Table Of ContentWallerstein, R.S. (2000). Forty-Two Lives in Treatment: A Study of
Psychoanalysis and Psychotherapy.
Wallerstein, R.S. (2000). Forty-Two Lives in Treatment: A Study of Psychoanalysis
and Psychotherapy. , 1-768. Other Press New York.
Forty-Two Lives in Treatment: A Study of Psychoanalysis and Psychotherapy
Robert S. Wallerstein, M.D.
Contents
Preface to the Softcover Edition xi
Preface xix
Section I. Preview and Rationale
1. The Conception and Purpose of This Volume 5
2. The Congruence of Observation and Conclusion: Comments on Earlier 14
Publications
3. Conducting and Describing a Long- Term Psychotherapy Study: Questions 28
and Issues
Section II. Overview and Organization: The Problem, the Methods, the Design
4. Questions and Basic Premises of the Project 47
5. Selection and Characteristics of the Patient Group 56
6. The Three Phases of the Project 71
7. Procedural Aspects of the Project 102
Section III. The Patients and Their Characteristics
8. Symptoms and Illness Configurations 121
9. Issues of Diagnosis and Implications for Treatment 158
Section IV. The Treatments and Their Characteristics
10. Treatment Modality: Plans and Changes 185
11. Treatment Setting and Context 215
12. Therapist and Patient Factors Affecting Treatment 236
Section V. The Treatment Course: The Processes of Psychoanalysis and Expressive
Psychotherapy
13. Analytic Cures 265
14. Varieties of the Transference Neurosis 278
15. The Analysis of the Hysterical Patient: Limitations? 293
16. Analysis of a Narcissistic Patient 321
17. The “Transference Psychosis” 329
18. Other Psychotic Treatment and Posttreatment Reactions 344
Section VI. The Treatment Course: The Processes of Expressive-Supportive
Psychotherapy
19. The Expressive Psychotherapeutic Mode 373
20. Supportive Psychotherapy: Varieties of the Positive Dependent 389
Transference
21. Supportive Psychotherapy: Other Supportive Mechanisms 451
22. “Rescue” by Factors Other than Psychotherapy 489
Section VII. The Treatment Courses and Outcomes: Overviews
23. Overall Treatment Results 513
24. Changes in HSRS Ratings and Changes in IQ 529
25. Turning Points in Treatments 540
26. Treatment Disruption by External Pressures 550
27. Treatment Failures and “Untreatable” Patients 561
28. The Patients' Marital Families: Problems, Changes, and Treatments 573
Section VIII. The Follow-Up Courses and Outcomes: Overviews
29. Follow-Up in General: Observation Spans and Degree of Cooperation 587
Obtained
30. The Impact of Follow-Up upon Treatment Termination and Resolution 598
31. Posttreatmem Returns for Help: Psychotherapy and Other Therapy 606
32. Stability at Follow-Up: The Role of the Environment 619
33. The “Therapeutic Lifer” 631
34. Termination and Follow-Up: Comparative Assessment 641
Section IX. What Have We Learned from These Cases?
35. Second-Guessing: Misdiagnoses and Wrong Treatments? 653
36. “Heroic Indications” for Psychoanalysis Reconsidered 668
37. The Expressive-Supportive Dichotomy Reconsidered 682
38. Insight, Structural Change, and Their Relationship Reconsidered 700
39. Overall Results-and Their Bases 720
40. Tasks for the Future: Psychotherapy Research 734
Appendices
1. The Patient Code 747
2. The Patient Outcomes 749
3. The Concordance of the Patients 752
4. Bibliography of the Psychotherapy Research Project 756
5. References 761
Name Index 769
Subject Index 771
Preface to the Softcover Edition
Forty-Two Lives in Treatment was first published in 1986 as the final clinical
accounting of the Psychotherapy Research Project (PRP) of The Menninger
Foundation, chronicling the treatment careers and the subsequent life careers of forty-
two patients—half in psychoanalysis, half in equally long-term, psychoanalytically
informed, expressive and supportive psychotherapies—originally treated in the
decade of the 1950s and with follow-up information, which extended, in a significant
segment of the cohort, over the full 30-year span of observation. Each of the forty-two
cases, referred to in a variety of places in different contexts throughout the book, was
also described in extenso as a case report (or rather life report) in its particular place
in the book, in a fullness that has become unhappily all too rare in the psychoanalytic
literature.
The major findings and conclusions of this most ambitious and far-ranging
psychotherapy research program ever conceived and carried out are comprehensively
described in over one-hundred-pages in the final section of the volume. They were
subsequently condensed for presentation purposes at a symposium of the Boston
Psychoanalytic Society and Institute (Wallerstein 1988a) into a set of six sequential
propositions (here stated in highly abstracted summary form).
1. The distinctions made so regularly in psychodynamic literature between true
structural change in personality organization and functioning, presumably based on
the interpretive resolution of underlying intrapsychic conflict, and mere “behavioral
change” or changes in “manifest behavior patterns” that are (invidiously) considered
just “altered techniques of adjustment,” presumably all that could come out of other
noninterpretive change mechanisms (i.e., the varieties of supportive
psychotherapeutic techniques adduced throughout the book in the descriptions of the
treatments of the research cohort), were simply not sustained in our research study.
The changes reached in our more supportive therapies, and via intrinsically supportive
mechanisms, seemed often enough just as much structural change, just as enduring
and stable, just as proof against future environmental vicissitude, that we should no
longer accept that the one way—the interpretive-uncovering mode—has an exclusive
corner on effecting true structural change. Put differently, our findings led us to
question strongly the continued usefulness of the effort to so closely link the kinds of
changes achieved with the intervention mode, expressive-interpretive or supportive-
“ego maintaining,” by which they are brought about.
2. The conventional proportionality argument that therapeutic change will be at least
proportional to the achieved conflict resolution is, put this way, almost
unexceptionable. What became clear in PRP, however, is that there can be
significantly
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more change than that based on true intrapsychic conflict resolution on all the varying
(supportive) bases described in this book, through which change can be brought
about, as well as properly proportionate change where the change is all or “purely” on
the basis of conflict resolution with proportionate insight—if such an ideal type can
ever actually exist in practice.
3. Often linked to the proportionality argument, though clearly distinct and much
more debatable, has been the necessity argument: that effective conflict resolution is a
necessary condition for at least certain kinds of change, i.e., true structural change.
Yet an overall finding from PRP—almost an overriding one—was the repeated
demonstration that a substantial range of changes were brought about via the more
supportive therapeutic modes and techniques, cutting across the gamut of declared
supportive and expressive (even analytic) therapies, and that in terms of the usual
criteria, these changes were (in many instances) quite indistinguishable from the
changes brought about by typically expressive-analytic (interpretive, insight-
producing) means.
4. A counterpart to the proposition based on the tendency to overestimate the
necessity of the expressive (analytic) treatment mode, and of its operation via conflict
resolution to effect therapeutically desired change, has been the other proposition,
based on the happy finding that the supportive psychotherapeutic approaches,
mechanisms, and techniques often achieved far more than was expected of them—in
fact often enough reached the kinds and degrees of change expected to depend on
more expressive and insightful conflict resolutions—and did so in ways that
represented indistinguishably “structural changes,” in terms of the usual indicators of
that state.
5. Considering these PRP treatment courses from the point of view of
psychoanalysis as a treatment modality, just as more was accomplished with
psychotherapy than expected, and more stably and more enduringly, especially in its
more supportive modes, so psychoanalysis, as the quintessentially expressive
therapeutic mode, was more limited than had been anticipated or predicted—at least
with these sicker than usual private practice patients, who were sent or brought to The
Menninger Foundation because of its psychoanalytic sanatorium setting, with its
possibilities for the backup protection, care, and life management of these individuals
under conditions of (temporary) behavioral disorganization and incompetence.
Actually, the significant failure of the so-called “heroic indications” for
psychoanalysis (Glover 1954) invited, in our view, a repositioning of the pendulum in
its swings over time around this issue, more in the direction of “narrowing
indications” for (proper) psychoanalysis along the lines marked out by Anna Freud
(1954).
6. The predictions made for prospective therapeutic courses and outcomes tended to
be for more substantial and enduring change (more “structural change”), where the
treatment was to be more expressive-analytic and where the changes were expected to
be based more on thoroughgoing intrapsychic conflict resolution. And pari passu,
again in terms of the conventional wisdom, the more supportive the treatment was
intended to be (had to be), the more limited and inherently unstable the anticipated
changes were predicted to be. All of this was consistently tempered and altered in the
actual implementation in the treatment courses. The psychoanalyses and the
expressive psychotherapies were systematically modified in the direction of
introducing more supportive components, often accomplished more limited outcomes
than promised (hoped), and as indicated, with a varying but often substantial amount
of that accomplished by noninterpretive, i.e., supportive, means.
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The psychotherapies, on the other hand, often accomplished a good deal more than
initially expected, and, again, however the admixture of intervention techniques was
originally projected, with much of the change on the basis of more supportive modes
than originally specified.
What all this labor in PRP added up to can be most broadly generalized as follows:
Ƞ The treatment results with those selected as appropriate for psychoanalysis or for
varying mixes of expressive-supportive therapeutic approaches, tended—with this
patient sample—to converge, rather than diverge.
Ƞ Across the whole spectrum of treatment courses, from the most expressive to the
most avowedly supportive—the psychoanalyses included—the treatments carried
more supportive elements than originally intended, and these supportive elements
accounted for substantially more of the changes achieved than had been originally
anticipated.
Ƞ The nature of the supportive aspects of psychotherapy, as conceptualized within a
psychoanalytic framework, and as deployed by psychoanalytically knowledgeable
therapists, bears far more respectful specification, in all of its form variants, than has
usually been accorded it in the psychoanalytic literature.
Ƞ Perhaps most important, from the study of the kinds of changes reached by this
cohort of patients, partly on an uncovering, insight-aiming basis, and partly on the
basis of the opposed covering-over varieties of supportive techniques, the changes
themselves—divorced from how they were brought about—often seemed quite
indistinguishable from each other, in terms of being so-called real or structural
changes in personality organization.
These were then the overall central findings and conclusions of PRP, as discerned in
the detailed study and documentation in this Forty-Two Lives in Treatment. Within
the psychotherapy research literature this capstone book—the final publication in
what had been a sequence of almost seventy articles, including six books and
monographs, written by close to twenty authors, and published over a quarter-century
span—was hailed as the most ambitious and comprehensive psychotherapy research
program ever conceived and carried to conclusion, one that combined group-
aggregated results across clusters of patients of meaningful size (outcome studies),
with intensive individual longitudinal studies of each of the patients in the research
cohort over their entire span (process studies), from their initial evaluations for
treatment within the two-week-long Menninger Foundation diagnostic evaluation
process, through the entire duration of their treatments (up to 12 years in some
instances), and then into a specified several year follow-up period (with follow-up on
100 percent of the cohort), and beyond that, with as much of an open-ended follow-up
as circumstance might make possible and our span of interested observation might last
(with fully a third of the patients followed-up over a 12-to-24-year period). Mostly it
was lauded as a program of psychoanalytic therapy research that carried real
implications for clinical practice and technique, one that could really make a
difference in guiding the practicing clinician in treatment planning and execution.
In an article that I entitled “The Generations of Psychotherapy Research: An
Overview” (in press), I outline what I call four distinct generations of psychotherapy
research starting as far back as the first studies (as early as 1917), each successive
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generation marked by progressively increasing conceptual sophistication and
technological enhancement. PRP is described there as an exemplar of the third
research generation, marked by prospective inquiry; by specification of criteria at
each step in judgment; by efforts to control for potential bias, confounding and
contamination of judgments; by the fashioning of predictions about each therapeutic
course and outcome, to be validated or refuted by subsequent assessment; by the clear
separation of outcomes achieved at termination from those discerned at subsequent
follow-up, with efforts to account for further changes, either consolidations or
regressions that took place in the post-analytic phase; and, most critical, through all of
this, by trying to achieve the integrated benefits of both process and outcome studies.
It is on the basis of all this that Bachrach et al., in their comprehensive review of the
entire research literature to that point on the efficacy of psychoanalysis, declared in
1991: “Systematic, methodologically informed research about psychoanalytic
outcomes began with The Menninger Foundation Psychotherapy Research Project….
[It] is by far the most comprehensive formal study of psychoanalysis yet undertaken
and remains the only study of outcomes that spans almost the entire life cycle of many
of its patients” (p. 878)…. [It] stands in a class by itself among psychoanalytic
research efforts” (p. 884). In their article's overall summation on PRP, Bachrach et al.
stated: “The prospective design, clinical focus, scope, duration, extensive collection of
case histories spanning decades, painstaking accumulation of followup information,
quantitative sophistication, careful definition of terms, and systematic review of
treatment processes and outcomes from multiple points of view, are all admirable
features of the study” (p. 884).
It was exactly this kind of response from our psychotherapy research colleagues,
coupled, at the same time, with an awareness that PRP was conceived and carried out
within the psychoanalytic conceptual framework of the 1950s (when it was
inaugurated) and within the technical state-of-the-art research method and design of
its time, that in the mid-1980s in San Francisco, together with a new group of research
colleagues, I undertook the organization of a successor project, dubbed PRP-II. This
new project took as its starting point a major methodological limitation of PRP, that
its statements concerning the most important outcome issue, the achievement (or not)
of “structural change in the ego” rested ultimately on the clinical judgments of the
research evaluators, seasoned psychoanalysts and psychoanalytic researchers to be
sure, and making their judgments on the basis of a vast accumulation of clinical and
projective test data on each research subject, but nonetheless without built-in
safeguards to maximally insure against the judges' biases and subjectivities.
PRP-II, in its more than a decade of development and operation now, has been
devoted to the creation of a clinically acceptable and relevant metric for the
assessment of ego structure and structural change, which we have called Scales of
Psychological Capacities (SPC), with judgments of scale points to be based in part on
usual clinical interview data, and in part on supplemental data derived from a
specially prepared semi-structured interview with inquiries directed by specific probe
questions geared to the seventeen distinct Scales. Work on PRP-II has been
proceeding steadily ever since, with three publications to this point from our own
group (DeWitt et al. 1991; Wallerstein 1988b; Zilberg et al. 1991), and another from a
group in Sweden (Sundin et al. 1994); the Scales are currently being studied and used
by more than twenty psychotherapy research groups around the world, mostly
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in Europe, and in seven different language translations. But that is another story,
perhaps a successor book.
The response of the psychoanalytic clinical world to Forty-Two Lives has been
equally heartening, though less foreseen. In large part, I am sure, the very positive
response to the book, and to my presentation of the main PRP findings at the Boston
symposium (1988a), reflected the changing Zeitgeist during this time period, the
general retreat from the very austere, authoritative model for psychoanalytic
technique propounded originally by Kurt Eissler (1953) in the heyday of American
ego psychology, who declared that proper psychoanalytic work consisted of veridical
interpretation alone, appropriately dosed and timed of course, leading via repetitive
offerings over time (the process of working through) to insight, and ultimately to
change and “cure.” For at least two decades this model served as the benchmark
against which proper analytic technique (at least that carried out in America within
the then regnant ego psychology paradigm) would be measured, with any departure
from its rigid strictures designated as “parameters” that might be indicated in relation
to the clinical exigencies of patients with less than Freud's “normal ego,” but would
need to be resolved (i.e., totally undone) within the analytic interaction in the interest
of analytic thoroughness and completeness.
By the time Forty-Two Lives appeared, the rigid constraints of the Eissler model had
been largely dissipated through the efforts of many analytic workers—the “alliance”
concepts of Elizabeth Zetzel and Ralph Greenson, the “humanization” of the analytic
interchange articulated by Leo Stone, the focus on the analyst as a new object (in
addition to being the reactivated transference-drenched old object) with whom
“integrative experiences” could (should) be achieved, as reconceptualized by Hans
Loewald, among those foremost in bringing about this shift in analytic climate—and
yet the coercive aura of Eissler's original dictum still somehow survived, still coloring
many psychoanalytic superegos. What was said by so many, in response to my Boston
presentation of our PRP findings, was that this was such a “courageous” talk—a
feeling that I had not especially experienced—since it confronted Eissler's
“interpretation only” thesis so directly. “You give us permission to say what we really
do in our everyday analytic work, and not have to confine what we experience to
corridor confessions to trusted colleagues, nor to have to hide it from our analytic
seniors or omit it from our case write-ups.”
Though this was by no means an original PRP intent, and was in fact a truly
unanticipated and surprising finding, the major role of other-than interpretation, the
whole array of what in the language of the time we called “supportive” mechanisms
of techniques; the major role that these played in the changes effectuated in even the
most “purely” psychoanalytic treatments, did indeed fit when Forty-Two Lives was
first published—with the new perspectives on the psychoanalytic change process,
then emerging under the kinds of influences adumbrated just above, even in the
American heartland of the ego psychology frame and its austere technical precepts as
articulated by Eissler.
The language of this newer discourse was no longer necessarily the same. The
language of expressive and supportive techniques was a product of the ego
psychology era, made popular in the early writings of Robert Knight, Merton Gill,
Leo Rangell, and Leo Stone, when they were elaborating the distinctions, the
similarities, and the differences, in the spectrum of psychoanalytically derived and
informed psychotherapies, from the most expressive psychoanalytic psychotherapy
(closest in form
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and method to psychoanalysis proper) to the most single-mindedly supportive
psychoanalytic psychotherapy, as these were all delineated in the 1940s and '50s
within the ego psychology paradigm. This was a language brought to its most
comprehensive statement in Paul Dewald's 1964 volume, Psychotherapy: A Dynamic
Approach, a detailed explication of the distinctions between expressive and
supportive therapeutic approaches to every aspect of the treatment process from the
initial encounter to the closing session. And PRP, creature of its time, was cast in that
language of expressive (interpretive, uncovering, insight-aiming) and supportive (ego
maintaining or strengthening, suppressive, covering-over) approaches in its initial
conceptualization, over the entire course of its operation, and, to avoid potential
confusion, in its ultimate publication, even though in the meanwhile a major shift in
the identifying rubrics had occurred, to the current language of the interplay of
interpretive and relationship factors in together conducing toward effective
therapeutic change.
The language of expressive and supportive modes and techniques has never
completely died out, however, and during the same decade of the '80s in which Forty-
Two Lives was published, two major volumes appeared in the psychoanalytic
psychotherapy literature, both cast in the expressive-supportive language, and each
representative of the effort called for in the PRP conclusions, to give a more
respectful place conceptually to the nature and the specific form of supportive
methods in dynamic therapies: David Werman's The Practice of Supportive
Psychotherapy (1984), and Lawrence Rockland's Supportive Therapy: A
Psychodynamic Approach (1989). Nonetheless, this language preference is fast losing
favor, but I would submit that conceptually it slides almost seamlessly into the
language of interpretation vis-à-vis relationship in their contrapuntal roles at the
center of current-day concerns with the full elucidation of the change process in
psychoanalytic psychotherapies.
It is for these reasons of my strong convictions about the continuing signal importance
of PRP, its findings and its conclusions in relation to our cutting-edge present-day
clinical and research concerns about the therapeutic process and how it brings about
change, that I have always felt troubled that the high cost of a hard-cover volume of
this scope has posed such a barrier to the circulation that all of us involved in our
thirty years of partnership work in PRP would have wished for it. It thus becomes for
me a most felicitous circumstance that Other Press has seen fit to assume the
softcover rights and to undertake, in this much less costly way, to give this volume a
renewed lease on life to the widened mental health professional audience—both
clinical and research—that I have always wanted for it. I hope that that faith proves
justified.
References
Bachrach, H. M., Galatzer-Levy, R., Skolnikoff, A. Z., and Waldron Jr., S. (1991). On
the efficacy of psychoanalysis. J. Amer. Psychoanal. Assn. 39:871-916.
Dewald, P. (1964). Psychotherapy: A Dynamic Approach. New York: Basic Books, p.
307.
DeWitt, K. N., Hartley, D. E., Rosenberg, S. E., Zilberg, N. J., and Wallerstein, R. S.
(1991). Scales of psychological capacities: development of an assessment approach.
Psychoanal. Contemp. Thought 14:343-361.
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Eissler, K. R. (1953). The effect of the structure of the ego on psychoanalytic
technique. J. Amer. Psychoanal. Assn. 1:104-143.
Freud, A. (1954). The widening scope of indications for psychoanalysis: discussion. J.
Amer. Psychoanal. Assn. 2:607-620.
Glover, E. (1954). The indications for psycho-analysis. Journal of Mental Science
100:393-401.
Rockland, L. H. (1989). Supportive Therapy: A Psychodynamic Approach. New
York: Basic Books, p. 308.
Sundin, E., Armelius, B.-Å., and Nilsson, T. (1994). Reliability studies of scales of
psychological capacities: a new method to assess psychological change. Psychoanal.
Contemp. Thought 17:591-615.
Wallerstein, R. S. (1988a). Psychoanalysis and psychotherapy: relative roles
reconsidered. Annu. Psychoanal. 16:129-151.
Wallerstein, R. S. (1988b). Assessment of structural change in psychoanalytic therapy
and research. J. Amer. Psychoanal. Assn. 36(Suppl.):241-261. Reprinted in The
Concept of Structure in Psychoanalysis, Theodore Shapiro (ed.), Madison, CT:
International Universities Press, 1991, pp. 241-261.
Wallerstein >(in press). The generations of psychotherapy research: an overview.
Werman, D. S. (1984). The Practice of Supportive Psychotherapy. New York:
Brunner/Mazel, p. 192.
Zilberg, N. J., Wallerstein, R. S., DeWitt, K. N., Hartley, D., and Rosenberg, S. E.
(1991). A conceptual analysis and strategy for assessing structural change.
Psychoanal. Contemp. Thought 14:317-342.
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Preface
Like the 42 individuals whose stories it tells, this book has turned out to have many
facets. It is the final clinical accounting of the Psychotherapy Research Project (PRP)
of The Menninger Foundation, chronicling, over now a 30-year span, the treatment
careers and the subsequent life careers of a cohort of 42 patients, half treated in
psychoanalysis and half in equally long-term expressive and supportive
psychoanalytic psychotherapies. The book is a combined process-outcome study of
these intensive treatments. They have been examined from several perspectives (those
of the patient, of the therapy and the therapist, and of the interacting external life
situation) and over several points in time (focused as an Initial Study before treatment,
a Termination Study after treatment, and a Follow-Up Study several years later); PRP
is probably unique in the world of psychotherapy research in having obtained 100%
follow-up information, which in a significant segment of the cohort has extended over
the full 30-year span of observation. In this, and in other senses that will emerge in the
reading of the book, PRP has probably been the most comprehensive as well as most
ambitious psychotherapy research program ever conceived and carried out. Its
theoretical framework has been psychoanalysis, and its theoretical goal has been to
amplify, revise, and extend the theory of psychoanalytic therapy.
