States of Mind Analysis of Change in Psychotherapy

CRITICAL ISSUES IN PSYCHIATRY An Educational Series for Residents and Clinicians

Series Editor: Sherwyn M. Woods, M.D., Ph.D. University of Southern California School of Medidne Los Angeles, California

A RESIDENT'S GUIDE TO PSYCHIATRIC EDUCATION Edited by Michael G. G. Thompson, M.D.

STATES OF MIND: Analysis of Change in Psychotherapy Mardi J. Horowitz, M.D.

DRUG AND ALCOHOL ABUSE: A Clinical Guide to Diagnosis and Treatment Marc A. Schuckit, M.D.

A Continuation Order Plan is available for this series. A continuation order will bring delivery of each new volume immediately upon publication. Volumes are billed only upon actual shipment. For further information please contact the publisher.

States of Mind Analysis of Change in Psychotherapy

Mardi J. Horowitz, M.D. University of California School of Medicine

San Francisco, California

Plenum Medical Book Company. New York and London

Library of Congress Cataloging in Publication Data

Horowitz, Mardi Jon, 1934-States of mind.

(Critical issues in psychiatry) Bibliography: p. Includes index. 1. Psychotherapy. 2. Personality change. I. Title. II. Series. [DNLM: 1. Psycho­

analysis. 2. Psychotherapy. WM460.3 H816s) RC480.5.H67 616.8'914 78-10957 ISBN-13: 978-1-4613-2891-9 e-ISBN-13: 978-1-4613-2889-6 DOT: 10.1007/978-1-4613-2889-6

First Printing-March 1979 Second Printing-March 1984

© 1979 Mardi J. Horowitz, M.D. Softcover reprint of the hardcover I st edition 1979

University of California 1350 3rd Avenue, San Francisco, California 94143

Plenum Press, New York A Division of Plenum Publishing Corporation

233 Spring Street, New York, N.Y. lool3

All rights reserved

No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microftlrning,

recording, or otherwise, without written permission from the Author

Foreword

Some will wonder why this book, with its specific focus on the pro­cess of change in psychotherapy, was chosen for inclusion in "Crit­ical Issues in Psychiatry: A Series for Residents and Clinicians" as our books are generally devoted to a broad topical survey of some im­portant clinical area in the practice of psychiatry or a related mental health discipline. The answer will become rapidly apparent to the reader, for Dr. Horowitz has developed an exciting, creative, and practical method whereby any psychotherapist can understand, monitor, conceptualize, and evaluate the process of change in psychotherapy.

His method of "configurational analysis" utilizes direct clinical observations of emotional states, role relationships, and information processing to systematically, in a step-by-step fashion, organize and describe clinical data. It can be employed at any point in the therapeutic transaction, from the time of initial presentation to the time of termina­tion or follow-up. This method of organizing information about a person, his problems and resources, and the nature of the psychotherapeutic transaction provides the therapist with a powerful tool with which to both understand and communicate how and why change occurs, or does not occur, in psychotherapy. It can be applied all the way from the description of large-scale patterns to the microanalytic dissection and understanding of a small segment of a therapy session.

This is an invaluable book not only for established clinicians but also for students and their supervisors as they attempt to understand the complexities of psychopathology and psychotherapy. It is not an easy book, and not one which can be skimmed lightly for its essence. However, those who take the time to read it seriously and thoughtfully will be rewarded with a conceptualization of inestimable value in their clinical work.

v

vi FOREWORD

Mardi Horowitz is Professor of Psychiatry at the University of California, San Francisco, where he is Director of the Center for the Study of Neuroses at the Langley Porter Institute. The Center received one of the eight clinical research center grants recently awarded by the National Institutes of Mental Health. Dr. Horowitz's research and teaching credentials are evident in this scholarly contribution to education, research, and clinical practice.

Sherwyn M. Woods, M.D., Ph.D.

Preface

Although the individuality of each of us defies any classification sys­tem, types of persons do recur. When we change, we do so in unique ways; nevertheless, repetitive patterns can be recognized. Does the behavioral scientist always have to start from ground zero when it is necessary to describe and explain a person and the change in a per­son? An avoidance of all theories enables him to cast the broadest pos­sible net. But, unfortunately, he always starts at the beginning, is not alert to certain signals and so misses them, and leaves no scientific foundation upon which others can build.

On the other hand, if we approach the complexity of human per­sonality and change with a rigid preformed theory of categories, we will make observations only according to these restrictive classifica­tions. The scientific knowledge that we do accrue will contain distor­tions, and repeated observation by the same means may perpetuate these distortions. Our present belief systems contain such distortions, distortions that include illusions about those interventions that induce change processes. A proliferation of new techniques for psycho­therapy marked the recent era but did not lead to a clarification of the change process; the field needs a method for careful statement of prob­lems and examination of how, when, and why change occurs.

Between the paths of naive empirical stances and rigid theoretical positions lies an opportune area for a flexible method of description and explanation, one whose evidence is based on observation. The configurational analysis approach described in this book is an effort at systematization of such a method. It provides a step-by-step approach to description of human problems, resources, and processes of change, and a method for assembling and organizing information. Repetition is a vital aspect of this method and results in a gradual clarification of interactive patterns; such clarification, in sequence, is essential in a

vii

viii PREFACE

complex human field wherein definitive statement by means of a single-stage analysis of evidence is impossible. The avoidance of rigid classifications or preformed definitions allows individual qualities to emerge and determine labels.

The sequence of the steps in configurational analysis begins with a summary of patterns at the level of direct observation. Inferences to explain these patterns from interactive points of view are developed gradually, at several levels of abstraction. Static situations are not pre­dicted or necessary; the aim of the method is to describe changing sit­uations and enduring patterns of determinants of change.

Configurational analysis is not new. It combines and expands the useful components currently inherent in our science. This is appropri­ate because the problems of describing persons and the changes they undergo are not new; they have been carefully studied in a variety of mental health service and research settings. Case presentations and evaluations of treatment process have been the backbone of training for all mental health professionals. But the levels of solution to the problem of how to understand, evaluate, write about, or present a given person and treatment have been so frustrating that they prompted distinguished psychologist Paul Meehl (1973) to finally write a despairing paper entitled "Why I Do Not Attend Case Confer­ences"!

The usual solution to the problem of organizing this kind of infor­mation goes something like this: First, there is a summary of the major problem states of the person, for instance, his episodes of suicidal ru­mination, anxiety attacks, or confused behavior. The person's present and past relationships to work and to significant others are then eval­uated; currently active demands, conflicts, struggles, and limitations are discussed in relation to the person's controls and resources. Next, the process of treatment is explored, with focus on both the content of interaction between therapist and patient, and the form of that in­teraction. Finally, there is examination of outcome or current status.

Configurational analysis follows this form, but in a much more systematic manner that reduces its difficulties and prevents confusion at various levels of abstraction. Clinicians, in discussion, often do not communicate well because they focus on different parts of the total picture. The levels of abstraction most commonly confused, or even regarded as antithetical, are those of interpersonal relationship and images of self and other, and those of information processing and in­formation control. Configurational analysis allows us to see these levels as both distinct and interactive; it allows a step-by-step look at the total picture.

PREFACE ix

One problem with the typical case conference and formulation is the multiplicity of agendas. Issues of self-esteem, conformity, and status blend with scientific objectivity. The therapist wants the patient to do well, and he wants to do well himself. Even after presentation, discussion of the issues is often cloudy. Time is short, variables are many, every discussant presents a slightly different point of view, responses are made without order, and contradictory explanations are seldom stated at similar levels of abstraction or in the same descriptive language. Much more would be gained from systematic case review by clinicians armed with an approach and with time to contemplate re­peated patterns. Also, such review early in treatment would allow ra­tional plans for subsequent interventions.

It is my hope that the main contribution of configurational analy­sis will be to provide a method for ordering information about a per­son, his problems, and the processes of change. In the material that follows, I present an outline of the steps that can lead to sequential clarification of cloudy issues, and a series of formats that can assist in the organization of information for each step. These formats are pro­vided in two languages: linear prose and visual statement. The prose descriptions are given at the beginning of each step; the visual state­ments consist of diagrams that show how to organize interrelated sets of information. For example, a particular diagram about information processing shows the interrelationship between the meanings of current events, respondent ideas, enduring attitudes, emotional re­sponses, controls, and the effect of controls on subsequent conscious experience.

The world seems to be composed of two types of people: those who are helped by diagrams and those who are confused by them. I include myself among the former and hope for some like-minded read­ers. For us, visual-spacial language as a complement to prose allows contemplation of ideas in two forms. I beg the forbearance of those who dislike diagrams. I have attempted to make them more palatable by using consistent formats, and have also gained confidence through teaching: Trainees who initially rejected diagrams eventually found them valuable for depicting casual interactions that might otherwise have been too cumbersome to describe clearly.

Such formats also advance a general theory of mental operations. In essence, this theory is psychoanalytic, although it modifies existing formulations. The energic point of view is replaced by a modified ego psychology that emphasizes information processing and the structural aspects of self and object representations. Emotions are not seen as drive derivatives but as consequences of and contributors to ideation.

x PREFACE

The defense mechanisms as usually described are perceived as inade­quate to explore the territory. Those classical defenses usually regarded as processes, are here regarded as outcomes. Control opera­tions are seen as the processes that accomplish these defenses. For ex­ample, undoing is viewed as the result of controls that switch sets of ideas, and so oscillate emotional or action responses; repression is seen as the result of various controls that inhibit the representation of ideas. These are not radical revisions, but efforts at increased theoreti­cal precision. By stating controls, one in effect rotates the turret of the microscope and examines process on a finer level. This diminishes the gap between theory and clinical observation.

Configurational analysis begins with descriptions of large-scale patterns. Once they are observed, we will examine finer patterns and arrive, finally, at a microanalytic process. The systematic approach avoids a premature microanalytic preoccupation; the eventual mi­croanalytic process is a check against the gross formations, because it compares the explanatory power of formulations with direct material such as transcripts or videotapes.

The steps of configurational analysis, and the formats for each step, are useful in training in psychopathology and psychotherapy, and in other mental health services. As a research tool, they offer a method for examining human processes of change in a repetitive man­ner, and can be applied to successive cases selected because of similar­ity. They present clinicians with a means for selective case review, ei­ther to study what has happened, or to plan improvements when a therapeutic impasse occurs.

Since configurational analysis lists statements in a replicable for­mat, independent clinicians can follow this method and compare re­sults. Wherever agreement is reached, consensual validation of pat­terns would be apparent. Where disagreements occur, another review of the retained data would allow for adjustments to common defini­tions and language, or rejection of unsupported assertions. This con­cept of replication by use of the same format is seldom applied in clinical psychology and psychiatry, yet it is a paradigm that can en­compass the richly interwoven variables of human life and the logistic and ethical problems of research with human beings.

Configurational analysis could also provide another format for organizing psychological information in applied psychodynamics. One could subject Hamlet to a description of his recurrent states of ambivalence, paralysis of action, deadly decisiveness, and pretense of gaiety or of madness; one could describe his various self-images and core models of role relationship, and explain his changes in state by

PREFACE xi

the ways in which he processed information. Similarly, in a psycho­history one could plot the states, images, and information-processing styles of a person whose decisions interacted with important events.

Configurational analysis is, then, an extension of basic clinical paradigms and a movement toward greater precision and objectiv­ity. I believe that its strength lies in its embeddedness in clinical observation, and hope that its use will advance theory and practice.

Mardi J. Horowitz, M.D. San Francisco

Acknowledgments

I based this text on research supported by a Clinical Research Center Grant from the National Institute of Mental Health (MH, 30899-01) and grants from the Chapman Research Fund and the Fund for Psychoana­lytic Research of the American Psychoanalytic Association. The Na­tional Institute of Aging, through their grant to the Human Develop­ment Program (AG, 00002-05) at the University of California, San Francisco, provided additional support for the study of nonpatients. Visual materials used in the text were funded in part by an Innovative Teaching Grant from the Academic Senate of the University of Califor­nia. Precursory work on the basic concepts would have been impossi­ble without the extended support provided by two Research Scientist Development Awards from the National Institute of Mental Health (MH, K322573).

Nancy Wilner edited the entire work, contributed to it, and did far more than that. She encouraged the project from beginning to end, attended to the larger conceptualizations as well as the details essential to bringing any work to completion, and provided invaluable moral support.

The visual materials are the product of successive efforts at graphic clarity done in collaboration with Eric Stoelting of the Medical Illustration Department, UCSF. Carolyn Clayton typed and retyped the many drafts of each chapter, with unusual precision and skill. Jordan Horowitz assisted with the bibliography. To all of them, my profound thanks.

I also express my gratitude to colleagues who read and criticized the text: Robert Wallerstein, Alan Skolnikoff, John Starkweather, and Michael Hoyt, and to Charles Marmar, who also contributed to this work. Colleagues and students at the Langley Porter Institute, Mount Zion Medical Center, and the San Francisco Psychoanalytic Institute

xiii

xiv ACKNOWLEDGMENTS

helped provide the theoretical platform on which these elaborations rest. Those whose influence was most important are Robert Waller­stein, Joseph Weiss, Harold Sampson, Emanuel Windholz, Edward Weinschel, Stanley Goodman, Emmy Sylvester, Norman Reider, and William Barrett. The Department of Psychiatry at Stanford University and U.c.L.A. arranged all-day seminars so that the configurational analysis approach could be explored and revised on the basis of re­sponses by fresh professional audiences. Discussion with Eric Berne, Jane Loevinger, Otto Kernberg, and Jacob Arlow were important to my focus on states and the explanation of role relationships. Many contacts with Joseph Weiss and Harold Sampson on the processes of therapeutic change and discussions with George Klein, Irving Janis, and Richard Lazarus provided vital filaments for the information­processing components of the text. Attention to the importance of out­come evaluation was centered through exchanges with David Malan, Nancy Kaltreider, Clifford Attkisson, William Hargreaves, and the members of the Menninger Psychotherapy Research Team. I recom­mend their works to the reader.

My deepest appreciation goes also to my wife Nancy and children Ariana, Jordan, and Joshua for sacrificing time to text and sustaining me throughout. Gratitude from all of us, author and reader alike, goes to Janice, the fictional name of the person whose consent allowed her work in therapy to be used for these research and teaching purposes, and to other patients whose concerns for the need to help others led to similar courageous decisions.

MJH

Contents

Introduction Plan for Configurational Analysis: Summary of Illustration Case 1

Part I. The Definition of Problems

Chapter One Description of Problems

Chapter Two States and State Cycles

Chapter Three Self-Images and Relationship Models

Chapter Four Ideas, Emotions, and Controls

Part II. Processes of Change

Chapter Five

Modification of the Transition between States

Chapter Six

23

30

48

76

97

Development of Self-Images and Role Relationships 103

Chapter Seven

Working Through Ideas, Feelings, and Modifying Controls 123

xv

xvi

Part III. Description of Outcome

Chapter Eight

Alteration in the Frequency and Quality of States

Chapter Nine Modification of Self-Images and Role Relationships

Chapter Ten Change in Ideational Constellations and

Information-Processing Style

Part IV. Applications of Configurational Analysis

Chapter Eleven

Use of Configurational Analysis in Teaching

Chapter Twelve

Research Applications (with Nancy Wilner and Charles Marmar)

Chapter Thirteen Applications during Treatment

Appendix Transcript Illustrations

A. Relationship Processes: The Therapeutic Alliance B. Working Through: The Homesickness Theme

References

Index

CONTENTS

155

159

166

175

196

209

221 221 246

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277

States of Mind