In a psychotherapy session like Session I, where there are two patients and two therapists, the program not only provides for phases of technical employment, but also for a complementary relationship between the co-therapists. And techniques are tailored to the patients and their relationships. Also, since a given session is but one encounter in a programmed series of sessions, the strategy of psychotherapy is more complicated than the mere phasing of techniques described in Chapter 11.
These matters are the subject of Chapter 12. I will describe first the complementary relationship between the men, then sketch an overview of their strategy for the ten sessions they held with Marge. In concluding I will comment on behavioral change in psychotherapy.
THE WHITAKER-MALONE COMPLEMENT ARIT Y
Consider once again the format each man used for the session. Whitaker changed his behavior according to the following phases:
1. He began the session by sitting back with his arms and legs crossed, listening and questioning. He moved forward in three shifts at six-minute intervals, stepping up the pace of his attention to Marge, his support of her, and his challenges to Mrs. V’s story.
2. At 23 minutes he explained the sessions, at the same time making his second physical contact with Marge and dismissing Mrs. V from further attendance.
3. In Phase II Whitaker became relatively inactive. He held his position near Marge and continued to talk to both women, but Malone moved forward, too, and afterward participated lexically and kinesically with Marge.
Malone behaved as follows:
1. Malone started the session in a position almost identical to Whitaker’s: sitting back in his chair with his legs and arms crossed. From this position he intermittently rocked forward and intervened, censoring Marge and inviting Mrs. V to continue.
2. At 24 minutes Malone rocked forward and confronted Marge as usual, but this time he did not sit back again. He stayed in the forward position until the end of the session, adding to Whitaker’s explanation and contending actively with Marge.
At 29 minutes both men ended the session. Malone glanced at his watch, whereupon Whitaker made a customary gesture of completion. He brushed his palms off on each other. Then he sat back in his initial position, leaning back in his chair, crossing his legs and arms. He remained silent until 31 minutes when he and Malone both stood up and terminated the session.
The Complementary Program of Postural Progression
Notice that both men moved in toward Marge but they did so differentially — Whitaker moved in step by step, while Malone held back until 24 minutes and then moved all the way forward in one jump. Nevertheless, these moves were interrelated. They were parts in a larger, complementary program of progression which the men shared. In review, the following sequences show this complementarity:
1. During the first six minutes both men sat back with their legs and arms crossed. Thus they were in parallel or congruent postures. (Since Malone had his left leg over his right and Whitaker had his right leg over his left, this isomorphism was ‘mirror-imaged’.)
2. At 6 minutes Whitaker took one step forward in his format of moving in, but Malone did not shift his basic posture. As a consequence the parallelism of positioning which had obtained for the first six minutes no longer was in effect.
At 12, 18, and again at 23 minutes, Whitaker made a further shift toward Marge which Malone did not duplicate.
3. At 24 minutes Malone did move in. He moved all the way forward to the position that Whitaker had attained by his step-by-step progression. Thus the two men again came into parallelism or isomorphism of positioning. They remained in this complementarity until minute 29.
Thus the men remained in parallelism for the first 6 minutes and again from 24 to 29 minutes. Even though each of their moves was not complementary, their progression of positions was. Technically, we would say that the complementarity was evident at the level of their total parts of performances — in their program of positions.
Note also that the rate of progression was a function of their role in a given session. In Sessions III and IX, when tak« ing the active role, Malone moved in at six-minute intervals while Whitaker retained the initial, baseline position during these four moves. The more mobile man in any session related most actively and explicitly to Marge. The other encouraged or inhibited that vis-à-vis. These roles were exchangeable in the system. The relation of these two progressions are diagrammed in Figure 12-1.
The two men did not, at any point, speak to each other or even fully look at each other. The progression was regulated by a set of signals we called pipe signalling. About one minute before each shift in the postural progression, the man who was going to shift would make a pipe signal.1 The other man would, within a minute, respond with a pipe signal. Then, and only then, would the active physician shift his posture.
In systems, each move in represented (or is a signal of) the occurrence of a parameter, the state of relationship differing after the parameter has been introduced. Presumably, the time of such introduction follows some assessment of the readiness of the group members. In this case, the order and nature of the shift is dictated by the tradition of these men’s approaches or the tradition of psychotherapy in general; i. e. , it is programmed. This may be analogous to the process of education, in which the order of subjects is dictated by tradition, with the time of their introduction representing some assessment of the student’s readiness.
The General Nature of the Whitaker-Malone Comp!ementarity
The Whitaker-Malone relationship can thus be described in behavioral terms as a complementarity of performances. The relation of their postural shifts was but one indicator of a conjoint performance which had the following general characteristics:
1. Open. Although their relationship was continuous and progressive in the postural and kinesic modalities, the two men appeared dissociated in the lexical modality. They never spoke to each other and only once exchanged glances. Covertly, then, they appeared unrelated. Their relationship was not closed, impenetrable, or excluding, but rather receptive and open.
Thus, the Whitaker-Malone twosome contrasted with the oscillating, closed, cross-monitored, mother-daughter dyad. We could conjecture that this openness offered a paradigm to the women, who seemed to have no model of being allied while also being open to other relationships. At any rate, the openness seemed to be a factor in the relationship that formed. It tended to break down subgroups or exclude twosomes and establish a larger group.
2. Multilayered in Communicative Modalities. The complementary relation sustained simultaneously two !ayers of communicative activity. Lexically, there was a relation of positions that corresponded to the narrating of the women’s history. Kinesically, by splitting, the girl was brought into relationship to the men by quasi-courting and contacting. Rapport was initiated and the mother was eased out of the active group.
3. Programmed. That the men did not speak to each other, used little search behavior, and moved forward in highly regular steps indicates that these patterns could not have been created de novo in the session. They must belong to an institutionalized procedure evolved earlier in the relationship of the men. Often the men moved together like practiced dancers or musicians following a well-known score.
THE OVER-ALL STRATEGY
The men told us that they employed two strategies in Session I: (1) they obtained a history of the women’s problem, and (2) they established rapport with Marge. I would like to reformulate this second strategy more comprehensively. I would say that the men gradually supplanted Mrs. V with Whitaker in the parental role and then began re-educating Marge in the context of this more favorable social structure. They accomplished the first of these steps in Session I; I will try to conceptualize this process first and then I will tell briefly about their usage of the new situation in subsequent sessions.
Step 1. The Replacement of Mrs. V
As I have already theorized, a premature attempt to break the mother-daughter symbiosis would have failed (Chapter 10). Psychotherapists, having discovered this, have developed techñiques for tactical maintenance of patient dependencies until they can replace them with more workable relationships such as the alliance with the therapist. Whitaker and Malone, I think, tried to kill two birds with one stone in Session I: they replaced Mrs. V with Whitaker and they obtained Mrs. V’s blessing on the exchange. Theoretically this move may have made Marge more tractible or cooperative by relieving her guilty loyalty to her mother.
But Whitaker and Malone added another aspect to the pursuit of this strategy. They split the usual function of juggling which the individual therapist may find so difficult: i. e. , maintaining the existing social relationships of the patient while changing them. They separated their roles in the session and assigned each of these tasks to a role. Whitaker took on the job of inducing rapport with Marge while Malone supported the mother, regulated the pacing of the Whitaker-Marge rapport, and took the villain’s part in preventing a premature coalition so that Whitaker did not appear rejecting.
Let me try to explain these ideas in social systems terms.
Maintaining a Cohesive Group for Enacting the Transaction
Simmel (1902) pointed out that in a group of three, there was a striking tendency for two to pair off against the third. More recent experiments by Mills (1953) seem to confirm Simmel’s work. Looking at Session I, one could argue that in this group there were tendencies to form excluding or opposing twosomes. It may be that the tendency in any group is to break down into subgroups which are at variance with each other or which at least tend to go off in divergent directions. However, if a group is to carry out certain purposes for which it is assembled, it must maintain itself for a time in integration or stability. Some mechanisms, then, are required to offset any tendency toward disintegration or schizmogenesis (Bateson 1958; Parsons 1961). This may well be one of the functions of oscillation.
There seemed to have been an unwritten rule in Session I that no participant be ‘left out’ by the formation of a new relationship. When Marge and Whitaker formed a relationship, Malone turned to Mrs. V; after Malone criticized Marge and Whitaker abandoned Marge, Mrs. V turned to her. Whenever any change occurred in the configuration of relations, some other change immediately or simultaneously occurred which for a time maintained the basic organization: two complementary relations vis-à-vis each other.
The mother-daughter relationship, it seems, was unstable in both phases, elaboration or opposition. The stability of the group, however, was made possible by oscillation. I conjecture that tendencies for clique formation or subgroup cohesion (Talmon-Garber 1959) can be offset in any group by oscillation because oscillation fosters the continuation of the larger group structure. Its function can be termed morphostatic (Maruyama 1963).
In other words, the function of the monitoring seemed to be to maintain some order of dynamic equilibrium — to prevent the continuance or dominance of either of two ‘extremes’: the motherdaughter symbiosis on the one hand, or the split into opposing alliances on the other.
It would be a mistake in such a system to settle for the simpie inference that the monitoring person is acting solely from some personal motivation like jealousy or the fear of being left out. First of all, monitoring was an interchangeable role. If Malone did not engage in monitoring, Mrs. V did; when it was Malone who engaged in alliances with the girl, Whitaker performed the monitoring. At this writing, such monitoring seems to be a general characteristic of any group so composed. Malone, as the monitoring performer, did not simply force his actions upon unwilling others. Whenever interrupting occurred, it occurred in the face of progressive ‘openness, * dissociation, and search behavior. In other words, the participants in an alliance ‘invited’ interruption. All four participants in Session I contributed to maintaining the oscillation between elaboration and opposition.
The Use of Covert, Kinesic Behaviors to Initiate Change
While the lexical units were oscillating back and forth from elaboration to opposition, another set of relations was occurring that was progressive and of a very different nature and significance. These were mediated by quasi-courting along with handplaying, Kleenex-displaying, and contacting. Each step in the kinesic series brought the therapists closer to their stated goals for this session.
The alliance-forming behaviors of Whitaker and Marge, when they had lexical components (e.g. , challenging), were interfered with and monitored actively by both Mrs. V and Malone. This interference terminated the Whitaker-Marge alliance and precipitated the flip-back from opposition to elaboration. The kinesic behaviors, on the other hand, were monitored neither by Malone nor (after twelve minutes) by Mrs. V. Not only did Malone fail to interrupt these kinesic units, but he encouraged them actively.
It was as if the developing relationship of Marge, first to Whitaker then to Malone, was permitted so long as it did not have overt lexical elements or maybe so long as it did not turn to challenging and opposing the mother. In any event, the kinesic units developed between Marge and the men without visible interference at a time when opposing and elaborating were continuously being monitored, interruped and terminated.
In contrast with oscillation, which seemed to maintain a steady state, the kinesic unit seemed to modify the quality of the relationship or to bring about a shift in who participated in a given subgroup. Each step in Whitaker’s moving in seemed to be a parameter in the Ashby sense (1956), and the system reestablished a steady state at a new, greater intensity of Marge-Whitaker closeness and mother-daughter distance. The moving in was presumably intended to disrupt the mother-daughter interdependency, exclude Mrs. V from active participation, and bring Marge into rapport with both men.
Communicationally, we surmise that covert but progressive kinesic-postural activities can escape monitoring and lead to shifts and relationship formation when !exically manifested relations are in steady states.
Use of the Complementary Relationship in this Balancing
Thus the men seemed to encourage oscillation while introducing kinesic behaviors to change the oscillation.
At lower levels the behavior of the men seemed oppositional. For example, one man supported Mrs. V, the other challenged her. At the higher level, however, these pieces can be understood as a complementary unit for maintaining the equilibrium of the mother-daughter relationship until such time as they could alter it. The clinician experienced in psychotherapy of schizophrenia will see in these approaches a familiar idea. In individuai therapy of children or schizophrenic patients, the therapist treads a line between encouraging rebellion against constricting parental introjects and preventing the patient from showing hostile or unsocial displays that engender too much guilt.
Just as a therapist sometimes backs down from pressure that frightens his patient in order to reassure or allow recalibration, Malone would interrupt to reaffirm Mrs. V’s rationalizations or quiet the challengers. A moment later Whitaker would reapply the pressure and make overtures of rapport to the girl. These actions, divergent at the lower level, can be complementary in terms of holding Mrs. V out of panic, obtaining her blessing upon their relationship to Marge, and giving Marge support without stampeding her into too early a break from her symbiotic attachment.
It seems to me that this is fundamental strategy in any rapport formation, i. e. , to fit in with the patient’s expectations or his internalized lifelong rhythms and patterns, in order to form a common ground, a familiar and tolerable equilibrium. The therapist may have to promise to change the status quo or the patient will see no hope or use in therapy, but he had better not try to do so too soon.
The two therapists, by personifying these influences and by bringing the mother to the initial sessions, where she and Marge could play out their usual patterns, seemed to cast the scene in the interpersonal field, where it could be more readily apprehended. Maybe this is what they mean when they speak of working with current interaction rather than memory and past fantasy (Whitaker and Malone 1953, 1959; Whitaker, Malone, and Warkentin 1956).
Excusing Mrs. V from the Group
I presume the following: When the men considered the developing rapport between Whitaker and Marge to be stable, Mrs. V’s dismissal was announced. In the process Whitaker explained the purposes of the session and promised an ultimate reunion between mother and daughter — thus providing a rationale for Mrs. V’s absence and a hope upon which she could justify leaving the girl in the men’s hands. In the process Whitaker seemed to test or affirm his relationship with Marge by making the second tactile contact.
Step 2. The Subsequent Use of the New Whitaker-Marge Relationship
In Phase II Malone actively addressed the girl and moved synchronously with her. He continued his tones of disapproval and scolding in Session I. But in subsequent sessions he flirted with Marge, combed her hair, rubbed her feet, talked about sex with her and was in general friendly and noncensoring.
In these subsequent sessions it was Whitaker who sat back and took the relatively inactive role. He did not move in toward Marge until late in a session. He also took over the regulatory role. He encouraged Marge to relate to Malone when she tried to dissociate from him and he sometimes intervened if the relationship between Malone and the girl seemed threatening or oversexualized. Thus Whitaker became the regulating therapist.
But an important difference had occurred. Whitaker maintained his rapport with Marge. He supported her and maintained a brotherly kind of attitude. He beca?ne her ally in her new venture of relating to Malone. And Malone acted the part of quasi-courting partner. He encouraged Marge to talk about sex and to make physical contact with him and care about him without sexuality. This plan was developed because the men felt that Marge needed to learn about friendship with a man without having avoidance or sexual intercourse as her only alternatives (English et al. 1966).2
COMMENT: BEHAVIORAL CHANGE
There was no question that Marge’s behaviör changed during the sessions with Whitaker and Malone. Even in Session I she became obviously less autistic and more alert by Phase II, and in subsequent sessions her behaviors of sprawling, shocking, and repelling ceased. But there was a sharp difference of opinion about the significance of these changes among the psychotherapists who observed the series. Some observers said that the changes would be transient because they merely reflected the absence of the mother. In this point of view one can argue that Marge’s improved behavior was a consequence of her relationship with the men and was merely an extension of her improved behavior in any Period Z. On the other hand, some observers argued that Marge’s awareness of the situation and her ability to behave realistically with men was improved by the sessions and they believed these changes would be lasting. They believed that Marge had learned some new and more realistic patterns of behaving.
A difference of opinion reflects a difference in criteria of change among clinicians. Classically it has been recognized that two orders of improvement can occur in psychotherapy.
1. A ‘transference improvement’ often occurs as soon as the patient forms rapport — as soon as he agrees to enter treatment and forms a trustful relationship to the therapist. But such improvements are considered to be temporary. Psychoanalytic clinicians believe that no change has occurred in the patient’s conceptions, so they feel that the patient’s improvement will not be carried over to relationships beyond that with the psychotherapist.
2. A lasting improvement with insight is believed to occur when the patient knowingly can change the contexts of his life and adapt his behavior and his affective state to situations and relationships other than those of the therapy.
The expressive or insight psychotherapist believes, then, that only insight and change in conceptions lead to lasting change. But other clinicians argue that behavior can be changed by altering visible behavior with techniques such as reinforcement (Wölpe 1958; Krasner and Ullman 1965).
Theoretically this argument may be doctrinal. Behavior, metabehavior, and context are but aspects of a single system, and in principle one cannot change any aspect of this system without changing the others. But practically and strategically it may make a difference which of these aspects is influenced first in the processes of psychotherapy and it remains probelmatic whether change without insight is lasting or necessary. But we can, I think, spell out more carefully what we mean by behavioral change from the study of transactions like Session I.
Consider first that an individual’s range of behavior will be constrained by the immediate context, by the ongoing transaction. Given a describable phase of a known transaction, a person has a number of options for allowable behavior — maybe one or two parts, several positions and relations, maybe a dozen usual points and gestures, and a few hundred syntactic sentences. By observations we can roughly catalogue a repertoire in any immediate stable context for a given participant as I have done in this volume. Marge, for instance, had a characteristic and repetitive set of behaviors in any Period 1 and a somewhat different set in any Period Z.
As various alternative behaviors appear in the progress of a transaction, we do not necessarily have to postulate that a significant change has occurred in the participant’s life situation or in his conceptions at higher levels of context. Thus Marge showed a progressively greater employment of alert, sexually active, agressive, and related behavior as Session I went on — a change a psychiatrist would regard as healthy or indicative of improvement. But this change was obviously associated with a greater and greater persistence of the Period 2 constellation and Marge had behaved in this more normal fashion in any Period 2 from the beginning of the season. We have no grounds to postulate that she had learned any new behavior or experienced a durable change in her life-space. To do so we would have to show, at least, that her Period Z behavior persisted during a Period 1 type of context or that even with her mother present she did not fall again into Period 1 types of relationship.
In subsequent sessions Marge’s improved behavior continued, but her mother did not attend subsequent sessions and there was no repetition of the Session I context for us to observe. Many of us had the impression that Marge’s behavior did demonstrate new learning but the proposition is not demonstrated.
On the basis of long-term observation, however, we could probably establish that three basic types of change could occur from a participant’s experience in a transaction. These, of course, coincide with the three types of context I have been differentiating throughout Part II of this study.
1. A repertoire of allowable behaviors might be extended by any change in the immediate context of the transaction.
2. A transaction (or series of them) could alter the lifespace arrangements of a participant’s life and permit him access to portions of his behavioral repertoire which he had been unable to use.
3. A participant could learn parts, positions, and other units of behavior which he had not previously acquired.
Presumably these changes could occur either by alterations in the actual immediate situation, life-space arrangements, or life experience, or else because of changes in the subject’s conception of these immediate, mediate, or remote contexts. In psychotherapy both of these eventualities probably occur. For example a patient’s concept of his relationships might lead him to change his institutional memberships and circle of friends, whereupon he might be able to have new experiences and learn new patterns appropriate for these new life contexts.
In an ongoing series of psychotherapy sessions, the various loops in complicated interacting systems changes are the subject of discussion, suggestion support, and so on. As any change occurs these are techniques for dealing with it. For example, if Marge left her mother, she would need to learn new ways of dealing with men. Whitaker and Malone anticipated this situation and they spent most of the subsequent sessions in teaching her such behaviors. If she failed to learn programs of behavior suitable to new life context, she might well have to return to the interlocked relationship with her mother and this return might have precluded further chances for her to learn. So we could conceive of psychotherapy as an applied communicative effort to impinge on strategic loops in the vicious cycles of a schizophrenic patient’s life. So far as I know, courses of psychotherapy have yet to be studied by systematic and direct observation and the success of the efforts remains a debatable subject.