Letter to Hanna Segal

In this letter, Winnicott disputes Segal’s statements at a scientific meeting about the psychoanalytical treatment and management of psychotic patients. Winnicott writes that Segal seemed to imply there is no essential difference between the management needs of a psychotic and a neurotic patient. Winnicott is alarmed by this statement and questions it.

A-B Type Therapists and the Authoritarian Personality

This study tested an early contention by Betz that it is the A-B type therapist's authority orientation which most significantly mediates success over schizoid and neurotic patient groups. The authoritarian has been described as conventional, rigid in thought, insecure, concrete, and intolerant of ambiguity, paralleling the description of B-therapists, while As are seen as nonauthoritarian. Ss listened to tape-recorded communications from neurotic and schizoid patients and responded “therapeutically” in free written form at the end of each of five segments per tape. Analyses of variance indicated only minimal support for the hypothesis that the A-B dimension is related to authoritarianism.

A Therapist's Prediction of a Patient's Dyad Grid

A neurotic patient is like a traveller in unfamiliar country forced to rely upon a deficient or systematically falsified map. The joint explorations undertaken with the therapist can enable the patient to revise this map. One condition which must be met for this to occur is for the therapist to recognize clearly how the patient sees his relationships with others, including the therapist. The present paper reports a method of investigating how far this condition is met, using a dyad grid test completed by the patient and by the therapist.

Behaviour Therapy in the Treatment of Psychoneurosis

According to Wolpe (1964b) “conditioning therapists as a rule undertake treatment of all cases of neurosis“. However, some limitations in the application of conditioning therapies must be recognized, and the nature of their difference from psychotherapy requires definition. Considering the problem of unconditioned anxiety, which Wolpe (1964a) defines as occurring with an ongoing conflict situation when there are simultaneous impulses to opposing actions, we observe that Wolpe does not claim that conditioning therapies are applicable here. But behaviour therapists do not believe that anxiety generated by conflict plays a part in the causation of neurosis, and wholly discount the significance of repression. In general, mature personalities tend to resolve their conflicts, motivated by the driving force of anxiety, but in neurotically ill individuals, often unable to face problems arising out of personal shortcomings, these conflicts are not always in full awareness, though they may not be very deeply “repressed”. Quite rightly, behaviour therapists point out that in their case material, where conditioned neurotic reactions constitute the main symptoms, the patient may recover, though the forgotten incidents remain forgotten, as for instance in functional amnesia. Accordingly they conclude that resolution of repression is not a prerequisite for recovery. But, as even many psychoanalysts concede, the detail of the forgotten memory, the repressed incident, is of less importance than are the associated affects and attitudes, and it is these which often cannot be squarely faced by the neurotic patient. Unconditioned anxiety aroused by conflict comes indeed within the orbit of psychoneurosis. Wolpe (1964b) alludes to this as follows: “You may find a person who is in a chronic conflict situation … which arouses emotional tension, perhaps all the time; … treatment of neurotic anxiety reactions may be much impeded by emotional disturbance due to the life circumstances. But the behaviour therapist can often instigate action leading to the resolution of difficult situations.” How Wolpe (1964a) accomplishes this is described when he deals by behaviouristic analysis with reactions in which “crucial stimulus antecedents are obscure”. Claiming that it is possible to establish the stimulus antecedents of reactions in every variety of neurosis, he states that the patient may simply be unaware of certain of his reactions, because of “conditioned inhibition of awareness of particular responses”. He quotes a case of unacknowledged rebellion of a patient against domination by her husband, in whom the complete exposure of this set of attitudes within her led to the possibility of their expression and to therapeutic change. Although Wolpe (1958) denies that this type of phenomenon constitutes repression, he appears to imply a very similar event when he discusses “conditioned inhibition of awareness”. It seems pedantic to insist that these are conceptually quite different and to claim that behaviour therapists are unique and original in trying to uncover underlying attitudes and affects.