A Conversation with Henry Stein

BOL: Alfred Adler’s name is better known to today’s therapists than are his ideas and methods. Your dedication to this body of work must be based on the belief that contemporary practice is diminished because Adler’s contributions are not fully enough understood or used currently. What are the key elements of the Adlerian contribution to contemporary practice?

STEIN: Adler has much to offer not only to the practice of psychology but also to society in general. Our democratic way of life has eroded badly into widespread self-interest and indifference. Improvement must come not only from the top down, but mainly from the bottom up. We need individual citizens who are capable of carrying out democracy in their daily lives. Adler’s theory can be used to guide this work–to foster the development of a democratic character structure in the individual, and to prevent many of our social problems. Adlerian psychology was developed to realize the values of social equality, cooperation, and responsibility for the welfare of others. It can help re-vitalize our democracy.

Adler’s primary index for mental health is the person’s feeling of community and connectedness with all of life. This sense of embeddedness provides the real key to the individual’s genuine feeling of security and happiness. When adequately developed, it leads to an attitude of cooperative interdependency and a desire to contribute. These qualities are essential for building a healthy democracy. Adlerian child guidance and psychotherapy strengthen this feeling of community.

An Adlerian diagnosis is based on the assumptions of the unity and self-consistency of the personality, and an orientation toward an unconscious fictional goal. It re-directs understanding away from “past cause” to purpose, or “future cause.” We gradually help the client understand, evaluate, and modify this goal, as well as the consistent pattern of dealing with life that supports it. Our belief in the creative power of the individual, to freely make choices and correct them, offers an encouraging perspective on responsibility and change.

Classical Adlerian psychotherapy is characterized by a diplomatic, cooperative working relationship that establishes the feeling of equality. Through Socratic questioning, the client is respectfully guided through cognitive change: clarifying thinking and feeling, making conclusions, and coming to decisions. Guided or eidetic imagery may be used to promote affective change. Role-playing and marathon group techniques can support behavioral change. A twelve-stage therapeutic structure provides a guideline for planning strategies and evaluating progress. This foundation also acts as a springboard for creative improvising and inventing. Each therapy is different, adapting to the uniqueness of the individual.

Adler’s vigorous optimism, his vision of optimal human functioning, and his humanistic philosophy of life can provide constant inspiration for a behavioral scientist.

BOL: In order to appreciate the texture of the Adlerian approach, let’s talk a little about Adlerian “diagnosis.” With a ‘modal’ actual or imagined patient/client in mind, could you walk me through an inital evaluation of a patient’s problem?

STEIN: My preliminary evaluation starts when I first meet the patient in the waiting room, since Adler suggested that everyone will express his or her style of life most clearly in a new situation. I look for the degree of contact in the eyes and greeting, the level of activity and posture in the short walk to the office, the initiative in choosing a seat, and the posture when seated. Anything unusual, over- or under-done, is of particular interest. Many people very eloquently express their attitude toward life in that brief episode.

After some preliminary questions about health problems, medication, and drug/alcohol use, I ask about the patient’s difficulties. As the problem or symptom unfolds, I am especially interested in when the difficulty began and what else was happening at the time. This may reveal where and when the person’s courage or ability to cooperate faltered. Present circumstances may also be denying the person the subjective success, significance, or pleasure they expect.

I want to see the patient’s problem in the context of their main life tasks,so I ask about their work, love/sexual life, family, and friendships. This provides an overview of their level of functioning and what they value.

Within the first hour, I try to elicit a preliminary sketch of their early childhood situation, including: descriptions of each family member, relationships, attitudes, feelings, family atmosphere, and earliest childhood memories. I make notes of these descriptions, including the feelings and body language expressed.

I am especially interested in the difficulties that the individual has struggled with and overcome. These conquests often provide strengths to build on. What they have avoided in life may reveal their felt deficiencies.

After the first interview, I review my notes and try to imagine a line of psychological movement leading from the patient’s memories of childhood, through the present situation and difficulties, to a future goal of ultimate compensation, significance, and security. I try to connect to this line all of the patient’s thinking , feeling, and actions, including their attitude toward me and the task of therapy.

For example, a man in his mid 40’s was referred to me after completing an out-patient alcohol treatment program. He was very frustrated with his career as a criminal investigator, experienced very little intimacy with his wife, and had no friends. Although he conducted extremely thorough investigations that resulted in convictions, sentences rarely included jail time.

His cold and isolated childhood left him very bitter: an unhappy mother; a remote father; and a hell-raising older brother whom he hated, but who was the center of the parents’ attention and frequently got away with illegal behavior. By contrast, he was a compliant child who didn’t make any trouble, and was ignored.

The felt neglect of his father and lack of love from his mother were at the roots of his inferiority feelings. His life style was catching many “bad guys” and seeing that they were locked up. Since many were not, he was perpetually frustrated. He also viewed his parents and brother as unpunished criminals. His unconscious goal was to secure compensation and revenge for his miserable childhood. Revenge was not working out to his satisfaction, but he did look forward to the compensation of a comfortable retirement, a symbol of what he felt entitled to.

His attitude toward me was guarded and minimally expressive. What made him competent in surveillance work, observing others without being seen, was a handicap in making a personal relationship. Two strengths could be built on — he had conquered both alcohol and nicotine dependencies.

In general, my early guesses are either confirmed or modified in subsequent sessions as I gain more detailed information, which includes a written questionnaire. Frequently, a binocular view of oral and written information is very useful.

A more refined evaluation emerges within the first few weeks, since I spend a good deal of time organizing, analyzing, and synthesizing the case material. This process is facilitated by the use of computer software programs, resulting in a series of conceptual maps: a multi-generational genogram that clarifies family member descriptions and relationships; a time-line diagram that highlights significant positive and negative events; and a matrix that organizes my conclusions about the patient’s style of life, including: inferiority feelings, compensatory fictional goal, level and radius of activity, use of symptoms and emotions, degree of community feeling, private logic, earliest recollections, and the antithetical scheme of apperception. These maps provide an on-going guide for treatment planning.

OL: Your vignette makes the Adlerian assessment process crystal clear. I know from what you have said elsewhere that you view therapeutic intervention as an “art” and therefore it must be a harder to characterize briefly. I am stuggling to frame a question that will get at this…… How about this: Could you spell out a couple of frequently used interventions and indicate the circumstances in the therapy that would signal you when to use them? (If you feel that a different question would take us to the heart of the matter, please answer it instead.)

STEIN: At the first meeting, I frequently ask Adler’s favorite diagnostic question: “If you no longer had your symptoms, what would you do?” In their answers, patients frequently reveal the problems or responsibilities that they are trying to avoid.

In the early stages of treatment, after establishing an empathic connection, I use a therapeutic adaptation of Socratic questioning to help patients clarify meanings and feelings, recognize the purpose of emotions and actions, identify the consequences of behavior, and generate alternative solutions to problems. There are over fifty Socratic strategies that utilize a series of leading questions to help patients reach their own conclusions. To illustrate one, testing the validity of behavior by multiplying it, I asked a man who liked speeding and running red lights, “What would happen if everyone did the same thing?”

In the middle stages of therapy, after patients achieve more confidence through a series of encouraging new successes, I gradually unfold an interpretation of their style of life and fictional final goal. Earliest childhood recollections offer fertile opportunities for discussing the concrete situations, feelings, and actions that embody the life style. They can also provide effective springboards for launching new attitudes and behaviors.

A very passive, pampered patient recalled a memory of early childhood that vividly expressed his demanding, expectant attitude. He remembered lying in bed on a cold winter morning, refusing to get up until his grandmother warmed his underwear in the oven. We first discussed the meaning of this memory, and then he tried to imagine several alternative scenarios, including one of getting up early to help his grandmother build a fire. He gradually realized that simply being cute and sad would not bring another pampering grandmother into his life, and that there was a new form of reciprocal gratification more suitable to an adult man.

I frequently have to invent strategies that fit the uniqueness of the patient and the moment. A severely depressed young man came to me after seeing many psychiatrists over a period of fifteen years. After working with him for nearly a year, he complained, “No has ever understood me!” Knowing that he had an appreciation for drama, I proposed that I play him and recite a soliloquy of his inner thoughts. He was intrigued and agreed to have me do it. For about five minutes, I expressed his private logic, attitudes, and feelings about his family, then concluded with his opinion of me. He was very adept at denying the more traditional therapeutic expressions of empathy and insight, but this unexpected form got through to him.

Another case may help illustrate the potential variety in presenting interpretation. A young boy had killed a small pet at school. He lived in a very aggressive, competitive family. His deep anger could not be openly expressed at home. Hand puppets permitted him to express a great deal of murderous rage safely in my office. He selected “Dracula” to kill my collection of thirty puppets. Over a period of weeks, he gradually selected less aggressive characters, who first protected each other, and later on played together. When I felt he was ready to understand why he had killed the animal, I selected a “Wise Old Owl” puppet to Socratically guide him into insight. His appreciation for my help was expressed through a very affectionate “Puppy Dog” puppet.

The most effective Adlerian interventions are creative applications of Adler’s basic principles. To achieve significant cognitive, affective, and behavioral change, we do not follow any by-the-numbers procedures. We have to invent the means of accomplishing many therapeutic tasks that include: providing constant encouragement, reducing inferiority feelings, increasing the feeling of community, re-directing the striving for superiority, promoting the feeling of equality, interpreting the purpose of behavior, and stimulating social contribution.