Developmentally Based Psychotherapy

Stanley Greenspan's book details a new developmental theory that attempts to unify and extend the practice of psychotherapy. Drawing on his extensive clinical work and research, he elucidates the earliest stages of human development and clarifies the impact that difficulty in these stages has on the development of personality and psychopathology. He points out that although many experienced therapists intuitively incorporate developmental principles into their own eclectic approach, few therapists apply these principles in a systematic way. Adopting a more comprehensive developmental approach, he asserts, can expand the range of patients that can be helped by psychotherapies. Therapeutic strategies can be constructed to deal with complex psychopathological problems such as the role of constitutional factors in anxiety states and affective disorders, problems in forming and maintaining relationships, and problems of severe character pathology. In his second chapter, Greenspan amplifies the basic principles of his developmental model. Most patients have characterologic difficulties and display interactive patterns related to the very early phases of character formation. Therapies that aim to help patients verbalize feelings or alter behaviors are helpful within a narrower range of patients. These therapies, however, will not prove helpful to patients with more severe pathology. This is because of the therapist's tendency toward over- or underestimation of the patient's developmental level and overreliance on interpretive verbal techniques. For example, patients are mistakenly assumed to be able to picture and verbalize their feelings, when, in his view, they lack this highly differentiated representational system. Four basic principles of the developmental model and the six levels of early development must be used to build a developmental profile. Examples illustrate how this approach can determine the therapeutic tactics most helpful to each patient (e.g., support versus interpretation). In chapters 3 through 7 the author details the early developmental phases, giving examples of psychopathological problems that have their origins at each level. He points out the importance of constitutional, maturational, and interactional/environmental factors in the development of these problems and shows how a parent's—or therapist's—mode of interaction can worsen or ameliorate the difficulties. The final three chapters focus on clinical techniques to enhance representational capacities. Greenspan says that most patients require extensive structural changes (referable to the previously unmastered levels of skills such as self-regulation, boundary definitions, and gestural communication) before they can benefit from the more traditional verbal interpretive approaches. The appendix describes his model for assessing these developmental levels. This text has many strengths. Greenspan's descriptions of early development are rich and thought-provoking. They provide another dimension for understanding personality development and psychopathology, building on and expanding the works of Freud, Piaget, Mahler, Kernberg, Kohut, and others. His unique perspective will give many therapists pause about their overreliance on interpretive techniques that focus primarily on conflict. This book will be a welcome addition to the library of any serious student of psychotherapy. However, therapists expecting a text with simple constructs for addressing vexing clinical problems will find instead a rich and complex text that will require careful study to enable integration of these concepts in a systematic way. Overestimating the patient's ability to experience and represent feelings unnecessarily prolongs therapy into a lengthy, intellectualized process resulting in little or no progress, Greenspan maintains. He uses as examples patients who go off on tangents, rely on gestural behavioral communication, or withdraw into aloof detachment in the transference and in their lives generally. It should be noted, however, that the developmentally informed interventions of Greenspan's own model often take many months or more to lead to structural change. Other therapeutic models have differently addressed many of these same issues. Davanloo, for instance, has shown that these modes of behavior may not represent this kind of structural difficulty in the personality but may instead be “tactical defenses” employed by the patient to manage anxiety in the transference situation. For example, obsessive patients may describe thoughts or a behavior, or they may use a vague intellectualized term that covers how they feel (such as “bothered”). Character pathology may originate with constitutional factors, as Greenspan postulates; however, it would be costly to consider these tactical defenses as representing deep structural problems requiring lengthy interventions to bring these patients to the level at which they can experience and represent their feelings. With proper identification and clinical intervention, these tactical defenses are often rapidly relinquished. Patients with highly syntonic character pathology are able to experience and represent their feelings. Certainly, the extent to which these behaviors and modes of communicating represent tenacious structural difficulties or readily yielded tactical defenses can be empirically tested. This text is rich in clinical examples and is complex and thought-provoking in its formulations. I recommend it highly to psychotherapists and researchers in child development, regardless of their school of thought.