Last September, Guilford Press published The Psychoanalytic Process: Theory, Clinical Observation and Empirical Research by Joseph Weiss, M.D., Harold Sampson, Ph.D., and the Mount Zion Psychotherapy Research Group. Their work employs vigorous research methodology, moving in a direction many feel psychoanalysis must choose if it is to survive. Weiss, who developed the theory presented in the book, contends that analytic patients are primarily warding off unconscious motives, as well as instincts and their derivatives. Also warded off are unconscious beliefs arising from the traumas of childhood. Weiss postulates that patients have conscious and unconscious plans to disconfirm these repressed pathogenic beliefs. The analyst, rather than being merely a transference figure who frustrates, can enable the patient to carry out his plans. The analyst does this by passing “tests” and thereby creates conditions of safety whereby the patient can experience and be aware of what was heretofore too dangerous.
Dr. Wilson: Robert Holt said, “Psychoanalysts must begin to face the fact that their primary and typical form of research, the uncontrolled clinical case study, is devoid of scientific value except as a source of hypotheses”. Morris Eagle said about your new book, “As far as I know, it's the only book in which a coherent theory of the analytic process (developed by Weiss) is presented and then followed by systematic research testing the implications of that theory”. How did your own creative process work in developing your ideas? Did the seeds of your ideas germinate from observations of your own clinical work?
Dr. Weiss: I wrote an article in 1952, Crying at the Happy Ending in which I tried to explain why sometimes people cry when they're happy rather than when they're sad. I developed the idea that the reason people cry when they're happy is that they're capable then of tolerating the sadness because it's safe.
In 1956 I joined a research group organized by Windholz. In studying process notes on analyses conducted by myself and others, I observed that patients repressed ideas until they felt it was safe to bring them out. I studied an analysis which I conducted myself. The process notes were for six or more years.
Dr. Wilson: You say your work is true to the later Freud. Can you expand on this?
Dr. Weiss: Freud, in The Outline , developed an hypothesis that the person (or his ego) has control over his repressions and that he brings forth things when it's safe. He said that a person who wants to bring an unconscious idea forth does the following: He thinks about it. He thinks about the present situation. He thinks about past experiences which may bear on whether he can safely bring it out or not. He may perform trial actions or tests to see if he can. Then he makes a decision. This is all unconscious.
In early Freud, it was quite different. In The Interpretation of Dreams, Freud tried to develop a model of the mind, based on physical science, which runs automatically without any thoughts, without any decisions or beliefs. Freud didn't adhere to that model completely, although he wanted to. For example, in The Interpretation of Dreams he wrote that a person brings forth dreams at night because it's safe to do so; the censor permits it. This is the same idea he developed in The Outline about daytime mental activities. I call it the higher mental functioning model.
Starting with ego psychology, Freud developed the higher mental functioning model. In the old theory, he thought everything was regulated automatically by the pleasure principle. In Beyond the Pleasure Principle, he made the observation that patients repeat things that aren't pleasurable, which never could have been pleasurable. This made him change his theory about the importance of the pleasure principle and its universality.
Also he began to observe how important guilt was in human life, and he gradually emphasized the importance of unconscious guilt. Freud also eventually moved toward a position in which he assumed that almost all mental activities which a person can do consciously, he can do unconsciously, as well. He can make decisions, regulate repressions, infer beliefs, almost everything except focus attention. This is a far cry from the old model, and I've based most of my theorizing on the later theory.
Dr. Wilson: You brought up the notion of unconscious guilt. Your ideas about it seem to reflect Freud's ideas on the negative therapeutic reaction, as well as Reik's and Bergler's on masochism. Do you see your theory as being similar in any way?
Dr. Weiss: Well, yes, in a way. I think almost every neurotic, as Freud said, has his neuroses nourished by unconscious guilt. For example, suppose a man is having terrible fights with his wife. It isn't just because he has aggressive impulses. He has aggressive impulses and they are important, but you'll discover when you find out more about this guy that he's punishing himself. Maybe his father fought with his mother a lot; and he can't have a happier life than his father. Or maybe his father and mother enjoyed the idea that he had a bad temper and he had to comply with them. There's some kind of guilt there, too, as
well as a powerful impulse. In my view, the impulses, while important, aren't the entire story. Powerful impulses which are not particularly useful, like terrible aggression or drinking a lot or overeating are almost all supported by some kind of unconscious guilt, anxiety or belief.
Dr. Wilson: I'm interested in how you conceptualize trauma. Is it a highly subjective state based on unconscious fantasy as Freud indicated when he moved away from his early seduction theory, or is it real objective trauma as postulated by Mason and Alice Miller, as well as others?
Dr. Weiss: I believe trauma plays a part in the development of pathogenic beliefs. In varying degrees, it's always based on both internal and external factors. A person may be traumatized by castration threats or by projecting rivalry onto his father, and then assuming that his father will castrate him. But either way I think that as he experiences it, it's a real threat. The important thing is that he feels threatened and develops the belief that if he is aggressive or competitive or rivalrous, he'll be punished.
I also think, when someone faces some kind of catastrophe, he'll develop a pathogenic belief. David Beres' (PSC, 1958) research shows that. He found that all kids who were placed outside of the home developed the idea that it was their fault, that they were being punished by their parents because they were bad.
I think there is a complementary series in which internal and external factors play roles. In some people, internal factors are greater, with denial and projection being important; and in others, external factors are more important.
Dr. Wilson: Your ideas have caused quite a stir. You mentioned a debate or discussion that occurred recently within the San Francisco Psychoanalytic Society on your ideas. How did this meeting go?
Dr. Weiss: Several neutral members of the institute organized three two-hour debates. They all read the theoretical chapters of my book; Wallerstein was the moderator. The disagreements were extremely pointed. Each side was polite yet constructive. They presented their views directly, in a respectful way. I think the audience got a great deal out of it. I think everybody learned—I did. Even the opponents did. It made us re-examine our own convictions.
Dr. Wilson: So, it's a good example of how controversy can be turned to good account, an open forum?
Dr. Weiss: Yes. There was mutual respect in this meeting.
Dr. Wilson: Morris Eagle, while praising your work on the psychoanalytic process, says that one of its definite limitations is your assumption that good therapeutic outcome is largely the result of the emergence of warded off themes and contents. This is in line with the hallowed role of insight and awareness in psychoanalytic therapy. He also questions the degree of generalizability of your results. Are you attacking these criticisms by way of any outcome studies? Dr. Weiss: We are showing that our ideas have been supported in brief psychotherapy outcome studies. I want to say that the research work has been shared with Hal Sampson. We're co-directors of the Mount Zion Psychotherapy Research Project.
Dr. Weiss: I think some people assume my theory is avoiding the issue because guilt is relatively tolerable and aggression is not. I disagree with them. Real guilt is intolerable. Aggression is sometimes easier to take.
I had a patient who had escaped from Nazi Germany when she was 12 to live with a wealthy family. She told me, when she first came to me, that she was very glad her parents were killed, that they were a millstone around her neck. It took her years to face her intense guilt, her concern for her parents, her sorrow. Her hatred of them was easy to tolerate.
Her guilt was almost intolerable. It took her a long time to give up the idea that she was glad they had died. This was all defensive against the guilt. Guilt and remorse are among the most painful of all human emotions. I think people can often face their aggressions more easily.
People often conceal their guilt by claiming that they are pleasure seeking. “I drink too much because I just happen to like alcohol” or “I can't give up a good meal” or “I like to gamble”. They won't admit to doing it to destroy themselves. Self-destructive impulses are hard to face. Guilt is an extremely compelling emotion; anxiety is an extremely compelling emotion. Facing them and dealing with them is not the easiest thing in the world.
As regards Kohut, I don't know his work well enough to comment in depth. But when a patient admires you a great deal, Kohut says you should accept it, or tolerate it, and I think this is often correct. It is not always a defense against aggression. There are patients who come to you who are very ashamed of their mothers and fathers. They have been mistreated and abused. They're very proud to get an analyst who is a decent person. The fact that they can admire you enables them to face all the shameful elements in their childhood. It makes it safe for them to cry at the happy ending. The fact that they feel they have something good, something they can hold onto, that they are proud of, is not really a defense against aggression, and it won't prevent agression from coming out if that's a crucial element.
Regarding mirror transference, I think it's fine to let patients take center stage. It may make it safe for them to face all kinds of things. A patient whose analysis I had supervised had parents who never listened to him, and he had to worry a lot about them. In treatment, he didn't want to be treated; he wanted to be listened to. Later on, other material came out. It wasn't prevented from coming out by the fact that the therapist didn't interpret it for a long time. It did not prevent his accepting interpretations from the therapist later on.
Dr. Weiss: No, I would not. Our research shows that Grunbaum's ideas are not particularly correct either. He believes there is no basis for the theory
of repression. He says that what analysts do is suggest to the patient, on the basis of their theories of the unconscious mind, what the patient had repressed. The patient complies and the analyst thinks that this confirms the theory. This is not true. We have shown that patients bring forth material that our judges say was repressed and that the analyst had never interpreted. We think we have strong evidence for the theory of repression.
Dr. Wilson: Well, Grunbaum is not a clinician.
Dr. Weiss: No, he's a philosopher. I also think that psychoanalysis is testable by rigorous quantitative scientific methods. That is the way to go in developing our science. Scientific research requires our kind of work. The fact that it cannot be done quickly, that it can't be done in six months or a year, doesn't mean it can't be done. It took us four or five years of study to get our results, but that is the way in most sciences. People expect to get too much too easily.
Dr. Wilson: Your results certainly justify the time spent.
Dr. Weiss: Yes, I believe they do, and our results have greatly influenced our own thinking. We may be on the right track.
A very good example that is well known among analysts is the man who masturbates all the time. It isn't just because he has an intense need for sexual gratification; he's probably worried about his penis. He wants to prove it's okay, that he hasn't injured himself. It's not possible to account for all psychopathology on the basis of impulses seeking gratification. It's usually supported by unconscious guilt, and I think this is often overlooked.
Two people in our group, John Curtis and George Silberschatz, are studying brief psychotherapy of 16 sessions. They're doing follow-up studies, six months and a year after the finish of therapy. The results are coming out much as we predicted. They show that outcome correlates highly with the way the therapist behaves. When the therapist passes the patients' “tests”, and makes the right interpretations, patients do well.
Eagle thinks I over-emphasize the importance of insight, but I don't think a person has to have complete insight into his problems in order to do better. If the therapist passes the “test” the patient is offering him, he may get better even though he doesn't become completely conscious of the process. He may be able to change his pathogenic beliefs even though he doesn't become completely conscious of these beliefs and see their irrationality. I can give you an example from our brief psychotherapy research.
An Israeli had tremendous survivor guilt. He and his parents went to Israel. He was successful there, but his parents couldn't adjust. His parents were unhappy. In the therapy, he took his parents' role with the therapist, putting the therapy down, complaining, whining—as his parents did with him. He felt responsible for his parents and their happiness, and he also felt guilt because he did much better than they did.
We thought the therapist handled it well by not caving in to criticism and feeling guilty. The therapist told the patient that he (the patient) felt guilty and worried about his parents because he was doing better than they were. The patient rejected the whole thing. We thought the therapy went well because the therapist didn't feel put down by the patient, as the patient had felt put down by his parents. This guy, by the way, quit therapy after 14 sessions, rather than going the full 16. He said it was no good. We predicted he was going to do well, and he did. He said the therapy did no good, but in the follow-up he reported feeling well. He had the insights that the therapist gave him. This illustrates that the patient's evaluation of the therapy is not always correct.
Dr. Wilson: So, there is a kind of unconscious cognitive restructuring going on even though patients are not necessarily aware of that? If the therapist does the right thing?
Dr. Weiss: Right. The patient claimed he got no insight at all, but he really did. Of course, I think people do get insight in analysis; I think the insight is very important, but I think cognitive restructuring can go on even without insight, or with limited insight.
Dr. Wilson: You mentioned your outcome studies on brief psychotherapy. How applicable is your theory to psychoanalytic psychotherapy and psychoanalysis proper?
Dr. Weiss: The theory applies to all kinds of therapy. People have pathogenic beliefs which they have to change. This theory is applicable in all treatments because it is about how the mind works.
Dr. Wilson: There seems to be a subtle shift in basic assumptions about humanity in theories such as yours that emphasize a more positive, optimistic view of man; that is, that people have a drive toward mastery of what troubles them. I see certain similarities in this view of man to some of Kohut's underlying assumptions. The analyst, thus, becomes more of a nonthreatening or—in your terminology—neutral force for their development. People critical of later theories emphasize that and say that they rob psychoanalysis of the blood and guts of libidinal and aggressive instincts.
Dr. Wilson: How would your ideas relate to the corrective emotional experience, as proposed by Alexander?
Dr. Weiss: I think the corrective emotional experience has been underestimated, but I don't exactly agree with Alexander. Patients do get new experiences in the analysis and these new experiences are very important for a successful analysis. I believe the patients get them by “testing” the analyst. The patients seek the new experiences. If the analyst is good, they will get the corrective emotional experience. I believe corrective emotional experience leads to insight.
By the way, Freud implied a corrective emotional experience in The Outline. He said something like this: We know how the patient puts the analyst in the role of the superego, which gives the analyst a chance to educate the patient, to indulge in a bit of after education. It would be wrong for an analyst to abuse this, but a certain degree of it might be all right.
I tend to agree with what Rangell said, that patients get corrective emotional experience not mainly from what the analyst does, but from what the analyst doesn't do. I believe that the idea that corrective emotional experience keeps the patient from gaining insight is incorrect. Consider the person who had parents that he was ashamed of. Assume that he is proud of his analyst and the analyst permits him, for a period of time, to enjoy his pride. This will not prevent the patient from bringing out his shameful memories; in fact, it will enable the patient to bring them out, and it will not prevent the patient from bringing out his aggressions to the analyst.
I haven't read enough of Alexander to know what he does or doesn't do, but I believe problems come from pathogenic beliefs, that one way the patient works to change these beliefs is by “testing” them and getting corrective emotional experiences, and that this process leads to insight. Suppose the patient has castration anxiety. He believes castration is a punishment for sexuality. He talks about sexual experiences and fantasies. The analyst is non-punitive, perhaps supplying a corrective emotional experience. It may make it easier for the analyst later on to interpret his fear of castration. So, I think corrective emotional experience leads to insight, rather than preventing insight as has been argued.
Dr. Wilson: So, it seems that you're saying there is a definite relational aspect to this. What you do may be as important as what you say.
Dr. Weiss: You don't have to do any play acting to create this. The patient will relate to the therapist and by “testing” him give himself the experiences he needs to get. Anna Freud said that the patient extracts from the analysis the experience he needs. I agree.
Dr. Wilson: Can you say a bit more about your ongoing research?
Dr. Weiss: The research Hal Sampson and I do is carried out with tapes and transcripts of analyses and psychotherapies. We make hypotheses about the therapeutic process and then test them.
We disagree with Spence's ideas that research is impossible—we believe that there are objective recurring patterns which can be tested and re-tested. For example, oftentimes during an anaylsis, unconscious ideas come forth not secondary to interpretation. There are several possible explanations for this. One is intensification of impulses based on frustration, so that the impulses or ideas push through to consciousness. Another is that the patient has developed a sense of safety which allows him to bring forth these ideas.
Now, these two hypotheses predict different findings. The frustration hypothesis predicts that the patient has conflict or increased tension before bringing the unconscious ideas forth, and the safety hypothesis predicts a more relaxed state before bringing them forth. Or a less anxious one. We did a research study to test the one hypothesis against the other. Using reliable methods that eliminated bias, we found a number of unconscious ideas coming forth not secondary to interpretation. By using the Gottschalk-Gleser and the Mahl measures of anxiety, we could measure how the patient felt when the repressed mental contents were coming forth. We found that patients had less anxiety when these repressed ideas emerged than they did in random segments. We also measured these same segments with the experiencing scale. This scale reveals the degree of defensive isolation; i.e., how much a person is truly experiencing what he is talking about. We found the experiencing was high when the anxiety was low. Our research strongly supports the idea that the patient brings forth repressed mental contents when he can safely experience them.
Let me go through that one more time because I think it's a little obscure. If an impulse pushes through to consciousness against repression, you should have increased anxiety when it's coming forth. If it comes forth because affect is isolated from it, you would have no anxiety, but you would have low experiencing. If it comes forth because it's safe, you would have high experiencing and low anxiety. We tested these alternative hypotheses and our results support the safety hypothesis.
This illustrates the idea that psychoanalytic hypotheses are testable by rigorous quantitative methods. We think the way to do research is by testing hypotheses, one against the other. It isn't that we're trying to disprove the drive hypothesis, we're trying to show the importance of the unconscious control hypothesis. It explains the data very well and it is one of Freud's main hypotheses.
Dr. Wilson: I gather you would not agree that psychoanalysis is a hermeneutic science, as some contend?