Lester Luborsky is one of our most prominent psychoanalytic researchers. His book, Principles of Psychoanalytic Psychotherapy: A Manual for Supportive-Expressive Treatment, was recently published by Basic Books. As Dr. Holzman points out, this is the first guide to psychoanalytic psychotherapy to appear in manual format, so we asked Dr. Holzman to have Dr. Luborsky explain manuals to us.
Dr. Holzman: This is a significant event for psychoanalysis—it is the publication of the first guide to psychoanalytic psychotherapy in manual format. Since I wrote the foreword to it, I may be an appropriate person to ask you to explain the format of the book to our colleagues. How is this manual different from the hundreds of other books on psychoanalytic psychotherapy?
Dr. Luborsky: The field is going through a small revolution in research and practice that requires the use of manuals. This is psychoanalysis' first entry in that field. In just the past five years it has become a de facto necessity for anyone doing comparative research on psychotherapies to have a manual. It was never needed or expected before five years ago, but now there is no research proposal comparing psychotherapies that comes to NIMH without a manual or a promise of a manual.
Dr. Holzman: You should explain then, what is a manual?
Dr. Luborsky: To qualify as a manual requires three components: 1) a representative selection of the principles of technique, 2) concrete examples of each technique so that there is no question what is meant by the technique, 3) a set of measuring scales for each technique so that anyone—the therapist or observers—can judge the degree to which a sample of the therapy fits the principles of the technique. Obviously this third characteristic of manuals is the most special and requisite.
Dr. Holzman: What are the sources from which you drew the principles of technique in the examples?
Dr. Luborsky: Since my aim was to be representative, I reviewed the most authoritative sources. The primary source is the Ur source, Freud's recommendations on technique. I also drew on the well-described principles of psychoanalytic psychotherapy from the Menninger Foundation tradition. Lastly, I was influenced to some extent by recent psychotherapy research on these techniques (such as the significant power of measures of the helping alliance for predicting the outcomes of the treatment). It was the Menninger Foundation tradition that provided the term “supportive-expressive” where “supportive” refers to the patient's experience of the relationship as helpful and “expressive”
refers to the patient's acquisition of understanding through clarification and interpretation of transference.
It is here that the book offers a novel form of guidance to the therapist's interpretations—a clinically simplified version of the core conflictual relationship theme method as a way of delineating the transference pattern so that it can more readily serve as the focus for the therapist's interpretations. I should add that much of that work on the core conflictual relationship theme method was funded by the Fund for Psychoanalytic Research of the American Psychoanalytic Association, which was tremendously helpful to me at the moment it was needed.
Dr. Holzman: The book has been out for six months. Have you heard how it is being used?
Dr. Luborsky: Happily, I can report that it is filling the need that it was intended to fill. For those doing research on psychoanalytic psychotherapy it has been adopted generally, both for studies of the usual time open-ended psychotherapy as well as for time-limited psychotherapy. Additionally, supervisors of psychoanalytic psychotherapy have found it helpful as an adjunct to their supervision.
It was not meant, of course, to serve as a substitute for supervision. Several of the therapists in my supervision groups (at the University of Pennsylvania Department of Psychiatry) observe that it gives them a review of the theory and the related techniques so they can see how the everyday supervision fits into the larger framework of psychoanalytic psychotherapy. Morton Reiser tells me that they have had similar experience at his Department at Yale. Even highly skilled therapists often have that reaction and tell me about the special use fulness of the core conflictual relationship method for guiding interpretations.
Dr. Holzman: We come now to the inevitable comparison—how does the psychoanalytic psychotherapy in the manual compare with classical psychoanalysis?
Dr. Luborsky: I take that up in the book, for there are many who wonder along similar lines. There are, of course, obvious structural differences provided by the use of frequent sessions and of the couch. Also, classical psychoanalysis more often relies on the class of techniques having to do with achieving understanding, that is, interpretive methods, and relies less on facilitation of the relationship by supportive techniques. Yet, in practice, psychoanalytic psychotherapy and classical psychoanalysis are often similar in some basic respects for some patients. I am interested in making a second manual suitable for classical psychoanalysis by revising and adapting this current one; several other people have expressed a similar interest.
Dr. Holzman: As someone who knows the book thoroughly, I want to say as I did in the foreword: This is a splendid book and fills a crucial function for psychoanalytic research and practice. It is not only the manual format that is responsible for the success of its exposition, but the way you systematically demystify the treatment process and take the reader through the method step by step in a sequence of intervention strategies. It is good that it arrived when it did—at a time when psychoanalysis needs and is ready to develop its research underpinnings.