Freudian Treatment Schedules
Freud (1856-1939) was the founder of the modern psychotherapeutic interview. After abandoning hypnosis, he adopted a technique called ‘free association’. This was a technique in which he encouraged his clients to ‘talk’ with the minimum interruptions to their outpourings. Initially, they were helped to familiarise themselves with the technique and then encouraged to communicate thoughts, memories and feelings without censorship. This became known as the ‘Fundamental Rule’.
He listened to their verbalisations keenly and intuitively and as a result claimed to gain insights into the workings of the unconscious minds of his clients. He unearthed fragments of unconscious memories, heard his clients struggle to ‘repress’ and ‘resist’. With such a method of interviewing and its supposed concomitant insights into the mind of the human being, Freud made an inestimable impact on the psychological, anthropological and literary ideas of his time. His influence was profound and far reaching and is still very much with us today. Freud’s objective, then, was to employ a psychotherapeutic technique that would enable the client, with the analyst’s help, explore his/her conscious and unconscious personality to a degree that would eventually result in a
reconstruction of the personality. Such reconstruction, it was claimed, would bring personal growth. The world of medicine and psychiatry was slow to show any interest in Freud’s innovations but eventually a few psychiatrists began to integrate Freudian insights into the framework of the standard psychiatric interview.
THE INTERPERSONAL EMPHASIS OF SULLIVAN
Any discussion of the psychotherapeutic interview must recognise the contribution of Harry Stack Sullivan (1892-1949). Sullivan saw the interviewer as a ‘participant-observer’. He was not over impressed by data collected about the client from other sources. Unlike Freud he was a ‘face to face’ man. He was not in sympathy with Freud’s suggestion that the analyst should sit behind the client. He recommended that the therapist should sit at a 45 or 90 degree angle to the client. Such an arrangement, he argued, freed the client from the discomfort of being stared at. For Sullivan, the therapist is an active participant in the therapeutic process. The therapist observes the client but while observing is affecting the relationship in which he/she is an active participant. The interview is a communication between two people. Sullivan is not just concerned with what is said but also how it is said. The client’s expressive behaviour is a rich source of information for the therapist but Sullivan points out that the therapist’s behaviour in the relationship will also have an effect on the data received from the client.
The therapist must be alert at all times to register subtle behavioural changes in the client’s communications. Sullivan believed that the therapist is the expert in interpersonal relations and should be the instrument whereby the client makes his/her interpersonal relations more effective. The therapist is another human experience for the client although it is true the setting is a professional one.
In order for the therapist to be an alert, effective observer, he/she must be an alert self-observer. Since the therapist is a human being too, he/she is subject to the normal range of human emotions such as boredom, frustration, anger, love, etc. The therapist must be aware of these reactions and ensure they do not interfere with effective observation of the client. Sullivan, then, saw himself as an active participant in the interpersonal encounter with the client. This participation was far greater than Freud’s although it should be acknowledged that Freud had already taken decisive steps in this direction. He had always considered himself an important diagnostic instrument (as witness the phenomena of transference, countertransference, resistance, abreaction). Sullivan divided the interview into four stages or parts; the inception, the reconnaissance, the detailed enquiry, and the termination.
The Inception
The client describes his/her problem(s). The therapist listens and assumes the rôle of observer. The therapist’s task is to discover the reasons for the client’s entry into therapy and to gain some understanding of the nature of the problem.
The Reconnaissance
In the reconnaissance stage of the interview, the therapist gathers facts. The gathering of facts develops into a case history. It is from this case history that the therapist makes his/her tentative hypotheses. The therapist, having gained a background to the problem, presents the client with a summary of his/her conclusions. Much of this information will have been gathered by the therapist questioning the client. In the event of the client having difficulties responding directly to the question, Sullivan would encourage free association. “You seem to be a little stuck with that question? Just let your mind roam freely when I repeat it.” Sullivan, however, was never an advocate of free association as the main therapeutic technique. He thought it should be used judiciously and its products
examined in the setting of dialogue.
The Detailed Enquiry
In the detailed enquiry, the therapist focuses sharply on the client’s interpersonal difficulties. Symptomatic behaviours are scrutinized and explored such as anxiety, depression, distorted thinking, etc. The therapist seeks to test his/her initial, tentative hypotheses.
The Termination
It is at this stage that the therapist sums up. He/she discusses findings and proposes a plan of action which also explains the possible consequences of any action undertaken. Sullivan strongly believed that every therapeutic session should conclude in a structured way and not be left with loose ends. The therapist should leave the client with some insight, or a clarification of an issue, at the end of every session throughout the course of therapy. The Sullivanian approach is more open than the Freudian. The Sullivanian client is more involved in his/her therapy from the outset. The client is made aware of the therapist’s discoveries and both long and short term goals. It is generally a more carefully planned process than psychoanalysis and not as instructional.
