Promoting the Patient’s Capacity to Suffer:A Revision of Contemporary Notions of

Psychotherapeutic Aim

James Tobin, Ph.D.Licensed Psychologist PSY 22074220 Newport Center Drive, Suite 1

Newport Beach, CA 92660949-338-4388

Assistant Professor of Clinical Psychology601 South Lewis Street

Argosy UniversityOrange, CA 92868

714-620-3804

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Evidence-Based Practice

• Ours is an environment of evidenced-based practice and managed care (APA Presidential Task Force, 2006; Hunsley, 2007).

• Symptom reduction and demonstration of progress: “the standard of care.”

• If progress doesn’t occur, something is wrong with the psychotherapist’s abilities or the treatment provided or both (see Wachtel, 2010).

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An Atmosphere of Pressureon Therapists-in-Training

• Not only to diagnose, intervene, and help, but to cure (the helping profession has become the curing profession).

• Traditional notions of “abstinence” are not taught in training programs: the therapist acts upon the patient vs. promoting something within the patient (see Eisold, 2007).

• Supervision is largely goal-focused, not process focused.

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The Helping Profession, the Curing Profession

• Therapists-in-training place enormous expectations on themselves, many of which are misguided (see Misch’s 2000 paper “Great Expectations: Mistaken Beliefs of Beginning Psychodynamic Psychotherapists”), and many of which come from unresolved historical issues re: “treating/healing” a pathological caregiving figure (Miller, 1997).

• These characterological predispositions are activated in the current environment of symptom reduction and therapy outcome.

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The Therapist’s Role: To Relieve the Patient’s Suffering

• Assumptions and beliefs about therapeutic action and the therapist’s role: coping and resilience.

• Relieving the patient of his/her “suffering”– novice therapists want to help the patient feel better and do better.

• This is arguably a narcissistic position, i.e., both personally and professionally (it can be argued that it is more about us than about the patient).

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How Does This Way of Thinking about the Therapist’s Role Affect What We Do?

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Case VignetteSupervision Vignettes

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Sterile Therapy

Chad Kelland’s recent quote:

“You mean we can tell the patient what we really think?”

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Sterile Therapy

1. Affirming / validating the patient.

2. Avoiding CT / empathy based on identifications with the patient.

3. Press to keep the therapy space ordinary, not “extraordinary,” i.e., manners/politeness are emphasized (as featured in Stanley Kubrick’s films “The Shining” and “2001: A Space Odyssey”).

4. The therapist is inhibited and what the patient can handle is under-estimated!

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“Collusion of Resistance”

• These are “interactional resistances [that make the] psychotherapeutic work [revolve]s around noninsightful symptom relief, inappropriately shared defenses, enactments and gratifications” (Karlsson, 2004, p. 570).

• Karlsson (2004, p. 569) elaborates: “both [therapist and patient] unconsciously avoid understanding because they fear the understanding will create too much psychological pain.”

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Role Assignments in the Therapeutic Dyad

• Collusions of resistance have to do not only with avoidance of pain, but also with the pressure to stay in roles to maintain “the ordinary.”

• Therapist (healer) and patient (healing/healed). • Both clinical vignettes feature the emergence of

something that, for the supervisee, does not match the role they assume.

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“Two-ness” and the Need to Keep Things Ordinary

• The “two-ness” of the human condition inevitably puts pressure on the role assignment.

• The dyadic system is compelled to keep each person in their role.

• Anxiety ensues as the need to keep things ordinary mounts (inhibitions about harming or offending the patient by introducing something extraordinary).

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Kubrick’s Status-Quo

• The need to keep things ordinary is very strong and occurs all the time in clinical interactions and intrapsychic experiences.

• These phenomena manifest in avoidant behaviors (vignette #2) or in dissociative processes (vignette #1). In this context, dissociations are what is being “intuited” for fear of traumatizing the patient.

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If Not Symptom Reduction, Then What?An Alternative View of Therapeutic Action

1. The therapist must help the patient come into full contact with the reality of his or her experience and learn from it (see Bion’s 1962 text “Learning from Experience”).

2. This will likely cause the patient (as well as the therapist) suffering that each must bear.

3. The therapist’s main focus is to detect dissociated material (internally and relationally) and offer it to the patient in the form of what Renik (1996, 1999, 2006) calls “logical thinking” or “alternative constructions of reality” – the patient compares/contrasts the therapist’s constructions with his/her own. 14

If Not Symptom Reduction, Then What?An Alternative View of Therapeutic Action

4. The art of therapy involves learning how to move seamlessly back and forth between the patient’s narrative and alternative perspectives and areas of inquiry that emerge (this may cause suffering but non-traumatically so ….. ).

5. This involves role adherence and flexibility, i.e., shifting between the ordinary and the extraordinary, always being a “two” and knowing when and how to reveal your two-ness (C.K.)

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Therapists-in-Training: How to Utilize Their Two-ness Effectively

• Some novice therapists claim their “two-ness” too aggressively: a problem of “exhibition” (too little neutrality/poor tact/role avoidance).

• Others are reluctant to embody their two-ness and to use it as Renik advises: a problem of “inhibition” (hyper-neutrality/overly heightened tact and manners/role restriction).

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Shame is Gradually Replaced by Regret

• What patients most need is “location of the intuitions about reality that have not received adequate confirmation or support from others” (Eisold, 2005, p. 365).

• Shame can be viewed as the patient’s dissociated intuitions about experience that were avoided or denied by others (if the therapist also avoids/dissociates ….)

• Gradually increasing the patient’s (non-dissociated) contact with experience alters shame-based defenses, thereby promoting learning/suffering); this is the main theme of the film “Magnolia.”

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An Essential Paradox

• Our patients need to suffer what they have dissociated and not yet learned (the therapist detects dissociated material); paradoxically, the therapist cures by helping the patient suffer.

• For Freud, the goal of therapy is “determin[ing] the role we play in our unhappiness and the role assigned to fate” (Thompson, 2004, p. 149).

• “hysterical misery into common unhappiness” (Breuer & Freud, 1893-1895/1955, p. 305, as quoted by Thompson, 2004, p. 136).

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Supervision as Suffering

• The supervisee avoids multiple contacts with experience in therapeutic interactions with patients (including traumatic, shame-based identifications), i.e., colludes and dissociates.

• The supervisor is in conflict vis-à-vis the supervisee: he wants her to learn but not to be uncomfortable or to suffer.

• This leads to the ongoing tension re: staying in the ordinary (Kubrick) vs. moving into the extraordinary – a dilemma throughout supervision.

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Supervision as Suffering

• To the extent to which the supervisor can tolerate holding/containing the supervisee, and does not remain too rigidly attached to a role vis-à-vis the supervisee, he will capitalize on extraordinary moments as they emerge (not collude in resistance or dissociate from them) and non-traumatically offer them to the supervisee for exploration.

• This helps the supervisee see what she had been avoiding or dissociating, but perhaps also intuiting (shame transforms into regret and learning occurs).

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Supervision as Suffering

• The supervisor is also open to the supervisee’s capacity to pick up on avoidances/dissociations emanating from the supervisor, and does not respond defensively when the supervisee raises them.

• All of this models “a way of being” for the supervisee (an alternative view of therapeutic action) re: safety/discomfort she can internalize and use with her patients.

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Supervision as Suffering

• The two-ness of the supervisee is a reality the supervisor can never deny – role is replaced by process.

• This will allow the supervisor to exhibit when he would otherwise prefer to inhibit, and vice versa (a role flexibility or willingness to be used by the supervisee).

• This teaches the supervisee that the supervisor must locate and respond to the supervisee’s developmental needs, just as the supervisee must do so with her patients. 22

References

• APA Presidential Task Force on Evidence-Based Practice (2006). Evidence-based practice in psychology. America Psychologist, 61, 271-285.

• Bion, W.R. (1962). Learning from experience. London: Heinemann.

• Eisold, K. (2007). The erosion of our profession. Psychoanalytic Psychology, 24, 1-9.

• Eisold, K. (2205). Using Bion. Psychoanalytic Psychology, 22, 357-369.

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References

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• Karlsson, R. (2004). Collusions as interactive resistances and possible stepping-stones out of impasses. Psychoanalytic Psychology, 21, 567-579.

• Hunsley, J. (2007). Addressing key challenges in evidence-based practice in psychology. Professional Psychology: Research and Practice, 38, 113-121.

• Misch, D.A. (2000). Great expectations: Mistaken beliefs of beginning psychodynamic psychotherapists. American Journal of Psychotherapy, 54, 172-203.

• Miller, A. (1997). The drama of the gifted child. The search for the true self. New York: Basic Books.

References

• Renik, O. (1999). Getting real in analysis. Journal of Analytical Psychology, 44, 167-187.

• Renik, O. (1996). The perils of neutrality. Psychoanalytic Quarterly, 65, 495-517.

• Thompson, M. Guy (2004). Happiness and chance: A reappraisal of the psychoanalytic conception of suffering. Psychoanalytic Psychology, 21, 134-153.

• Wachtel, P. L. (2010). Beyond ‘ESTs’: Problematic assumptions in the pursuit of evidence-based practice. Psychoanalytic Psychology, 27, 251-272.

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