messer, s. - behavioral and psychoanalytic perspectives at therapeutic choice points

7/29/2019 Messer, S. - Behavioral and Psychoanalytic Perspectives at Therapeutic Choice Points

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Psychotherapy Volume 25/Spring 1988/Number 1

CLINICAL CHOICE POINTS: BEHAVIORAL VERSUSPSYCHOANALYTIC INTERVENTIONS

ARNOLD A. LAZARUS AND STANLEY B. MESSERRutgers The State University of New Jersey

Editor's Note: This article was presented as a debate at the conference named in the footnote. Althoughthe format deviates from the style of the journal, the special nature of the debate prompted its inclusion.A point-counterpoint clinical dialoguebetween a behavioral and apsychoanalytic practitioner underscoresfundamental differences as well asshared points of emphasis. Indiscussing a case treated by Lazarus,Messer selected "choice points" wherehe would have intervened differently,while also noting significantcommonalities. Lazarus's rejoindersand Messer's rebuttals help to clarifyareas of divergence and convergenceby focusing on practical rather thanphilosophical and theoretical issues.

Alongside the separate development of psy-choanalytic therapy and behavior therapy havecome efforts to juxtapose one with the other forthe purpose of comparing, contrasting, or inte-grating these therapies. Such attempts have beencarried out at quite different levels of analysisincluding the philosophical (Messer, 1986a;Schacht, 1984), the methodological (Franks, 1984),the metatheoretical (Messer & Winokur, 1980,1984), the concep tual (Goldfried, 1980; W achte l,

We express our gratitude to Allen Fay and Seth Warrenfor their incisive comments on an earlier draft of this article.

A more extended version of this article was presented andcommented on from a family systems perspective by EllenWachtel at the Third Annual Conference of the Society forthe Exploration of Psychotherapy Integration, Evanston, Illinois,May 1987.

Reprints may be ordered from Arnold A. Lazarus or StanleyB. Messer, GSAPP, Rutgers University, P.O. Box 819, Pis-cataway, NJ 08855-0819.

1984), and the clinical or technical (Rhoads, 1984;Wachtel, 1977). What the literature lacks, however,is clinical dialogue between behavioral and psy-choanalytic practitioners focusing on specifictherapeutic interventions. Such a dialogue can helpground the current debate regarding integrationand eclecticism in clinical realities and practicein a way that philosophical and theoretical con-ceptualizations frequently cannot. A case discussionhas the potential to reveal fundamental differencesin practice between these therapies as well as topoint to shared emphases and opportunities forintegration.In the case presented below, Ms. Davis wastreated by Dr. Lazarus, an eclectic, behaviorallybased thera pist, at two different stages: first "be -haviorally" for circumscribed problems (symp-toms), and at a later date, "multimodally" (Lazarus,1981, 1985) for a much more pervasive range ofdysfunctions. In reading through the case of Ms.Davis, Messer, a psychodynamically orientedtheoretician and clinician, was to select "choicepoints" where he would have intervened differently,stating his rationale for eschewing certain strategies,

while explaining what he would have done instead.Commonality of approach was also to be noted.We trust that this format will help to clarify areasof convergence and divergence between currentversions of behaviorally based and psychoan-alytically oriented therapies.The Treatment of Ms. DavisStage 1

When Ms. Davis first consulted Lazarus, shewas 32 years of age, a slim, attractive, and stylishlygroomed woman who appeared somewhat tenseand deferential. Recently married for the second

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A. A. Lazarus & S. B. Messertime, the fifth-grade schoolteacher complained oftwo specific problems.1. She was afraid to travel beyond a 10-mile radiusof her home unless accompanied by her hus-

band, her mother, or a trusted friend. Thisagoraphobic problem had followed an unex-pected panic attack while she was in the throesof her divorce three years previously.2. She w as a com pulsive hand washer who notonly scrubbed her nails and fingers at least10 -1 5 times a day but also bathed or showered4 - 6 times a day. Coincidentally or otherwise,she dated the onset of this pattern to an abortionat age 25 . "Over the years, it has just becom ea lot worse," she declared.Prior to her second m arriage , she had consulteda psychiatrist who prescribed Valium. M s. Davisstated: "It did calm me down but not enough tocure my habits." A second therapist was consulted,who , she said, concluded that her symptoms were"deep-seated" and recommended intensive andsomewhat extended therapy. "It all sounded tootedious and expensive so I just let it go. . . . Butlately, it has gotten me dow n." Ms. Davis thereuponwent on to explain that she and her husband were

moving out of state in less than two months. "Ifpossible, I'd like to leave my craziness behindand start in a new place without these old hab-its. . . . Do you think something can be done forme in less than two months?" When asked spe-cifically what she wished to derive from the time-limited treatment, she stated: "Two things. I wantto be less nervous so that I can drive places, andI want to wash and bathe like a normal person."Apart from being obsequious and tense, Ms.Davis impressed Lazarus as an anxious and timid

woman who had other problems and "neuroticage ndas ." Nevertheless, could she learn to "driveplaces" and "wash and bathe like a normal person"in the short time at our disposal? She was informedthat it would be possible to make substantial gainsin a couple of months if she was truly motivatedto change and was willing to carry out extensive,systematic, and anxiety-generating homework as-signments. Since psychotherapy outcome data in-dicate that phobic and compulsive problems re-spond best to behavioral techniques (Rachman &Wilson, 1980), the treatments of choice were drawnfrom this discipline.

It is well known that a therapist's credibility isbuttressed by em phasizing that the recommendedprocedures have been endorsed by a respected

secondary group (Janis, 1983). Thus, Ms. Daviswas first given information about the value ofdeep muscle relaxation, imaginal and in vivo ex-posure, and response prevention, replete with se-lected journal articles and book chapters for herto peruse. (As a schoolteacher, she found thispedagogical emphasis especially congenial.) Re-laxation training com menced in the office and wassupplemented with cassette recordings for regularhome use. Since she reported that positive andcoping imagery exercises enhanced the relaxationeffect and promoted an inner sense of "calm con-fidence," additional cassette recordings were madein the office, employing images that Ms. Davisfound especially calming.

M s. Davis was asked to choose whether shefirst wished to tackle the "driving phobia" or her"compulsive washing" and she selected the latter.Since some degree of response prevention is vir-tually a sine qua non for the successful ameliorationof compulsive habits (Rachman & Hodgson, 1980),and since Ms. Davis had read the pertinent literatureon the subject, she was ready to begin. "Are youa thoroughly honorable person?" she was asked.The therapist went on to explain that responseprevention was usually performed on an inpatientbasis, carefully monitored by staff members. Shewas told that to succeed as an outpatient, she wasentirely on her honor.

Step one was in the form of an agreement thatshe would wash her hands no more than four timesa dayonce in the morning, once before lunchand dinner, and once before bedtime. The max-imum time to be spent washing, scrubbing hernails, and so on was one m inute (for which purposea timer was to be used without fail). It was im-pressed upon her that there were to be no excep-tions to this four-times-a-day, one-minute-per-timeregimenalthough she was allowed to rinse herhands very briefly after going to the toilet. Shewas reminded to employ the relaxation and imageryto offset the inevitable anxieties. She was to callthe therapist at 9 PM each night to report on herprogress.

It was pointed out that her excessive washingmight be a self-punitive measure to offset the guiltthat the abortion had engendered, and like LadyMacbeth, perhaps she was attempting to "cleanseher soul." She was told: "I will assume that allof this is now in the past, that you have beenpunished enough and are now sufficiently cleansedto give up the symptoms." (The rationale for thisstatement is that it could trigger a pattern of self-talk that would assuage her guilt and implicitly

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Clinical Choice Pointsgrant permission for the mitigation of self-punishingcognitions.)Ms. Davis was able to adhere to the handwashingschedule but tended to increase her showeringtime (up to 45-minute showers) to compensate.Response prevention (more accurately, responseattenuation) was accordingly applied to Ms. Da-vis's bathing and showering. She agreed to haveno more than one bath and one shower, or twobaths or two showers a day, for a maximum of15 minutes per shower and 20 minutes per bath.Moreover, the four-times-per-day, one-minute-per-time handwashing was not to be exceeded. Shewas informed: "I know this won't be easy, but ifyou really want to beat the problem, this is theway to go. Just bite the bullet." A gain, M s. Daviswas invited to call nightly to report on her progress.During the third week, while maintaining theaforementioned frequency and duration of all herhandwashing, bathing, and showering activities,she was instructed to expose herself to numerousstimuli that she characteristically avoided (e.g.,using public telephones, borrowing and using afriend's com b or brush, handling mo ney, playingball with the children, and putting soiled laundryin a hamper without scrubbing or rinsing her handsthereafter). During this "exposure phase," Ms.Davis, of her own accord, added "car trips outsidethe safety zone" to her regimen. (The therapisthad decided to table any in vivo exposure for her"driving phobia" until she seemed less agitatedover the drastic reduction of compulsive washingand bathing. Since she reported, with pride, thatshe had driven to a shopping cen ter some 20 milesfrom her house and had enjoyed browsing throughseveral stores, she was encouraged to "forge aheadon all fronts.")

Office therapy time (at weekly intervals) wasdevoted to repeated admonitions to avoid any"slips" because of the ubiquitous dangers of "in-termittent reinforcement" that could bring herback to "square one." The continued relevanceof systematic in vivo exposure was also under-scored. In the office, imaginal desensitization wasemployedthe client clearly visualized herselfcoping with specific travel-related situations beforeventuring into them. Ms. Davis was, in fact, pro-vided with a host of imagery techniques (e.g.,picturing herself coping in various situations,imagining herself resisting the temptation to washor shower, and visualizing several calmness-pro-ducing scenes to be used at will). She was alsogiven more intensive training in deep muscle re-laxation and rhythmic abdominal breathing ex-

ercises, all to be used in situations where she felttense or anxious.By the time Ms. Davis and her husband lefttown, she reported having little difficulty in main-taining the agreed-upon washing and showeringroutines, and her driving distance exceeded a 50-mile radius. Her use of Valium was down to 5mg at bedtime, and she was encouraged to dis-continue its use as soon as possible due to theaddictive potential of the drug. She was stronglyreminded of the need to maintain vigilance in hernew environment or else a relapse would be almostinevitable. In the course of the next five to sixmonths, several letters and a few telephone callswere exchanged between client and therapist, allpointing to the consolidation of her gains. Never-theless, it had been evident from the start thatMs. Davis was basically unassertive, anxious,and tense. Lazarus had recommended a therapistwho could help her deal with these issues, andhe emphasized the advantages of an assertivenesstraining group. She followed through on neitherof these suggestions.

M s. Davis consulted Lazarus again almost twoyears later. Her husband had left her for anotherwom an, and she had just returned to New Jersey,deeply depressed and living with her parents. Be-fore outlining the second phase of her therapy,there are specific issues and questions that revolvearound phase one.The time-limited treatment sequence that Ms.Davis had undergone for her compulsions andphobic disorder was predominantly behavioral.In terms of treatments of choice, there is compellingevidence that performance-based-methods areusually superior to verbal, cognitive, or conver-sational procedures, especially in phobias andcompulsions (e.g., Barlow & Waddell, 1985;Steketee & Foa, 1985). Nevertheless, there areseveral short-term or time-limited psychodynamicapproaches, and it would be interesting to knowwhether Messer might have recommended andpreferred a different modus operandi. Does heimagine that psychoanalytic interventions wouldhave been as effective, more effective, or lesseffective than those that were administered? IfMs. Davis had approached Messer for help, howmight he have proceeded?

Messer's Response to Stage 1Influenced, perhaps by the short time periodavailable to treat Ms. Davis, Lazarus adopted thestrategy of the traditional behavior therapist anddirected therapy at the client's presenting com-

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A. A. Lazarus & S. B. Messerplaintsagoraphobia and compulsive washing.While the traditional behavior therapist insists thattherapeutic objectives are value judgments to bedetermined primarily by the client (Wilson &O'Leary, 1980), the psychoanalytic practitionerbelieves that the therapist must participate veryactively in clarifying and formulating such ob-jectives (Messer, 1986b). Regardless of whetherthe time available for treatment was long or short,I would have carried out a thorough evaluationto determine the extent of Ms. Davis's psycho-pathology, the nature of her personality disposition,and her personal history. This is not a matter ofgilding the lily, of collecting da ta for its own sake,nor of merely satisfying the clinician's intellectualcuriosity. Guided by a theory which views habits(or symptoms, as I would call them) as integrallyrelated to the person's cognitive-emotional makeup,I would be acutely sensitive to the role they playedin the clien t's overall psychic life. At the extreme,if Ms. Davis's dysfunctions were a way of pre-serving her sanity, of maintaining a tenuous holdon reality, they are preferable to a possible declineinto psycho sis. If such were the case, I would notbe in a hurry to rid her of these symptoms. InMs. Davis's case, I can be sure that an experiencedclinician like Lazarus has satisfied himself thatsuch a danger does not exist.

Let us assume, therefore, that Ms. Davis hasa masochistic or obsessive-compulsive personalitydisorder, or trends in one or both of these directions,and that a central problem, viewed psychodynam-ically, is guilt over actual "crimes" (having anabortion; leaving her husband) or a fantasizedcrime ("I wanted to kill my husband") which arenot acceptable to her ego. She concretizes thesought-for absolution or cleansing of her guiltthrough incessant washing (as Lazarus astutelyrecognizes), and/or protects herself against rec-ognizing or acting on her own feelings (murderous?sexual? dependency? guilt?) when away from homeby having someone accompany her. The agora-phobia might also be viewed as separation fearkindled or rekindled by the breakup of her marriage.I would not assume, as does Lazarus, that all ofthis is now in the pas t, that she feels sufficientlypunished, and that she is ready to give up thesymptoms. If these dynamic issues are sufficientlystrong or embedded, Lazarus's statement to heralong these lines would have only a temporaryeffect in mitigating self-punishing cognitions orin assuaging guilt.

Having clarified for myself some of these matters

in the assessment interview(s), I would then befaced with the question of how best to utilize thetwo months at our disposal. If it seemed unlikelyto me that any headway could be made in theshort time available by virtue of the severity ofthe problems, my preference would be that shebegin therapy when she arrives in her new location.If, on the other hand, I judged 1) that there wereno clear contraindications to a brief therapy (suchas severe depression, drug abuse, primitive de-fenses, etc.), 2) that she was a well-motivatedclient, and 3) that a suitable focus could be for-mulated, I might suggest a short-term contractbuilt around that focus. I would probably want tosee her twice weekly so that we would have about15 sessions in which to work.

There are now several well-formulated modelsof short-term therapy from which to choose (e.g.,Davanloo, 1980; Malan, 1976; Mann & Goldman,1982; Sifneos, 1979; Strupp & Binder, 1984).The brief dynamic therapies all share the followingcharacteristics (Rasmussen & Messer, 1986; Wi-nokur, Messer & Schacht, 1981): 1) formulatinga focus in psychodynam ic terms ; 2) high therapistactivity along the lines of the focus; 3) settinggoals near the outset of therapy; and 4) specialattention to the termination phase of therapy.In conducting the brief therapy, I would viewmy role more as a facilitator than as an educatoras Lazarus conceptualizes it, although I wouldagree that both therapies share the goal of somekind of new learning. I concur, in general terms,with Lazarus's emphasis on client responsibilityand participation in therapy and, like him, wouldconvey this in some manner to the client. In dy-namic therapy, however, what is considered es-sential is the client's cooperation in the processof looking inward at her conflicts and outward at

the nature of her interpersonal relationships, ratherthan in doing homework conscientiously as pre-scribed in behavior therapy. I would not tell Ms.Davis that her symptoms were "deep-seated" asdid a previous therapist, nor draw upon the authorityof a respected secondary source (such as Freud)to buttress my credibility. I would view the latterstrategy as too blatant an effort to capitalize onclient suggestibility which, viewed from withina psychoanalytic value framework, relies tooheavily on acquiescence to external authority. Iwould rather help Ms. Davis develop inner con-victions about her problems and the therapy basedon her own critical faculties. (No te, however, thatthis is a relative matter as there are suggestive

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Clinical Choice Pointselements in psychoanalytic therapy as well.) In-stead, I would try to demonstrate, in vitro if pos-sible, how her complaints were related to herhistory, her inner struggles, and her personalityfunctioning. That is, like Lazarus, I would try toenlist her cooperation and her agreement to thetherapeutic plan, but would do so by heighteningher interest in self exploration. If this failed, andshe was clearly not am enable to such an approach,I would be prepared to refer her to a broad-basedbehavior therapist like Lazarus.Lazarus Replies to M esser's Response to S tage 1

Perhaps one of the most significant differencesbetween behavior therapists and psychoanalyticallyoriented clinicians is the extent to which the lattertend to pathologize. I have seen many clients whohad been diagnosed as borderline characters, in-cipient psychotics, or narcissistic personality dis-orders, and who, from my perspective, sufferedonly from eminently treatable hypersensitivities,social skills deficits, and irrational beliefs. Evenin the face of florid schizophrenia, when patientsare responsive to antipsychotic m edication, prob-lems such as phobias and compulsions are amenableto the same behavioral treatments that Ms. Davisunderwent (cf. Curran et al., 1982).

At graduate school in the late 1950s, my psy-chodynamically oriented professors warned methat a neurosis is often a defense against a psychosisand insisted that "symptom removal" could havedire consequences. I thought that this canard hadlong since been laid to rest, and was thereforesurprised to find it resurrected by Messer. In myexperience, "if Ms. Davis's dysfunctions were away of preserving her sanity, of maintaining atenuous hold on reality," I would probably nothave gained her cooperation. A behavioral maximis that in the face of noncompliance, one returnsto the drawing board and conducts a more thoroughfunctional analysis in search of antecedents andmaintaining factors that might have been over-looked. The re are instances where habits or symp-toms serve important functions or are reinforcedby secondary gains. In these cases, the most heroicbehavioral techniques usually meet with limitedsuccess as clients refuse to relinquish their "sym p-toms." Problems of "resistance" or behavioralnonresponsiveness have been discussed in somedetail (Fay & Lazarus, 1982; Lazarus & Fay,1982).

By the time Messer had conducted his "thoroughevaluation to determine the extent of M s. Davis's

psychopathology, the nature of her personalitydisposition, and her personal history," how wouldhe still have two months at his disposal for 15sessions of brief therapy? Instead of wasting time ,it seemed preferable to enter into a highly targeted,time-limited treatment aimed at achieving theclient's goalsto attenuate her driving phobiaand compulsive washing.I am particularly struck by the fact that Ms.Davis sought treatment for her phobic and com-pulsive habits. Had she seen Messer or anotherpsychodynamic practitioner, her stated desire tobe freed from her specific fears and debilitatinghabits would have been discounted. At best, afterruling out serious psychopathology, drug abuse,primitive defenses, and so on, some "focus" wouldbe selected for inward exploration. This is likesetting out to buy a car and unknowingly w alkingnot into a showroom but a school for mechanicsand signing up for a course in transmission repairs!

Since Messer, despite his psychodynamic li-neage, describes himself as "a student but not ascholar of behavior therapy" (Messer, 1986ft, p.1261), I expected h im to concur with the behavioralrecommendations, while perhaps also advocatingthe examination of basic conflicts and encouraginggreater self-exploration. I know of no data providedby Mann, Davanloo, or Strupp & Binder thatwould point to special expertise in dealing withphobias or compulsions, nor am I aware that"looking inward at her conflicts" would have en-abled Ms. Davis to leave town feeling less phobicand more mobile.

Parenthetically, it might be mentioned that Ifind methods of cognitive restructuring, role re-versal, the facilitation of "a-ha" experiences, theuse of humor ("ha-ha" experiences), and the ex-ploration of interpersonal conflicts far more en-gaging than the use of in vivo or imaginal de-sensitization, response prevention, flooding, andmost other behavioral techniques. I employ notwhat intrigues or fascinates me personally, butwhat has been shown to be clinically effective.Messer's Rejoinder to Lazarus (Stage 1)

Although there may be some truth in La zarus'scharge that psychoanalytic therapists tend to over-pathologize, the countercharge is equally valid:behavior therap ists too often constrict their atten-tion to readily observable behaviors while ne-glecting the larger picture of pathology . Laz arus 'sstrictly behavioral app roach to M s. Davis in Stage1 is a case in point. By disregarding M s. Dav is's

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A. A. Lazarus & S. B. Messerpossible underlying personality disorder, anddealing only with her obvious behavioral dys-function, Lazarus achieved a focused but not abroad-based success, certainly when judged fromthe point of view of her m ore pervasive prob lems.In buying a car it is often valuable in the longerrun to learn something about its motor, trans-mission, and body construction even if one doesnot learn how to repair the car oneself.

Clearly, I do not regard the assessment andevaluation phase as wasting time. Because theproblem is framed more broadly in dynamic therapythan in traditional behavior therapy (as conductedby Lazarus in his Stage 1 therapy), it is essentialto conceptualize the problems to be addressed byunderstanding as clearly as possible, in one tothree sessions, the client's life experience andpersonality functioning. These early interviewsare employed to chart a course (particularly if ashort-term therapy is indicated) which includesthe formulation of a dynamic focus as well astherapeutic goals. Moreover, the distinction be-tween assessment and treatment proper is probablymore apparent to the therapist than to the clientwho experiences the therapist's basic modus op-erandi from the outset, be it labeled assessmentor treatment. For the client the process of treatmenthas begun from the first moment of therapist-client contact, so in this sense too, no time hasbeen wasted.

Ma nn, D avanloo, and other brief dynamic ther-apists will treat problems like Ms. Davis's in time-limited dynamic therapy (see Mann & Goldman,1982; Davanloo, 1978), but will do so within amore broadly defined area of intrapsychic or in-terpersonal conflict. What we lack currently arestudies directly comparing these two approachesalong dimensions considered important by eachkind of therapist, which w ould include symptomaticalleviation, conflict resolution, and behavioral andpersonality change. In the absence of such studies,I would point to the empirical findings of similaroutcomes among therapies (Luborsky et al., 1975;Smith et al., 1980), as well as to value differencesin what constitutes worthy outcomes. There arereal differences here that cannot be overlooked,especially when comparing traditional behaviortherapy focusing on symptomatic change, andpsychodynamic therapy focusing on resolution orgreater mastery of defined areas of client conflictor dis-ease. To my mind, this is not a matter oftherapists indulging their own preferences and tastesin conducting one therapy or another while dis-

counting client needs, as Lazarus contends, butin their value o rientations as to what really m attersto people and what constitutes genuine change.While I do consider myself a "student of behaviortherapy ," my approach to integration does not callfor behavioral techniques grafted onto an explo-ration of basic conflicts, as Lazarus supposes andas others have proposed. Rather, I have pointedto a certain kind of de facto confluence of attitudesamong cognitive and neobehavioral therapists onthe one hand, and ego-analytic and short-termdynamic therapists on the other, which makestheir therapeutic outlook and behavior more similarthan was true in the past. I will elaborate belowon how this applies, for example, to goal setting,approaches to promoting action or insight, theview of affect in the two therap ies, and the natureof the therapeutic relationship.Stage 2

When Ms. Davis reappeared some two yearslater, she was literally unrecognizable. She wasat least 40 pounds heavier, had cut her hair ex-tremely short, had exchanged her contact lensesfor unstylish spectacles, wore no makeup, andwas dressed in loose-fitting je ans, a large tatteredsweater, and battered sandals. For the previousthree weeks, she had been staying with her parents,avoiding her friends, and "trying to come to termswith what has happened" to her. It appeared thatshe had been almost totally subjugated by herhusband who, soon after they had relocated, hadaccused her of deliberately looking and dressingprovocatively so that other men would be attractedto her. At his behest, she had cut her hair, grownfat, changed her style of dress, and had avoidedusing makeup because he liked only "naturalwomen." While continuing to work as a school-teacher, she bore the full responsibility for allhousehold chores, and also mothered her husband 'sthree-year-old daughter. A carpenter by trade, herhusband worked for a construction company, buthad strong literary aspirations. He devoted manyhours each week to dictating communistic politicalcommentaries, his own philosophies, various shortstories, and a novel. Since they could not affordto pay someone to transcribe this material, it fellon Ms. Davis's shoulders. She would get up at4:30 AM to fit this additional work into her dailyschedule. Moreover, she stated that her husbandinsisted that she engage in several sexual practicesthat she found distasteful. Despite her ardent effortsto do his bidding, he met another woman whom

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Clinical Choice Pointshe described as a "soulmate" and moved in withher.Ms. Davis appeared to satisfy many of the di-agnostic criteria of a major depression, but thediagnosis was not clear-cut. An adjustment disorderwith m ixed emotional features could also be en-tertained. Her family physician prescribed Xanaxand Elavil, and within two w eeks she was calmer,sleeping better, and crying less. Ms. Davis statedthat she was afraid that her "bad habits" werecoming backshe was washing and showeringto excess, and she felt her "old fears" when drivingto visit a friend who lived 15 miles away. I tooka firm stand. " Le t's get rid of that nonsense now.Go right back to the response prevention, themental imagery, and the desensitization." For-tunately, the "relapse" was short lived, and therapywas then concerned with the following issues:1. Her sadness at ending the marriage. The mostpainful aspect here was her concern for herhusb and 's child, whom she had grown to lovevery deeply and "who had come to feel likemy own flesh and blood."2. Ways of obtaining emotional support duringher divorce. At the therapist's instigation, sherenewed many friendships and obtained em-ployment as a substitute teacher.3. Her tendency to allow others (especially men)to dominate her and mistreat her. Ms . D avis'stwo marriages had followed a similar trajectory,although it was she w ho had initiated the divorcewhen her first husband finally "went too far"by bringing his paramour to live in their hom e.4. Her general lack of assertiveness, her over-com pliance, her poor self-esteem, and her gul-libility.

The therapist lent his approval to the fact thatM s. Davis was allowing one of her friends, afashion consultant, to work on her appearance.Within three months she was back to her slim,well-groomed, attractive, stylish self. The m ainstayof therapy during that period had been on herfeelings of loss, regret, self-blame, and confusion.A major treatment focus revolved around her themeof under entitlement, of the subservient "script"she had followed (especially with men), and onthe ravages of her Calvinistic upbringing. Thetherapist's role was supportive, accepting, chal-lenging, didactic, and disputational. For example,the therapist explained again and again why Ms.

Davis's perception of a deity was more diabolicthan divine.She was asked to read several books (biblio-therapy), especially chosen to augment her overallassertiveness. Since she attributed many of herinadequacies to her mother's timidity and over-zealous religiosity, and to her father's sexist andmale chauvinistic outlook, several family meetingswere held with Ms. Davis, her parents, and hersister (2 years younger). The goal here was tochange some of the family communications vis-a-vis Ms. Davis as an adult, and to modify thesubtle "you can't do it" parental messages thatundermined her confidence. Thus, when her fatheroffered to handle the divorce proceedings on hisdaughter's behalf ("I know how to deal with law-yers, and I will see to it that she won't be short-changed!") M s. Davis (having previously rehearseda speech with the therapist in private) boldly statedthat she would prefer to fight her own battles,and would look to her father for adv ice if needed.The father capitulated. The upshot of the familymeetings, to quote Ms. Davis was: "I feel morerespect coming from my parents, and my sisterand I have grown a lot closer."

M s. Davis appeared to have no clear-cut senseof personal entitlement; the notion that she hadrights seemed quite alien to her. It took a lot ofpersuasive power to convince her that a people-pleasing, self-effacing outlook was anything butlaudable, and that assertive living was not tan-tamount to a self-centered, egotistical modus viv-endi. Thereafter, considerable time was devotedto additional behavior rehearsal and role playing,especially with regard to the handling of her di-vorce, and with respect to dealing with employers,colleagues, and certain "friends."

It then struck the therapist that his relationshipwith Ms. Davis had too much in common withher other male-female interactions. She was play-ing the role of the obedient, and perhaps over-compliant client, presumably intent on pleasingthe therapist, just as she had endeavored to pleaseher father and her two husbands. Accordingly,Ms. Davis was urged to become her own person,and not to live for the therapist's approval oranyone else 's approbation. Role playing and mentalimagery were employed wherein she was calledupon to upbraid the therapist and to go counterto his advice when not in agreement w ith it. Soonthereafter, a specific situation arose in which sheexercised her "freedom of thought." Ms. Davishad learned that her first husband would be passing

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A. A. Lazarus & S. B. Messerthrough New Jersey and asked the therapist whetheror not she should meet him and "find out whereI went wrong." The therapist took the positionthat this was inadvisable for two reasons: 1) itwas best viewed as a relationship from the pastand it would probably be better not to reactivateunpleasant memories; and 2) it was likely to leadto obsessive rumination and self-recrimination.At the next session she reported having gonecounter to this advice, with excellent results. Sheand her first husband had gone out for dinner and,after a brief postprandial walk, had returned toher apartment and spent almost the entire nighttalking. He allegedly emphasized that the breakupof their marriage was entirely his fault and thathis own immaturity was at the core of all theirdifficulties, and he had described her as a "raregem."

At this junc ture (approximately six months intothe therapy), M s. Davis went on w hat she termed"a sex binge" with five different men in one week(each of whom she had met at a singles bar). "Ithink I wanted to convince m yself that I can attractmen, and that I can get them to do what pleasesme for a change." While eschewing any moralimperatives, the therapist pointed out the dangersof contracting AIDS, herpes, and other venerealinfections through indiscriminate sex. One of thesemen, a successful attorney, became a steady datefor awhile until Ms. Davis rejected him becausehe had also tried to date one of her close friends."That's the new me," she declared, "one falsemove and you're dead!" Semiparadoxically, thetherapist wondered aloud to what extent the slave-girl mentality still existed within her, whether ornot, sooner or later, she would revert to doingsome man's unfair bidding. She laughed. "Onlyif someone is literally holding a gun to my head!"

During the course of therapy, several additionaltopics were examinedMs. Davis's choice ofmen; her desire for children and residual guiltfeelings over the abortion she had had; and herfuture plans (e.g., remarriage, having childrenversus adopting them, being able to let go emo-tionally of her stepdaughter).M s. Davis was seen twice weekly for a month,weekly for three months, and once a fortnight foranother four months (a total of 8 months or 29sessions). Thereafter, she was seen approximately

once every three or four weeks for another fivemonths. (Booster sessions aimed at consolidatingand extending treatment gains are excellent relapse-prevention strategies.)

Significant gains have accrued and have beenmaintained. She has been off all medication andhas not reported or displayed any signs of depres-sion or undue anxiety for at least 8 months. Sheweathered her divorce extremely well and hascontinued to work as a full-timefifth-grade eacher.In her own words, she has "come to terms witha lot of things." The only residual dysfunction ofany significance is manifested in her choice ofmen. She appears to have "rescue fantasies" andgravitates toward men who are her social andintellectual inferiors. In the rescue process, thesemen end up exploiting her, a pattern that wasevident in her two marriages. This aspect of herconduct and residual problems with self-esteemare the focus of her treatment.Messer's Response to Stage 2

In this second phase of therapy, w e see a differentkind of therapist at work, one much more broadlybased than the behavior therapist of the earlierphase. I would point particularly to Lazarus's at-tention to Ms. Davis's emotional life, includingsadness over loss, anger with men, and guilt overassertion. I laud his attention to her need for emo-tional support, to the importance of her renewingsocial relationships, and to her becoming gainfullyemployed. These are valuable aspects of a sup-portive, ego-building psychotherapy which I en-dorse. In addition, there is now a recognition ofthe client's pervasive personality pattern, even ifit is not named as such. I am referring to Ms.Davis's tendency to allow others, especially men,to dominate her and mistreat her, to the script ofunderentitlement, to her gullibility, lack of as-sertiveness, and sense of inadequacy. While Laz-arus and I may agree on a diagnosis of depressionon Axis I of DSM-III, I would now be inclinedto consider an Axis II diagnosis of "self-defeatingpersonality disorder" (which appears in the ap-pendix of DSM-IIIRevised), or what psycho-analysts traditionally have referred to as a ma-sochistic personality.

Lazarus and I differ, however, in some of theways in which we would address her personalityproblems. He attempted to persuade Ms. Davisthrough rational means that her outlook and stylewere not laudable and tried to show her by en-couraging behavioral rehearsal and role playinghow she might behave more assertively. By con-trast, I would help her to become more fully aw areof her self-defeating and submissive style by notinghow eager she was to please me and how readily

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Clinical Choice Pointsshe abdicated her own initiative in wanting me totake the lead in therapy. I would ask her if thisdid not have a familiar ring, anticipating that shewould tell me more about how she behaved sim-ilarly with her two previous husbands, with othermen she dated, and, throughout her life, with herfather. She would be encouraged to explore herwishes in this regard and what purposes they served,for example, to win a man's love, to avoid beingangry with him, or to have anyone be angry withher for expressing her more mature needs for in-dependence and control. Early memories typicallyarise spontaneously at this point, often with con-siderable feeling. She might relate how she sawherself as bad or undeserving as a child, and rec-ognize how her parents' treatment of her contributedto the skewed sense of herself. Her positive andnegative identifications with them would loomlarge, including her mother's timidity and over-zealous religiosity. Despite the importance of herfamilial identifications, I would not recommendfamily sessions because I would view my task ashelping her to take the initiative in differentiatingherself from her family, which ultimately wouldbe more ego strengthening than having her parentsback off at my suggestion.

The difference between us that I am highlightingis the role of therapist as facilitator, interpreter,or elicitor of the client's inner life in contrast tothe role of persuader, environmental arranger, orteacher. Lazarus, in encouraging Ms. Davis tobecome more her own person, in urging her notto live for his app rova l, in telling her to go coun terto his advice if she disagreed, paradoxically con-tinues the role of the dominant and controllingman whom she will strive to please. I note howshe then compliantly disregarded his advice notto see her first husband. Lazarus might view thisact of defiance as a sign that the therapy is suc-ceeding in helping her to become more confidentand assertive; I wonder if it is not a sign of hergrowing attachment to Lazarus and a replay ofher eagerness to submit to a man's directives.Like Lazarus, I suspect that the extremes of hernew reactions to men ("One false move and you'redead") belies her comfortableness with her newpersona.

An indicator of M s. Da vis's attachment to Laz-arus, in my view, is her subsequent flagrant sexualacting-out. My guess is that she harbors romanticand sexual feelings for Lazarus which she displacesonto other men by having sex with five of themin one week. I would not accept at face value her

explanation that she was doing what pleased her.Like Lazarus, I would not view this as salutary,but as behavior to be closely examined in thetherapyand not just because of the dangers ofvenereal infection or considerations of conventionalmorality. In helping her to express such feelings,one would have to interpret the defenses she woulddisplay in attempting to hide such intimate feelings.("I am bad to have such thoughts; God will punishme; You will laugh at me or humiliate me"). Suchexploration could help reveal m ore about her guiltfeelings and religious beliefs and how these haveaffected her view of her own actions (having anabortion, leaving her husband) and the formationof her symptoms of washing and agoraphobia. Bybecoming more fully conscious and aware of suchhitherto unconscious factors, she would, it is hoped,feel relief from her symptoms and enjoy a greatersense of mastery over her life. By experiencinga benign, caring, respectful, and attentive maletherapist, she would see how it is possible to betreated by a man, which would serve her as anew introject. She would undergo a correctiveemotional experience, and carry away a more be-nign feeling toward men and an enhanced senseof her own worth. To a degree, she is achievingthis with Lazarus, but I believe that she is alsocomplying with his strong directives and to thisextent is prevented from fully attaining the senseof autonomy she so clearly desires.

Regarding the termination of treatment, Iwould proceed differently than Lazarus. While itmay be true that booster sessions can preventrelapseand for the more disturbed client this isparticularly desirablethe tapering off of therapyin such a fashion can serve to dilute the strongfeelings that typically arise when one finally sep-arates from a significant other. In Ms. Davis'scase, a more definitive termination could meanlearning that she can experience sadness, appre-ciation, regret, even guilt or anger toward hertherapist, and still be able to separate with anintact, enhanced sense of herself as an autonomous,self-initiating, and mature adult.Lazarus Replies to Messer's Response to Stage 2

Unlike Stage 1, the second treatment phaseenters territories that are more nebulous and opento debate. Messer correctly points to the paradoxof the compliant client who obediently disobeyedmy directive, thereby remaining essentially ac-quiescent. Nevertheless, Ms. Davis subsequently

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A. A. Lazarus & S. B. Messerdealt more assertively with her father (on twoseparate occasions), resisted unfair work demandsfrom her (male) princ ipal, and managed a difficultsituation with her lawyer whose authoritativemanner would probably have completely intimi-dated her prior to her assertiveness training.Messer's contention that her sexual acting-outwas related to "romantic and sexual feelings" forme seems totally without any substance or foun-dation. There was never even the slightest hintthat Ms. Davis harbored any physical or sexualfeelings for me. In place of the sex object, thehusband, or lover, there were signs that in herfantasies, she perceived me as the perfect father.Rather than wishing to share my bed, she mayhave pictured herself living in my home, seeingme in a purely paternal or avuncular role.From a social learning perspective (Bandura,1986) two features predominate: 1) Her submissivemother seems to have served as the major femininerole mod el, and 2) there is evidence of an acquiredcognitive schema to the effect that she is unde-serving and unworthy of the best. These areas arenow the focus of our ongoing treatment. Whetherthe tactics of Messer, Davanloo, Mann, Sifneos,or Strupp & Binder would prove more effectivethan those of Lazarus is an open question. Whatevercorrective emotional experiences may actuallyensue from the therapeutic relationship, I haveno doubt that she regards me as "a benign, caring,respectful, and attentive male therapist." In myexperience, an active-directive therapeutic posturedoes not truncate clients' capacities to develop aself-initiating, autonomous, and mature modusvivendi. Many clients, especially in the beginningphases of therapy, welcome guidance and direction,but as they grow more assertive, develop socialskills, acquire interpersonal confidence, and ex-perience better control over their feelings and be-haviors, they introduce modifications into thepatient-therapist relationship. To maintain ther-apeutic neutrality when the client is crying outfor pedagogical assistance is, in my view, a seriouserror. Paradoxically, the less assistance you offera dependen t client, the longer that person is likelyto cling to his or her dependent ways, but often,when smothered by the therapist, such individu-als begin to develop and assert their autonomy.Certainly Ms. Davis has better control over herfeelings, her relationships, and her habits; herself-esteem, while still needing improvement, issignificantly greater, and she has a healthier overallsense of self (including her entitlements).

Rejoinder to LazarusLazarus acknowledges the paradox of this obe-dient client complying with his directives to becomeher own perso n, but he sweeps aside my objectionby pointing to the behavioral gains achievedacting assertively w ith her father, resisting unfairwork demands from her boss, and managing adifficult situation with her lawyer. On the face ofit, these are impressive gains, but at the risk ofbeing accused of carping perfectionism, I mustdemur. I am not prepared to gauge the resolutionof M s. Da vis's problem s, as I have defined them,on the basis of such behavioral indicators alone(although I do not dismiss their potential impor-tance). Lest I appear niggardly in my critique ofthe outcome of Ms. Davis's therapy, I will spellout my position in some detail.Lazarus and I now seem to agree on Ms. Davis'smajor disposition, which is to please others, tosubmit too readily to extraordinary demands (e.g.,rising at 4:30 AM to type her husband's musings,making herself unattractive, etc.), to feel under-entitled, and to retreat in the face of male power.Knowing this, how can we distinguish genuineimprovementthat is, changes coming from anenhanced view of the selffrom M s. Da vis'songoing attempts to satisfy her therapist. Afterall, she may merely be reenacting with the therapistthe core neurotic conflict that she has demonstratedthroughout her life: "If I ally myself with or submitto a powerful male, I will get the affection, caring,and sexual gratification, that I so desperately need."If the therapist is very active regarding his ex-pectations and directives, rather than relativelyneutral, how shall we determine whether thechanges that have come about were self-initiated,deriving from a stronger sense of centeredness,rather than reflecting Ms. Davis's same old com-pliance with authority and willingness to do thebidding of others? Is Lazarus concerned aboutthis question? Is he satisfied with the changes asthey stand even if they turn out to reflect prim arilyher wish to please him? Strong therapist expec-tations can have a powerful influence on the clientwhich, in the absence of her associations, mem-ories, dreams, and so on, leave us no choice butto speculate about the meaning to her of his be-havior. Lazarus has been gratifying her wish tobe guided by a powerful man. Without knowingwhether she is "doing it for Daddy," is intent ondefying him, or has truly come to terms with hersubmissiveness, I am reluctant to endorse whole-heartedly the stated behavioral gains.

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Clinical Choice PointsIf these gains are due to her effort to please, Ialso question how long-lasting they will be. Ifthe changes w ere accomplished only to please thetherapist, might they not dissolve once the therapistis not present to sustain them? [Lazarus contends

that he is not too concerned w hether or not changesare initiated in order to please the therapist. Thenew behaviors have an impact on the client's sig-nificant othe rs, and in the final resort, the rewardsthat emanate from the environment will sustainand reinforce them.]I concur with Lazarus's belief that Ms. Davissees him in a paternal or avuncular role. Thisdoes not preclude her experiencing him at othertimes as a potential romantic and/or sexual partner.Although Lazarus protests that "there was never

even the slightest hint that Ms. Davis harboredany physical or sexual feelings for me ," how can1 be sure when the nature of their relationship wasnot deliberately opened up for discussion? Beyondthis, as someone guided by psychoanalytic theoryregarding masochism, I wonder, too, about ma-sochistic fantasies that Ms. Davis may harbor towhich Lazarus may be resonating in alluding toher "slave-girl mentality" and her "doing someman's unfair bidding."Concluding Remarks

While it is true that behavior therapy is friendlierthan it once was to some cognitive concepts es-poused by psychoanalysts, and that some psy-choanalytic therapists adopt a problem-orientedfocus similar to behavior therapists, distinctiveand fundamental points of departure remain clearlyevident. Franks (1984) emphasized that psycho-analysis and behavior therapy "employ differentlanguage systems and different data bases," and"differ drastically with respect to such matters aswhat constitutes acceptable methodology, data,and outcome ev aluation" (p. 23 7). Lazarus is any-thing but a rigorous behaviorist, and Messer isno dyed-in-the-wool psychoanalyst, and yet evenbetween two self-styled liberal clinicians, basicdifferences remain.

Our commentaries tended to highlight some ofthe different perspectives and clinical attitudes inpsychodynamic therapy and behavioral or mul-timodal therapy (see Messer & Winokur, 1984,for further discussion of contrasting ways ofknowing and visions of reality in psychoanalyticand behavior therapy). Nevertheless, there wasalso some sim ilarity of outlook in Laz arus's Stage2 multimodal approach and Messer's psychody-

namic approach to this case, reflecting currenttrends in our two theoretical orientations (seeMesser, 1986b, for an elaboration of such trends).We both set rather similar-sounding, but notidentical goals for Ms. Davis after the assessmen tperiod (e.g., therapy was concerned with "hertendency to allow othersespecially mentodominate her and mistreat her"). In our discussingthe optimal relationship to the client, we agreedon the importance of a caring, respectful, andattentive attitude. Lazarus noted, as did Messer,a predominant transference pattern ("She wasplaying the role of the obedient and perhaps ov-ercompliant client, presumably intent on pleasingthe therapist just as she had endeavored to pleaseher father and her two husbands"). Note, however,that Lazarus largely used this information to en-courage Ms. Davis not to live for his or anyone'sapproval, whereas Messer would have used it toenable her to fully express and analyze the rangeof feelings she would have toward him, in orderto enhance her freedom to act in accordance withenlarged behavioral possibilities. Unlike sometraditional behavior therapists, w e were both veryattuned to Ms. Davis's affective state, allowingher feelings of sadness and guilt to emerge. Lazarusmoved quickly to dispel such negative feelingsby suggesting immediate action, while Messerwould have allowed their fuller expression evenwhile exploring, in a less directive manner, someof the social and vocational options she could bepursuing . Finally, in the cognitive realm, Lazarusand Messer were both interested in examiningMs. Da vis's scripts and saw these as guiding fic-tions or core constructs that must be addressed inpsychotherapy in one fashion or another.ReferencesBANDURA, A. (1986). Social Foundations of Thought andAction: A Social Cognitive Theory. Englewood Cliffs, N .J.:Prentice-Hall.BARLOW, D. H. & WADDELL, M. T. (1985). Agoraphobia.In D. H. Barlow (Ed.), Clinical Handbook of PsychologicalDisorders. New York: Guilford Press.CURRAN, J. P., MONTI , P. M. & CORRIVEAU, D. P. (1982).Treatment of schizophrenia. In A. S. Bellack, M. Hersenand A. E. Kazdin (Eds.), InternationalHandbook of BehaviorModification and Therapy. New York: Plenum.DAVANLOO, H. (1978). Basic Principles and Techniques inShort-Term Dynamic Psychotherapy. New Y ork: SpectrumBooks.DAVANLOO, H. (1980). A method of short-term dynamic psy-chotherapy. In H. Davanloo (Ed.), Short-Term DynamicPsychotherapy. New York: Jason Aronson.FAY, A. & LAZARUS, A. A. (1982). Psychoanalytic resistanceand behavioral nonresponsiveness: A dialectical impasse.

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FRANKS, C M . (1984). On conceptual and technical integrityin psychoanalysis and behavior therapy. Two fundamentallydifferent systems. In H. Arkowitz and S. B. Messer (Eds.),Psychoanalytic Therapy and Behavior Th erapy: Is IntegrationPossible"? New York: Plenum.GOLDFRDED, M. R. (1980). Toward the delineation of therapeuticchange. American Psychologist, 35 , 991-999.JAMS, I. L. (1983). Short-Term Counseling. New Haven,Conn.: Yale University Press.LAZARUS, A. A. (1981). The Practice of Multimodal Therapy.New York: McGraw-Hill.LAZARUS, A. A. (Ed.) (1985). Casebook ofMultimodalTherapy.New York: Guilford Press.LAZARUS, A. A. & FAY, A. (1982). Resistance or rationali-zation? A cognitive-behavioral perspective. In P. L. Wachtel(Ed.), Resistance: Psychodynamic and Behavioral Ap-proaches. New York: Plenum.LUBORSKY, L., SINGER, B. & LUBORSKY, L. (1975). Com-

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41 , 1261-1272.MESSER, S. B. & WINOKUR, M. (1980). Some limits to theintegration of psychoanalytic and behavior therapy. AmericanPsychologist, 35, 818-827.MESSER, S. B. & WINOKUR, M. (1984). Ways of knowingand visions of reality in psychoanalytic therapy and behaviortherapy. In H. Arkowitz and S. B . Messer (Eds.), Psy-choanalytic Therapy and Behavior Therapy: Is IntegrationPossible! (pp. 63-100). New York: Plenum.

RACHMAN, S. & HODGSON, R. (1980). Obsessions and Com-pulsions. Englewood Cliffs, N.J.: Prentice-Hall.RACHMAN S. & WILSON, G. T. (1980). The Effects of Psy-chological Therapy (2nd ed.) . New York: Pergamon.RASMUSSEN, A. & MESSER, S. B. (1986). A comparison andcritique of Mann's time-limited psychotherapy and Dav-anloo's short-term dynamic psychotherapy. Bulletin of theMenninger Clinic, 50, 163-184.RHOADS, J. M. (1984). Relationships between psychodynamicand behavior therapies. In H. Arkowitz and S. B. Messer(Eds.), Psychoanalytic Therapy and Behavior Therapy: IsIntegration Possible1? (pp. 195-211). New York: Plenum.SCHACHT, T. E. (1984). The varieties of integrative experience.In H. Arkowitz and S. B. Messer (Eds.), PsychoanalyticTherapy and Behavior Therapy: Is Integration Possible"?(pp. 107-131). New York: Plenum.SIFNEOS, P. (1979). Short-Term Psychotherapy and EmotionalCrisis. Cambridge, Mass.: Harvard University Press.SMITH, M. L., GLASS, G. V. & MILLER, T. I. (1980). TheBenefits of Psychotherapy. Baltimore: Johns Hopkins Uni-

versity Press.STEKETEE, G. & FOA, E. B. (1985). Obsessive-compulsivedisorder. In D. H. Barlow (Ed.), Clinical Handbook ofPsychological D isorders. New York: Guilford Press.STRUPP, H. H. & BINDER, J. L. (1984). Psychotherapy in aNew Key: A Guide to Time-Limited Dynamic Psychotherapy.New York: Basic Books.WACHTEL, P. L. (1977). Psychoanalysis an d Behavior Therapy:Toward an Integration. New York: Basic Books.WACHTEL, P. L. (1984). On theory, practice, and the natureof integration. In H. Arkowitz and S. B. Messer (Eds.),Psychoanalytic Therapy and Behavior Therapy: Is IntegrationPossible? (pp. 31-52). New York: Plenum.WILSON, G. T., FRANKS, C. M., BROWNELL, K. D. & KENDALL,P. C. (1984). Annual Review of Behavior Therapy: Theoryand Practice, vol. 9. New York: Guilford Press.WILSON, G. T. & O'LEARY, K. D. (1980). Principles ofBehavior Therapy. Englewood Cliffs, N.J.: Prentice-Hall.WINOKUR, M ., MESSER, S. B. & SCHACHT, T. E. (1981).Contributions to the theory and practice of short-term dynam icpsychotherapy. Bulletin of the Menninger Clinic, 45, 125-142.

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