Dr. Michael J. Greenberg drmichaeljgreenberg.com Complete Articles — All 31 pieces in one readable PDF OCD Treatment: Rumination-Focused ERP & Psychoanalytic Integration Table of Contents 4 Understanding OCD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 A Simple Explanation of OCD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 The Core Fear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Malan's Model of OCD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Three Types of OCD Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 OCD as a Defense Mechanism 21 RF-ERP . . . . . . . . . . . . . 21 Rumination-Focused ERP: Turning Exposure On Its Head . . . . . . . . . . . . . . . . . . . 23 Targets and Rationales for RF-ERP Exposures . . . . . . . . . . . . . . . . . . . . . . . . 26 Defining and Demarcating Compulsion . . . . . . . . . . . . . . . . . . . . 29 Rumination-Focused Case Conceptualization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 RF-ERP Order of Operations 34 Pure O & Compulsive Rumination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Understanding Pure O: You Are Not Having Intrusive Thoughts All Day, You Are Ruminating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Defining Rumination 37 Rumination is a Compulsion, Not an Obsession, and That Means You Have to Stop Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 How to Stop Ruminating . . . . . . . 43 I Know How to Stop Ruminating but I Can't Seem to Stop All the Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 RF-ERP Preliminary Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 How to Stop Paying Attention . . . . . . . . . . . . . . . . . 52 Awareness, Attention, Distraction, and Rumination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 'Thought Suppression' Has Nothing to Do with Rumination, so Why Does It Feel like You Can't Stop? . . . . . . . . . . . . . . . . . . . . . . . . . 57 How are You Justifying Rumination? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Causal Justifications . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Anatomical Models of Rumination . . . . . . . . . . . . . . . . . . . . . . . . . 66 What to Do When You're Triggered 69 Why ACT and Other Mindfulness-Based Interventions are Not the Solution to 'Pure O' 72 Other Types of OCD . . . . . . . . . . . . . . . . . . 72 Treating Sensorimotor OCD (AKA Somatic OCD) . . . . . . . . . . . . . . . . . . . . . 75 When You Have OCD but You're Not Afraid of Anything: Treating 'Just Right' OCD, Random Rituals, and Compulsive Behavior . . . . . . . . . . . . . . . . . . . . . 78 Treating Two Types of Contamination OCD 80 Miscellaneous 80 It Matters How We Talk About OCD: The Importance of Using Language of Agency . . . . . . . . . 82 Rethinking the Process and Treatment of Compulsive Rumination . . . . . . . . . . . . . . . . . . . . . . . . 85 Why Rumination is a Continuous Loop . . . . . . . . . . . . . . . . . . . . 87 Exposure Is About Learning, Not Habituation . 89 Using Imaginal Exposure When Practicing ERP from the Perspective of Learning Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 4 Understanding OCD A Simple Explanation of OCD https://drmichaeljgreenberg.com/a-simple-explanation-of-ocd/ Many people think that OCD symptoms are random. They are not. The goal of this article is to provide a simple framework for beginning to see the coherency in these symptoms. The framework begins with the idea that everyone has a worst fear. While most people would describe their worst fear in terms of a concrete event (e.g., losing a loved one, going to jail, losing all their money, getting cancer, going to hell, etc.), what they really fear the most is the emotional state they associate with that event, and their actual worst fear would be experiencing that emotional state forever. People with OCD are afraid of making a mistake that they can't take back, one that would lead them to experience their most feared emotional state forever. This is their Core Fear. The person with OCD avoids doing anything that could potentially lead to their Core Fear (avoidance), and feels compelled to do things to protect themselves from their Core Fear (compulsions). OCD symptoms are thus strategies that the person with OCD uses to protect themselves from their Core Fear, whatever that might be. The person with OCD is like someone with a gun to their head. They are so terrified of what could happen if they didn't do these strategies that they lose any sense that they have a choice about whether they do. Put another way, they lose their sense of agency. Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 5 The person's subjective lack of agency regarding their symptoms worsens as they've been doing those symptoms for a longer and longer time, because they have so many experiences of feeling as though they don't have a choice about doing them. Furthermore, as time goes by, they may not remember what they were so afraid of (if they ever even knew). Not understanding why they're doing what they're doing only adds to the feeling of not having control. OCD symptoms can be exhausting and limiting, and can cause excruciating anxiety. But perhaps the worst part of OCD is this feeling of total powerlessness to exert any control over them. We treat OCD by restoring a person's sense of agency, or control. Rumination-Focused ERP (RF-ERP) helps restore a person's sense of agency by helping them to understand why they engage in their symptoms and by systematically helping them to exercise control over those symptoms. Sometimes this requires teaching them how to exercise control (e.g., how to stop ruminating). Other times it just requires helping them to do things, or not do things, despite how terrified they are of the potential consequences. While simple explanations leave a lot out, I hope the above will serve as a starting point for discerning the coherency in OCD symptoms. More in-depth perspectives can be found in the articles on Malan's Model of OCD, The Core Fear, Three Types of OCD Cases, and Targets and Rationales for RF-ERP Exposures. Notes * An exposure may also provide an opportunity to disconfirm an expected negative outcome of a certain behavior, but RF-ERP does not see this as the primary way that exposure works. Moreover, it is not always possible to prove that doing X won't lead to Y. In RF-ERP the primary goal of exposure is to learn that you have a choice, regardless of the outcome. Please note that this article is for your information only and does not constitute clinical advice or establish a patient-psychologist relationship. Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 6 The Core Fear https://drmichaeljgreenberg.com/the-core-fear/ Understanding the Core Fear is foundational to effective treatment of OCD, and can unlock even the most baffling cases. Dr. Elna Yadin introduced the idea that each person with OCD has a 'Core Fear,' and that their avoidance and compulsions are aimed at preventing it. This idea is very powerful, because OCD symptoms can seem very random and nonsensical, but when you see them as strategies aimed at preventing the Core Fear, they suddenly make a lot of sense. According to Dr. Yadin, the most common Core Fears are ruining (causing irreversible damage), suffering, being bad in some way, being completely alone, and death. Though I fully agree with Dr. Yadin's idea that each person with OCD has a Core Fear, I have a somewhat different perspective on what that means. Avoided Emotion Based on my experience, I believe that the Core Fear is always a form of emotional suffering, and that even if a person endorses a concrete event as their worst fear, what they are really afraid of is some specific form of emotional suffering associated with that event. More specifically, they are afraid of doing something that would lead to being in that state of emotional suffering permanently. The specific type of emotional suffering that an individual most fears can be highly individual. It is typically a form of emotional suffering that they have experienced themselves or witnessed someone else experiencing. Some common examples are: • Feeling judged, ashamed, or rejected Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 7 • Feeling disconnected, untethered, alone, or abandoned • Feeling hopeless, helpless, or trapped • Feeling contaminated, uneasy, or 'off' • Feeling inferior, not good enough, worthless, or like a disappointment • Feeling how I felt when X happened, when I was abused, etc. • Feeling vulnerable (e.g., to shame, rejection, or harm) When the person perceives something as a potential path to experiencing this form of emotional suffering permanently, they attempt to prevent this from happening, via either avoidance or compulsion. When for some reason they begin to experience this form of emotional suffering, they frantically try to escape it through the same means. To summarize what's been said thus far about the Core Fear: • Each person has only one. • It is a specific form of emotional suffering. • The person is afraid of experiencing this state of emotional suffering permanently. • A person is triggered by anything that causes them to feel that form of emotional suffering in the present, or represents a potential avenue to experiencing that state of emotional suffering permanently, in the future. • All forms of avoidance and compulsion are attempts to protect the person from experiencing this form of emotional suffering permanently. Why is it so important to identify the Core Fear? In my experience, I have found that identifying the Core Fear, and figuring out how all forms of avoidance and compulsion are aimed at preventing it, makes ERP more precise, more effective, and faster. It is one factor that significantly reduced the number of sessions I need to treat someone with OCD. I believe that the main reason it's so important to identify the Core Fear is that OCD treatment is about choosing to take risks, and you can't choose Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 8 to take a risk if you don't know what the risk is that you're taking. Here are several other reasons it is so important to identify the Core Fear: • It helps the therapist and patient to develop a simple and accurate case formulation. • It enhances the patient's sense of agency by showing them that their symptoms are actually strategies that they are using to protect themselves, and that they could choose to let go. • By identifying the goal of the avoidance and compulsions as avoiding emotional suffering, it allows the patient to assess that their strategies are backfiring by causing emotional suffering. • Mapping out the causal connection between the trigger and the Core Fear underscores the unrealistic nature of the sequence of events that would have to go perfectly and irreversibly wrong in order to arrive at the Core Fear. • Identifying the outcome that is expected to occur without compulsion/avoidance provides the opportunity to see that this outcome didn't happen. • Identifying the Core Fear facilitates precise exposure exercises. • It allows you to catch subtle manifestations of avoidance and compulsion that might not have been identified as symptoms but are important to address as part of treatment. • For all of the above reasons, it helps cultivate the willingness to let go of avoidance and compulsion and to participate in ERP. So how do you identify the Core Fear? Below are the steps I use to identify the Core Fear with my patients. • Monitor: Trigger → Feared Outcome → Behavior (Avoidance or Compulsion) • Review the monitoring and for each Feared Outcome, identify the worst possible personal consequence, and how the person would feel if that happened. Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 9 • Identify the feelings that all of these have in common. • Ask the patient if they can connect that feeling to one or more painful early experiences. • Go back to any symptoms that don't seem to be connected to the hypothetical Core Fear and see if the patient can figure out how they might indeed be connected, or adjust the hypothetical Core Fear to fit them in. • If you have the right Core Fear, everything will fit. • The Core Fear should ring true to the patient. • Consider asking the patient to monitor their symptoms again with the hypothetical Core Fear in mind, and to either confirm that the hypothesis fits, or bring in examples of symptoms that don't seem to fit. • Adjust or refine the hypothesized Core Fear as needed. • Start ERP work based on your hypothesized Core Fear, but remain open to revising it in light of new information. In my experience, identifying the Core Fear has been a key factor in making ERP more precise, and consequently faster and more effective. Please note that this article is for your information only and does not constitute clinical advice or establish a patient-psychologist relationship. Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 10 Malan's Model of OCD https://drmichaeljgreenberg.com/malans-model-of-ocd/ Published December 2022 In his book Individual Psychotherapy and the Science of Psychodynamics, Dr. David Malan offered a simple model for conceptualizing the emotional and relational dynamics underlying OCD. This article presents my simplified version of Malan's model, largely loyal to the original but filled in and slightly adjusted. I have found this model to be very helpful in identifying some of the emotional and relational factors contributing to people's OCD symptoms. The Basics: Emotional Conflict and Repetition Emotional Conflict Malan's model is based on the idea that a psychological symptom is the result of an emotional conflict. An emotional conflict means that allowing oneself to feel what one would naturally feel would lead to a painful emotional consequence. In order to resolve this conflict, the natural feeling is given expression in a way that somehow manages to avoid the painful emotional consequence. To accomplish this, the natural emotion is transformed or disguised in some way. Passive aggression is an easy example. Let's say a person feels angry at another person, but feeling angry at them evokes shame or a fear of retaliation. Passive aggression gives expression to their anger while avoiding those consequences. In this model of psychopathology, psychological symptoms serve the same function as passive aggression: They give expression to a natural feeling in a way that manages to avoid a painful emotional consequence. Behind every psychological symptom is a healthy, natural feeling that isn't being felt or acknowledged. Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 11 To summarize, there are three parts to this model: • The natural feeling (How would a person naturally feel in a given situation?) • The painful emotional consequence (Why can't they feel that way? What painful emotional consequence are they afraid of?) • The symptom (What happens that manages to express the natural feeling while avoiding the painful emotional consequence?) Repetition Psychodynamic/psychoanalytic theory maintains that people tend to repeat the same emotional and relational patterns over and over again. This indicates that whatever emotional conflict is driving a current symptom will be similar to emotional conflicts the person has experienced in the past, and also similar to emotional conflicts the person currently experiences in other areas of their life. Turning to OCD In order to apply this model to OCD, we first need to introduce the concepts of attachment and healthy aggression. People have two sets of needs in relationships: We need to be connected to other people, and we need to protect ourselves and get our individual needs met. We'll use the terms attachment and healthy aggression to refer to these two sets of needs. Examples of healthy aggression include: • Feeling/expressing needs and wants • Feeling/expressing anger when one's needs and wants aren't met • Taking for oneself (satisfying one's own needs and wants) • Feeling/expressing personal boundaries and setting limits • Feeling/expressing anger or disagreement • Feeling/expressing disappointment in another person; recognizing the bad in others; ambivalence • Feeling/expressing the need to be autonomous; separating from others Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 12 • Feeling/expressing sexual needs and wants According to Malan, when feelings of healthy aggression cannot be felt or acknowledged because they pose a threat to attachment, these feelings may manifest as OCD symptoms. To illustrate this, here are some common examples: • Many people with harm OCD are unable or afraid to feel or acknowledge normal, healthy anger towards people they love. • Many people with relationship OCD are unable or afraid to feel or acknowledge normal, healthy ambivalence towards a loved one. • Many people with contamination OCD are unable or afraid to feel or acknowledge normal, healthy feelings about having their boundaries violated in some way. Before going any further, I want to make the following abundantly clear: None of the above means that a person's obsessions are true. For example, it does not mean that the person with OCD about killing their baby actually wants to kill their baby. Rather, it means that the symptom reflects a natural, healthy feeling that the person is unable or afraid to feel or acknowledge. Integration with ERP I am not recommending that we replace ERP with psychodynamic/psychoanalytic therapy. I am recommending that we enhance ERP by integrating everything that psychodynamic/psychoanalytic theory and therapy can contribute to our understanding and treatment of OCD. Malan himself called for such an integrative approach, writing that 'perhaps the treatment of the future will be a combination of behaviour therapy with dynamic psychotherapy.' It makes me sad that Malan died in 2020, and that I just missed the chance to tell him that such an integrative approach is now available. Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 13 Specific ways of using a psychodynamic/psychoanalytic approach to enhance ERP include: • Facilitating exposure: Turning healthy aggression (any specific form the person is afraid of) into an exposure — saying no or setting boundaries, expressing needs or wishes, expressing anger, criticism, or disappointment, doing something autonomously, etc. • Facilitating response-prevention: Not understanding why we are doing a certain compulsion can make us feel out of control. Conversely, understanding why we are doing what we are doing can help restore our sense of agency and control over our behavior, which can in turn make it easier to stop. • Helping patients navigate internal experiences: While ERP provides guidance about our behavior, it doesn't provide much guidance about what to do with our emotional experiences. Works Cited Bowlby, J. (1980). Attachment and loss. Basic Books. Malan, D. H. (1979). Individual psychotherapy and the science of psychodynamics. Butterworth. Winnicott, D. W. (1994). Hate in the counter-transference. Journal of Psychotherapy Practice & Research, 3(4), 350-356. Please note that this article is for your information only and does not constitute clinical advice or establish a patient-psychologist relationship. Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 14 Three Types of OCD Cases https://drmichaeljgreenberg.com/three-types-of-ocd-cases-2/ Published December 2022 As discussed in The Core Fear, an individual's OCD symptoms are aimed at avoiding a specific form of emotional distress, or Core Fear. And as discussed in Malan's Model of OCD, OCD symptoms are aimed at preventing a loss of attachment. So is the Core Fear always a loss of attachment? The answer is that while the fear of losing attachment is always in the background, loss of attachment is not always the form of emotional distress around which symptoms are organized. This article discusses three types of cases, or three different ways in which symptoms may be organized: • Cases in which loss of attachment is the Core Fear (meaning symptoms are organized around avoiding the pain that would come from being without attachment) • Cases in which vulnerability to loss of attachment is the Core Fear (meaning symptoms are organized around avoiding the distress of feeling vulnerable to losing attachment) • Cases in which the feeling of the symptom itself is the Core Fear (meaning symptoms are organized around avoiding the distressing feeling associated with a symptom) Type 1: When Loss of Attachment Is the Core Fear In many cases, the Core Fear is indeed some individual version of loss of attachment. This means a person's symptoms are organized around avoiding the pain of being without attachment. Because this is a highly individual, subjective experience, we cannot simply say that the Core Fear is loss of attachment and leave it at that. Rather, we have to elicit the patient's personal Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 15 version of this feeling. Type 2: When Vulnerability to Loss of Attachment Is the Core Fear In other cases, the Core Fear isn't loss of attachment, but rather vulnerability to loss of attachment. In these cases, the person prioritizes stability over attachment. If there's a chance of losing attachment, they'd rather just get it over with. For these people, the most distressing feeling is, metaphorically, lying in bed with the front door open, or walking around waiting for something to knock you down. It's important to understand what is going on in these cases because otherwise the person's behavior may sometimes seem completely irrational. For example, they may fear being alone, but then avoid relationships; or if they are attached, they may do things to sabotage that attachment, or reject themselves before they can be rejected. It's also important to note that in these cases, a person may feel unsafe when they are not anxious, because they feel as if they are letting their guard down. In other words, feeling anxious feels safe, and not feeling anxious feels unsafe. When this is the case, it is important to help the person become aware of this conflict regarding letting go of rumination, as well as how they may unconsciously search for something to worry about. Type 3: When the Feeling of the Symptom Itself Is the Core Fear Finally, in some cases the Core Fear is the distress associated with the symptom itself. These people often say they aren't afraid of any external consequence, they're just afraid of being trapped in the symptom forever. This is often the case in sensorimotor cases, certain types of contamination, and 'just right'/random ritual/compulsive behavior cases, as well as many emetophobia cases. Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 16 I believe that cases like this may result when a person has experienced their symptoms as posing a threat to attachment; for example, if a person is rejected, shamed, or invalidated for their symptoms. I think of these as 'double conflict' cases, because there is an underlying conflict that produces the symptom, and then there is another layer of conflict associated with the symptom itself. An upsetting but common example of this is when parents react to a child's symptoms by blaming the child for not working on their anxiety, not wanting to get better, or not doing their exposure homework. This reaction to symptoms can collude with the dynamics driving the symptoms, and make things even worse. Conclusion I believe that understanding how symptoms are organized is an essential part of conceptualizing an OCD case. It helps restore a person's sense of agency by helping them to understand why they are doing what they are doing, helps in designing a more effective behavioral intervention, and helps identify underlying emotional and relational factors to be addressed as part of treatment. Please note that this article is for your information only and does not constitute clinical advice or establish a patient-psychologist relationship. Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 17 OCD as a Defense Mechanism https://drmichaeljgreenberg.com/ocd-as-a-defense-mechanism/ Published March 2025 In Malan's Model of OCD, we introduced the idea that OCD functions as a defense mechanism that negotiates an emotional conflict. In this article we'll go into further detail regarding the origins of emotional conflicts and how OCD functions as a defense. We'll then use that understanding to conceptualize a psychoanalytic approach to treatment. Digesting Emotions When we are infants, we don't have any understanding of our feelings. We just experience the physical sensations of those feelings. For example, when a baby is hungry, they experience the painful, distressing sensations associated with hunger — but they don't have any understanding of what's happening to them. If all goes well, the baby cries and the parent understands that the baby is hungry, responds in a way that reflects that understanding, and conveys that the feeling in no way threatens the relationship. Over time and through repetition of this process, the baby develops their own understanding of what they are feeling, and develops the sense that the feeling can be experienced within relationships, without overwhelming or alienating the other person. Metaphorically, this process develops our ability to digest those feelings. When we can do so, experiencing them is painless and easy: We feel the feeling and we effortlessly move on to the next moment. There's no problem and no need to do anything. Emotional Intolerances If the above process is what makes feelings tolerable, breakdowns in this process are what make certain feelings intolerable. For example, if our caregiver Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 18 reacts with anger, distress, dismissal, or withdrawal, we may develop the sense that that feeling threatens our relationships with other people. The difference between food and feelings is that we can't actually get rid of a feeling. The most we can do is use defense mechanisms to keep the feeling out of our conscious experience. Defense mechanisms accomplish this by either preventing us from consciously experiencing the feeling, or by preventing us from understanding what we are feeling. All of this happens unconsciously. To any reader with OCD: No, this does not mean that your obsessive fear is true. It means that your obsession is actually there to protect you (perversely, to be sure) from some completely natural and healthy feeling that is intolerable to you because you never developed the capacity to digest it. Displacement 'Displacement' is a defense mechanism that moves our feelings away from their original context to a new context. Displacement accomplishes this by moving the feeling to a symbolic context that in some way captures the feeling — at a safe distance from its original context and meaning. An example: someone who has an intolerable feeling of anger at their family, and becomes preoccupied with an obsession that they have left the stove on and will burn down the house. Undoing While many different psychological symptoms could be conceptualized as involving displacement, it's 'undoing' that is the real hallmark of OCD. Undoing is an attempt to neutralize an intolerable feeling. In OCD, undoing often happens in the context of displacement. Returning to the example above, the person who becomes preoccupied with an obsession that they may have left the stove on (displacement) then repeatedly turns the stove off (undoing). Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 19 Needless to say, turning the stove off over and over again can never actually get rid of a person's anger. That's why a compulsion never feels satisfactory and never makes the obsession go away — because it was never about the stove. That's also why OCD gets worse in times of stress — not simply because a person is depleted generally, but because whatever experiences are causing the stress are also evoking certain intolerable feelings, and the person's need to displace those feelings inflates their OCD symptoms. How Psychoanalytic Treatment Works In the simplest terms, having someone hold us while we experience a feeling is what develops our capacity to hold that feeling within ourselves. And in the simplest terms, psychoanalysis is about being held by someone while we hold our feelings. Through this process, we develop the ability to digest feelings instead of trying to get rid of them, and in this way feelings that were previously intolerable become tolerable. Integrating RF-ERP and Psychoanalysis How do we reconcile the above, which emphasizes the need for help, with RF-ERP, which emphasizes agency? Technically, there's no contradiction: We can control our behavior even when it feels like we can't, and we can't control our unconscious feelings. Integrating RF-ERP with psychoanalysis requires holding both in mind, moving between them, and allowing them to influence each other. Conclusion The psychoanalyst could say to the behaviorist: Congratulations! Your patient has stopped checking the stove ... but they still can't tolerate being angry at someone they love, so have you really addressed their problem? Dr. Michael J. Greenberg • drmichaeljgreenberg.com Page 20 And the behaviorist could say to the analyst: Congratulations! Your patient is beginning to acknowledge angry feelings in their relationships ... but you've been seeing them for quite a while and they're still spending hours each day checking the stove, so have you really addressed their problem? And both of them would be right. Each of these approaches has an advantage and a limitation. I propose that there is no need to choose between them, and that we can help our patients the most by bringing these approaches together. Works Cited Klein, M. (1946). Notes on some schizoid mechanisms. The International Journal of Psychoanalysis, 27, 99-110. Little, M. (1951). Counter-transference and the patient's response to it. International Journal of Psycho-Analysis, 32, 32-40. Malan, D. H. (1979). Individual psychotherapy and the science of psychodynamics. Butterworth. McWilliams, N. (2011). Psychoanalytic diagnosis (2nd ed.). Guilford Press. Winnicott, D. W. (1965). The maturational processes and the facilitating environment. International Universities Press. Please note that this article is for your information only and does not constitute clinical advice or establish a patient-psychologist relationship.