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This article from the magazine Self & Society by Lavinia Gomez (available here in full with her permission) formulates in clear terms the tensions between humanistic and psychodynamic perspectives which anyone trying to integrate the two has to struggle with. It manages to avoid traditional oversimplifications, misunderstandings and mutual prejudices which were part and parcel of the polarisation between these perspectives. Lavinia traces the development of non-interpretative techniques (of which there is a great variety and range, developed and used by humanistic therapies) back to the early days of psychoanalysis and the work of Ferenczi. She points out the dangers of these techniques. Out of a consideration of an ‘opposite therapeutic position’ (which recognises and uses the transference) versus an ‘alongside position’ (which uses these more active, directive techniques freely) she suggests the notion of ‘containment’ as a crucial ingredient in the therapeutic process.

Michael Soth has written a response to her article ('Integrating humanistic techniques into a transference-countertransference perspective') in which he agrees with her about the importance of the transference and containment. In addition he suggests a perspective where - under certain conditions - these two principles can be integrated with non-interpretative techniques (as used in Gestalt and Body Psychotherapy).

HUMANISTIC OR PSYCHODYNAMIC -

what is the difference and do we have to make a choice ?

by Lavinia Gomez - Self & Society Vol. 31 No.6 Feb/Mar 2004

A therapeutic crossroads
My client is a young woman, white, middle-class and well-educated. She came into therapy because she feels unable to proceed in any direction with her work life, or make meaningful contact with anyone apart from her partner; she has been very unhappy for a long, long time. In sessions, she often lapses into silence, unable to move or speak. Sometimes we can talk around this, and it soon became clear to both of us that this state reflects her inner relationship with her mother. She knows that her parents love her, and she loves them; but she grew up without really questioning that how she thinks, feels and acts must match what her mother expects and can cope with. Otherwise, and particularly if anger is involved, she is overwhelmed with foreboding and terrible guilt. Coming into therapy has brought these dangerous feelings to the fore; but it is as though I am her mother, and so she cannot speak.

As I sit with my client in her agony of self-consciousness, I have a choice to make. I could introduce an active mode of therapy. We could take her mother out of me and put her on a cushion where, with my encouragement, she might be able to develop communication back and forth. Alternatively, we might explore the acute bodily tensions that are part of her paralysed state, to help her give voice to what they are mutely saying. I would be taking the choice of standing alongside my client so that we could face her problems together. We would be locating those problems essentially outside the therapeutic relationship.

Or I could follow the other route. Instead of detaching her sense of her mother from me, we could leave it where it is. My client would then be encountering her mother in me, as it were, giving her the chance of resolving her difficulties ‘live’, in her own way. I would be taking the choice of standing opposite my client,and her problems would be likely to become concentrated within the therapeutic relationship. When I refer to the ‘alongside’ and ‘opposite’ approaches, or the ‘alongside’ and ‘opposite’ therapeutic positions, this is what I mean.This would usually be seen as an example of the humanistic-psychoanalytic divide. Many people would say that a humanistic therapist would position himself alongside the client and work actively, and a psychoanalytic therapist would place himself opposite the client and refrain from active interventions. (We’ll leave aside the integrative option for the moment.)
But is it that simple? No-one can deny that there are deep disjunctures between modes of therapeutic practice. Bioenergetics is a very different animal from classical psychoanalysis, for example, and the two could not be amalgamated without modifications which proponents of each approach would see as outright mutilation. But it would be no easier to combine bioenergetics with a pure person-centred approach; yet both are classified as humanistic psychotherapies, while psychoanalysis is generally not. So incompatible approaches do not necessarily fall on different sides of the humanistic-psychoanalytic gulf. Nor do the ‘alongside’ and ‘opposite’ positions exactly match up to humanistic and psychoanalytic approaches. It is difficult to see how any approach other than the psychoanalytic could be conducted from the ‘opposite’ position; but this is not because it is impossible in principle, but because no competitor theory has developed which works in the same way. However, the ‘alongside’ position can be taken up by a psychodynamic therapist as easily as any other. Rather than standing ‘opposite’ the client and working directly through the transference, the therapist’s perceptions of the transference dimension can be used to inform therapeutic interventions in exactly the same way as any other theoretical system. In fact, this reflects the different ways in which the terms ‘psychodynamic’ and ‘psychoanalytic’ are generally used. Both use the same body of theory, but in ‘psychodynamic’ psychotherapy, the therapist stays outside the transference and works alongside the client, while the ‘psychoanalytic’ psychotherapist positions himself opposite the client and works through the transference. So things are more complicated than they might appear.

There are three main points I’m going to be suggesting. First, that there is no essential divide between a psychodynamic and a humanistic approach, because there is nothing to stop psychoanalysis from being included as a humanistic psychotherapy: we do not necessarily have to choose between the humanistic and psychoanalytic or psychodynamic labels. Second, that there is, nevertheless, a crucial difference between a therapy which depends on the therapist working alongside the client, and one which depends on the therapist working opposite the client; I believe we do have to choose which therapeutic position we are primarily going to work through in relation to each individual client. This difference is not the same as the humanistic/ psychoanalytic divide, but represents a conflict going all the way back to Freud’s psychoanalysis. Third, that choosing one or other position does not settle the matter. Taking either to an extreme carries grisly therapeutic hazards, and all approaches have to find a way of bearing each of them in mind. I hope to convey how my main theoretical touchstone, Object Relations, developed out of the psychoanalytic conflict of approaches to offer one way of thinking about this tension through concepts such as containment and therapeutic presence.

The Division - humanistic or psychodynamic, or humanistic and psychodynamic ?
My main point here is that there is nothing in the humanistic approach that rules out a psychodynamic orientation or the psychoanalytic method, and nothing in the psychoanalytic approach that rules out the humanistic spirit. It is not the same in reverse: there is plenty in the psychoanalytic approach that is incompatible with many humanistic methods, and most humanistic methods run counter to the psychoanalytic approach.

The words alone tell us this. ‘Humanistic’ is a 17th century term which in itself means nothing more than ‘concerned with human matters’: Sometimes this implied human rather than divine matters, sometimes human rather than scientific matters; often, it involved faith in the human species as capable of moral and social progress. All these meanings are picked up in the range of views represented in the field of humanistic psychotherapy. ‘Psychodynamic’, meanwhile, merely describes the psyche as dynamic or active, and ‘psychoanalytic’ simply says that it is complex, or capable of being analysed. This makes the humanistic category by far the bigger bag; the idea that the psyche is active and complex is a human matter, but there is more to human matters than the nature of psychical processes.Of course, this is begging the question: it is not how they define themselves today. In the directory of the UK Council for Psychotherapy, the Psychoanalytic and Psychodynamic Section describes itself through the derivation of its theories:

“These therapies are based on psychoanalytic theory and practice. The central principle is that much distress has been caused by events in early life which we are no longer aware of. The therapy offers a reliable setting for the patient to explore free associations, memories, phantasies, feelings and dreams, to do with past and present. Particular attention is given to the interaction with the therapist, through which the patient may relive situations from their early life, the transference. In these ways the patient may achieve a new and better resolution of long-standing conflicts.”

No automatic contradiction appears between the two approaches, and indeed there is considerable common ground. Most humanistic psychotherapies do not rule out either transference or unconscious levels of experience nowadays; and while they might hope for more than the resolving of old conflicts, this would certainly be one of their aims.

Does psychoanalysis as a whole pass the humanistic test? According to the Humanistic and Integrative Section of the directory, “Humanistic Psychotherapy is an approach which tries to do justice to the whole person, including body, mind and spirit.”I don’t think we would find a psychoanalytic approach that would declare that it only tries to work with only part of the person. It might not define ‘person’ in the same terms; but then, nor do many humanistic approaches. The definition continues:“lt represents a broad range of therapeutic methods. Each method recognises the self-healing capacities of the client and believes that the greatest expert on the client is the client. The humanistic psychotherapist works towards an authentic meeting of equals in the therapy relationship.”

Some humanistic psychotherapists rule out psychoanalytic approaches on these criteria. They object that psychoanalytic practitioners see only what is pathological, and believe that they themselves are the real expert on the client; while the obsession with the transference, they argue, prevents a meeting between equals.

I think these are misunderstandings. Although the emphasis may be different, psychoanalytic practice depends on supporting, not supplanting, what is seen as the psyche’s intrinsic striving for integration; it is designed to unstick the process of self-development without implanting new ideas in the mind. Equally, the psychoanalytic practitioner cannot know in advance the significance of any thought or feeling, dream or symptom, because it depends entirely on its meaning for the patient. Where unconscious processes are concerned, the patient may be as much in the dark as the therapist. But interpretations can only be arrived at through attunement to the patient and her associations, and are only confirmed when they ‘click’ in the patient’s own emotional and cognitive recognition, or lead to an undamming of the therapeutic process. It is the client’s unconscious that psychoanalytic approaches treat as ‘expert’. Finally, psychoanalytic psychotherapy relies on the therapeutic alliance as the stable context for the turmoil of transference; this is the kind of realistic, co-operative partnership between more or less equal adults that humanistic psychotherapy espouses. The aim of psychoanalysis is to move towards the dissolution of the transference and the possibility of the more real and authentic meeting between equals that this brings. So I would argue that psychoanalysis meets these criteria as well.

These are the grounds on which I believe that humanistic psychotherapy can include psychodynamic and psychoanalytic approaches; and why, working mainly from a background of Object Relations, I feel entitled to call myself and be registered as a humanistic psychotherapist as well as a psychoanalytic therapist. Despite differences in emphasis, I do not find psychoanalysis to be intrinsically non-humanistic; the humanistic / psychoanalytic divide does not go ‘all the way down’.

So how did such a rift develop between them?

The Divergence between psychoanalysis and humanistic psychology
The divergence which put humanistic psychotherapy on the map was due to factors other than psychotherapeutic theory. Humanistic psychology arose in 1950s and 60s America, in reaction to behaviourist and psychoanalytic approaches which were judged as oppressive, complacent and frankly boring. The ‘growth movement’ aimed to make psychotherapy a powerhouse of liberated individuals. It was part of a general socio-political trend towards the overthrow of established structures ranging from civil authorities to the nuclear family, under slogans such as ‘the personal is political’, the ‘sexual revolution’ and liberation movements for all minority sections of society. This climate of rebellion was the hub around which a range of psychologies gathered. These included approaches unrelated to psychoanalysis, such as those of Maslow and Rogers, as well as those developed by disaffected analysts such as Perls, Berne and Reich.

What the growth movement did not do is engage with psychoanalysis in detailed conceptual argument: this was simply not what it was about. This is often not appreciated by the psychoanalytic world, which typically used to deride humanistic practice for its comparative lack of theoretical sophistication. It tends not to take on board that the humanistic psychology movement was motivated by emotional rather than intellectual factors, and represents protest rather than critique.

... and within psychoanalysis
This leaves the theoretical question unanswered. We still do not know if there is a philosophical conflict between the two approaches that we have not yet identified. Amazingly, however, the divergence of the growth movement from psychoanalysis echoes an earlier controversy along very similar lines and in a very similar context; and because the conflict took place within psychoanalysis, the theoretical arguments are easier to make out. The Freud-Ferenczi dispute was also part of a socio-political movement erupting in the twenty years following the First World War, as the growth movement was thrown up in the wake of the second. It failed to overturn the psychoanalytic status quo, and fizzled out in a mixture of repression by the psychoanalytic establishment, silent assimilation of some of its values and ideas, and a general sinking of differences in the run-up to World War II, to resurface thirty years later as the growth movement.

The 1920s saw an unprecedented radicalisation of psychoanalytic theory and practice. Inside and outside psychoanalysis, there was a new focus on society and on the body - both inescapably bound up with a war situation. The psychoanalytic ego was beginning to be theorised in bodily terms as ‘ego feeling’ or ‘ego sensation’ by Paul Federn, mentor to Wilhelm Reich. At the same time, psychoanalysis was becoming more ambitious in its aims. Freud had designed psychoanalysis as a way of discovering what was in the mind, leaving the use of this knowledge strictly to the individual. The movement known as ‘political psychoanalysis’ suggested it must do more. As well as interpreting the psyche, psychoanalysis should work to change not just to the individual but the social psyche, with the 1930s ‘sexual revolution’.

This led to a blossoming of creativity within psychoanalysis; but what proved impossible to either integrate or ignore was the bitter dissension between Freud and his so-called ‘favourite son’, Sandor Ferenczi, which led to a wholesale backing-off from risk-taking in psychoanalytic practice. Ferenczi made a sustained effort to reorient the style, focus and accessibility of psychoanalysis. He complained that psychoanalytic therapy was becoming an ‘educative’ rather than a therapeutic procedure. As the sole medium of psychoanalytic training, analysts routinely incorporated theoretical teaching and supervision into the analysis of trainees, and were concerned to make their analytic experience as rigourous as possible. Ferenczi felt that this had produced a generation of analysts who duplicated their own experience by prioritising cognitive understanding over feeling experience, insisting on long and ‘deep’ treatments regardless of expense, and misusing their power imposing punitively rigid boundaries and excessive non-responsiveness under the banner of therapeutic neutrality. His mission was to extend the range of patients with whom psychoanalysis could work, and to make it more effective at less cost in money, time and suffering.

Ferenczi’s main theoretical innovation was to propose that the outer causes of neurosis were more, rather than less, important than the inner causes; and therefore that the vehicle of psychotherapeutic change must be at least as much external as internal. In a startlingly early anticipation of Object Relations, he argued that neurosis is the consequence of a lack of love in early life, and that the effects of the instinctual imbalance that Freud held ultimately responsible are negligible by comparison. Accordingly, he set out to make good the deficiency, on the basis that the deprived patient needs real new experience, rather than just to gain insight. The ball of therapeutic responsibility is returned to the therapist’s court: “Psychoanalytic cure is in direct proportion to the cherishing love given by the psychoanalyst to the patient”, he writes. The therapeutic process might be accelerated, he thought, through active interventions on the part of the analyst: he tried out guided fantasy and relaxation, tasks and time limits, and argued for the return of the cathartic and hypnotic techniques that Freud had definitively rejected. He experimented with systematically gratifying rather than frustrating his patients’ yearnings, offering affectionate embraces, extended times, and sessions on demand. His concerns about the potential for the misuse of power went as far as ‘mutual analysis’ in which he was willing to exchange roles if the patient wished. Recognising that the therapist’s countertransference was as central to the therapy as the patient’s transference, he was the first to recommend that supervision should be seen as a necessity rather than a mark of failure.
This led to a regeneration of psychoanalytic theory and technique; but it is not surprising that these brave moves met with mixed results. Ferenczi took on patients that more cautious analysts would not have touched with a bargepole - sometimes with unexpected success. Often, however, he and his patients became impossibly enmeshed. Some were unable to endure being away From him, and he himself became exhausted. In 1930, he writes: “I dedicate four and sometimes five hours a day to my main patient, ‘The Queen’. Psychoanalysis, as I’m now practising it, takes much more out of one than previously has been assumed.” The next year: “For the first time for years, I am on holiday without my patients.” Two years later he died of pernicious anaemia, aged 60.

We can only applaud Ferenczi’s commitment, courage and imagination; but we can also understand the horror with which Freud foresaw the dismantling of the framework of his profession. The respectability and even the survival of psychoanalysis hung in the balance, a ‘Jewish’ science within increasingly anti-Semitic regimes. A general retrenchment followed Ferenczi’s death. His name was largely airbrushed out of psychoanalytic history, rumours spread that he had gone mad, and any mention of touch, active techniques or over-experimental attitudes went underground. Nevertheless, Ferenczi’s work had an unacknowledged but enduring effect on mainstream psychoanalysis. He is now recognised as the forerunner of relational and intersubjective approaches, and the link between classical psychoanalysis and Object Relations; but clearly his work has just as much in common with humanistic methods and attitudes, and must have contributed just as much to them through the concerns he shared with the generation of analysts from which some of the humanistic pioneers emerged.

The traditional conflict between humanistic and psychoanalytic approaches thus started out as a conflict within psychoanalysis which was then mapped on to the psychoanalytic/humanistic divide. It lived on within psychoanalysis in the ‘anti-psychiatry’ movements which sprang up in Britain and the USA, and in the continuing tension between classical and Object Relations approaches. What does this difference amount to?

The Difference - two therapeutic philosophies

Ferenczi recognised the need for the therapist to be ‘alongside’ as well as ‘opposite’ the patient, but did not realise that each position carries constraints. His experience suggests that we may have to make some kind of choice as to which therapeutic dimension we are going to work through. Yet whichever way we choose, the client seems to suffer.

Ferenczi went to an ‘alongside’ extreme because he thought the classical analysts had gone to an ‘opposite’ extreme. In neither case does the therapeutic relationship seem to reflect the equal partnership that humanistic psychotherapy places at the centre of the therapeutic encounter and psychoanalytic psychotherapy relies on as the ‘therapeutic alliance’ underpinning the therapeutic process.

One way of looking at the problems is to identify the different therapeutic philosophies that are involved. In practice, all relational therapies operate on a mixture of the two, but we can separate them out for the purposes of clarification.

At its purest, an ‘alongside’ approach treats therapy as growth. It assumes that the human condition is fundamentally harmonious, and that problems arise through the impact of trauma rather than through a surplus of destructiveness. This means that a change in external conditions can assuage the legacy of the past, and the client can grow beyond the trauma. With trust restored, the negative patterns set up for self-protection should drop away, as there would be nothing to maintain them. This process could be accelerated, and more positive patterns encouraged, by the appropriate use of techniques. Since the client’s problems are located between the patient and the outside world, there is no therapeutic rationale for the therapist becoming embroiled in them; negative transference in particular is seen as something that holds up progress in therapy, rather than something that the therapy happens through. A positive attitude from therapist and client, an open and co-operative relationship between more or less equal adults, and theoretical and practical know-how on the part of the -therapist, should be enough to see the therapy through.

By contrast, and again at its purest, the ‘opposite’ approach sees therapy not as growth, but as untangling the knots which prevent growth. It sees problems as arising from the inside, and being aggravated by external t events and conditions; this may go back to a constitutional difficulty in coping with life’s setbacks. By the time the patient arrives for therapy, something intrinsic to her psyche is stopping her from using the ordinary good experiences of life to recover from earlier trauma. Since this ‘something’ is unknown to the patient as well as the analyst, it can only be discovered by providing an empty relational space in which the unconscious dynamics can take form.

The analytic couch, the relative inactivity of the therapist, the frequent sessions and the use of free association are all designed to open the way to this process; and sooner or later, the patient slides into her characteristic relational quagmire. The analyst attempts neither to play into this nor out of it, but to keep interpreting the meaning of the patient’s experiences and actions from a neutral position. This may enable the patient to gain insight into what she is doing and feeling, work her way through it, and resume her interrupted self-development. Since growth is assumed to happen naturally once the impediments have been cleared, giving the patient further assistance would be confusing and interfering. The task of therapy is solely to ‘clear the ground’ for growth.

Probably no-one will be feeling particularly happy at this point. To all but the most single-minded of therapists, the ‘alongside’ group come over as gullible fools,and the ‘opposite’ group as cold technocrats: exactly the terms in which the psychoanalytic and humanistic lobbies have traditionally lambasted each other. We know, of course, that therapies seldom go as smoothly as either of these accounts suggests. Both approaches carry their own pitfalls, and combining them can make things even worse.

Problems of the ‘alongside’ position

The therapeutic potential of the ‘alongside’ position depends on client and therapist seeing and experiencing themselves and each other reasonably realistically; it is only this that keeps the client’s difficulties located outside the therapeutic relationship. But we know that people tend not to see themselves, let alone each other, realistically, and that this is even less likely when one person is seeking emotional help from another. As Freud discovered, the intimacy of the therapeutic setting is tailor-made to arouse unrealistic hopes on the one hand, and unjustified distrust on the other.

Any ‘alongside’ therapeutic relationship is vulnerable to transferential distortion, but this vulnerability is greatest in a muddled therapeutic relationship; we can see the potential for confusion in all ‘alongside’ approaches most clearly in a ‘multipositional’ approach. Some humanistic and integrative therapists advocate an approach like Ferenczi’s, with the therapist attempting to conduct the therapeutic relationship through both positions, shifting between them in response to the process of therapy. Every therapy is different; but examples of where this works well tend to involve clients who are already mature and resourceful enough to make the best use of whatever is available to them, taking inconsistencies more or less in their stride. But even these clients do not and probably should not necessarily remain in such an enviable psychological state throughout their therapy; and in any case, as Ferenczi discovered, there are always those clients who seem to make the worst use of whatever is offered them, by consistent misinterpretation.

Thus the intrinsic tendency towards transference is increased when the client is more disturbed or deprived, and when the therapist acts into the developing transference - for example, by trying to make up for her past and present losses, as Ferenczi tried to do. This leaves both client and therapist in danger of an insidious seduction. Working through the transference requires the client to retain or develop a minimal sense that the therapist is not the real target of her feelings; it is only this that keeps the focus on herself, rather than the fascinating figure in front of her. But if too much from the past is unresolved, what is transferred can become overwhelming, and the client may genuinely think that the phantom appearing ‘opposite’ her is the same as the real person ‘alongside’ her.

We can see how this could happen with my client. However frozen she appears, a great deal is happening in relation to me, or rather, in relation to who she takes me to be. She cannot look at me, but when I look away from her she is devastated and quietly furious. In the consulting room I seem impossibly intimidating, but once out of the door and walking down the street, she pours her heart out to me. The other side of the negative transference is the positive transference How easy it would be to unwittingly divert her from her struggle with herself to a hyper-focus on me, in a search for an external solution which could only bind her to me.
The ‘alongside’ position has its home in the co-operative partnership of humanistic psychotherapy, and in the therapeutic alliance on which psychoanalytic psychotherapy depends. But as the transference sets in, the client becomes progressively less able, and also less willing, to distinguish between the therapist as object of transference in the ‘opposite’ position, and the therapist as equal partner in the ‘alongside’ position. The space provided when the therapist takes up the ‘opposite’ position puts nothing in the way of a regression in which everything can become very simple, very concrete and very intense. If the therapist plays into this, and the client gains satisfaction from the therapist’s action, whether an active technique or a modification of the frame, she may take it as a promise to deliver totally, for life; the more deprived the client, the more likely she is to experience the therapist in this way. With the ‘alongside’ therapeutic relationship collapsing, powerful and primitive expectations are lasered on to the therapist, who is expected not just to understand but to fulfil them. Disappointment then appears as anything from a horrendous betrayal to an imminent threat to her continued existence. Many complaints taken out against therapists arise from this kind of confused and desperate state.

We can see now what Ferenczi’s more disturbed clients must have gone through. Encapsulated within their psychic prisons, they could neither see him realistically nor hold on to what they took from him. The cherishing love he endlessly poured into them served only to convince them that their well-being was his to give. Ferenczi tried to be everything to his clients: not just a stand-in for their ancient transference hopes, nor simply an equal partner alongside them as they struggled, but also the parent of their dreams and his. Like them, he lost sight of the distinction between the ordinary person he was in the therapeutic alliance and the magical figure he appeared to be in the transference. His attempt to subsume the transference relationship of the ‘opposite’ position into the realistic therapeutic alliance of the ‘alongside’ position looks not just risky, but misguided.

Problems of the ‘opposite’ position
Yet it does not help to simply subtract the alongside position and its potential seductions from the equation. This gives the distant stance criticised by Ferenczi, the growth movement, and humanistic psychotherapy today.

The primary aim of the classical analyst is to maintain a clear projective screen onto which the patient’s dynamics are cast; that is why he considers that the less the therapist puts in, the better. But Object Relations reminds us that human beings are irreducibly social: we cannot live as persons outside relationship any more than we can live as bodies outside oxygen. Imagine a keen scientist from Mars wanting to find out what the human body was like in its ‘normal’ state, without the constant interference from the surrounding oxygen. But removing a body from oxygen is not a simplifying act and does not give a pure physical state; it is a forceful action resulting in an abnormal and pathological physical condition. In the same way, depriving a person of relationship is not a neutral act but a powerful negative intervention. It does not show us the pure state of the psyche, but is likely to provoke an intensely disturbed psychic state. As an intrinsically relational creature, if the client does not feel that the therapist is in some sense alongside her, she will assume that he is against her; the only other possibility is to fall into a psychical ‘black hole’.

Just as Ferenczi’s positive interventions ended up seducing some of his patients, the distant analyst’s negative intervention freezes them out. In both cases, the therapeutic alliance between equal adults dissolves into a regressed transference. This is always and inevitably disastrous: therapists who work through the ‘alongside’ relationship lose their channel of therapy, while those who work through the ‘opposite’ position lose the essential therapeutic alliance without which no therapy can proceed.

Mediation by containment
We can begin to see why therapy cannot work if the ‘alongside’ relationship is neglected, any more than if the ‘opposite’ relationship is ignored; but there is no final answer to the dilemma we are faced with as therapists. These twin therapeutic dangers go with the territory of psychotherapy; they are always with us, and cannot be avoided. We can, however, think beyond them to therapeutic relationships which don t succumb in either of these ways. The terms I shall be using emerge from an Object Relations context; but every approach will have its own means of understanding the conflict of positions and the associated therapeutic hazards.

Like Ferenczi, Object Relations approaches tend to see psychotherapy as a reparative personal relationship; yet like classical psychoanalysis, they place transference in the centre and eschew non-interpretative interventions. So how do they manage to avoid the worst of both worlds ?

How do any of their patients manage to avoid seduction by positive transference on the one hand, or persecution by negative transference on the other ?

One way of thinking about this is through a therapeutic factor common to both positions. Instead of focusing on what the analyst does, Object Relations shifts the focus to how the therapist is. Therapeutic presence goes back to the ‘freely-floating attention’ that Freud saw as opening the way for the unconscious communion of analyst and patient.

It was taken forward in any number of Object Relations concepts: Klein’s containment ; Winnicott’s ‘facilitating environment’, ‘environment-mother’ and ‘subjective object’; Bion’s reverie ; and Balint’s splendid ‘harmonious interpenetrating mix-up’. All these expressions are trying to reach towards the notion that the therapist’s actions matter less than the state of mind they come with and in which they are received. It is not so much the words of the interpretation that are transformative, but the atmosphere and intention in which the interpretation is made.

This crucial generic factor, which we can sum up rather arbitrarily as ‘containment’; is a nebulous and difficult thing to pin down, crossing many ordinary dichotomies of thought. Emotional openness is needed, and also discriminating thought. It takes focused attention, but a moment of deliberateness kills it. From the client’s point of view, its essential mark is simply that something about the therapist’s presence or way of responding leads her to experience or accept herself more clearly or more fully. From the therapist’s point of view, containment is not a way out of commitment, but the precursor to responding. Before he can bring the fragments from the client’s expressions and his own countertransference into a coherent whole, he has to simply hold them. Only then can what emerges ‘fit’ the therapeutic moment; but his efforts to still his being and attune to the client only come to fruition if they are met by the client. The process of containment is above all an exchange.

For both therapist and client, the containing/contained exchange mediates between the realistic therapeutic alliance and the regressed transference relationship. For each, it connects the therapist who is ‘alongside’ the client with the transference figure who is likely to be ‘opposite’ her. But the important thing is that this happens without confusing them. Where dramatic techniques and ‘clever’ interpretations risk drawing attention to the therapist, this does not happen in containment: there is an enhanced awareness of the client, but no more than a background awareness of the therapist. It is this that enables the client to draw from the therapist’s presence without gaining a surrogate mother or father. Some proponents of both the ‘opposite’ and ‘alongside’ approaches explain the therapeutic process as the internalising of a new parental figure.

I think this lays the therapy wide open to the dangers we have been discussing, by making the therapist too important in his own eyes, and in those of his clients or patients. The reparative relationship that Object Relations speaks of does not mean that it becomes a new relational structure, but rather that the client takes from the therapist’s presence what she needs to bring her into closer touch with the good aspects of her existing inner relationships. In doing so, she adds to and reorders her existing internal world, without instituting a brand new relational complex. This puts her in a better position to recognise her blocks and self deceptions, so that she herself can go beyond them in whatever way she chooses.

So when my client finally leaves therapy, I hope it will be with a shrunken sense of me, and an amplified sense of herself and the richness and complexity of her inner and outer relational worlds. Otherwise, she will not really have become more free. But just as she cannot plan what she will take from my presence, so I cannot choose what will be drawn. Ferenczi tried to give his patients the specific experiences that he and they thought they needed. Perhaps he could have trusted that his thoughtful attention and inextinguishable personal qualities might have been enough.

Where does this leave us?

To recapitulate: in answer to the question of the relation between humanistic and psychodynamic psychotherapy, I have suggested that the true division in psychotherapy is more practical than theoretical. It does not depend on whether our therapeutic approach is one that is usually classified as humanistic or as psychoanalytic, but on whether the problems are focused outside the therapeutic relationship or within it, and therefore whether the active therapeutic position is ‘opposite’ or ‘alongside’ the client.

Whatever our theoretical approach, I believe this means committing ourselves to one or other kind of therapeutic channel in each therapeutic relationship; but this does not mean foregoing all forms of integration. If we choose a pathway of change through being ‘alongside’ the client, we are free to use any combination of theories and techniques that makes sense in this particular therapy, including psychoanalytic theory, just so long as the client’s attention is drawn to her own issues rather than our actions. What we are not free to do is encourage a fixation on ourselves by promoting an ‘opposite’ position, and trying to conduct the therapeutic work through both channels.

If the therapeutic route we choose is through the ‘opposite’ position, we are confined to a psychoanalytic approach of some kind, because this is at present the only theory which explains what happens when we do this. But we can add to this perspective by bringing insight from any other source. Body Psychotherapy might foster a somatic dimension to our awareness of ourselves and the client; concepts drawn from approaches such as Gestalt can help us monitor the quality of our presence and engagement. What we cannot afford to do is use the active techniques on which these approaches usually rely, because we risk confusing the client into thinking that they are being offered by the looming figure opposite her, rather than the mundane person alongside her.

In the end, it is the containing and being contained interchange that makes a therapy good enough if it succeeds, or not totally bad if it fails; and since the conflict of positions is practical not theoretical, this is true for all therapeutic approaches. Containment is just as much a safeguard against the stereotypical overactive humanistic ‘guru’ as against the underactive psychoanalytic ‘blank screen’. Humanistic therapists follow exactly the same profess of centring and attuning to reach the appropriate intervention, or non-intervention, and convey it in a way that can be used. The ‘opposite’ and ‘alongside’ channels can both be the conduit of therapy, to the extent that they facilitate containing and being contained. Inside or outside an official psychotherapeutic relationship, it is this that opens the way to the change which mysteriously becomes possible when people meet together and achieve good faith.

‘Containment’ is just the Kleinians’ term. All approaches, whether psychoanalytic or humanistic, must articulate what they see as most essential in their own wav, with echoes of this same enigmatic exchange. This holds the truly exciting possibility of a meeting ground for a transtheoretical dialogue. Perhaps amore communicative psychotherapeutic world is not unthinkable, however far away it seems to be.