Beginnings: The Art and Science of Planning Psychotherapy (Book Review)

Author:  Peebles-Kleiger, Mary Jo
Publisher:  Hillsdale, NJ: The Analytic Press, 2002
Reviewed By:  Fonya Lord Helm, Winter 2004, pp. 44-45

This book illustrates sound and solid therapeutic principles that emphasize the need for careful attention to the patient’s strengths and weaknesses and the connection between a strong therapeutic alliance and a positive outcome. Peebles-Kleiger backs up these principles both with the research done at the Menninger Clinic in the 1960’s and current research. The principles outlined here provide clarity that cuts across the different theoretical approaches in psychoanalysis.

When I read this book, I was reminded of my richly rewarding supervisory experience with Ernst Ticho, who, like Peebles-Kleiger, also spent many years at the Menninger Clinic and was aware that it was possible to create a psychotherapy made for each patient using a mixture of both exploratory (expressive) and supportive interventions. He taught that twice-weekly psychotherapy was much better than once weekly, no matter what the diagnosis, and that the patient’s regression was better controlled by the therapist’s technical skill and activity than by limiting contact.

Peebles-Kleiger plans the patient’s treatment carefully, and while the treatment plan is made at the beginning of the work, she understands that it needs to be continually revised and the goals re-examined as the treatment progresses. She has many suggestions for ways to evaluate how to help the patient build an alliance, asking questions to find out what helps the patient talk about herself without discomfort. She is aware of the importance of creating a sense of safety. She also points out that it is useful to invite the patient to collaborate in finding out what helps her regulate her feelings.

When Peebles-Kleiger notices that, during the evaluation (or any other time), the alliance is threatened by the patient’s starting to get tense and upset, she asks if it is something she said or did (p. 60-61). She advocates testing to see if the patient noticed her own emotional upset and can reflect on what triggered it. If the patient can do that, she can work with alliance breaches. If she can’t, the therapist will try out other alliance-mending interventions, closer to the patient’s abilities. Examples are: (1) defusing the emotional intensity through humor, a change of subject, an apology, a focus on facts or logic, (2) focusing on findings connections between behavior and feelings, and (3) regulating self-cohesion with an “empathic” holding stance (Modell, 1978). She is trying to get some idea of the extent to which the patient can (1) mobilize reflecting functions along with experiencing ones, (2) work actively on a problem, rather than passively waiting, and (3) work collaboratively with a “helpgiver” (p. 63).

Peebles-Kleiger notes that experienced therapists tend to understand a patient’s style intuitively and use the complementary responses required to engage productively with that style. She advocates articulating this intuitive apperception of the capacity for alliance by identifying the patient’s pattern of templates. Interpersonal templates (formed by experiences and repeated interactions with people) are called belief systems or schema by cognitive therapists, and object relationship paradigms or transferences by psychodynamic therapists. “Throughout the varying domains of discourse… the concept remains the same—outside our awareness, we apprehend patterns in our experiences and forge templates from these patterns in order to anticipate the workings of the interpersonal world. These templates color our perceptions of others, our expectations of others, and, consequently, our behavior toward others” (p.167).

She is aware of how important it is to focus on the patient’s strengths. She states: “In one context, we might think about such limitations in being able to relate as deficits in the capacity for relationships. Here we turn that thought on its head, and, instead of looking at what is missing, we focus on what is there, as a way of finding a toehold or potential building block in the work of constructing an alliance. For example, a patient who can tolerate only showing formality and stiffness may be helped toward an alliance if we are willing to accept and view the patient’s stiffness as an adaptive self-protection that is enabling him to stay in the room—a step in an alliance-building process. As a corollary, we can sometimes find in problematic ways of relating (e.g., unremitting demands on us; repetitive, self-sabotaging behaviors; persistent cynicism or snipes) the effort the patient is making to maintain relatedness even while seeming to undermine it” (p. 176-177).

As part of a thorough evaluation, she advocates using techniques such as (1) sharing a feeling of being “puzzled” (p. 65) when she doesn’t understand and (2) noticing and exploring discontinuities (p. 64). These techniques, while appropriate for a formal evaluation in a setting with good inpatient backup, may be problematic for the outpatient therapist, since such techniques can create an unpleasant ambience that works against establishing the feeling of safety necessary for the establishment of a therapeutic alliance. For example, if the therapist says she is “puzzled,” the disadvantage is that the patient may feel slightly disoriented. Pointing out discontinuities may create tension because the patient is unaware of the discontinuity. The therapist is going after something that is unconscious, and the patient may feel startled and criticized. Peebles-Kleiger indicates that she is very aware of the need to use such techniques carefully.

Another very useful part of this book is the assessment of the patient’s ability to regulate and understand her emotion. The assessment includes evaluating the amount of external help the patient will need to regulate intense emotion and assessing the level of emotional awareness the patient has available. The process is unsettling for patients and she attempts to make the evaluation feel as safe as possible.

In discussing emotional issues with the patient, Peebles-Kleiger is sensitive to the patient’s needs. For example, when the patient doesn’t know what triggered something emotional in her and the emotion doesn’t remind her of anything, Peebles-Kleiger suggests that the therapist tell the patient that she will “vow to help in working together to unravel the mysteries behind the stirring” of the strong emotion. “Doing so will tag the work as important, offer hope in finding an answer, and convey a model of working as a team” (p. 75).

Peebles-Kleiger also discusses models of deficit and underlying disturbance. She considers it important to evaluate the patient using such models, but notes, “one could protest that this approach of conceptualizing underlying disturbance is unnecessary and artificial. People, relationships, and behavior lack precise regularity, cannot be predicted ahead of time, and are better helped by a dynamic growth model than by a compartmentalized repair model (Sid Frieswyk, personal communication, April 7, 2000, quoting Jock Sutherland)” (p. 117). She sticks to her point of view, however, wanting to identify “where healthy development has gone awry.” She is aware that some of the deficit models help make important distinctions, so she advocates using them, and yet, at the same time, she is good at focusing on the patient’s strengths. Her approach is thoughtful and she is aware that the way the therapist thinks about the patient or holds the patient in mind is very important. She emphasizes the importance of the therapist’s hopefulness and optimism as a stance that is necessary for the patient’s growth and successful treatment. Menninger et al. (1963) emphasize the enormous importance of the effects of hope, which they define as belief in one’s own efforts and, conversely, the death-facilitating effects of despair, which they define as belief that one’s efforts make no difference. They state, “ ‘Hope implies process; it is an adventure, a going forward, a confident search’ (p. 385)…. Nancy McWilliams (1999) goes one step further. She explicitly tells patients in intake that she has hope by saying, ‘I think I can help you’ (p. 35)” (p. 269).

Peebles-Kleiger also includes an understanding of the neurophysiological consequences of trauma, including some very interesting recent research, and she elaborates on technical approaches to take account of these effects. Helping the patient gain control of and regulate affect becomes the focus. She notes that full resolution is not possible, and the goal of treatment is “fewer recurrences, further apart, less intense, recognized for what they are (as temporary remembrances with a trigger rather than indications of a permanent deteriorating state), and resolved more quickly” (p. 165).

She also integrates attachment research into her overview of relatedness. She outlines five categories: marked aversion to connection, disorganized attachment, insecure attachment, and two categories of secure attachment. She has some good suggestions for engaging patients who are hard to reach, and notes “that tone of voice, speed and rhythm of movement, inflection, and facial expression often carry the bulk of the communication weight…” (p. 219-220).

This excellent book is suitable for both beginning and experienced therapists and analysts. The clinical vignettes illustrate her main points well and the integration of research in her presentation of the technical recommendations is outstanding.

McWilliams, N. (1999). Psychoanalytic case formulation. New York: Guilford Press.
Menninger, K., Mayman, M. & Pruyser, P. (1963). The vital balance: The life process in mental illness. New York: Viking Press.
Modell, A. (1978). The conceptualization of the therapeutic action of psychoanalysis:
The action of the holding environment. Bulletin of the Menninger Clinic, 42: 493-504.
Needleman, L.D. (1999). Cognitive case conceptualization: A guidebook for
practitioners. Mahwah, NJ: Lawrence Erlbaum Associates.

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