PRC PSYCHOTHERAPY MANUAL
DEFINITIONS AND EXAMPLES OF PSYCHOANALYTIC COMMUNICATION
version: December 6, 2018
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Many students of psychotherapy and psychoanalysis have found the definitions and examples given here useful in leading to a clearer understanding of what the therapist contributes in psychotherapy. In several places elsewhere on this website, we describe the evidence that these activities lead to benefit for most patients. In this manual, we also describe the various aspects of the patient’s contribution, as well as the interaction between patient and therapist. Again, the benefits of these activities are described elsewhere on the website, but the evidence that psychoanalytically informed and inspired psychotherapies lead to benefit for most patients has by now become very strong.
The Analytic Process Scales (APS) manual has been used primarily for research since 1999, but it has also proved useful for introducing and defining psychoanalytic concepts to clinicians, psychiatric residents, psychology students at all levels, and candidates in psychoanalytic training. Here is our adaptation of the manual for the web for teaching. It contains descriptions of different ways that psychotherapists tend to communicate with patients, and similarly, how patients communicate with their therapists. Most of the most detailed instructions for carrying out the ratings for each of these measures have been removed. Those wishing to use the full manual for actual research may contact the PRC for the full manual.
We believe that the scales cover many of the central aspects of analytic activity, both by patient and analyst. Since the original development of the APS, they have been applied by psychology interns as well as senior analysts, to recorded analytic sessions, and then recorded short-term psychodynamic and cognitive behavioral sessions, with reliable results. Click here for a more detailed history of our past work in this area of research.
Although the case examples below were inspired by actual patients, they have been extensively disguised and fictionalized, both for the purposes of the manual and confidentiality, so that the final vignettes bear little relation to actual persons. The APS group, after working for a number of years using the APS scales, decided to add additional scales more closely examining the nature of the interactions occurring between patient and therapist. We called these the Dynamic Interaction Scales (DIS). This was a result of our finding that it was the quality of the therapist’s communication which most closely foreshadowed positive therapeutic progress, more than any one particular aspect of the therapist’s activity (Waldron et al. 2004a, 2004b). The presentation here is organized with the the APS variables first: therapist, then patient variables, followed by the DIS variables: therapist, then patient, then interaction variables. Altogether, we feel that these descriptions capture a great deal of how we understand various effective therapeutic communications between patient and psychotherapist.
TABLE OF CONTENTS
Introduction to Rating APS Therapist Variables Therapist communications frequently contain a blend of more than one type of communication. Communications may take different verbal forms, such as statements, questions, analogies, metaphors, parallel examples, and stories.
The therapist encourages elaboration by requesting that the patient continue with what he or she has been relating. The therapist may briefly ask “Because?”, inquire in a general open-ended way “Can you tell me more about that?”, or seek associations to a particular part of the communication: “What comes to mind about the car emerging from underwater in the dream?”
Case: An Angry Man
SCORED 0 when the therapist does not encourage elaboration at all.
Example: A man in his middle years started analysis because of angry behavior and a perversion. Recently, he has been felt alienated from his wife. This morning, as on many previous occasions, he arrives late for his session. Upon entering, he asks “Do you think that your clock is a few minutes fast?” The therapist responds “I think you’re seeking to find fault with me because you feel troubled about arriving late this morning.”
Explanation: The communication is an interpretation containing no particular encouragement of elaboration.
SCORED 2 when the therapist asks the patient with at least mild intensity, and in a general way, to expand on what has just been said. The request is moderately direct or moderately complex and detailed.
Example: The patient responds “You think that I’m turning the tables on you again. Maybe so. I didn’t work very much yesterday; I was feeling kind of sad.” The therapist replies “Can you tell me more about that?”
Explanation: The therapist requests elaboration moderately directly about the patient’s sadness and avoidance of work. It is a general inquiry made with mild intensity and very little complexity.
SCORED 4 when the therapist requests with at least moderate intensity that the patient expand on a particular aspect of what he had just stated. The encouragement to elaborate is strongly direct or strongly complex and detailed.
Example: The patient continues “I walked to the train with Karen [his wife]. I asked her if she wanted me to treat her to a coffee, which she did . . . Boy, she’s really a hard person to get along with . . . The therapist intercedes “Last week you said that you were finding Karen difficult to reach, and that you felt she was alienating you. Just now, after you said that Karen is hard to get along with, you stopped speaking, and I had the distinct impression that you had something quite particular in mind. Can you tell me what you were thinking at the moment that you said that she’s hard to get along with.”
Explanation: The therapist has the impression that the patient is conflicted and avoiding something important. He recalls a similar instance of the subject, and notes the pause following the current version. He asks the patient, in a strongly direct and complex manner to elaborate on his thoughts at that particular moment.
Clarification calls attention to surface features of the patient’s expressions, indicating that they are emotionally noteworthy and warrant further consideration. Rating the degree to which the communication calls attention to insufficiently noticed surface features which are easily recognizable by the patient, including psychological connections or a group of features with similar meanings. Clarification differs from interpretation in that it focuses on features, connections, or meanings which can easily enter awareness, while interpretation aims at transforming meaning by bringing features outside awareness into full awareness. Since surface connections always have parallel deep connections, the division between clarification and interpretation may sometimes be indistinct. Clarification and interpretation may be blended in the same communication.
Case: A Sexually Anxious Young Man
SCORED 0 when the communication does not call attention to insufficiently noticed surface features.
Example:A young man is being treated in analysis for premature ejaculation and little romantic contact with women. During the first session of the week, he says “I was talking with Susan Friday night while we were watching television at her apartment. She disagreed about my political views, and I ended up feeling furious at her.” The therapist asks “Can you tell me more about it?”
Explanation: The therapist has not delineated any communications on the therapeutic surface.
SCORED 2 when the therapist to a moderate degree calls attention to insufficiently noticed surface features which are easily recognizable by the patient, including psychological connections or a group of features with similar meanings. The clarification is usually moderately direct or moderately complex and detailed.
Example: The patient continues the session: “The others left, and Susan asked me if I wanted to stay and cook some dinner with her. The kitchen got warm, and she took off her shirt; and she didn’t have a bra on under her T-shirt. I started to feel really strange and sweaty, and had trouble breathing. It took me fifteen minutes to recover . . .” The therapist notes: “Feeling strange, sweaty, and breathless were anxious feelings.”
Explanation: The communication moderately highlights a group of the patient’s experiences and indicates that they are feelings of anxiety. The clarification is moderately direct and mildly complex and detailed. This communication is also an interpretation, since the patient was previously quite unaware that the sensations were manifestations of anxiety, but this does not affect the rating for clarification.
SCORED 4 when the therapist to a strong degree calls attention to insufficiently noticed surface features which are easily recognizable by the patient, including psychological connections or a group of features with similar meanings. The clarification is usually strongly direct or strongly complex and detailed.
Example: The patient continues: “Maybe you’re right . . . I went to that party on Saturday night, and Allie, who is a painter, asked me to dance. She’s very nice . . . and I think I’ll call and take her out . . . I’m starting to feel shaky, like I’m going to pass out and die [pause] Wow! That was weird!” The therapist remarks “When you were thinking about calling Allie for a date, you started feeling shaky and faint. Friday night, when you were looking at Susan’s breasts, you had similar sensations of strangeness and breathlessness. In both instances, you were getting anxious while you were with an attractive woman.”
Explanation: The therapist emphatically places two sets of experiences into a meaningful assembly of anxious responses to women, to be understood better at a later time. The clarifying part of the communication is strongly direct, complex and detailed. Connecting his attraction to the women with his expressed anxiety makes this communication an interpretation as well; however, that is independent of the rating for clarification.
Rating the degree to which an communication aims at transforming the patient’s understanding by bringing emotional features that are out of awareness into full awareness, particularly elements of conflict and deep inapparent connections between various emotional features. Complex interpretations usually describe conflictual connections between the patient’s impulses or affects and resulting fears, moral concerns, and defenses. They may involve multiple examples or a variety of family and social influences. Clarification differs from interpretation in that it addresses surface aspects which are readily available in awareness. It may group similar elements by their superficial connections but not deep connections. Since surface relationships always have parallel deep connections, the border between clarification and interpretation is often indistinct, and interpretations and clarification may be blended together.
Case: The Woman Who Lost Her Brother
SCORED 0 when an communication is not aimed at transforming understanding by bringing emotional features into full awareness.
Example: A woman in her middle years is being treated in analysis because she fears public speaking and has difficulties in assertiveness. She recently won a promotion over a male competitor. At the start of the session the patient says “I went on a call to a large investment company today without preparing the technical information enough. It went all right, but I’ll never be any good at this job.” The therapist says “You’ve been feeling insufficient at work recently. I wonder what might be stirring up these feelings at this time.”
Explanation: No attempt is made to bring features into conscious awareness.
SCORED 2 when the therapist moderately attempts to transform the patient’s understanding by bringing emotional features that are out of awareness into full awareness, particularly elements of conflict and deep, inapparent connections between emotional features. The interpretive portion of the communication is usually at least moderately directly expressed or mildly complex and detailed.
Example: The patient continues: “I had a scary dream. I was in a sports car and a man in another car was shooting at me . . . It’s my brother Frank’s birthday next month. He died in a car crash the summer before I started boarding school. Frank was very talented and liked by everyone . . . I know that you think that I’m overly worried, but John [the competitor] knows all about the products and I know nothing.” The therapist says “One of the reasons that you’re thinking about failing at work is that you feel uneasy about outdoing John for the promotion.”
Explanation: The communication connects the patient’s conscious worry about imminent failure with her inferred conflicts about triumphing over her colleague. However, the underlying rivalry with her brother is not mentioned. The interpretation is moderately direct and moderately complex and detailed.
SCORED 4 when the therapist strongly attempts to transform the patient’s understanding by bringing emotional features which are out of awareness into full awareness, particularly elements of conflict and deep inapparent connections between emotional features. The interpretive portion of the communication is strongly direct or moderately complex and detailed. At this level, potentially transforming connections are usually made between the patient’s impulses or affects and other conflictual components, such as defenses. There is often more than one example which may link some combination of recent, past, and transference experiences.
Example: The patient continues: “It’s curious that I should dream of a car. Frank died in a car accident . . . That was a terrible year for me . . . I thought that my parents sent me away to school because they felt he wouldn’t have taken the car out if I hadn’t screamed so much . . . maybe you’re just waiting for me to lose the job, so you can get rid of me too.” The therapist responds: “You are uneasy about outdoing John at work because this stirs up your feelings about your brother dying. It is as though you caused his accident, so that now you have to be banished, or ruined in some way. Earlier you said you called on an investment company without preparing, as though to ensure your own failure. The man shouting at you from the other car in your dream was perhaps denouncing you as you denounce yourself. You cannot do well because you did something terribly wrong. Your parents sent you away; you think, to punish you, and you imagine I will do the same thing.”
Explanation: The communication strongly connects the patient’s inferred present-day guilt about winning the promotion with guilt about her brother’s death, and fantasies of being banished by the therapist, and banishment by her parents. The interpretation is strongly direct, complex. and detailed.
Rating the degree to which the communication aims at support to maintain collaboration and progress, in the current or future sessions, by moderating excessive feelings of emotional threat, discomfort, diminished self-esteem, or physical endangerment. Support includes a large number of responses, such as approval, reassurance, encouragement, heightened concern, extra warmth, special empathy, emphasis on achievements, advice, suggestion, permission, prohibition, aiding reality assessment, assisting planning, education, self revelation, and discussion of additional modalities such as medication, or cognitive-behavioral exercises. Accurate interpretations which help a patient to approach a conflicted area of life in a new more adaptive way may provide the most support to a patient’s underlying goals, but this rating focuses on more direct and obvious support.
Case: An Impotent Man
SCORED 0 when the communication offers no support.
Example: A man in his forties tends towards dramatically heightened feelings and enactments of conflict. When upset, his reflective capacity tends to decrease sometimes leading to self-injury. Recently, since falling in love, he has become unable to maintain an erection during intercourse. The patient starts a session by saying “I feel like a child. Last night I asked Lisa [his girlfriend] to tell me that she won’t leave me because I’m sexually incapacitated. It feels so bad when she pulls away from me, I just can’t take it!” The therapist responds: “You have spoken many times before about feeling bad when a woman pulls back from you. How did you feel about Lisa last night in particular?”
Explanation: The communication contains an ordinary degree of empathy, with no specific attempt to provide support.
SCORED 2 when the communication aims to maintain collaboration and progress by moderating excessive feelings of emotional threat, discomfort, diminished self-esteem, or physical endangerment. The support is at least mildly direct or mildly complex and detailed.
Example: The next day the patient appears more distressed and depressed. “I became soft right away again. I slept only about five hours last night. Lisa took an Ativan last night. Do you think that I should be taking medication?” The therapist responds: “That’s something we can consider more specifically later, but for the time being let’s look at what is going on with you emotionally, and why you’re feeling so distraught.”
Explanation: The patient appeared harried and tired, suggesting a possible need for support to maintain his progress. The therapist gives moderate support by offering to speak about medication later on, thereby reassuring the patient that he can continue his exploration without foregoing the medication question. The support is moderately direct, complex, and detailed.
SCORED 4 when the support is at least moderately direct or moderately complex and detailed.
Example: The following day the patient is still agitated and exhausted. “I’m in a fog . . . I couldn’t have sex with Lisa again . . . She says that I’m going to work out all of my problems and then walk out on her. I told her that she was the only one who was talking about leaving . . . I know that Lisa’s withdrawal feels the same to me as my mother being muddled when I was a kid.” The therapist intervenes “In the past it’s been very hard for you to tolerate strong unpleasant feelings. This time you contained them well and saw that Lisa had turned things around on you. You connected Lisa’s withdrawal with memories of your mother’s disorganization. You’re really putting us in a position to understand more of what’s going on.”
Explanation: The patient is agitated and working less well in the session. The therapist strongly supports him by affirming his ability to remain reflective in the face of disruptive feelings, and admires the connection he made between his perception of Lisa’s withdrawal and his mother’s preoccupied states of mind. The support is very direct and very complex and detailed.
A defense is any psychological expression which serves to protect the patient against objectionable impulses, affects, thoughts, or fantasies. Rate the degree to which the communication is aimed at addressing the patient’s defenses in action at that moment during the segment. Among the most commonly observed defenses are repression, denial, avoidance, and rationalization. Other usual defenses are intellectualization, isolation, reduced or heightened affect, self- or other-directed aggression or sexuality, identification, projection, idealization, grandiosity, withdrawal, and confusion. When an emotional feature is performing a defensive function, it may also express impulses, moral requirements, or concerns about reality.
Case: The Teacher With An Ulcer
SCORED 0 when there is no attempt to address defenses.
Example: A teacher suffers from unrestrained outbursts of temper, depression, and ulcer symptoms. During a session she states “I have to make up my fall teaching schedule. I want to work more than last year, even though it means less time with my children.” The therapist responds “Time with your children versus work is something you’ve been mentioning frequently lately.”
Explanation: No attempt to address a defense appears in the communication.
SCORED 2 when the therapist moderately aims at addressing defenses in action at the moment during the segment. The focus on defense is reasonably specific, and is either moderately pointed or moderately complex and detailed. Complexity may be reflected in communications suggesting that the patient’s behavior or symptoms are ways of defending against impulses, affects or threats; and there is usually no mention of previous occurrences of the defenses.
Example: The patient continues: “I have to speak with Ellen [her supervisor] to find out my teaching schedule for next year. I think I’m only getting one class, and Marie [a competitor] will take over the rest. She’s charming and pushy, but has very little experience. It’s just wrong! . . . [long silence]” The therapist intervenes: “While you were talking about Marie taking over your teaching assignments, you had intense feelings and fell silent. Something troubled you about what you were feeling and interfered with your telling me more about it.”
Explanation: The communication aims to address the defenses of denial and avoidance. It is moderately specific and direct in connecting these defenses to feelings of threat, but does not delineate unwanted impulses or affects, or the nature of the threat.
SCORED 4 when the therapist strongly aims at addressing defenses in action at the moment during the segment. The focus on defense is highly specific, and is either strongly direct or strongly complex and detailed. It typically points to emotional features eliciting the defenses, such as impulses or affects, and fantasied fears or moral consequences; it and may include previous occurrences of the defenses.
Example: The patient continues: “As I’m lying here, I’m having bad ulcer pains. I had a terrifying dream last night of a bloody bear skin hanging on a wall, and woke up screaming . . . The violence in the dream makes me worry that there’s something terribly wrong with me, that I’m evil!” The therapist says, “You dream that something bloody has happened, and feel as though you did the violence. You had trouble putting into words your violent feelings towards Ellen and Marie because to say it seemed wrong. But that terrible anger is what emerged in your dream last night, and this morning it is turned against your own body in remorse.”
Explanation: The communication strongly and specifically tries to show the patient her defenses of denial, repression, and turning anger back on herself, which attempt to protect her against her anxiety and guilt about her violent feelings. These interpretations of defense are very pointed and complex.
Rating according to the degree to which the communication tries to draw attention to the patient’s responses to the therapist or the therapeutic situation. The score increases as the effort to focus on these responses is more specific and direct, or more complex and detailed. Complexity may call attention to similar previous responses to the therapist or other persons. The length of the therapist’s contribution should not necessarily influence its score.
Case: The Man Who Missed His Therapist
SCORED 0 when there is no attempt to focus on the patient’s reactions to the therapist or the therapeutic situation.
Example: A young man entered analysis because of impotence and inhibitions. While a female supervisor was on vacation, he felt inexplicably anxious and baffled. Last week, while his therapist was away, he was again anxious. Yesterday he became confused as he recalled the death of the grandmother who raised him. The patient begins “The cab driver took a long route to my office this morning and I felt like a captive. The therapist asks “Did you consider selecting the route yourself?”
Explanation: The communication makes no sufficiently manifest reference to the therapist or the therapeutic situation, although presumably the patient has just arrived by cab for his therapeutic session.
SCORED 2 when the communication tries to draw attention to the patient’s reaction to the therapist or the therapeutic situation with moderate specificity and directness, or moderate complexity and detail. The communication usually does not mention similar previous responses to the therapist or other persons.
Example: The patient replies “I couldn’t find my billfold in the cab just now, and I wondered what it would be like to borrow the money from you . . . As I was leaving the last time, I stole one of your tissues to blow my nose. I assume they’re only for people who are crying.” The therapist intercedes “You thought about borrowing money from me, and then felt uneasy about taking a tissue. You want something from me but feel reluctant to reveal it.”
Explanation: The communication calls attention to a conflicted wish and fantasy about receiving something from the therapist. It is moderately specific, direct, and complex.
SCORED 4 when the communication tries to draw attention to the patient’s reactions to the therapist or the therapeutic situation with a high degree of specificity and directness, or abundant complexity and detail. The communication usually includes similar previous responses to the therapist or other persons.
Example: The patient continues: “It’s strange; you being away annoyed me . . . I guess that response is a little crazy. Of course, you deserved your vacation.” The therapist intervenes “You feel you need to see me, to get something from me, and here I have taken off! It upsets and unsettles you, just as you were baffled when your supervisor went away. Yesterday you told me how it felt to lose your grandmother, and you felt that confusion all over again. When I go away, you are more than ‘annoyed’; you are so lost and angry that you’re afraid you might be crazy.”
Explanation: The communication is strongly specific, direct, and complex in addressing the patient’s feelings of being unhinged because he is angry and at being parted from the therapist. It presents two other parallel instances involving meaningful persons.
Rating the degree to which the therapist’s communication attempts to focus on the patient’s conflicts: that is, impulses or affects, and their feared consequences, moral concerns, defenses, and the connections between any of these – including related fantasies and memories. Interpretation and clarification address conflict most directly. Encouraging elaboration and support are usually scored at 2 or less.
Case: An Embarrassed Woman
SCORED 0 when the therapist does not attempt to address the patient’s conflicts.
Example: A young woman started analysis because of anxiety and sexual inhibition. She begins the session by talking about her adolescence, and getting attention from boys – and her embarrassment about her body. Shifting to the present, she continues “Tom and I went to the museum on Sunday. We talked about Greek and Roman art, and other things.” The therapist asks “What other things did you discuss?”
Explanation: Nothing about the patient’s conflicts is mentioned.
SCORED 2 when the communication moderately attempts to focus on the patient’s conflicts: that is, tries to focus on a couple of elements of conflict, such as impulses or affects, their feared consequences, moral concerns, and defenses – perhaps generally points towards some connections between them. The communication is moderately direct or moderately complex and detailed, and may address some fantasy or memory content.
Example: The patient responds “He asked me a lot of questions about what I like to do, and about my family, which was embarrassing. I couldn’t say very much to him.” The therapist replies “Tom’s romantic interest and personal questions in you are painfully embarrassing to you, so you want to avoid letting him know you better.”
Explanation: The therapist calls attention to a few elements of conflict: implied forbidden wishes to be sexually attractive, related affects of embarrassment, and considerable defensive inhibition. The communication is moderately direct and complex.
SCORED 4 when the communication strongly attempts to focus on the patient’s conflicts: that is, several elements of conflict, such as impulses or affects, their feared consequences, moral concerns, and defenses, and the connections between them. The communication is strongly direct or complex and detailed. It often includes at least a moderate fantasy or memory content, as well as other similar instances of conflict. At this level the communication often presents some combination of recent and past experiences and references to the therapist.
Example: The patient continues “Tom and I saw a romantic and sad movie last night, about the woman who married C. S. Lewis and changed him into a warm and loving man. Afterwards we sat on the sofa, and I started to really feel cozy. I blushed so much that I had to get up to make some tea [pause]. This is so embarrassing . . . Is the time up yet?” The therapist notes “You speak about having warm feelings while you were sitting on the sofa with Tom, and that you felt very embarrassed and had to leave the room. As you tell me about these warm feelings, you begin to feel embarrassed here also, and stop speaking. You’re afraid of having sexual feelings with Tom and me – you distanced yourself from Tom by leaving the room, and here you created distance by thinking about the end of the session.”
Explanation: The therapist strongly focuses on three elements of conflict: her affectionate and sexual feelings, the related affect of embarrassment, and defenses of denial and withdrawal. The communication shows links between features of conflict appearing in a response to the therapist and a recent experience. The focus is strongly direct and complex.
Rating the degree that the communication focuses on emotionally significant childhood, or adolescent experiences, and connects them with more recent experiences – including reactions to the therapist or the therapeutic situation.
Case: A Promiscuous Woman Who Had Childhood Bladder Surgery
SCORED 0 when there is no developmental focus in the communication. A woman in her early twenties started analysis because of difficulties with her college studies and promiscuous sexual behavior. From the age of two onwards, she and her mother had endless stubborn struggles, and at the age of five she had multiple bladder operations. Stubborn opposition frequently occurred in her relationship with the therapist. The patient is fifteen minutes late for the session and says “I really don’t have much to tell you today . . . I saw George last night [a married European boyfriend], and he bought me a dress but I think that I’ll return it for rent money . . . I had a dream this morning in which I felt very strange and couldn’t move . . .” The therapist asks “Can you tell me more about the strange feeling?”
Explanation: The communication shows no developmental focus.
SCORED 2 when the communication seems to focus to a moderate degree on childhood and adolescent experiences, and their connections with more recent experiences, including reactions to the therapist and the therapeutic situation.
Example: The patient continues “I dreamed last night. I was lying in bed, with a strange, dry feeling in my mouth and a sickening antiseptic smell in my nose . . . Before I went to sleep, George cut his hand and bled a lot. I started to shake and cry, and couldn’t sleep.” The therapist remarks “It seems that your dream was stimulated by George’s bleeding, which evoked memories of you being in the hospital as a small child and feeling very frightened.”
Explanation: The communication, reasonably well, connects the incident of bleeding and the dream with a short, general reconstruction of her childhood experiences of hospitalization. It is moderately direct, complex, and detailed.
SCORED 4 when the communication appears to focus strongly on childhood and adolescent experiences, and their connections with more recent experiences, including reactions to the therapist and the therapeutic situation.
Example: The patient continues “I don’t know why you always get back to that. I don’t remember the hospital at all. You’re always trying to put words in my mouth [silence]. I’m not thinking about anything [long silence].” The therapist intercedes “Often, when I draw your attention to something you find painful, such when you were in the hospital, you feel that I’m forcing you to look at something. You become stubborn, and have those old feelings from your training years of wanting to oppose me, hold back, and withdraw. It’s the same kind of struggle you had with your mother from the time you were very small.”
Explanation: The communication strongly focuses on a general reconstruction of some repeated developmental experiences. It is very direct, complex, and detailed, showing that past reactions to her mother are specifically linked to her repeated transference responses.
To What Degree Does the Therapist’s Communication Concentrate on Issues of Self-Esteem?
Rating the degree to which the communication concentrates on issues of self-esteem, which may include self-esteem development or the role self-esteem plays in conflict, transference, and other emotional features. Self-esteem is a feeling or attitude of self-worth, which is generated and constrained by many factors. Conscience activity is a most important regulator of self-esteem through its functions of praising and rewarding, or criticizing and punishing. Self-esteem experiences vary widely. Although self-worth is the most inclusive term for self-esteem, there are roughly four overlapping categories of feelings of self-esteem, each having a spectrum between high and low ends. These overlapping affects are: (1) feelings of pride, including feelings of being superior, heroic, or entitled (as opposed to feeling shamed, inferior or humiliated, which represent the low self-esteem side of the spectrum); (2) feelings of being virtuous, truthful, or honest (as opposed to corrupt, guilty, or deceitful); (3) feelings of being lovable, personally valuable, or cared for (as opposed to loathsome, insignificant, or scorned); and (4) feelings of being effective; that is, capable, powerful, dominant, in control (as opposed to insufficient, ill-equipped, submissive, or lacking in self-control).
Case: The Self-Critical Businessman
SCORED 0 when there is no focus on self-esteem. A man in his fifties entered analysis because of recurrent depression. He avoids feelings of affection and closeness. The patient begins “I was thinking in the cab about Dr. Roche [the referring physician] saying that your office was close, when it actually takes fifteen minutes to get here . . . I know you’re thinking that I’m saying something about you.” The therapist: asks “What occurs to you about that?”
Explanation: The therapist does not mention issues of self-esteem, although the patient probably feels diminished in thinking he has been misled.
SCORED 2 when the communication concentrates moderately on issues of self-esteem, including self-esteem development, or the role that self-esteem plays in conflict, transference, and other emotional features. The focus on self-esteem is usually moderately direct or at least mildly complex and detailed.
Example: The patient has been depressed since writing a report about a disappointing second business quarter. He continues “I am not feeling too well today. Ben [his business partner] thought my report was too downbeat, and I’m not up to arguing with him . . . I’m going on a selling trip to Toronto. I’m not very good at that.” The therapist replied “You seem to be feeling weak and insufficient so you can ignore feeling angry at Ben, which is threatening to you.”
Explanation: The communication focuses moderately on the patient’s self-esteem, indicating that his feelings of weakness and insufficiency serve to defend against dangers he feels are the result of his angry feelings. The focus on self-esteem is moderately direct, complex, and detailed.
SCORED 4 when the communication concentrates strongly on issues of self-esteem, including self-esteem development or the role that self-esteem plays in conflict, transference, and other emotional features.
Example: The patient says “I got a call from a college classmate last night, asking for money for the school . . . I can’t remember if I paid you this month. You’re going to say that I think you’re not worth the money . . . I’m not very good at this. I don’t remember dreams, and most of the time I can’t understand what you’re telling me.” The therapist intercedes “After thinking I might not be worth the money, you emphasize your supposed insufficiencies, such as not remembering dreams or not understanding me. You diminish yourself to protect against dangers you feel are posed by your anger at me. It’s similar to what happened earlier in the session with Ben, when you felt tired and weak to avoid the results of your angry thoughts about him.”
Explanation: The communication strongly indicates how the patient’s expressions of lowered self-esteem defend against his fear of angry confrontations with his therapist and his partner. The focus on self-esteem is strongly direct, complex and detailed.
Rating the degree to which the communication introduces a special emphasis, urgency, or reiteration which shows the patient that she is denying, avoiding, or minimizing some emotional feature. The intent is to assess a component over and above the ordinary confrontational element of an interpretation, which draws attention to some aspect which the patient is not clearly aware of at the time. Scoring this variable requires listening to the audio recording, since the confrontational aspect of an communication may be conveyed by vocal tone as well as verbal content. For this reason, the examples presented here are incomplete.
Case: The Impulsive Egg Donor
SCORED 0 when no special emphasis is conveyed in the communication.
Example: A single woman in her thirties has mostly had women lovers since entering college. She has been unhappy with an increasingly successful career as a police administrator. Seemingly from nowhere, she announces that she will donate an ovum to her infertile married sister, with whom she has had a stormy relationship. After her disclosure, she talks about annoyances at the office. The therapist intercedes in an even voice “The egg donation is significant in your relationship with your sister, which you seem to be keeping to one side.”
Explanation: The therapist speaks with ordinary emphasis.
SCORED 2 when the communication introduces a moderate degree of special emphasis, urgency, or reiteration, conveyed in voice tone or content. It is reasonably direct and at least mildly complex and detailed in the confrontational features.
Example: The patient continues “It’s really not a big thing. With me, Evelyn [her sister] will be sure that the donor is reasonably smart and good looking . . . I’ve been thinking about men again . . I dreamed about having sex with my brother-in-law last night . . . ” The therapist responds with reasonably distinct emphasis “Your involvement with the egg donation will surely be brief, but your conflicts about your romantic and sexual desires, and your relationships with your sister and brother-in-law, will have lasting importance.”
Explanation: The therapist confronts the patient with moderate emphasis and forewarning, expressed in voice tone and content.
SCORED 4 when the communication introduces a strong degree of special emphasis, urgency, or reiteration, conveyed in voice tone or content. it is very direct and at least moderately complex and detailed in its confrontational features.
Example: The patient continues “The procedure probably won’t work the first time . . . I went to a party with Fran [a girlfriend] last night, and things got a little wild. I took a couple of hits on a joint and did some cocaine. Fran’s worried that they’ll test my urine and I’ll get caught again.” The therapist intercedes in a strongly emphatic tone “You’ve arranged to donate an ovum to your sister without considering much about what it means to you. Now you’re flirting with getting fired if your urine tests positive, which itself is probably connected to the egg donation. You’re doing these things instead of looking at your romantic life and your desires for a child! You need to consider these matters in earnest before you significantly hurt yourself!”
Explanation: The therapist speaks with very decisive emphasis and a strong sense of urgency, communicated by both vocal tone and content.
Rating the degree to which the therapist’s feelings, conveyed by vocal quality and verbal content, seem to contribute to and shape the impact of the communication. The score increases as feelings shape the communication more directly and immediately. This variable includes all affects that contribute to the therapist’s remarks. It consists of the therapist’s helpful feelings, which add vividness and meaning to the communication and encourage the patient’s participation, as well as feelings which may interfere with the therapeutic work and alienate the patient, including those arising from the therapist’s own problems. Feelings are transmitted by voice tone, inflection, and cadence, as well as verbal content. If there is a disparity between the therapist’s voice quality and verbal content, rely more upon the voice quality. Rating this variable requires listening to the audio recording, making the examples presented here are incomplete.
Case: A Woman With Money Problems
SCORED 0 when the rater does not observe that the therapist’s feelings contribute to the impact of the communication beyond that found in usual relaxed conversation. A woman in her forties is in her first year of analysis because of marital discord and her submission to mistreatment. She delays paying bills and is constantly being dunned for money. Her payment for analysis is invariably late. She says “We’re short of cash, so I won’t be able to pay your bill this month, but I’ll pay it all next month.” The therapist replies in an even tone “The way that you deal with money seems to be quite special.”
Explanation: The communication expresses no more feeling than the minimum present in the words and tone of relaxed conversation.
SCORED 2 when the rater observes that the therapist’s feelings contribute to the emotional impact of the communication to a moderate degree. The feelings are moderately immediate and direct. This variable encompasses all feelings, whether they seem to be helpful or interfering.
Example: The patient continues “We have a lot of expenses, and I have to be careful. My mother and father really do have problems with money. But we only spend money on restaurants and going out.” The therapist responds with moderately vivid feeling “Your regular delay in paying bills is quite usual. For instance, you haven’t paid a bill here in a timely way since we began the analysis.”
Explanation: The rater sees that feelings contribute to the communication to a moderate degree.
SCORED 4 when the therapist’s feelings contribute to the emotional impact of the communication to a strong degree. The feelings are strongly immediate and direct.
Example: The patient continues “There was one time I paid you before the end of the month . . . I think you’re the one with the money problems! None of my friends pay for canceled sessions . . . Are we going to talk about something worthwhile, or waste some more time here?” The therapist replies with very sharp irritation “Look! you’re turning this whole thing around! You have considerable problems with money, as does your whole family. I’m asking you to look at an important matter, and you’re simply ignoring what I’m saying!”
Explanation: The therapist expresses intense feelings of exasperation and irritation, which bespeak a loss of patience with the patient’s denial and opposition.
Rating the degree to which the communication appears to express sympathy, admiration, warmth, or affection towards the patient, beyond an ordinarily agreeable demeanor. The rating increases when the friendly aspects of the communication are more direct or elaborated. The length of the therapist’s contribution should not necessarily influence its score. Listening to the audio recording is necessary for scoring since the amicable features of an communication are conveyed by voice tone as well as by verbal content.
Case: A Man Who Loves His Wife
SCORED 0 when the communication appears to express no sympathy, admiration, warmth, or affection beyond an ordinarily agreeable attitude.
Example: A man in his middle years has a loving relationship with his wife and is hardworking in both his career and the analysis. During a session he says “My friends Martin and Elaine said that I’m very supportive of Allison [his wife] in dealing with her cancer, but I really don’t understand what they’re talking about.” The therapist evenly observes “For some reason you need to deny these qualities.”
Explanation: The communication expresses an ordinarily good-natured content and tone.
SCORED 2 when the communication expresses, through voice tone or content, moderate sympathy, admiration, warmth, or affection towards the patient, beyond an ordinarily agreeable demeanor. There is moderate directness or at least mild elaboration in the portion of the communication conveying amicability.
Example: The patient continues “Her fortieth birthday is coming up in a month, and I’m getting her a photograph of the main street of the little town where she was born, when the road was still unpaved. She loves the town.” The therapist responds warmly “That’s a very thoughtful gesture.”
Explanation: The communication praises the patient moderately beyond ordinary positive demeanor.
SCORED 4 when the communication expresses, through voice tone or content, strong sympathy, admiration, warmth, or affection towards the patient, beyond an ordinarily agreeable demeanor. There is usually strong directness or at least moderate elaboration of the portion of the communication conveying amicability.
Example: The patient continues “It’s just such a relief that we’re finished with the radiation and chemotherapy. Allison’s been so brave and optimistic about it, but I could have helped her more. I could have been better at getting her to talk about her disease . . .” The therapist, seemingly deeply moved, says “You’ve been exceedingly attentive and loving to her during this difficult time, as solid as a rock through all of it. I don’t see how you could have been a better husband! You’re being perfectionistic about what you could have done for her, similar to what you require of yourself in your management work, and your responsiveness here in the analysis.”
Explanation: The communication is extremely warm and admiring of the patient in content and vocal tone. It is strongly direct and highly elaborated in praising his actions with his wife.
Rating the degree to which the communication expresses antagonism, anger, or personal hostility towards the patient. Listening to the audio recording is necessary for scoring because the hostile features of an communication are conveyed by voice tone as well as by verbal content.
Case: The Critical Husband
SCORED 0 when no hostility is conveyed by the communication.
Example A: A highly competitive man is dissatisfied with his wife’s ambitiousness. He has criticized and devalued his father since childhood, while his father has rarely opposed him. Starting a session, the patient heatedly criticizes his daughter’s gymnastics coach for failing to correct her elementary errors. The therapist intercedes in an even voice: “You seem to be feeling a frustration of your own competitiveness, which goes beyond your concern for your daughter’s welfare.”
Explanation: The communication does not appear to express anger or hostility.
Example B: The patient continues: “My daughter could be a contender in the state championships, so I’m going to try to get the coach replaced. You’ll try to stop me, because you always interfere when I move to get someone fired at work.” The therapist replies in a strong but relatively neutral way: “This is another instance where you want to take action without giving much thought to what it means to you. If you’re not willing to look at your experiences, you’re not going to get much from talking about them here!”
Explanation: Although the therapist is forcefully confronting, his tone of voice does not show antagonism, anger, or hostility towards the patient.
SCORED 2 when the communication appears to express, through voice tone or content, moderate antagonism, anger, or personal hostility towards the patient. There is usually moderate directness or mild elaboration in the part of the communication expressing hostility.
Example: The patient continues “I know that I’m getting too angry! There’s also something with Katerina [his wife]. She was offered her first show to produce, and she’s going to turn it down. It’s the same old story; she doesn’t want to try anything!” The therapist responds in a somewhat harsh and angry tone “You’re too involved in her career, and don’t seem to think about whether it’s harmful to her or not!” Explanation: The therapist confronts the patient, expressing moderately direct anger through voice tone and content.
SCORED 4 when the communication appears to express, through voice tone or content, strong antagonism, anger, or personal hostility to the patient. There is usually strong directness or moderate elaboration in the part of the communication conveying hostility.
Example: The patient says “I was sitting at the gymnastics meet yesterday and Anika [his daughter] was doing wrong things in the vault, so I went down to the bench and told her to run faster on her approach. The coach heard me and made a bad face and turned away.” The therapist responds angrily “You see the coach as inadequate and run roughshod over him, just as you did with your father, whom you dumped on! You’re continuing the same self-centered behavior with the coach, without regard for his feelings or what you’re teaching your daughter!”
Explanation: The communication is highly and directly critical of the patient, and personally attacks him through voice tone and content. The seemingly valuable content is irrelevant to rating the degree of hostility.
This variable measures the degree to which the communication follows key aspects of the therapeutic surface by concentrating on the patient’s immediate experiences, where the patient’s feelings may be most accessible. Rating the degree to which the communication follows the patient’s various meaningful feelings, the distinctive unpleasurable feelings of anxiety, guilt, shame, or low self-esteem, or the defenses evoked at the moment. Subtle feelings can show the way to less apparent conflicts, or defenses in action at the moment, such as denial, which may require communication before addressing impulses and fantasies. Expressions of low self-esteem, particularly, may be implied and require special alertness.
Case: A Very Needy Woman
SCORED 0 when the communication does not follow the patient’s immediate emotional focus because it disregards meaningful affects, distinctive feelings of anxiety, guilt, shame, and low self-esteem, or the defenses active at the moment.
Example: A depressed woman in her thirties pays her bill with several checks over the course of the month. Having just broken up with her boyfriend, she rushes into a session twenty minutes late, appearing depressed, anxious and guilty. In a flood of words she tells of her day’s activities, without mentioning her anxiety, guilt, or lateness. The therapist remarks “You don’t seem concerned about your lateness here today.”
Explanation: The communication tactlessly addresses the patient’s defensive avoidance while bypassing her feelings of anxiety, guilt, and low self-esteem, which might well include her feelings of guilt about being late.
SCORED 2 when the communication moderately follows the patient’s meaningful affects, distinctive feelings of anxiety, guilt, shame, and low self-esteem, and the defenses evoked at the moment. There is moderate directness or complexity in following the patient’s emotional focus which may include a reasonable degree of tactfulness concerning patient’s self-regard and feelings of vulnerability .
Example: The patient cries and continues “I feel terribly alone [sniff] . . . I told Anne [a friend] about David [her ex-boyfriend] and me breaking up . . . I’m going to have lunch with her today. I also had a long talk with Irene [another friend] last night, and she thinks he’s incredibly self centered . . . No one will ever love me! [cries] I’ll be all alone.” The therapist replies, “You respond to David’s loss with strong feelings of being unworthy and unlovable, despite your friends’ close attention to you. We need to understand why you actually accentuate these painful feelings.”
Explanation: The communication offers moderate support to the patient’s low self-esteem by mentioning her friends’ affection for her. It tactfully clarifies the patient’s defensive intensification of her suffering, and follows the patient’s immediate focus with a moderate degree of directness and complexity.
SCORED 4 when the therapist strongly follows the patient’s meaningful affects, distinctive feelings of anxiety, guilt, shame, and low self-esteem, and the defenses evoked at the moment. There is strong directness or moderate complexity in following the patient’s immediate emotional focus, which is usually includes significant tactfulness when the patient’s self-esteem is low.
Example: The patient continues: “I saw you shopping in the food market yesterday, and was surprised at how full your cart was. Seeing that you buy so much makes me feel very small. When I write you a check for more than a week, I feel that I’m losing too much money . . . I’ve never told you, but sometimes when I’m in a store, I pick up clothes and put them in my bag. I feel dirty and sick about it.” The therapist says “You feel just terrible about yourself, because of your strong desires for large quantities of food and clothes, and for wanting to keep all your money for yourself. You’ve tried not to show me your desires, but they come out in your repeated actions of taking the clothes from stores. You are driven to do what makes you feel awful about yourself, and it leads you to fear that I’ll disapprove of you.”
Explanation: The repeated emphasis on the painfulness of the patient’s guilt and shame, and on how she is defensively driven to make herself feel bad, puts the therapist on her side. A high degree of tactful support is combined with the interpretation, to help the patient look at some difficult subjects. The communication is very direct and complex in following the patient’s immediate emotional focus.
This is a global variable that rates the overall quality of the communication. The rating takes into account the aptness of the communication’s type, the potential usefulness of its content, and the skill of its presentation. The skill of the presentation is scored higher when the communication is more tactful, well timed, and its language is more clear, vivid, or likely to appeal to the patient. The score also increases when the communication is more direct or more relevantly complex and detailed.
Case: The Man Whose Brother Entered a Cave
SCORED 0 when the type of communication, or its content, or the skill of its presentation do not suit the patient’s expressions at all.
Example: The patient is a vulnerable, self-defeating young man who is conflicted about expressing his anger and started analysis because of insufficient progress in his career. This session starts with the patient describing an evening with his parents and his younger brother, John, who has been visiting. “The dinner with my parents went all right. John and I walked past a beautiful church and I pointed out a carving on an arch. John seemed interested, but didn’t have much to say about it, so I started talking about work. The therapist said “You seem to have let your brother get the best of you.”
Explanation: Although the communication applies to the patient generally, its content does not match the patient’s communications and it is insufficiently tactful.
SCORED 2 when the communication is a moderately suitable response to the patient’s communications. The type or blend of types of communication is at least reasonably apt, the content addresses the patient’s expressions in a potentially moderately useful way, and the presentation is reasonably tactful, well timed, and verbally appealing to the patient. There is a moderate degree of directness or relevant complexity. If an communication seems useful and reasonably well designed, but not remarkable, the rating is usually 2 or less.
Example: The patient continues “John wanted to know if he could stay at my apartment and then, out of the blue, he punched me on the arm so hard that it really hurt. Well . . . I mean! . . . I told him that he could stay with me last night, but not over the weekend. We’re inviting a lot of people to a party on Saturday.” The therapist intercedes “You speak about your brother punching you on the arm, and then continue as if that were quite usual. You seem to be avoiding getting angry at John.”
Explanation: This blend of clarification and interpretation is an apt type of communication, which calls attention to the patient’s denial of his anger moderately well. There is reasonably suitable tact, timing, and verbal appeal, as well as moderate directness and complexity.
SCORED 4 when the communication is a highly suitable response to the patient’s communications. The type or blend of types of communication is very apt, the content focuses on the patient’s expressions in a potentially very effective way, and the presentation is usually very tactful, well timed, and uses clear and vivid language. There is usually a high degree of directness or strong relevant complexity, possibly linking current experiences with past experiences or experiences involving the therapist.
Example: The patient says “I had a dream last night. There were two holes in a barren rock and I was lying in one of them. I guess it means that I was dead, like in a grave . . . [sigh] . . . It reminds me of the time my family went on vacation when I was nine, and John and I found an opening in a rock face and he crawled in. The earth over the entrance started to slide, and my father ran over with a piece of wood and braced it. Dad turned to me white-faced and furious, and said ‘He could have died in there! How could you let him do that?’” The therapist says “Your father’s accusation touched on a deep feeling in you. John’s hitting you seems to have brought the accident and your father’s accusation back to your mind, that you would be willing to see John die. When you feel angry with him, you feel you are a really bad person. It’s as though you are guiltily saying, in your dream, ‘I’m the one who deserves to be in a rocky grave, not John.’ Feeling that you are capable of being so destructive leads you to back off from standing up for yourself; you tend to ‘lie down in the rock.’ You don’t stand up for yourself with John and you feel pessimistic about yourself and about this treatment helping you.”
Explanation: The interpretation is an apt type of communication, strongly calling attention to the punishment the patient feels he deserves for his past and present murderous impulses. The interpretation is sensitive, well timed, vivid, and dexterously expressed. Links between the patient’s recent conflicts and past experiences show considerable complexity. (For illustrative purposes, this communication is given as if said all at once. Most likely such an communication would best be given in a way that would give the patient an opportunity to respond to each part before proceeding to the next part of the communication.)
Several of the patient features, such as the contribution of patient feelings, are divided into two independent variables, the first assessing the reaction to the therapist or therapeutic situation, the second the reaction to persons and events outside the analysis. If the patient’s communication seems to be about an outside person but also refers to the therapist, it should be scored for the response to the therapist as well.
- A. Specifically about the Therapist or the Therapeutic Situation?
- B. In All Respects Other than the Therapist or the Therapeutic Situation?
These two variables deal with how easily elements of conflict can be identified, that is, impulses or affects, feared consequences of them, moral concerns, and defenses, and the relationships between any of them, including relevant fantasies and memories. When the patient is highly emotionally involved at the moment or reports immediately-lived previous experiences, score the segment at the highest level warranted by the other criteria of the variable. The score usually decreases when communications are more general. If the patient’s communication is about a person outside the therapeutic situation but also seems to refer to the therapist, score for the therapist as well.
Case: The Inhibited Executive Secretary
SCORED 0 when elements of conflict, including relevant fantasies and memories, cannot be identified.
Example: An executive secretary entered analysis because of sexual inhibitions. She starts the first session of a week by saying “I don’t adjust well to changes in plans. On Thursday Hal (her husband) said that he had to work this weekend, so we couldn’t go to the country. Then Friday night he said we could go after all, but I just couldn’t get myself together.”
Explanation: The patient describes a symptom of rigidity, but provides no indication of the underlying conflicts, fantasies, or memories.
SCORED 2 when the rater can identify with relative ease a couple of elements of conflict — that is, impulses or affects, feared consequences of them, moral concerns, or defenses — while the relationships between the elements, and related fantasies and memories, are usually less explicit. The patient is reasonably emotionally engaged at the moment or reports fairly immediately-lived previous experiences.
Example: The secretary continues: “I’m still thinking about my assistant. I treated her badly on Friday by giving her a long rush job, which didn’t have to get done until today. She’s very good with the lawyers, and when she has a warm response from them I feel very jealous . . . I hear you shifting in your chair — you must think I’m quite disgusting.”
Explanation: The patient expresses competitive and hostile impulses that conflict with her moral sense and evoke feelings of disgust, which are projected on to the therapist. Three elements of conflict – her impulses, disgust, and projective defense – are expressed with moderate directness and are relatively easy to identify. They are also moderately complex and very immediately-experienced.
SCORED 4 when the rater can easily identify several elements of conflict and some of the relationships between them, including related fantasies or memories. The conflictual elements and related fantasies are very directly presented or strongly complex and detailed, often showing more than one example and references to development. At this level, the complexity may include some meaningful combination of current experiences, past experiences, and experiences concerning the therapist. The patient is highly emotionally engaged at the moment, or reports very immediately-lived previous experiences.
Example: The secretary continues: “I experience a flood of things when I first lie down here. It’s kind of hard to lie down with just you, a man, in the room, especially when I’m wanting reassurance from you. I feel that it’s an intimate kind of thing . . . On Friday morning, after I left here, I went back to the office and one of the lawyers came in and started chatting with me. Well . . . I noticed his tie, which was red and coarsely woven, and very nubby . . . Well, I just reached out and I rubbed it with my fingers, and said, ’This has such a wonderful texture’ . . . I was just mortified, because I was sure his reaction was going to be so much disgust, because I was being so forward!”
Explanation: The patient feels intimately close to the therapist, and represses her sexual impulses towards him, displacing them onto recent memories of talking to the lawyer and rubbing his tie. During both the incident itself and its current retelling, she responds with strong feelings of disgust which she projects on to the lawyer. The patient’s sexual wishes, disgust, and defenses (repression, displacement, and projection), as well as their accompanying fantasies, are very easily perceived. She makes parallel, complex references to the therapist and lawyer, which are very immediately-lived and retold with emotion.
- A.Specifically about the Therapist or the Therapeutic Situation?
- B. in All Respects Other than the Therapist or the Therapeutic Situation?
Rating the degree to which the patient reflects on the experiences that she or he has been observing within herself, or reflects on comments made by the therapist about her. The score increases as there is a greater intensity of inner reflection and when the reflections are either more direct or more complex and detailed. When the patient is highly emotionally involved in self-reflection, score the segment higher. The score decreases when the inner reflection is more intellectualized or ruminative, or carries less meaning because feelings are suppressed. As the level of self-reflection increases, the patient’s communication becomes more nearly the equivalent of a helpful interpretation which the therapist might have made. If the patient is speaking about a person outside the therapeutic situation but also seems to be referring to the therapist, then score for the therapist as well.
Case: The Submissive Homemaker
SCORED 0 when there is no specific self-reflection beyond the minimum necessary for the patient to describe her experiences.
Example: A mother and homemaker in her middle years recently began an analysis because of depression and fears that her husband was losing interest in her. The patient says, quite monotonously, “I had a dream about snakes last night but I don’t remember anything about it . . . My husband and I have been talking about going to the West Coast on vacation, which we’re not going to do because it won’t fit in with our social commitments.”
Explanation: The patient speaks about a dream and a change in plans without reflecting on her inner experiences, which might include feelings about the dream or disappointment about the trip.
SCORED 2 when there is a moderate degree of reflectiveness about inner experiences or comments made by the therapist about the patient. The patient’s inward reflection is at least moderately pointed and direct or moderately complex and detailed. She is reasonably emotionally involved in her self-reflections, which may either be somewhat general or intellectualized, or show some suppressed or dramatically heightened feeling.
Example: The patient continues: “I was supposed to meet our lawyer, Richard, for lunch today to discuss dissolving my uncle’s trust. He canceled out on me again at the last minute. He thinks that because he’s a successful corporate lawyer he can cancel on me without it mattering. I resent his feeling that he can do whatever he wants; and I can’t let him do that to me. I won’t reschedule without discussing it with him first.”
Explanation: The patient feels resentful at being ill-treated by the lawyer. She reflects on her mounting anger and, consonant with her feelings, decides that she will no longer be submissive towards him. Her reflections are reasonably direct and complex, and she is quite immediately involved in her own inwardly directed reflectiveness.
SCORED 4 when there is a high degree of reflectiveness about inner experiences or comments made by the therapist about the patient. The patient’s inward reflection is very pointed and direct or very complex and detailed. She is very emotionally involved in her self-reflections, which are usually connected to specific lived experiences and robust feelings. At this level, the self-reflections often have the characteristics of a useful interpretation which the therapist could have made.
Example: The patient continues: “When someone comes out of your office I find myself looking at them and wondering how their treatment is going. You know that young woman with the long blond hair I mentioned yesterday. She looked so happy I wondered why you still see her. Maybe it’s because you enjoy talking with her, different from the way I believe you feel about me . . . You know, that woman looks very much like my younger sister Marge . . . She’s also beautiful and has been my father’s favorite, which has always bothered me. Now that I think about it, I’m always looking at your other patients and feeling uncomfortable. I’m starting to feel very uncomfortable about all of this.”
Explanation: The patient reflects intently about the relationship between the therapist and the attractive woman patient. She thinks about her younger sister, an earlier rival, whom she feels her father preferred. She ponders about always observing other patients, and notices that she is feeling increasingly conflicted. Her self reflections are strongly emotionally involved and connected to immediate experiences. They resemble a complex interpretation that the therapist might have given about her transference feelings of rivalry.
- A. Specifically about the Therapist or the Therapeutic Situation?
- B. in All Respects Other than the Therapist or the Therapeutic Situation?
Rating according to the degree that the patient’s feelings add to an understanding of her communications during the segment. The rating increases as the overall vocal qualities and verbal contents convey feelings that are more strong and explicit in describing the patient’s experiences. Feelings can be assessed by voice quality and verbal contents. Voice quality includes aspects such as intensity, speed, rhythm, tone, and inflective nuance, as well as hesitations, sighs, etc. The rater must listen to the audio of the session in order to rate this variable. The written examples presented below are insufficient to assess the patient feelings, since they do not include an audio recording. The feelings imparted by the verbal content may be inconsonant with those communicated by the voice quality. When there is a disparity between the affective qualities of the patient’s voice and the affective significance of his words, rely much more upon the voice.
Case: An Embarrassed Woman
SCORED 0 when the feelings conveyed by the voice quality and words do not convey the patient’s experiences beyond the feelings related during relaxed speech.
Example: A woman, who had recurrent pinworms as a child, entered analysis for depression and sexual inhibition. In a flat voice, she recalls a dream that her previous therapist considered important but that she never understood. “The dream had something to do with messy bed linens, and somebody making up my bed . . . It means nothing.”
Explanation: One would expect from the content of the dream that it would be accompanied by voiced feelings. But listening to the audio shows that her feelings are extremely dampened.
SCORED 2 when the feelings conveyed by the voice quality and content of the patient’s communication are moderately intense and explicit in conveying the patient’s experiences. The rating should rely much more on voice quality than verbal content.
Example: The following week the same patient consulted her gynecologist for a urinary tract infection. She is more lively because she feels more resentful, and says “The examination went all right, but he asked me very annoying questions, such as the last time that I had sex with my husband and what we did. I was as cooperative as I could be, but I won’t confide embarrassing things to someone who’s almost a stranger.”
Explanation: The patient’s feelings are freer due to her annoyance. Her words and the sound of her voice express feelings with moderate intensity, that add to the rater’s understanding of her sexual conflicts and feelings of humiliation.
SCORED 4 When the feelings conveyed by the patient’s voice quality and content are quite strong and very explicit in informing the rater’s perception of the patient’s experiences.
Example: The patient continues: “I should have been able to tell my doctor what he wanted to know.” The therapist intervenes: “You made a reasonable effort to be cooperative, but you felt embarrassed about your body and sex, much as you experienced during the examinations for pin worms when you were a small girl.” The patient replies “That was truly terrible; I felt I was dirty and different from the other children, even though we all had the same thing. . . The questions about sex were very upsetting. He started to write down all those private things — what if someone else ever read them? Oh my god!”
Explanation: The very direct feelings of anguish and embarrassment, expressed in words and the sound of her voice, very strongly convey the patient’s humiliation and fear of exposure about sex.
Rating according to the degree that the patient speaks of romantic or sexual feelings, fantasies, activities, and memories, which may include references to sexual attributes of the body. The rating increases as these expressions are either more direct or more complex and detailed. The length of the patient’s contribution should not necessarily influence the score.
Case: A Frustrated Woman
SCORED 0 when the patient does not mention romantic or sexual feelings, fantasies, activities, or memories.
Example: A businesswoman entered analysis because of self-destructive behavior. She frequently has affairs in which she is exploited. Deciding to concentrate on her work, she says “[Company X] has hardly sold any of their order this season and put it all on sale. I should just quit and work for someone else.”
Explanation: There is no mention of romantic or sexual issues.
SCORED 2 when the patient speaks to a moderate degree about romantic or sexual feelings, fantasies, activities, or memories. The patient is reasonably emotionally engaged in these expressions or reports fairly immediately-lived previous experiences.
Example: The patient continues: “I called my accountant, Jim, about my taxes. It’s obvious that we have a special relationship and I find him very attractive, and he has strong feelings for me. I’m upset that he was cool on the phone today, and then later he didn’t return my call.”
Explanation: The patient’s is moderately involved and direct in speaking about her romantic feelings.
SCORED 4 when the patient speaks to a strong degree about romantic or sexual feelings, fantasies, activities, or memories. The patient is strongly emotionally engaged in these expressions or reports very immediately-lived previous experiences. They are either very directly stated or are at least moderately complex and detailed.
Example: The patient continues: “I felt so upset that I called up my old boyfriend Vlad and had sex with him. We drank two bottles of champagne and stayed up until 4 AM. I must have come ten times, but I ended up feeling empty. Why can’t I ever work things out with someone like Jim?”
Explanation: The patient speaks about sexual and romantic matters in a very emotionally involved and direct way.
Rating according to the degree that the patient speaks about or manifests assertive, aggressive, or hostile feelings, fantasies, activities, or memories beyond what would be found in ordinary relaxed speech. By assertive we mean forceful, beyond ordinary vigor; by aggressive we mean competitive or angry with other persons. Hostility includes derogation, criticism, meanness, attack, or punishment toward other persons, toward oneself, or toward things. Some assertive, aggressive, or hostile aspects may be conveyed by tone of voice, so it is essential to listen to the audio-recording when scoring.
Case: An Angry Son
SCORED 0 when the patient does not show and says nothing about assertive, aggressive, or hostile feelings, fantasies, activities, or memories.
Example: A young man is in analysis because of recurrent episodes of depression. He was very intimidated by his father during his growing years and became significantly inhibited in his assertiveness and expressions of anger. He begins: “I’ve been meeting with the people at the new software company. We need to get a better idea of what our market is.”
Explanation: The expressions are assertive to the degree found in ordinary relaxed speech.
SCORED 2 when the patient shows or speaks to a moderate degree about assertive, aggressive, or hostile – feelings, fantasies, activities, or memories. The patient is reasonably emotionally engaged in these expressions or reports fairly immediately-lived experiences. They are either reasonably direct or moderately complex and detailed. The length of the patient’s contribution should not necessarily influence its score.
Example: The patient continues: “I’m very concerned about how things are going with Al [his new business partner]. He really is not getting the job done!” He becomes more intense: “It’s hard for me to say this, but I think the trouble is that he’s lazy. He just doesn’t exert himself enough!”
Explanation: The patient is directly assertive and critical to a moderate degree.
SCORED 4 when the patient shows or speaks to a strong degree about assertive, aggressive, or hostile feelings, fantasies, activities, or memories. The patient is strongly emotionally engaged in the these expressions or reports very immediately-lived experiences.
Example: The patient continues: “I got a letter from my father today, saying that he wanted me to sign over ten percent of the business to my cousin, who has made no contribution to it whatsoever! He said that he knows that I will disagree. I saw red! I want to punch him out!! He doesn’t care about me, he’s only thinking about his own comfort.”
Explanation: The patient is strongly critical and angry at his father, with a high degree of emotional involvement, directness, and complexity.
Score according to the degree that the patient notices that she has unpleasant or painful emotional experiences (such as anxiety, guilt, shame, depressed feelings, or feelings of insufficiency), observes that she has inhibitions (such as avoiding career advancement), sees that some of what she says or does leads to adverse consequences (such as provoking others), recognizes particular emotional symptoms (such as compulsions), or notes character symptoms (such as passivity). This can be expressed as the degree to which the patient is aware that they are “getting in their own way” in life.
Case: The Placement Director Who Overworks
SCORED 0 when the patient does not notice that her emotional experiences or expressions are unpleasant, inhibited, lead to adverse consequences, or include particular emotional symptoms.
Example: A job placement director at a school comes to analysis because of prolonged depression, severe anxiety, and frantic overworking. At the beginning of a session, she says “The administrator took away half of my space, and I can’t get my work done! I have eight programs to run, and I’m working seven days a week . . . It’s nice, though, because I don’t have to work usual hours; and If I want to, I can work till two or three in the morning.”
Explanation: The patient focuses on the administrator’s actions and her working conditions, while ignoring her own problems of depression, anxiety, and drivenness.
SCORED 2 when, overall, the patient moderately notices that she has unpleasant emotional experiences observes that she has inhibitions, sees that what she says or does leads to adverse consequences, or recognizes particular emotional or character symptoms.
Example: The session continues. The therapist asks “Don’t you yourself determine the number of programs offered?” The patient replies “I guess so. But I have to make every connection with employers possible, because there’s so little work out there for the students. It’s true . . . I’m not controlling myself . . . I’ll have to cut down the programs and try not to be so upset about it.”
Explanation: The patient responds to the therapist’s clarification by recognizing, to a moderate degree, that she is having problems in controlling the volume of her work and is becoming unduly distressed by it. Her description has moderate emotional involvement and conviction in her perception of problems, and moderate directness and complexity.
SCORED 4 when, overall, the patient strongly notices that she has unpleasant emotional experiences, observes that she has inhibitions, sees that what she says or does leads to adverse consequences, or recognized particular emotional symptoms, including character symptoms.
Example: During a session a few months later, the patient says “I don’t keep up being organized, and I can’t go on like this, because I’m wasting too much time looking for papers. I’ve been working on my study at home, and filled up fifteen boxes of stuff to throw out . . . My mother took care of her house meticulously and paid all her bills immediately. I can’t be like her – I feel miserable . . . Yesterday I avoided my paper work, and then when I got going on it, I couldn’t stop to eat dinner.”
Explanation: The patient acknowledges very uncomfortable feelings about her financial records and strongly sees that her lack of organization is a problem. She notices she has problems with compulsively avoiding work and compulsively getting lost in it. Her expressions have strong conviction and complexity, and include childhood memories of her mother’s contrasting meticulousness.
Rate the degree that the patient refers to meaningful childhood or adolescent experiences, which may be connected to more recent ones, including perceptions of the therapist. The patient may be unaware of the linkage or significance of the experiences.
Case: A Woman Intensely Competitive with Her Brother
SCORED 0 when there is no reference to emotionally significant childhood or adolescent experiences.
Example: A woman salesperson entered analysis because of depression and obsessiveness. Her parents have always doted on her older brother, John, and she begins a session by saying “I’m feeling depressed today . . . Maybe its because my mother asked me to come to see my brother, who’ll be at home for the weekend, but I may not go.”
Explanation: The patient describes experiences without referring to development.
SCORED 2 when the patient refers moderately to meaningful childhood and adolescent experiences, which may be connected to more recent experiences, including perceptions of the therapist. The patient may be unaware of the linkage or significance of the experiences.
Example: The session continues. The patient has just finished a project at work for which she received little recognition from her supervisor. She remarks “I don’t know why I’m feeling so bad . . . Ellen [the supervisor] didn’t say anything about my work. Bill [a co-worker] is always flattering her, and telling her personal things . . . I don’t know if I’ll see John on Saturday . . . We were always together as children because my mother was always in bed. He was ahead of me in school and got good grades, which made me feel stupid.”
Explanation: The patient mentions her childhood rivalry with her brother and makes an implied connection to her current co-worker rival. Her communication has moderate emotional involvement and a reasonable degree of complexity and detail.
SCORED 4 when the patient refers strongly to emotionally meaningful childhood and adolescent experiences, which are often connected to more recent experiences, including perceptions of the therapist.
Example: The patient continues: “I had a horrible dream last night in which I killed Richard [a former boyfriend] with a knife through his eye . . . It was reassuring to live with Richard because he reminded me of home . . . My brother and I shared the same room for six years. He wrestled in the schoolyard one day, and hit his head against a concrete wall and didn’t recognize anyone for the rest of the day. I prayed and prayed that he would be all right, and I never got angry at him after that.”
Explanation: The patient remembers sharing a room with her brother. Murderous impulses towards her former boyfriend, expressed in her dream, are implicitly connected with her brother and her current rival. She vividly recalls her the accident and her reaction formation following it. Her statements are highly emotionally engaged, direct, and detailed.
Self-esteem is a feeling or attitude of self-worth, which is generated and constrained by many factors. Conscience activity is a most important regulator of self-esteem through its functions of praising and rewarding, or criticizing and punishing. Self-esteem experiences vary widely. Although self-worth is the most inclusive term for self-esteem, there are roughly four overlapping categories of feelings of self-esteem, each having a spectrum between high and low ends. These overlapping affects are: (1) feelings of pride, including feelings of being superior, heroic, or entitled (as opposed to feeling shamed, inferior, or humiliated, which represent the low self-esteem side of the spectrum); (2) feelings of being virtuous, truthful, or honest (as opposed to corrupt, guilty, or deceitful); (3) feelings of being lovable, personally valuable, or cared for (as opposed to loathsome, insignificant, or scorned); and (4) feelings of being effective; that is, capable, powerful, dominant, in control (as opposed to insufficient, ill-equipped, submissive, or lacking in self-control). A person’s self-esteem experiences may lie within a baseline band of feelings found in ordinary people at usual times, or may be increased or decreased. Expressions of increased and decreased self-esteem are scored similarly, by their deviation from an ordinary baseline. Because self-esteem issues may be felt and implied, they should be scored when they are reasonably apparent to the rater, and would be reasonably apparent to most therapists. Whenever possible, infer the patient’s self–esteem from the context presented. For instance, infer that a man who is feeling shame and is hiding his sexual interest in a woman who attracts him is expressing lowered self-esteem, as well as a woman who is irrationally predicting failure and seems to be feeling insufficient. Be careful to notice the component of lowered self-esteem when a patient has depressed feelings or feels he has transgressed.
Case: A Haughty Woman
SCORED 0 when no issues of self-esteem are conveyed in the segment.
Example: A married woman entered analysis because of an unhappy romance with another man. She is flamboyant, self-centered, and imperious; and yet her capacities have developed very considerably during the period of treatment. The patient starts her session twenty minutes late and seems enraged: “I have been furious since yesterday! I wanted to reach Stan [her lover] and he was away.”
Explanation: No self-esteem issues can be reasonably inferred from the segment. The patient’s frustration and anger might conceivably indicate that she is feeling humiliated, but this is insufficiently apparent from her communication.
SCORED 2 when the patient’s expressions are moderately increased or decreased from an ordinary baseline of self-esteem, or moderately contribute to an understanding of the patient’s self-esteem or self-esteem development.
An example of decreased self-esteem rated 2: The session continues: “He’s not calling because I don’t mean enough to him. He was probably out with his pretty secretary Amy, she’s always flirting with him.”
Explanation: The patient is feeling insufficiently desirable to a moderate degree. Her remarks add somewhat to an understanding of her negative concerns about her attractiveness. There is moderate emotional involvement and directness.
An example of increased self-esteem rated 2: As the session continues, the patient switches to an elevated mood: “When I’m feeling bad, I need to speak to you. I called you at eight this morning and I didn’t hear from you by the time I left at nine. When I call you, I expect to hear back from you promptly!”
Explanation: The patient expresses moderately elevated self-esteem by speaking in an entitled and demeaning way to the therapist. Her remarks somewhat enhance an understanding that she defends against feeling inadequate by assuming a hostile superior air while devaluing others. There is strong emotional engagement, and a reasonable degree of directness and complexity. SCORED 4 when the patient’s expressions are strongly increased or decreased from an ordinary baseline of self-esteem, or strongly contribute to an understanding of the patient’s self-esteem or self-esteem development.
An example of decreased self-esteem rated 4: The therapist remarks “Because you feel so hurt by Stanley, you’re talking to me in a haughty and demeaning manner.” The patient becomes depressed again and bursts into tears: “Why should he want to see me? I can’t do anything. All I’ve known is how to interest men. You say that I can learn what I missed in school, but believe me I’ve never been able to learn anything. I’ll never be able to do any kind of serious work.”
Explanation: The patient shifts to strong underlying feelings of inferiority and humiliation. Her statements strongly express her profound but currently erroneous sense of having insufficient abilities. Emotional involvement, directness, and complexity are all strong.
An example of increased self-esteem rated 4: The session continues with the therapist saying “Your capacities have developed steadily over the past few years, but you feel too guilty about advancing beyond your mother to acknowledge that.” The patient becomes elated again: “You’re wrong! I’m going to walk out of here right now! . . . Why should I even bother talking to you? You have nothing to say to me. You can’t make me stay! You’re a weakling like my father and my husband! My father went out with his friends to play golf, and never cared about me. My husband is never home either, he’s always out working.”
Explanation: The patient speaks to the therapist in a highly grandiose and belittling manner. Her statements strongly link the defensively elevated self-esteem in her transference with childhood memories of disappointment with her father and feelings of rejection by her husband. There is considerable emotional engagement, directness, and complexity.
Score according to the degree that the response seems psychologically attuned to the therapist’s focus, potentially useful to the patient or progress in the treatment, and emotionally deep. Some common types of responses which seem consonant with the therapist’s focus and useful to the patient or her progress are: comprehension of the communication, development of related affects, integration with previously-known material, and elaboration of new related associations. They also include what can be called productive negation, when the patient disagrees with the therapist’s remarks in a way that may promote therapeutic progress, or productive selection where the patient ignores the therapist’s remarks which seem misleading, and finds something useful to respond to.
Case: A Self-Defeating Designer
SCORED 0 when the patient’s response does not seem psychologically attuned to the therapist’s communication or, if attuned, not at all potentially useful.
Example: An artistically gifted young woman often ignores impending mistreatment by others, and actually courts it. While she worked on a home design for an egotistical man, she ignored his abusive attitudes, as he picked her brain for her ideas and dismissed her. The patient begins: “I’m drawing up a bill for the thirty hours of work. I’ll call Alan [the client] to explain all the charges. It’s hard for me to talk to him, he always thinks he’s right.” The therapist intervenes: “That’s like asking the fox to guard the chickens! What leads you to want to call him in advance of sending the bill?” The patient responds “I told him I’d discuss the bill with him, so I have to do it . . . I think I’ll get him to pay and then I won’t give him my sketches. He won’t walk away from this so easily.”
Explanation: The patient shows no increased awareness that she is inviting trouble. Instead, she ignores the communication and reacts to the client’s exploitation with poorly directed anger and a fantasy of revenge.
SCORED 2 when the patient’s response to the therapist seems moderately psychologically attuned to the therapist’s focus, potentially emotionally useful to the patient or progress in the analysis, and at least mildly deep.
Example: The designer continues: “He pushes everyone around. It’s about time that someone taught him a lesson. He’s got poor taste, and he’ll end up with something very ugly. Anyway, he can’t start without the plans.” The therapist intervenes: “You are considering a ’revenge theory’ of doing business. Although you are aware of feeling angry at your client for discharging you, you minimize how particularly angry you feel that he doesn’t admire your work.” The patient responds “I’m just feeling upset . . . When I worked at the design firm last year, I felt that no one liked me. My parents said it was because I was better educated than they were, but I felt that I was different. And it bothered me that no one recognized that I was talented.”
Explanation: The therapist clarifies that the patient is specifically minimizing her anger at not being admired. The patient replies with a reasonably well-attuned, moderately useful and deep response in recalling her feelings of alienation and wanting to be admired. There is moderate emotional engagement, psychological directness, and complexity.
SCORED 4 when the response to the communication seems strongly psychologically attuned to the therapist’s focus, potentially very useful to the patient or progress in the analysis, and at least moderately deep.
Example: The designer continues the session: “I’ve been feeling more confidence at the modern dance group, but I’ve had difficulty learning the new number. Samantha [the director] said that anyone who takes so long to pick it up must be a bit dim . . . My mother used to smirk and say that I was stupid.” The therapist intervenes: “It’s been most difficult for you to recognize Samantha’s unkind and exploitative side, much as you ignored the signals coming from your recent design client.” The patient responds “In the last week, I’ve been thinking about how much people mistreat me, and I see that I feel that it’s inevitable that I’ll be treated badly. Some of it comes from how I handle things . . . I really got shook up yesterday – I found myself picturing Samantha in the hospital with cancer. Do I really want her dead? . . . I hardly ever get angry at my mother either . . . Maybe I’m angry at her too!”
Explanation: The therapist clarifies the patient’s avoidance of acknowledging the hurtfulness of the dance director and the design client. The patient responds by indicating that she understands that her expectations can elicit mistreatment. An important fantasy appears, expressing murderous impulses towards the director, followed by a dawning feeling that she may be hiding anger towards her mother as well. The response is strongly attuned to the communication, seems potentially very useful to the patient, and appears to be very deep.
This variable measures the psychotherapeutic value of the patient’s contribution during the segment, whether occurring in response to the therapist’s communication, or emerging from the patient’s independent momentum, or both. Score according to the degree to which there is a sense of forward movement during the segment in the depth or breadth of the patient’s or rater’s emotional understanding, in the intensity of the patient’s involvement and collaboration with the therapist, or in the quality of other emotional expressions. The score also increases as there is more psychological directness or complexity and detail. By improved understanding we mean better comprehension of any of the patient’s psychological features, such as conflicts, fantasies, identifications, or self esteem. Advances in emotional involvement and collaboration with the therapist include more emotional engagement, more reflection about the therapist or analysis, or more useful attention to the therapist’s focus. Improvements in other emotional expressions consist of a wide variety of psychological features, such as better control of impulses, awareness of affects, shifts in defenses, or relief of inhibitions (for example, under-assertiveness), symptoms, or character symptoms (for example, antagonism).
Case: The Businessman Afraid of His Father
SCORED 0 when there is no evidence of therapeutic gain in emotional understanding by the patient, nor improved involvement and collaboration with the therapist, nor gain in the quality of other emotional expressions. (However, if the material is informative to the rater, then a zero score would not be warranted, because the expressions of the patient could be turned to productive ends if the therapist understood and responded well to the communication.)
Example: A man is undertaking analysis because his wife finds him removed and insensitive to her concerns, and has threatened to leave him. He works in a family business founded by his father, who thinks he is insufficiently capable of major responsibilities. The patient begins with an indifferent tone: “There’s really nothing new, so I’m going to tell you the usual things . . . It’s a month since the baby was born, and Sally [his wife] is nervous because the nurse will finish this week . . . [with more enthusiasm] The appliance line is selling pretty well, which is a surprise in this economy.”
Explanation: The patient begins by declaring his lack of emotional openness, and then goes on to ignore his current emotions and those of his wife. There are no dimensions of therapeutic progress.
SCORED 2 when the patient shows moderate therapeutic progress in the depth and breadth of the patient’s or rater’s emotional understanding, the patient’s involvement and collaboration with the therapist, or the quality of other momentary expressions, such as better awareness of affects or shifts in defenses, inhibitions, or symptoms.
Example: The patient continues: “I was driving a company van yesterday, and a truck backed right into me. He took off like a bat, but I drove after him and got his license number! Back at the factory my father acted as if it was all my fault. A lot of time I end up feeling that he thinks I’m an ineffective person, and that he’s the great efficient operator.”
Explanation: The patient shows moderate understanding of his feelings of rivalry with the fugitive truck driver and with his father, as is seen in his relish of the chase and reflections about his father’s criticisms and self-importance. Emotional engagement, collaboration, and self–reflectiveness advance moderately, and his remarks show a reasonable amount of complexity and detail.
SCORED 4 when the patient makes strong therapeutic progress during the segment in the depth and breadth of the patient’s or rater’s emotional understanding, or the patient’s involvement and collaboration with the therapist, or the quality of other emotional expressions.
Example: The businessman continues: “I feel that my father doesn’t really want me to do better in the business, but I can’t be sure that’s really happening. Maybe I’m making it all up because I’m stressed out by the accident.” The therapist comments “At moments with strong emotional charge, like this one with your father, you become vague and indecisive so as to obscure feelings which frighten you.” The patient responds “I can’t see that at all . . . I guess I do stay away from confrontations with people at work; I can see that. Going against my father or the other people can be big trouble, so it’s better to just go along . . . I don’t open my mouth much here with you either. You understand this stuff better than I ever could, and you could make me look like a real jerk in about two seconds.”
Explanation: The patient responds to the therapist’s interpretation with moderate understanding of his passivity and his fear of his father and co-workers. He then reveals his concerns about being humiliated by the therapist. Although he has only moderate understanding of these experiences, he permits the rater to strongly comprehend the connections between the three sets of experiences with: his co-workers, his father and the therapist. Emotional involvement, collaboration, and self-reflectiveness have become strong, and there is much complexity and detail.
SCORED 0 When the therapist was evasive, defensive or actively worked to avoid expressing his or her own views. This can occur when the therapist actively muddies the water or misleads the patient in his or her response, but can also occur when the therapist is controllingly silent in response to a direct question from the patient. This variable would also be coded low when the therapist relies on what sounds like contrived interventions, perhaps based on theory that seems distant from the surface of the material and distant from what the patient can understand in the moment.
SCORED 2 When the therapist simply steers clear of the material that is offered, perhaps listening with what seemed like an evenly hovering attention, but without actively responding – including to a direct question when it is apparent that not responding allows the patient to reflect on his or her experience and to continue with his or her associations.
SCORED 4 When the therapist’s responses are direct, clear and transparent. A session that would rate highly on this scale would include interventions on the part of the therapist that feel genuine. The therapist would likely use evidence to support his or her interpretations. When the therapist failed to be empathic or made an error in understanding, the therapist acknowledged that the patient felt misunderstood, and would likely have actively worked to clarify the nature of the misunderstanding. In sum, the therapist took the occasion of communications from the patient to articulate information or points of view that conveyed clearly to the patient the therapist’s point of view.
SCORED 0 When the therapist is cold, remote or rejecting. Tone of voice is a central component in evaluating this variable. If there is a sense of disdain in the voice of the therapist, the score is clearly a 0. When the tone is more of disinterest or perhaps something that sounds more like boredom, a score of 1 would be more appropriate. When there is clear avoidance of an opportunity for a more personal response, this point in the hour that would receive a score of 0 may outweigh other moments that feel warmer.
SCORED 2 When the therapist is more than emotionally negative or neutral and the warmth of the therapist is tangential or must be inferred. The therapist’s responsiveness may be reflected indirectly or directly. An indirect response might by indicated by a supportive remark or even a story which conveys to the patient that the therapist appreciates what his or her experience is like.
SCORED 4 When the therapist’s responsiveness is clearly friendly, welcoming and warm it is easy to score this variable highly, but it could also be that engaged, confrontational but respectful interventions might also be highly rated.
SCORED 0 When, as the rater listens to the material, shifts in the patient’s feeling states do not result in a response on the part of the therapist. When there are many or significant moments when this occurs and they seem to hang in the air – there is an awkward feeling that the patient is alone with his or her emotional experience – a score of 0 is appropriate.
SCORED 2 When the therapist makes statements that reflect broader affective trends in the material. This may occur even though the therapist is not tracking changes on a moment to moment basis. The therapist’s statements should seem to be adequate and appropriate identifications of the major affects discussed or displayed. In so far as the summary statements are inadequate or distortions, the score would be lower (1 or even 0), but particularly apt summaries that captured the affective tone of the segment could be rated higher (3 or even 4).
SCORED 4 When the therapist is evidently responsive to subtle or immediate feeling shifts in the session, and expresses this by the remarks he or she makes (which need not have been very explicit or extended for a higher score on this variable). It is even possible that a therapist could express this vocally but non-verbally by giving an empathic grunt or coo in response to a particular emotional experience. More likely there is going to be a responsive calling of the patient’s attention to their affective state, perhaps noting a behavioral manifestation of it, like a tear, that is offered in a timely and sympathetic manner.
This item is intended to measure in a very broad way, the ability of the therapist to reasonably serve the patient as a platform on which to construct a psychological model of the therapist. This could be based on the therapist being very clear about the rationale for an intervention from a technical perspective or it could be a more personal revelation on the part of the therapist – even a straightforward self disclosure. But the intent of this item is to evaluate the presence of the therapist as a person, one with thoughts, emotions, and an inner life.
SCORED 0 When the therapist’s voice has a monotonal quality. Or if the emotional range of the analytic responses is extremely limited it is likely that a 0 score would be appropriate. But this variable is also intended to capture the content of the therapist’s responses. So, if the therapist avoided any comments which reflect her\his own subjective response to the material, even if challenged or encouraged by the patient, such a score would be warranted, even if there is some animation in the voice of the therapist. Alternately, a higher score may be warranted if the content is revealing of the psychological functioning of the therapist even if his or her tone is remote.
SCORED 2 When elements of subjectivity were evidenced by the therapist, but they were kept under strict control. An therapist might, for instance, have offered a metaphor, but not have elaborated on the ways that it could be applied or developed. A brief story or vignette would also be an example of a two-level response, as would an observation about the patient coming from the therapist’s perspective (e.g. I noticed that you look a bit mussed today). When the therapist is sharing their subjective experience, this should be rated regardless of whether doing so deepens the therapeutic dialogue or derails it.
SCORED 4 When personal, emotional and/or judgmental statements are made by the therapist. To achieve a rating of four, emotional investment on the part of the therapist will likely be evident in the tone of voice of the therapist and, in general, greater emotional tone will accompany higher ratings on this variable. The content of the statements from the therapist will also tend to be more extensive elaborations of their subjective experience – perhaps telling a detailed story or fleshing out a metaphor or enlivening an interpretation with details that seem to flow more from the therapist’s experience than from the material in this particular hour or in reference to earlier material the patient has produced. Again, this should be scored highly regardless of the impact on the quality of the therapeutic dialogue.
SCORED 0 When the therapist’s comments remain near the surface of material that the patient provides that does not appear to be central to his or her central dilemmas. This might occur when a patient is breezily reporting on his or her day and the therapist comments or questions – perhaps technically looking to clarify – but in a way that does not seem to deepen the therapeutic moment. This might also be scored if the therapist seems to defensively move the patient away from cental or disturbing experiences, perhaps by responding defensively to an accusation by the patient.
SCORED 2 It the therapist’s focus is on the material that the patient has brought to the hour, seems to deepen the work that the patient is doing, but the work seems somewhat tangential to the central issues or concerns of the patient. A score of three might be warranted it the therapist tries to steer the patient in the direction of more central concerns, but the patient’s resistance interferes with the therapist’s best efforts. A score of two, or even one would be warranted if the therapist’s focus while well aimed seems to lack clarity or be somewhat diffuse, or lacks lively expressiveness sufficient to engage the patient, or is insufficiently concrete to bring the issue into emotional focus. In this case, the therapist seems well intentioned but might be experienced as awkward by the patient.
SCORED 4 When the therapist clearly and articulately ties the material in the current session to the central concerns of the patient. This might occur when the patient is talking already about his or her central concerns and the therapist closely follows the patient’s good work, but it will be particularly striking when the therapist interprets the ways in which apparently tangential material is related to central concerns in ways that the patient can hear and resonate with.
SCORED 0 when there is little evidence of interplay. The patient may be so intensely preoccupied with external events or issues, or with reactions to the therapist, that there is no evidence of a process of interplay. The session could be emotionally intense – the patient may be convinced that this is what happened and there is no other way to think about it – or it could be almost devoid of emotion – a stale, lifeless enumeration of events that leads the rater to find his or her mind wandering. On the other hand, the patient may be so conceptually bound, perhaps elaborating on a theory about his or her psychological functioning, that there is little or no discussion of concrete, day to day material – whether about the facts of the day or about elements or evidence of fantasy, or perhaps a dream or a daydream.
SCORED 2 When the session is predominated by one mode or the other (concrete or conceptual) but there is some interplay and movement between the two realms, but the shift between them seems forced – or may occur primarily in response to the therapist’s offering a bridge rather than spontaneously.
SCORED 4 When the patient seems to move effortlessly between being immersed in associations and/or the current experience in the room with the therapist and reflecting on that. The feel of a session that would be rated 4 on this dimension is one in which the patient’s associations seem to call naturally for, and recieve, reflection – making sense of them – and these insights, in turn, fuel further associations that enrich and deepen the hour. The patient in this type of hour is deeply engaged in self analysis and the therapist might be a catalyst rather than the engine for the forward movement of the session. The therapist might be seen as following rather than leading the patient in an hour with a rating of 4.
SCORED 0 When a dream is mentioned, but it is not integrated into the rest of the hour or when it is dealt with as an entity unrelated to the waking life of the patient. This might occur when there is some work done to understand the internal workings of the dream, to clarify the plot and to understand it as a psychological event, but without tying it to the particular conscious functioning of the patient. It might also be that the dream is experienced as an alien occurrence – one that has little sense or meaning or, in so far as it does, is unrelated to the current experience of the patient.
SCORED 2 When the patient and therapist move back and forth between the dream and waking life but do so in a somewhat perfunctory way, perhaps relating elements in the dream to particular aspects of day residue. Here there might be a sense that the dream is pregnant with untapped possibility – that the therapist and patient sense there is more here than they are able to plumb, but it may also be that the dream, while addressed, is discarded or fails to take a central role in the hour, instead being an interesting but not deeply illuminating experience.
SCORED 4 When the interpretation of the dream takes center stage in the hour and it is clearly tied to the conscious, waking functioning of the patient. To achieve this rating, it is also important that there is a relatively easy transition from discussing the dream per se to recognizing the ways in which it is related to the broader psychological functioning of the patient. Leave blank when a dream is not referred to in the session or there is no content about it.
This item is a rating of the patient’s contribution. The therapist’s contribution to the same task is rated above already.
SCORED 0 when the patient does not seem to be focusing at all on central feelings giving difficulty in life. The patient may relate current events in a way that seems rote or devoid of meaning. The patient may also talk enthusiastically about a topic that is either in a relatively conflict free sphere or that seems tangential to the work of the analysis.
SCORED 2 If there is some focus, but either the focus does not seem aimed at the more prominent features discernible in the patient’s expressions, or the focus seems to lack clarity or be somewhat diffuse, or lacks vividness, or is at a level of abstraction that interferes with bringing the issue into emotional focus.
SCORED 4 When the patient addresses central issues and concerns in a compelling, productive manner. For the rating to be high there must be a sense of emotional immediacy in the room.
DIS Specific Interaction Variables
The experience includes those aspects which may be outside of conscious awareness, such as the therapist telling a story or a joke which is in tune with the patient’s state at the time.
SCORED 0 If there is strong evidence that the patient experiences the therapist as failing to understand him or her, feels put off or criticized etc. This is easiest to rate if the patient states this directly – perhaps complaining about the therapist’s failure to understand him or her. It is more difficult to rate if the rater experiences a lack of empathy. In this case, the rater should review critically the hour and determine if there is evidence that the patient experiences a lack of empathy. This may not be overt, but should observable.
SCORED 2 If there is a more ordinary level of harmony and sense of being understood. In this case, the patient appears to feel trusting that what he or she says will be reasonably well understood. If the patient brings forward difficult or potentially uncomfortable material and seems reasonably OK or even relieved by the therapists ability to respond to it, a rating of at least three is likely appropriate.
SCORED 4 If the patient appears to feel particularly well understood by the therapist. Generally there will be direct evidence of this, though it may not be dramatic. If the rater experiences the therapist as particularly empathic, he or she should review the hour for evidence that the patient does so as well. This does not necessarily need to be direct evidence, but caution should be used in scoring 4 when there is no direct comment by the patient about the quality of the therapist’s listening.
Differing from the previous item, the rater assesses the aptness of the therapist’s contribution in regard to feelings. The patient need not demonstrate an awareness of benefit, in fact the patient might not be aware of a finely tuned response or set of responses from the therapist. However, the item is considered an interactive value, because there must be evidence that the therapist’s efforts bear fruit in the patients response or further elaboration.
SCORED 0 if you believe the therapist is ignoring or leading the patient away from important feelings that could emerge in the therapy.
SCORED 2 if the therapist is muddling or middling along, for example in pursuing the meaning of some connection without a very good sense of the patient’s feelings.
SCORED 4 if the contribution seems highly skilled and sensitive to the patient’s feelings and of the patient’s readiness to become more aware of some aspects previously kept at more distance.
SCORED 0 If there is no or little indication of this kind of connection (by patient or therapist). This might occur in an hour where the focus is almost exclusively on events in the patient’s day to day life. It might also occur, though, in an hour where the therapeutic relationship is the focus of discussion, but it is not tied to the rest of the patient’s life. This could occur, for instance, when the patient is convinced that the therapist is failing him or her in some essential way, but does not see that this is thematically related to other essential failures that have occurred.
SCORED 2 If the patient and therapist note that what is occurring in other venues has occurred or is occurring in the therapeutic relationship. If this feels forced this might best be scored a 1, and similarly, if the observation is not developed beyond merely the therapist calling attention to it and perhaps sketching out the similarities, without the patient participating very much.
SCORED 4 If the therapist AND patient or the patient alone is able to richly and evocatively articulate the ways in which the therapeutic relationship has the flavor of and reflects important dynamics of other relationships in the patient’s life.
This item, like the previous one, addresses the total therapeutic milieu. However, its focus is upon engagement, which may be expressed also as enactment, whereas the previous item is more specifically an assessment of the approach to feeling.
SCORED 0 If the relationship seems mostly to lack the vitality of an engaged relationship.
SCORED 2 If there is significant engagement experienced by the rater, but it is not one that is explicitly expressed or demonstrated by the patient and/or therapist. This could be rated for a session in which there is a sense of a good working alliance that is not explicitly articulated, but also might be the rating for a session or series of sessions where the therapist and the patient appear to the rater to be engaged in an enactment, but this is not being discussed overtly between them or, if it is, is being discussed in a cursory or poorly formed manner. If the patient and therapist are beginning to become aware of an enactment, this might best be rated a three.
SCORED 4 If the patient and therapist are, together, working on understanding the dynamics of a vivid, lively relationship that each seems deeply involved and invested in. This might be the work of trying to understand an enactment but it also might be the work of trying to articulate how the transference has blossomed within the analytic relationship.
APPENDIX: Further History of the PRC and Research Group The authors, all experienced psychoanalysts, met starting in 1989 to take up the challenge of characterizing the contributions of patient and psychoanalyst to the therapeutic work. Although a century of study by individual clinician-researchers working with relatively small groups of patients has yielded a large body of knowledge about emotional functioning and treatment techniques, the definition and description of the work still remains limited, general, impressionistic, and strongly contested. The increasingly varying therapeutic approaches usually report data in narratives shaped by their theoretical outlook, making comparisons between different methods or individual treatments exceedingly difficult. Our efforts soon led to a consensus that we had to base our work on shareable data from audio recorded psychoanalyses and develop a way to make quantitative analytic observations in combination with the more familiar clinical ones. In developing our rating scales we selected well defined features, observable at the clinical surface, and discarded aspects that were overly abstract, unclear, or could not be rated reliably. Audio recorded sessions can be repeatedly assessed by different research strategies and eventually can be coordinated with other real-time observations of the mind and brain being developed elsewhere in neuroscience. Our original hope was that the assessment of what we considered as central psychoanalytic, or psychodynamic, features would allow for the characterization of the psychodynamic aspects of most therapies. As evidence has accrued that the APS indeed is suitable for this purpose, we have now changed the term “analyst” and “analytic” to “therapist” and “therapeutic” in this coding manual, with the exception of some of these introductory paragraphs. We have retained the name “ANALYTIC Process Scales” to emphasize the connection of the variables measured to aspects of psychoanalytic theory, and for reasons of continuity as well. In our view, psychoanalytic and psychodynamic are functionally synonymous terms. Since most of our group were originally physicians, we use the customary term of “patient”; however, “client” is equally appropriate. It is our hope that therapists with diverse points of view will find the APS useful and apply it in a variety of contexts. We expect valuable data to continue to emerge from comparing different techniques and styles of psychoanalysis, comparing psychoanalysis and psychoanalytic psychotherapy, and analytic psychotherapy with other types of psychotherapy, such as interpersonal or cognitive-behavioral treatments (Waldron & Helm 2004).]