In asking the questions that form the core of his response to this major phase of Harold's treatment, Henry Stein highlights the differences between his view of psychotherapy as illuminated by the work of Adler, and the system of therapy I have developed over the past 30 years and adjusted from the work of Tomkins in the past 10. The contrasts between us are visible in every sentence of his post, and our differences in attitude and approach so great that I doubt my ability to answer each of his comments in less than a chapter-sized post. Most startling among Henry's assumptions are his conviction that Harold had a tendency to punish women, and that his paralysis between the system of nurturance found in his family of origin and that provided by Meg was a symptom of his wish to hurt both. This is an easy analysis that conforms to the type of thinking common in our field at the other end of the century when the only sources of motivation were the drives Freud called "libido" and "aggression," but one I must view as astonishingly primitive in this era when we know so much more about human emotion. Even his view of depression as "self- punishment" is astonishing in an era I had thought more sophisticated about shame—to consider depression as "anger turned inward" in a period that recognizes anger at the self as an adult manifestation of shame affect disavows generations of progress in our field.
I'm glad that he "admires" my "patience, tenacity, and consistent support of Harold for five years," but am quite aware that within the world of psychotherapy, these are euphemisms for ways we therapists provide fairly minimal services to hold someone together rather than evoke profound change. I presented Harold as a successful professional whose limitations could be traced to his inability to handle more than certain levels of affective intensity, and tried to make clear that this inability derived from deeply ingrained characterological factors. Over the years, I've developed some expertise with every system of therapy that's passed through town, and I used every one of them in my attempts to help Harold break out of his apparent impasse.
Harold's therapy took so long because some of the factors responsible for his inability to tolerate affect at the higher end of its range were connected to his wish to preserve the best part of his relationship with both parents. The actual moment at which I chose to break the logjam with this particular stick of dynamite was the first in which I believed him ready to live within the new system represented by his relationship with Meg. Anybody who has dealt with obsessional adults knows their near-inability to rank-order or prioritize the factors involved in a major decision; in this group of patients it is common to find that they manipulate those around them to force resolution of such issues by external action rather than take personal responsibility. All I did in this particular instance was to produce an amount of affect in him that tipped the scales toward what he so clearly wanted to do; I acted in a manner egosyntonic with his own psychological system by pretending to be the kind of external force that normally resolves such matters for the severely obsessional individual. I see the tendency toward Obsessive-Compulsive Personality Disorder (DSM-IV) as more biological (firmware) than psychological (software), and the core limitations it produces only poorly responsive to psychotherapy of any kind or to psychopharmacology. (The more severe illness called Obsessive Compulsive Disorder (DSM-IV) does seem to improve with medication that increases the amount of serotonin available at certain interneuronal clefts, but Harold was not helped by such drugs.) The image of the 3x5 card remains useful in their relationship because obsessional people remain obsessional people all their lives, despite how much they gain from treatment and how much they change in a good marriage. Meg pulls out the image of the card whenever Harold gets too stuck in the old way and needs a reminder that he is under the control of the obsessional mechanism that can only be broken when he agrees to pay attention to affect! Can it be that there are still therapists practicing in our community who do not recognize that some stable characterological formations are based in neurobiology rather than early childhood trauma?
It would be unfair to the readers of BOL for me to attempt a comparison between the script theory advanced by Tomkins and the concept of fictional goal introduced by Adler and adduced by Henry Stein. At base, they are quite similar in that both take for granted that entire structures are built in the mind, structures that contain images of future and past, structures that carve the future as much as they limit it. Within affect/script theory, such scripts are understood as part of the ways we learn to group our past affective experiences in terms of similarities of stimulus- affect-response sequences, and treatment is based on our understanding of the group of such scripts described by Tomkins in volume 3 of "Affect Imagery Consciousness."
Vick Kelly has already mentioned our understanding of Socratic questioning as a system through which the one being questioned is placed in the position of a student, an inferior. At all times I want therapy to be conducted by equals, by peers, and any vestige of the assymetric power relationships common to earlier systems of therapy is unacceptable to me. When the therapist acts like a lawyer and places the patient on the stand, the difference in power is awesome; the affect associated with such therapist behavior must include great shame on the part of the patient. I believe that to be a patient produces a great deal of shame, that we must work hard to identify shame wherever it appears, and that we must to do little that produces unnecessary amounts of shame within therapy. I am, of course, mindful of the famous statement of E. James Anthony, to the effect that uncovering psychotherapy is an arena of shame, and that each secret uncovered must be accompanied by shame that must be worked through within the therapeutic relationship; there is no way a patient in therapy can avoid some amount of shame. But techniques that are at core shaming are unacceptable in our world.
Henry, you ask to gain deeper insight into my work. In the past decade I've published more than 3,000 pages of written and edited material, all of which is available to you. Read my 1992 book "Shame and Pride: Affect, Sex, and the Birth of the Self" to get an idea where I stand on the nature of human personality. Read my 1996 edited book "Knowing Feeling: Affect, Script, and Psychotherapy," in which a large group of colleagues use these theories in their therapeutic work. Read within that latter book Vick Kelly's superb chapter on "Affect and Intimacy" that has forever changed couples therapy and provided an entirely new way of understanding community. I've read a lot of Adler. It is time for you to read Nathanson.