108. Осознаваемые и неосознаваемые факторы в психотерапии. Дж. Mapмор (108. Conscious and Unconscious Factors in Psychotherapy. Judd Marmor)

University of Southern California, Schoo! of Medicine, Los Angeles, California, USA

It is the purpose of this communication to assay the relative importance of conscious and unconscious factors in the psychotherapeutic process. Before proceeding, however, it may be important to clarify what I mean by the term unconscious. Confusion has arisen in the use of this term because it is often referred to as "the unconscious", as if it encompasses a special area of the mind. Although such reification of the term may be justified metaphorically, it bears no relationship to concepts of brain function that have evolved in recent years. In contemporary neurophysiology the brain is now conceived of as a spontaneously active, complicated computer-like organ, which processes and monitors information from within and without the organism. On the basis of this processing it then transmits signals that activate or inactivate various organ-systems or behavior-systems. By far the greatest part of this operation of input appraisal, feedback, and output, goes on outside of awareness, although under particular circumstances it is possible to focus attention on one or another aspect of it.

There are also times when we become aware of the existence of these covert processes by the unexpected emergence of an incomplete or apparently inappropriate bit of behavior, whether in action, word, thought, or feeling. What Freud referred to as the "psychopathology of everyday life" - slips of the tongue, certain types of "accidents", "irrelevant" thoughts, or sudden "in-explicable" feelings - are manifestations of these hidden central nervous system processes. Thus, when we say that a wish, attitude, or feeling is unconscious, we mean that a behavioral system or integrate of systems having certain set goals is active within the central nervous system, but the person is not aware of the fact. Although such activity constantly occurs, it is particularly apt to be stimulated by circumstances involving conflicting goals or sets of goals, so that one set of behavioral reactions becomes inhibited by the central monitoring system in the interests of avoiding anticipated pain or danger. The existence of the inhibited reaction can be inferred nevertheless by the presence of certain inappropriate sequences of behavior, speech, thought, or feeling. When these sequences become particularly unpleasant or ego-dystonic, we call them symptoms, and individuals experiencing them may be motivated to seek outside help.

Such hidden wishes, thoughts, or feelings can often be brought into awareness by hypnosis. In 1895 Freud introduced a far-reaching technical innovation when he discovered that the same objective of broadening the field of awareness could be achieved by getting individuals to say everything that "came into their minds" without censoring anything. This technique, which he called "free association", facilitated the emergence into awareness of incomplete or inappropriate sequences of thought or feeling from which hidden behavioral sets could be inferred.

Some years later Jung adapted Wundt's word-association test to demon, strate experimentally that whenever a response to a word stimulus was significantly retarded or otherwise unusual in character, it could be demonstrated that the word stimulus was associated in the subject's mind with what. Jung called a repressed "complex".

More decisive experimental work in this regard was done by Luria (1) in 1924-25. Pointing out that "the ideal for the psychological experimenter has become the possibility to reconstruct artificially the phenomenon under examination because only this enables one to keep it entirely under control", Luria suggested to deeply hypnotized subjects that they were involved in situations that created intense guilt and anxiety in them. When awakened, these subjects all manifested a complete post-hypnotic amnesia for the event (whether or not such amnesia had been suggested), and only a few signs "like a heavy feeling, and a general anxiousness" could be observed as indicators of the hidden traumatic situation that had been implanted, so to speak, in their central nervous systems.

Luria then went on to test the word-associations and the charted motor responses (pressing a bulb with the right hand) of his subjects and found that, in comparison with the pre-hypnotic control findings, their verbal responses to words connected with the buried event became distinctly retarded, while their motor responses were strongly increased. In addition, when he tested their free associational word-chains, he observed that the subjects reconstructed the suggested event in their chain-series quite unintentionally, "not knowing why that situation had come to mind, and not being able to explain its contents". Luria concluded that "a strong emotion is hidden here... removed from consciousness, though apparently still active" and that "the affective complex constructed by us, though not yet being conscious, creates an affective state and determines the flow of the free associative series".

Luria's work has since been confirmed and extended by others (2), particularly by Erickson (3). These findings all point to the inescapable conclusion that significant central nervous system processes, often associated with powerful emotional components can and do exist outside of awareness, and influence not only behavior but also the flow and direction of our thoughts.

With these brief introductory comments I now turn to the main body of my thesis. For the past 20 years a major area of my work and interest has been directed toward understanding the nature of the psychotherapeutic process. Beginning in 1957, working with Franz Alexander and a number of other colleagues, a five year study of the psychotherapeutic process was begun that involved meticulously observing and recording through a one-way mirror all aspects of the therapeutic transactions between several experienced therapists and their patients. One of our basic premises in undertaking this study was that no psychotherapist, or patient for that matter, was in a position himself to objectively describe what went on in his psychotherapeutic work because his own immersion in the process rendered such objectivity impossible. Only an outside observer could accomplish this. It had always previously been assumed that such outside observation would interfere with the process, but we found that after some initial self-consciousness on the part of both therapist and patient, therapy went on as usual. These initial studies involved psychoanalytically oriented psychotherapy, but in subsequent years I undertook on my own to observe in a similar manner a wide variety of other therapeutic techniques - behavioral therapies, transactional analysis, gestalt therapy, client-centered counseling and some directive therapies (5).

Out of these studies and observations a number of conclusions concerning the nature of the psychotherapeutic process gradually evolved. It became increasingly apparent that psychotherapy was a transactional learning process between patient and therapist rather than - as had traditionally been assumed - something that the therapist does to or for the patient. Even more impressive was the fact that in all instances, multiple factors could be observed to be playing a significant role in the process, and that in no instance could the therapeutic outcome ever be attributed to the operation of a single technical intervention, as enthusiastic proponents of particular techniques tend to believe. Every therapeutic process involved a number of interacting variables encompassing the patients' and therapists' personalities, their relationship to one another, mutual hopes, expectations, and values, and the influence of past as well as current events on their lives. An additional striking finding was the degree to which non-verbal elements entered into and influenced the therapeutic transaction. Facial reactions of the therapist to the patient's behavior or speech, a questioning glance, a look of approval, a barely perceptible frown or lift of the eyebrows, a faint nod of the head or shrug of the shoulders, a posture of involvement or detachment, all served as cues to patients whose "antennae" were obviously alerted to the slightest indications of approval or disapproval, interest or disinterest, from the therapist. Even for those therapists who practiced behind a couch, the tonal nuances of their mm-hmms, the patterns of their silences, or the sounds of their shifting movements acted as similar cues. It has been demonstrated experimentally (6) (7) (8) that such non-verbal signals can not only influence the direction and content of patients' communications, but also have an operant conditioning effect on thought and behavior, reinforcing what is perceived as approved and discouraging that which is perceived as disapproved.

Specifically, eight elements were observed that seemed to be common denominators in all forms of psychotherapy, although the emphasis and particular mixture of these elements varied with the use of different techniques (9). In almost all instances we begin with a patient whose unhappiness, maladjustment or discomfort motivate him to seek help. Through a variety of routes he eventually arrives at the office of a therapist who by virtue of his professional status or reputation is endowed by the patient with help-giving potential. Thus, in almost all instances the patient comes not only with some motivations for change, but also with the hope and expectation that help will be forthcoming from the therapist he consults. The patient also brings with him certain historically acquired attitudes toward authority figures that will influence the nature and quality of his reactions toward the therapist in the course of the therapy. These attitudes are for the most part outside of his awareness and constitute what psychoanalysts have designated as transference reactions. By the same token the therapist, too, has certain historically acquired attitudes, values, ambitions, and prejudices of which he may also be unaware, that influence some of his reactions to the patient. These constitute what analysts have called countertransference reactions.

Apart from these unconscious attitudes, a number of reality factors significantly influence the development of a good working alliance in the patient-therapist interaction. The real attributes of the therapist - the degree of his empathy, genuineness, professional competence, intelligence, emotional maturity, and personal style - are relevant and important factors in the therapeutic process. Contrary to what is often assumed, therapists are not neutral, interchangeable units in an objective process that takes place regardless of the nature of the participants. The personality and real attributes of the therapist are intrinsic to what subsequently happens in his therapeutic transactions with his patients. Equally important to the nature and quality of the patient-therapist relationship are the real attributes that the patient brings to it - his intelligence, social and vocational competence, the nature and severity of his disorder, his capacity for verbalization, and the like. These brief listings are only a sampling of the complex variables that play a role in the crucial matrix of the patient-therapist interaction. We must also recognize that both therapist and patient at any moment in time are immersed in a larger system, one that encompasses political and social factors, cultural mores, religious and aesthetic attitudes, as well as the daily press of ongoing events in their lives. These elements continually impinge on the therapeutic process and neither patient, therapist, nor the process itself are immune to the influence of these currents from the outer world.

Given this basic initial matrix of a - hopefully - good patient-therapist relationship, almost all therapies include an initial period during which the patient reveals the nature of his problem to the empathically listening therapist. Regardless of whether the therapist chooses to make any interpretive comments at this time, the patient generally obtains some relief of tension from the experience. Freud considered this to be a simple release phenomenon and called it "catharsis", but it is probably a more complex reaction in which the patient's hopes and expectations of receiving help also play a major role. Although the release of tension is consciously experienced, the patient is usually quite unaware of how or why this release has occurred. If questioned about it, however, many patients are able to verbalize their feelings of increased hope that help will now be forthcoming.

Coincidental with this initial session, or soon after, almost all psychotherapists begin to convey to the patient specific information about a variety of matters - how the therapy will work, what is expected of the patient, and some idea of some of the presumptive reasons for the patient's difficulties, such as excessive dependency, insufficient assertiveness, overconcern about the opinions of others, fears of failure, sexual conflicts, and the like. (I am excluding illnesses that are assumed to be of biochemical origin from the context of these remarks.) In the course of therapy these "interpretations" may be placed within a historical framework (i. е., relationship to parents or siblings, traumatic experiences, etc.) or they may be couched in ahistorical terms, on a here-and-now basis. In either event such communications constitute bits of cognitive information that offer some logical explanation for the patient's difficulties and point out the direction or directions which he should take in order to feel better. In effect, an effort is thus being made to reprogram maladaptive patterns of behavior within the patients's central nervous system. Although the actual reprogramming ultimately occurs at some physiological level outside of awareness, this process of cognitive learning, by definition involves a conscious awareness of what is being learned. Occasionally, but not as often as we would like, such insights provide what Karl Buhler referred to as an "ah-hah" experience, a variety of sudden gestalt learning that enables the patient to generalize the knowledge obtained and apply it rapidly to many other aspects of his life.

On the other hand, there is another kind of learning that goes on in all psychotherapies that is largely unconscious, and that is the learning that takes place essentially through operant conditioning. All therapists, regardless of the technique employed, sooner or later begin to convey to their patients certain "desirable" therapeutic objectives and sets of value as well as indicating what is less desirable. Some therapeutic schools insist that this does not occur with their techniques because, they claim, they adopt a strictly neutral and value-free attitude with their patients. Laudable although such an objective may be, it is pragmatically impossible of achievement. Simply by virtue of the questions asked, of what the therapist chooses to focus on or ignore, and of what he considers to be "neurotic" (and therefore in need of changing) or "healthy" (and therefore not in need of changing) every therapist, wittingly, or unwittingly, conveys his values to the patient. In so doing, various aspects of the patient's behavior begin to be designated as desirable or undesirable and the responses of approval or disapproval received by the patient from the therapist in the course of therapy become an operant-conditionig system subtly shaping his behavior in the desired direction. As I have previously indicated, these therapist responses need not necessarily be verbal and overt. They often take place non-verbally and covertly, but are nonetheless effective - indeed, perhaps even more effective under such circumstances.

Another therapeutic element that occurs is what Franz Alexander called the "corrective emotional experience". This refers to the process in which the therapist consistently responds to the patient's behavior in ways that are different (i. е., more rational, more objective, more tolerant and understanding) from that of the significant past authority figures who have raised the pa0tient and shaped his personality. These differences in the therapist's responses provide another form of operant conditioning by virtue of which the patient is able to alter previously distorted perceptions. This, as well as the more usual type of operant conditioning, takes place outside of the patient's awareness and is a major unconscious element in all therapeutic procedures.

Still another variety of learning that occurs to a greater or lesser degree in all psychotherapies is what Miller and Dollard (10) have labeled as "social learning" and psychoanalysts call identification. It is striking to observe how over the course of time in therapy, most patients tend unconsciously to pattern themselves in various ways, attitudinally or behaviorally, after the therapist. In the context of a basically good patient-therapist relationship, the therapist inevitably becomes a model with whom the patient unwittingly tends to identify. Most or all of this takes place without the patient being aware of it.

Another common denominator in all forms of psychotherapy is suggestion or persuasion. In directive techniques, this occurs overtly and intentionally; in non-directive ones, it is usually covert and even unintentional; but it is always present to some degree or other. The implicit or explicit communication that the technique will be helpful if the patient cooperates with it, as well as the various indications he receives throughout therapy that certain forms of behavior are more desirable or healthy than others, all involve elements of persuasion and suggestion. Where the suggestion and persuasion are explicit the patient, of course, is aware of it and at least part of his response to it is at the level of consciousness. Where, however, these therapeutic factors operate covertly or implicitly, the patient is usually quite unaware of them and of the fact that he is being influenced by them.

All therapies involve some degree of testing of the new and unaccustomed modes of adaptation that are being learned. In behavioral therapies such tryouts are usually explicit and the process is called rehearsal. In gestalt therapies, too, there is often explicit rehearsal of assertive techniques and of various abreactive phenomena. In the non-directive dynamic psychotherapies and Rogerian counseling, the rehearsal may or may not be explicitly urged but it is always encouraged through various forms of implicit persuasion and suggestion. Analysits call it "testing reality" and it is an important part of the "working through" process. In actuality it is closely analogous to what is called "practice" in standard learning situations, and it involves a repetitive effort at reprogramming central nervous system mechanisms. Most of this takes place within the realm of the patient's awareness since it usually involves conscious effort on his part. However, there are frequently times when patients react differently or test new modes of adaptation without being fully aware that they are doing so. Thus both conscious and unconscious learning may be involved in this process.

Finally, inasmuch as the process of giving up accustomed modes of reaction, maladaptive though they have been, for new, more adaptive ones almost always involves some anxiety and resistance, the steady, consistent encouragement and emotional support of an empathic therapist is a necessary and important element of all psychotherapies. This takes place at both a conscious and unconscious level. The therapist himself may or may not be aware of the degree to which he is giving such support, and the patient may "or may not be aware of the degree to which he is receiving it.

In summary then, there are eight basic elements which appear to a greater or lesser degree in all psychotherapeutic techniques and may be regarded as common denominators of the psychotherapeutic process. These are: (1) A good patient-therapist relationship and working alliance, the basic matrix on which all else rests. (2) An initial release of tension, based on the patient's ability to discuss his problem with a person from whom he has hope and expectancy of receiving help. (3) Cognitive learning, by virtue of information or knowledge transmitted by the therapist. (4) Operant conditioning of the patient, via explicit or implicit approval-disapproval cues from the therapist, and also by virtue of repetitive corrective emotional experiences in the relationship with the therapist. (5) Social learning, by using the therapist as a model (usually unconsciously). (6) Persuasion and suggestion, - covert or overt. (7) Practice or rehearsal of more adaptive techniques, under the umbrella of (8) Consistent emotional support from the therapist.

As I have indicated, both conscious and unconscious processes are intertwined in these eight elements. The most conscious aspect of the psychotherapeutic process is that of cognitive learning in response to the therapist's interpretations and confrontations. We now know, however, that the "insights" thus acquired, although undoubtedly helpful and facilitative, are not absolutely essential for successful psychotherapy to occur. By far the most significant elements in psychotherapeutic process are those that go on outside of the patient's awareness. These are the subtle intricacies of the patient-therapist relationship; the degree of the patient's motivation; the degree of his faith in the therapy and his expectancy of receiving help; the operant-conditioning; the identification with the therapist; the effects of covert persuasion and suggestion; the consistent emotional support of the therapist as the patient gradually tests new modes of adaptation; and, finally, the impact of the larger outer system, encompassing social and political values, cultural mores, religious, philosophical and aesthetic attitudes and many other subtle factors both historical and current, which envelop both patient and therapist and impinge on the therapeutic process in ways of which they are both largely unaware.

Eight basic elements are involved to a greater or lesser degree in all psychotherapies: (1) a good patient-therapist relationship, (2) relief of tension associated with talking to a help-giving person, (3) cognitive learning, (4) operant conditioning, (5) imitative learning, (6) persuasion and suggestion, (7) practice or rehearsal, and (8) emotional support from the therapist.

These involve both conscious and unconscious processes. Cognitive learning involves conscious processes as do persuasion, practice and rehearsal, but the therapeutic influence of the other elements occurs largely outside of awareness. The outer historical and social system also has an important impact much of which is outside of the awareness of both patient and therapist.

References

1. Luria, A. R. The Nature of Human Conflicts (translated from the Russian by W. Horsley Gantt), Liveright, New York, 1932.

2. Huston, P. E., Shakow, D. and Erickson, M. H. A study of hypnotically induced complexes by means of the Luria technique. J. Gen. Psychol., 11: 65-97, 1934.

3. Erickson, M. H., Experimental demonstration of the psychopathology of everyday life. Psychoan. Quarterly, 8: 338-353, 1939; and numerous other papers.

4. Marmor, J. "Psychoanalytic therapy as an educational process". In Psychiatry in Transition: Selected Papers of Judd Marmor, Chap. 15, Brunner/Mazel, New York, 1975. "Psychoanalytic therapy and theories of learning". lоc. cit., Chap. 16. "The nature of the psychotherapeutic process". lос. cit., Chap. 23.

5. Marmor, J. "Dynamic psychotherapy and behavior therapy". In Psychiatry in Transition. Selected Papers of Judd Marmor, Chap. 24, Brunner/Mazel, New York, 1975.

6. Krasner, L. Studies of the conditioning of verbal behavior. Psychol. Bull. 55: 148-70, 1958.

7. Mandler, G. and Kaplan, W. K. Subjective evaluation and reinforcing effect of a verbal stimulus. Science, 124: 582-583, 1956.

8. Salzinger, J. Experimental manipulation of verbal behavior; a review. J. Gen. Psychol., 61: 65-94, 1959.

9. Marmor, J. The nature of the psychotherapeutic process revisited. Canadian-Psychiat. Assoc. Jоurn., 20: 557-565; 1975.

10. Miller, N. E. and Dollard, J. C. Social Learning and Imitation, Yale Univ. Press, New Haven, 1941.