produceschange “through the internalization, as new psychic structures, of attitudes and valuesexperienced in the relationship to the analyst” (p. 655) and through the “intrapsychictransformation of old transferences into new and more adaptive transferences, organizedaround a new object, the analyst” (p. 657).

But research findings of changes in representations in the treatment process (Blatt,Auerbach, & Aryan, 1998; Blatt, Stayner, Auerbach, & Behrends, 1996; Blatt, Wiseman,Prince-Gibson & Gatt, 1991) raise some interesting questions about these traditional viewsof therapeutic action and the mutative forces in the treatment process. In one study,seriously disturbed inpatients in long-term, intensive, psychodynamically informed ther-apy were asked to describe each of their parents, themselves, a significant other, and theirtherapist at the beginning of treatment and every 6 months thereafter, until termination oftreatment, which occurred, on average, some 18 months later. Analysis of some of thesedata indicated that increased cognitive sophistication and articulation of the representationof mother, father, self, and therapist were significantly correlated with independent clinicalassessment of therapeutic gain. These findings forced us to consider the nature of themutative factors in the treatment process, particularly what patients internalize in thetherapeutic process.

It is often assumed that patients internalize the therapeutic attitudes, functions, andvalues of the therapist and of the treatment process. But if patients project aspects of theirdistorted and conflict-laden early interpersonal relationships with primary caregivers ontotheir therapists, it seems possible that patients also selectively construct and then identifywith aspects of the therapist that are congruent with the patient’s fundamental needs andaspirations, and then more fully internalize these more adaptive elements through iden-tification. Transference projections may express not only distorted and pathologicalenactments but also patients’ more adaptive efforts to find, in the therapist and in thetherapeutic relationship, both consciously and unconsciously, strengths that they have haddifficulty claiming as their own. Both pathological and adaptive attributes may beprojected onto the therapist in the transference. Initially, more powerful pathologicalissues are usually projected onto the therapist, but as these pathological transferences are

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resolved in the therapeutic process, the patient can begin to project more adaptivecharacteristics onto the therapist—characteristics that are then eventually reinternalized infuller, more mature, and consolidated form through identification. Thus, patients may notjust internalize the therapeutic attitudes, views, and functions of the therapist, but, in thelater phases of the therapeutic process, they may also selectively internalize constructedaspects of the therapist that are congruent with their own fundamental needs, goals, andaspirations. As Sutherland (1963, pp. 117–118) noted,

More often the inner object acts as a scanning apparatus which seeks a potential object in theouter world. The subego of this system then coerces these people into the role of the innerobject. . . . The general aim of psychoanalysis . . . in terms of an object-relations model . . . [is]initiating and maintaining a process whereby repressed relationship-systems are brought backwithin the organizing system of the ego that then can be subjected to learning and adaptation.”

Similarly, Meissner (1980, p. 238), in discussing Fairbairn’s concepts of internaliza-tion, noted that “the ego in a sense is thought to scan the outer world for potential objectsthat fulfill . . . the role of inner objects,” and also stated, “External objects will be modified. . . to conform to or to realize the characteristics of these inner objects.” The transitionalobject, as discussed by Winnicott (1965, 1971), is constructed by the child by attributingproperties to the object that derive from the dynamics of the child’s inner life.

This process occurs in treatment as well. Identifications in therapy involve notonly the internalization of attributes of the therapist and the therapeutic process butalso the integration of those attributes that are congruent with preexisting qualities ofthe patient— qualities that the patient then more fully takes as his or her own. In thetherapist, patients find or see adaptive qualities that the patient partially possesses, andin a constructed representation of the therapist, patients eventually, through identifi-cation, consolidate these more adaptive qualities as their own. By identifying thesequalities in the therapist, this process consolidates, at a higher development level,basic adaptive qualities that the patient has long desired and sought. In other words,just as the infant is an active constructing agent in the mother–infant dyad (see, e.g.,Beebe & Lachmann, 2002, and Stern, 1985), the patient is an active constructing agentin the therapeutic process.

A Clinical Example of the Internalization of Adaptive Aspects of theTransference

A summary of a clinical example previously presented in detail elsewhere (e.g., Blatt etal., 1996) illustrates the process through which some patients not only internalize the activitiesand attitudes of the therapist but also actively seek to identify mature and adaptive qualities inthe therapist that are congruent with some fundamental qualities or functions that the patienthas aspired to achieve—the expression of which has been thwarted by the patient’s distur-bances and conflicts.

Alison, a 13-year-old adolescent, was admitted to a long-term, intensive, psychody-namically oriented treatment facility because of severe affective lability, suicidal ideation,substance (opiate) abuse, visual hallucinations, and delusions. Her diagnosis was psy-chotic depression in a borderline personality disorder, with substance abuse. At admissionto the hospital, and every 6 months thereafter to termination about 18 months later, shewas asked by an independent examiner to describe each of her parents, herself, asignificant other, and her therapist. These descriptions were recorded verbatim.

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Her self-description at admission was, “Depends on how I’m feeling. Sometimes I amoutgoing but other times I’m withdrawn. I don’t know.” On nonspecific inquiry by theexaminer, Alison noted that she did not want to describe herself because she gets upsetwhen she does and that she is either too conceited or too modest to answer something likethis.

At 6 months, Alison described herself: “I can’t describe myself—you describe me. It’shard—no it’s easy. Vulnerable. Hurt. Lonely. Sort of happy. Getting more confident—no—please write gaining confidence. Considerate.” Upon inquiry, she elaborated on theword “vulnerable” as “I can easily be hurt.” Upon inquiry into the word “hurt,” she said,“Can’t say more.” “Lonely” was responded to as “I’m suffering from a lack of caring. I’mnot cared about, the way I’d like to be.” “Considerate” was elaborated as “care aboutothers’ feelings.”

Many features of these two self-descriptions are of interest, including Alison’s initialambivalent and qualifying attitude about being outgoing or withdrawn, too conceited ortoo modest, and the task of describing herself as being too hard or too easy. This linguisticprecision in Alison’s self-descriptions suggest a movement toward differentiation, whichwas also expressed at 6 months in her request to change the phrase “getting moreconfidence” to “gaining confidence.” At admission, Alison described her therapist as“sweet, supportive, trusting, and caring.” At 6 months, however, she said, “I can’t describeher because I don’t know her. Seems to care about me. That’s it.”

After about one year of treatment, Alison developed a brief transient psychotictransference to her therapist, in part derived from the emergence of very difficult materialconcerning paranoid ideation that her mother wanted to kill her, with Alison containingher fear by sleeping with a knife under her pillow to protect herself from her mother. Asthis material was dealt with in treatment, Alison once again began to feel closer to herfemale therapist. In this regard, it is interesting and important to note the patient’sdescription of her therapist at the termination of treatment:

I’m trying to think of a word: Tactful in approaching subjects. That wasn’t the word I wasthinking of—not blunt—can say things in a better fashion. She can put things in a better waythat doesn’t sound so intimidating or so cruel. She’s sweet, generous, and has high morals.She’s a nice person. Has high standards.

One of the fascinating aspects of Alison’s description of her therapist at terminationis the emphasis on the therapist’s capacity to articulate things tactfully. In the patient’sdescription of this linguistic capacity in her therapist, the patient herself, as in herself-description at 6 months, is searching for the correct word to capture feelings andthoughts she is trying to communicate. It is impressive that Alison has constructed oridentified characteristics of her therapist that are congruent with the very dimensions thatshe enacted and verbally demonstrated much earlier in the treatment process, at 6 months,in her self-description, and that she was still seeking to acquire at termination.

Alison illustrates how patients internalize and consolidate desired and wished-forfunctions by creating or identifying these qualities in a therapist—qualities that they havesought to obtain from someone else for awhile because they cannot provide thesefunctions fully for themselves. Once these functions are experienced in the therapeuticrelationship, patients seek to consolidate these functions as their own, through identifi-cation with the therapist, and thus can obtain them, enact them, or exchange them throughmore mature forms of relatedness. In this sense, needed, desired, and wished-for functionsare projected onto the therapist and, eventually, through identification, made one’s own.

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This process of externalization and internalization (projective or vicarious identification;Auerbach & Blatt, 2010) is a complex integration and synthesis that results in psycho-logical structure formation through an awareness and acceptance of the eventual loss ofthe therapist (Meissner, 1981).

Attempts to understand the therapeutic process usually focus on aspects of thetherapist and of therapeutic technique but tend to ignore attributes that patients bring to thetreatment process. We assume that patients internalize aspects of the therapist in which wetake pride—our therapeutic attitude, activities, skills, and our interpretations, as well asour capacity to establish a therapeutic relationship. But in our pride over, and preoccu-pation with, our therapeutic skills, we have tended to ignore that patients play an activerole in the treatment process. Throughout treatment, and possibly beyond, patientsconstruct representations of their therapist on the basis not only of the projection ofprimitive needs and conflicts but also of more adaptive fundamental needs and goals.Because of relative therapeutic neutrality, of the therapist’s relative capacity to balanceimmersion in the patient’s experiential world with a stance just outside of it, therapistsexist as individuals for patients in limited but very special ways. This relative therapeuticneutrality—with it being understood that the analyst is never entirely free from his or herown therapeutic values and from the emotional pulls of the therapeutic relationship—allows, even encourages, patients to project onto us both pathological and adaptivequalities. These transference projections enable the therapist to understand importantaspects of patient’s distorted life experiences. But our patients also project qualities ontous attributes they are seeking to make their own. In our relative neutrality, we not onlyencourage patients to express their pathological transferences but also allow our patientsto locate more adaptive and constructive qualities within us—qualities that they areseeking for themselves and that, through processes of projection and identification,eventually come to consolidate as their own.

Introduction of Patient Dimensions into Psychotherapy Research

The active contributions of patients to the treatment process indicate that it is vital thatpatient dimensions be included in psychotherapy investigations. Numerous attempts todemonstrate the relative effectiveness of various kinds of psychotherapy usually yieldessentially inconclusive results. Most comparative studies of different forms of psycho-therapy generally indicate that “no one therapy has been shown to be overall significantlysuperior to any other” (Frank, 1979, p. 311). Extensive meta-analyses of comparativeoutcome studies have shown few differences between alternative forms of treatment (e.g.,American Psychiatric Association Commission on Psychotherapies, 1982; Blatt & Zuroff,2005; Blatt, Zuroff, Hawley, & Auerbach, 2010; Shapiro & Shapiro, 1982; M. L. Smith,Glass, & Miller, 1980). This lack of differences between the effectiveness of variousforms of psychotherapy is, at least partly, a function of the failure to distinguish amongpatients, instead expecting all patients to be equally responsive, in the same way, tovarious forms of treatment. Frank (1979, p. 312), for example, early in the history ofpsychotherapy research, noted “that the major determinants of therapeutic success appearto lie in aspects of the patients’ personality and style of life.” He saw as crucial thedevelopment of criteria for assigning different types of patients to different therapies.Based on research findings (e.g., Malan, 1976a, 1976b), Frank proposed that “verbal,psychologically minded patients who have motivation for insight do well in insight-oriented therapies whereas action-oriented patients may do better in behavioral therapies”

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151PATIENT’S CONTRIBUTIONS TO THERAPEUTIC PROCESS

(p. 312). He also suggested that patients who conceptualize their subjective world ingreater complexity may do better in unstructured situations, whereas less conceptuallycomplex patients may respond better to more structured therapy. Horowitz, Marmar,Weiss, DeWitt, and Rosenbuam (1984), in one of the early studies to consider patientdimensions in their research, found, in brief therapy for bereavement, that patients withdevelopmentally lower levels of self-concept responded to supportive treatment, whereaspatients with developmentally more advanced self-concept responded to insight-orientedtreatment (Blatt & Felsen, 1993).

The assumption of homogeneity among patients—that patients at the start of treatmentare more alike than different, and that patients all experience the therapeutic process andchange in similar ways—has been a major obstacle to the investigation of the processesof therapeutic change. Many psychotherapy investigators and research methodologists(e.g., Bergin & Suinn, 1975; Beutler, 1991; Blatt & Zuroff, 1992, 2005; Colby, 1964;Cronbach, 1958; Goldstein & Stein, 1976; Paul, 1969; Smith & Sechrest, 1991; Snow,1991) have stressed the need to abandon this homogeneity myth and, instead, to includerelevant differences among patients into research designs in order to address complexquestions about whether different types of patients are responsive to different aspects ofthe therapeutic process and change in different, but possibly equally desirable, ways (Blatt& Felsen, 1993; Paul, 1969). Harkness and Lilienfeld (1997, p. 349), for example, notedthat findings from research on individual differences “require the inclusion of personalitytrait assessment for the construction and implementation of any treatment plan that wouldlay claim to scientific status.” Thus, significant differences in sustained therapeutic changemight occur in different treatments as a function of differences in patients’ pretreatmentpersonality.

This persistent failure to include patient variables in psychotherapy research designsis partially a function of the difficulty identifying relevant patient characteristics thatmight be central to the psychotherapeutic process (e.g., Beutler, 1991). One possiblemodel that has been helpful in this regard, consistent with other object relations ap-proaches to the treatment process (e.g., Blatt & Shahar, 2004; Høglend et al., 2008; Piper,Joyce, McCallum, Azim, & Ogrodniczuk, 2002), is the two-configurations model ofpersonality development and psychopathology proposed by Blatt (1974, 2004, 2006b,2008) and colleagues (Blatt & Blass, 1990, 1996; Blatt & Shichman, 1983). This modelposits interpersonal relatedness and self-definition as basic dimensions underlying per-sonality development, personality organization, concepts of psychopathology, and mech-anisms of therapeutic change. This theoretical model, previously presented in detail (e.g.,Blatt, 2006b, 2008) elsewhere, is summarized here to demonstrate its potential value inintroducing relevant patient characteristics into psychotherapy research.

Two Configurations of Personality Development and Psychopathology

A wide range of personality theorists, from Freud (1930) to Bakan (1966), Wiggins(1991), and L. S. Benjamin (1995, 2003), propose that two dimensions—interpersonalrelatedness and self-definition (or communion and agency)—are fundamental componentsof personality development and organization. Consistent with these views, Blatt (1974,2004, 2008) and colleagues (Blatt & Blass, 1990, 1996; Blatt & Shichman, 1983)proposed that normal personality development evolves through a synergistic dialecticalinteraction between these two primary developmental dimensions across the life cycle.Throughout life, interpersonal relationships contribute to the development of a sense of

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self, and refinements in the sense of self contribute to the development of more matureinterpersonal relationships. Although most individuals try to maintain a balanced com-mitment to both of these fundamental dimensions of psychological existence and expe-rience, individuals generally tend to place somewhat greater emphasis or value on one orthe other of these two basic psychological dimensions. Extensive research (see summariesin Blatt, 2004, 2008; Blatt & Zuroff, 1992) indicates that this distinction defines twobroad, normal types of personality organization, one focused primarily on interpersonalrelatedness and the other primarily on self-definition, that engage and experience lifedifferently.

Extensive research (see summaries in Blatt, 2004; Blatt & Zuroff, 1992) indicates thatthese two personality dimensions are also the source of vulnerabilities to depression: (a)disruptions of interpersonal relatedness (e.g., loss, abandonment, or a need for closeness),and (b) disruptions of self-esteem (e.g., feelings of failure, guilt, or unworthiness).Research (see summaries in Blatt, 2004; Blatt & Zuroff, 1992; Corveleyn, Luyten, &Blatt, 2005) indicates that personality characteristics of self-critical perfectionism areoften central to the etiology, clinical course, and treatment of depression. Extensiveresearch (see summary in Blatt, 2004) indicates that patients with these two types ofdepression have different early-life experiences (Blatt & Homann, 1992), are vulnerableto different types of stressful life events (Blatt & Zuroff, 1992) to which they respond andexpress their depression differently (Blatt, Quinlan, Chevron, McDonald, & Zuroff, 1982),and are differentially responsive to different types of therapeutic intervention (Blatt,Zuroff, Quinlan, & Pilkonis, 1996).

Four major scales systematically assess these two personality dimensions: the Dys-functional Attitudes Scale (DAS; A. N. Weissman & Beck, 1978), the DepressiveExperiences Questionnaire (DEQ; Blatt, D’Afflitti, & Quinlan, 1976, 1979), the Sociot-ropy-Autonomy Scale (SAS; Beck, 1983), and the Personal Styles Inventory (PSI; Robinset al., 1994). All four of these scales measure an interpersonal or relatedness dimension,variously labeled “dependency,” “sociotropy,” or “need for approval,” and a self-definitional dimension, variously labeled “self-criticism,” “autonomy,” or “perfectionism”(Blaney & Kutcher, 1991).

The differentiation between individuals preoccupied with issues of relatedness orissues of self-definition has also enabled investigators to identify an empirically derived,theoretically coherent, taxonomy for the diverse personality disorders described in Axis IIin the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–IV; Amer-ican Psychiatric Association, 1994). Systematic empirical investigation with both inpa-tients and outpatients found that various Axis II personality disorders are meaningfullyorganized, in theoretically expected ways, in two primary configurations: one organizedaround issues of relatedness and the other around issues of self-definition. Even further,empirical investigations have found that individuals with a dependent, histrionic, orborderline personality disorder have significantly greater concern with interpersonalrelatedness than with issues of self-definition, whereas individuals with a paranoid,schizoid, schizotypic, antisocial, narcissistic, avoidant, obsessive–compulsive, or self-defeating personality disorder usually have significantly greater preoccupation with self-definition than with issues of interpersonal relatedness (Clark, Steer, Haslam, Beck, &Brown, 1997; Cogswell & Alloy, 2006; Goldberg, Segal, Vella, & Shaw, 1989; Levy etal., 1995; Morse, Robins, & Gittes-Fox, 2002; Nordahl & Stiles, 2000; Ouimette & Klein,1993; Ouimette, Klein, Anderson, Riso, & Lizardi, 1994; Overholser & Freiheit, 1994;Pilkonis, 1988; Ryder, McBride, & Bagby, 2008). These findings are further supported byattachment research that demonstrates that personality disorders can be similarly orga-

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153PATIENT’S CONTRIBUTIONS TO THERAPEUTIC PROCESS

nized in two-dimensional space, defined by attachment anxiety reflecting relatednessconcerns and attachment avoidance reflecting self-definitional issues (Blatt & Luyten,2011; Meyer & Pilkonis, 2005; Luyten & Blatt, in press).

Blatt (1990, 2004, 2006b, 2008) and colleagues (e.g., Blatt & Shichman, 1983)also conceptualize many major forms of psychopathology, in addition to depressionand personality disorders, as involving one-sided, distorted, intense preoccupationwith one of these two personality dimensions to the neglect or defensive avoidance ofthe other. Severe disruptions of the normal synergistic developmental process leadsome individuals to seek stability by placing exaggerated and distorted emphasis onone of these developmental lines, either interpersonal relatedness or self-definition,with marked impairment in the other dimension. Disorders with excessive preoccu-pation with issues of interpersonal relatedness, at the expense of the development ofa sense of self, are termed anaclitic because these individuals are preoccupied withleaning on others for emotional support (Blatt, 1974; Blatt & Shichman, 1983). Theseissues can be expressed at a very primitive level in experiences of fusion and merger,with a loss of boundaries between self and nonself in undifferentiated schizophrenia(e.g., Blatt & Wild, 1976); at a more intermediate level, around intense fears ofabandonment and neglect, in borderline and dependent personality disorders; or at amore advanced reciprocal level, around conflicts with being able to give as well asreceive love, in histrionic personality disorder (Marmor, 1953).

In contrast, self-definitional disorders with excessive preoccupied with the forma-tion and protection of the self at the expense of the development of interpersonalrelatedness are termed introjective because they often involve harsh self-criticism,perfectionism, and a need for control that have been internalized from similar suchattitudes from parents or other caregiving figures. Struggles around self-definition canbe expressed at a primitive level, in feeling persecuted (e.g., attacked or criticized) byothers in paranoid pathology; at an intermediate level, in excessive behavioral andideational control in obsessive– compulsive conditions; and at developmentally moreadvanced levels, in exaggerated concerns about self-worth in negative self-criticalconcerns in introjective depression, or in positive and sometimes grandiose preoccu-pations in narcissistic disorders. In general, the terms relational and self-definitionalrefer to these concerns in normal functioning, and the terms anaclitic and introjectiverefer to their respective decompensations in psychopathology. Blatt (2004; Blatt et al.,2010) also speculated that sustained progress in psychotherapy is expressed in areactivation of the previously disrupted normal dialectic developmental interactionbetween relatedness and self-definition, such that anaclitic patients eventually becomemore agentic and assertive, and introjective patients eventually become increasinglyinvested in interpersonal relationships (Safran & Muran, 2000).

Thus, the developmental constructs of interpersonal relatedness and self-definition providethe basis for an empirically supported and theoretically coherent model of personality devel-opment and psychopathology that has demonstrated reliability and construct validity—a modelfor introducing patient variables into the investigation of the treatment process. In contrast tothe atheoretical diagnostic system of the DSM (American Psychiatric Association, 1994),based primarily on manifest symptoms, the differentiation between anaclitic and introjectivepersonality organization and psychopathology is based on dynamic considerations, includingdifferences in primary instinctual focus (libidinal vs. aggressive), types of defensive organi-zation (avoidant vs. counteractive), and predominant character style (e.g., emphasis on objectvs. self-orientation and on affects vs. cognition; Blatt, 1991).

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Investigations of Patient-Treatment and Patient-Outcome Interactions

The distinction between relational and self-definitional personality organization andanaclitic and introjective forms of psychopathology was made at acceptable levels ofinterrater reliability in two investigations of long-term, psychodynamically oriented treat-ment—the Riggs-Yale Project (R-YP; e.g., Blatt & Ford, 1994; Blatt, Besser, & Ford,2007), and the Menninger Psychotherapy Research Project (MPRP; e.g., Blatt, 1992; Blatt& Shahar, 2004). Findings in these investigations indicate that anaclitic and introjectivepatients come to treatment with different needs, respond differentially to different types oftherapeutic intervention, and change in different ways—ways congruent with their basicpersonality organization.

Vermote and colleagues (e.g., Luyten, Lowyck, & Vermote, 2010; Vermote, 2005;Vermote et al., 2010) studied therapeutic change in a 9-month, psychodynamicallyoriented inpatient treatment program for personality disordered patients at the Kortenberg-Leuven Psychiatric Hospital (K-LS). Although Vermote et al. did not differentiateanaclitic and introjective patients in the K-LS at the outset of their investigation, theynoted, in conclusion, that their findings were congruent with the differential therapeuticresponse of anaclitic and introjective patients in the R-YP and the MPRP investigations(Luyten et al., 2010; Vermote, 2005; Vermote et al., 2009, 2010). Vermote (2005)concluded that not only were specific patterns of change noted in these two different typesof patients but also that different aspects of the therapeutic process seemed to havefacilitated their change—that the “anaclitic group,” like in the MPRP, responded tosupport and structure, whereas the “introjective group” profited from the explorativedimensions of the treatment process. Vermote et al. also noted that the continued andsustained improvement of introjective patients in posttreatment was consistent with thefindings of Bateman and Fonagy (1999, 2001) and with the consequence of their greatercapacity for internalization in introjective patients (Blatt & Behrends, 1987). Vermote(2011, p. 4) found these results so convincing that he and his colleagues at Kortenbergreorganized their clinical services to now offer “classical psychodynamic grouptherapy for severe introjective patients (obsessive— compulsive, narcissistic, para-noid), while for anaclitic patients (borderline, histrionic, dependent) [they] offer morestructured therapy like Mentalization Based Treatment, which is less based on insightand transference.”

These findings of therapeutic change in long-term, intensive, psychodynamic treat-ment in the R-YP, MPRP, and K-LS provide strong confirmation of Cronbach’s (1958, forexample) and Frank’s (1979) formulations that patients’ personality characteristics influ-ence therapeutic response, and that psychotherapy research needs to go beyond compar-isons of various forms of treatment in the reduction of focal symptoms (e.g., depressionor anxiety) to address more complex issues such as identifying mechanisms of therapeuticchange and identifying what kinds of treatment are more effective, in what kinds of ways,with which types of patients (Blatt & Shahar, 2004; Blatt, Shahar, & Zuroff, 2002; Paul,1969).

The differential response of anaclitic and introjective patients to different dimen-sions of the therapeutic process in long-term intensive treatment suggested that thewell-established differentiation of dependent (anaclitic) and self-critically (introjec-tive) depressed patients (Arieti & Bemporad, 1978, 1980; Beck, 1983; Blatt, 1974;Blatt et al., 1976, 1982) may be important in the systematic evaluation of differentforms of brief psychotherapy in treating depression. Thus, this distinction of these twotypes of depression was introduced into further analyses of data from the extensive

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155PATIENT’S CONTRIBUTIONS TO THERAPEUTIC PROCESS

and comprehensive Treatment of Depression Collaborative Research Program(TDCRP) sponsored by the National Institute of Mental Health (NIMH)—a remarkablyextensive data set established by Elkin and her NIMH colleagues (Shea, Parloff, andDocherty) that compared 16 weeks of medication (Imipramine, the antidepressant medi-cation of choice at that time) and a double-blind placebo with 16 sessions of manual-directed, carefully monitored, cognitive–behavioral therapy (CBT) or interpersonal psy-chotherapy (IPT) in the outpatient treatment of depression (Elkin, 1994). Eighteenexperienced psychiatrists and 10 experienced PhD clinical psychologists saw patients atone of three treatment sites.

The basic findings of the TDCRP (e.g., Elkin, 1994) indicated that medication(Imiprimine) led to a significantly more rapid decline in symptoms at midtreatment (atSession 8), but no significant differences were found in symptom reduction among thethree active treatments at termination (the classic “dodo bird effect”). Shea andcolleagues from the TDCRP, in an analysis of follow-up evaluations 18 months aftertermination, considered approximately 35% of the patients to have recovered becausethey had minimal or no symptoms for at least eight consecutive weeks followingtermination of treatment (Shea et al., 1992). Approximately 40% of these recoveredpatients, however, had relapsed by the 18-month evaluation. Thus, Shea et al.concluded that only approximately 20% of the 239 patients “fully recovered.” In sum,the TDCRP investigators found no significant differences among the three activetreatments at termination, and found that all three active treatment conditions wererelatively ineffective in producing therapeutic gain that was sustained through the18-month follow-up period.

Based on the two factors of the Dysfunctional Attitudes Scale (DAS; Weissman &Beck, 1978), administered at intake and periodically throughout treatment in theTDCRP, Blatt, Quinlan, Pilkonis, & Shea (1995) explored the impact of the DASNeed for Approval (NFA) and Self-Critical Perfectionism (SC-PFT) scales on thetreatment process in the TDCRP. Blatt and colleagues found that pretreatment levelsof self-critical perfectionism (SC-PFT, an introjective personality trait), measured bythe DAS (Weissman & Beck, 1978) significantly interfered with treatment outcome attermination across all four treatment conditions in the TDCRP. Pretreatment SC-PFTinterfered dramatically with therapeutic gain primarily in the latter half of treatment,beginning in the 9th treatment session. Only patients with lower SC-PFT had signif-icant therapeutic gain as they approached termination. Pretreatment SC-PFT was alsosignificantly associated with poor therapeutic outcome at the 18-month follow-up(Blatt, Zuroff, Bondi, & Sanislow, 2000).

Using latent difference score (LDS) analysis, a structural equation modeling tech-nique, Hawley, Moon Ho, Zuroff, and Blatt (2006) evaluated temporal coupled changesin symptoms and the introjective personality dimension, SC-PFT. They found thatdepressive symptoms diminished rapidly very early in the treatment with relatively littletherapeutic intervention, but, in contrast, SC-PFT diminished gradually throughout treat-ment. Despite the remarkably rapid decrease in depressive symptoms early in the treat-ment process, significant unidirectional longitudinal coupling indicated that changes inpatients’ SC-PFT predicted the decline in symptoms of depression throughout treatment.Thus, sustained therapeutic gain in the TDCRP, over all four treatment conditions, seemsto be the consequence of changes in the personality factors involved in depression. Thesefindings also indicate the need to further examine how these pretreatment personalityfactors impact on the treatment process.

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156 BLATT

Using the ratings established by Krupnick et al. (1996) of the degree to which patientand therapist contribute to the therapeutic alliance in the 3rd, 9th, and 15th treatmentsessions in TDCRP, Zuroff et al. (2000) found that pretreatment SC-PFT significantlyinterfered with patients’ participation in the therapeutic alliance, especially in the last halfof treatment.1 Shahar, Blatt, Zuroff, Krupnick, and Sotsky (2004) found that pretreatmentSC-PFT also significantly impaired patients’ perceptions of their social relationships assupportive. Thus, pretreatment SC-PFT interfered with interpersonal relationships both inand external to the treatment process. The disruption of these interpersonal relationshipsaccounted for almost all of the effects of pretreatment SC-PFT on treatment outcome attermination.

The quality of patients’ overall relationship with their therapist was assessed in theTDCRP at the end of the 2nd treatment session with the well-established (e.g., Gurman,1977a, 1997b) Barrett-Lennard Relationship Inventory (B-L RI; Barrett-Lennard, 1962,1985). The B-L RI, based on Carl Rogers’ (1957, 1959), “necessary and sufficientconditions” of effective therapy, assesses the degree to which patients experienced theirtherapist as warm, empathic and congruent. The B-L RI, very early in the treatment, wassignificantly related to a more positive therapeutic outcome at termination and at the18-month follow-up. It was also significantly related to a decline in SC-PFT over thecourse of treatment—a change that, in turn, led to further therapeutic gain. It is impressivethat the quality of the therapeutic relationship assessed so very early in the treatmentprocess (at the 2nd treatment session) had a significant impact on treatment outcome bothat termination and at follow-up, as assessed on a wide range of measures across all fourtreatment conditions (see also Blatt et al., 1996, and Kim, Wampold, & Bolt, 2006).Hawley, Moon Ho, Zuroff & Blatt (2007), in another LDS analysis, found that the strengthof patients’ participation in the therapeutic alliance in the 3rd treatment session signifi-cantly influenced change in their level of SC-PFT, which, as noted earlier, significantlyinfluenced the reduction of depressive symptoms.

Together, these findings clearly indicate that the quality of the early therapeuticrelationship and the extent of to which the patient participated in the therapeutic allianceplays a crucial role in the reduction of depressive symptoms as well as the disruptivenegative self-schema (SC-PFT; Zuroff & Blatt, 2006). Consistent with these findings, Itis important to note that more effective therapists in the TDCRP, in comparison withmoderately and less effective therapists, were significantly “more psychologically minded,eschewed biological interventions . . . in their ordinary clinical practice and expectoutpatient treatment of depression to take longer” (Blatt, Sanislow, Zuroff, & Pilkonis,1996, p. 1276).

In summary, the two-configurational model facilitated the introducing of crucialpatient dimensions into the investigation of both long- and short-term treatment. Themodel also posits that a goal of treatment is to enable both dependent (anaclitic) andself-critical (introjective) individuals to reestablish the synergistic process so they canestablish increasingly mature levels of both relatedness and self-definition. Research by

1 It is especially important to note that Krupnick and colleagues (1996), using the VanderbiltTherapeutic Alliance Scale (VTAS; Hartley & Strupp, 1983), rated the contributions of both patientsand therapists to the therapeutic alliance. Consistent with the basic premise of this article about theimportance of attending to the patient’s contribution in the treatment process, Krupnick et al. foundthat only the contributions of the patients to the therapeutic alliance, and not those of the therapists,were significantly related to therapeutic gain at termination across all four treatment conditions inthe TDCRP.

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157PATIENT’S CONTRIBUTIONS TO THERAPEUTIC PROCESS

Safran and Muran (2000, for example) suggests that dependent and self-critical patientsmay approach this goal from somewhat different directions—through different transfer-ence expressions and enactments. Issues of unreliable and inconsistent caring experiencesare expected to emerge with dependent patients, whereas self-critical patients will likelydeal with issues of failure and transgression, and with harsh, critical, punitive, judgmental,intrusive, and overcontrolling early relationships. Dependent (anaclitic) patients willusually focus, at least early in the therapeutic process, on issues of separation and loss ofgratifying relationships. The early focus of self-critical (introjective) patients will primar-ily be on establishing and maintaining a sense of self as separate, independent, andworthwhile. Exploration of these processes of therapeutic change await further investi-gation.

Conclusions

The findings and formulations presented in this article suggest that the contributions of thetherapist must be multifaceted and in response to the basic personality organization of thepatient. Thus, the unit of analysis in psychotherapy research should not be the patient orthe therapist in isolation, but the patient–therapist interaction. The effectiveness of thetherapist’s responses appears to be determined by whether it enables the patient toexperience the therapist as empathic and congruent (as measured, e.g., by the B-L RI) andto participate more fully in the therapeutic process (as measured, e.g., by the VanderbiltTherapeutic Alliance Scale; Krupnick et al., 1996) so that the patient can continue andextend the internal dialogue and exploration (Freud, 1937). Findings from long-termpsychodynamic treatment (e.g., the MPRP and the K-LS) indicate that dependent (ana-clitic) patients are responsive primarily to supportive interventions, whereas self-critical(introjective) patients are primarily responsive to exploratory interventions, Thus, theeffectiveness of specific therapeutic interventions must be defined and evaluated not inisolation but from the perspective of the patient–therapist dyad. In sum, the findings andformulations presented in this article clearly indicate the importance of focusing, in bothclinical practice and clinical research, on the patient’s contribution to the treatmentprocess and on the conditions that facilitate this participation.

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