The
Concept of Generic Psychotherapy The
Concept of Generic PsychotherapyA metaphor underlying the concept of generic psychotherapy is the distinction between a brand name drug and the generic compound or compounds of which it is composed. The basic aim of generic psychotherapy is to find the essential active ingredients in each form of psychotherapy. It is my hope that a manageably small set of fundamental parameters can be found that be can be used to explain the therapeutic action across the various brands of psychotherapy. What is being explored are the commonalties which operate in the various therapies. Brand names can be thought of as -- behavior therapy, psychoanalysis, interpersonal psychotherapy, etc. etc. The generic elements have to do with the varieties of therapeutic relationship, specific technical interventions like, reflection, interpretation, desensitization, and so forth. There are other efforts similar to the set of basic concept being put forth in generic psychotherapy. These movements have been called "technical eclecticism", "theoretical integration", and "common factors".
Theoretical integration involves a commitment to a conceptual or theoretical creation beyond a technical blend of methods. The goal is to create a conceptual framework that synthesizes the best elements of two or more approaches to therapy. Integration, however, aspires to more than a simple combination; it seeks an emergent theory that is more than the sum of its parts, and that leads to new directions for practice and research (Norcross & Goldfried, 1992 p. 11-12).
The common factors approach seeks to determine the core ingredients
that the different therapies share in common, with the eventual
goal of creating more parsimonious and efficacious treatments
based on those commonalties. This search in predicated on the
belief that commonalties are more important in accounting for
therapy outcome than the unique factors that differentiate among
them (
p. 13)
For an extensive review of these concepts see Norcross & Goldfried, 1992
.
The question then arises as to how the notion of generic psychotherapy
differs from eclecticism, integration, and common factors. Clearly,
there is much overlap. However, I think of generic psychotherapy
as a basic science of psychotherapy. An important emphasis has
to do with how to think about the various concepts found in psychotherapy,
and about how to relate them to basic thought that runs throughout
science. These modes of thought leads one to both bottom up reductionism,
and a to top down transpersonal world view. The meta concepts
begin to provide a kind of theory about theories. The interest
is in the essential experiences that all therapists see. A basic
thrust is to help therapists remove the filters of their theories
and move to a more immediately direct of experience of what is
happening in the treatment. The various theories chunk the clinical
experiences together differently. Rather than treating symptoms
as an emphasis generic psychotherapy is more concerned with what
clinical operations help a patient open up; what helps the patient
alter his or her relation to whatever he or she may be experiencing.
The particular content or the specific symptom is less central
than how the patient relates to their experience. The focus shifts
from a nosology of illness and a treatment armamentariun to experience
centeredness. This does not mean that one discards conceptual
maps, but it does mean that one does not act as if the maps were
reality itself.
Some navigational aids are needed to help find ones way in the
complex landscapes of the various realms of psychotherapy. These
aids can take the form of a set of fundamental concept which begin
to define the dimensions of psychotherapy space.
There are several basic considerations to help order ideas in
the domain of psychotherapy. But first it should be noted that
in keeping with the philosophy of these pages, which is a work
that continues to evolve, these are not exhaustive or definitive
lists. They are subject to your additions and corrections,
and most of all we need your examples
of applications of the concepts. So please read and respond.
A theory of normal psychological development provides the context
into which theories of illness and of therapeutic action can be
set. If one does not have a sense of what is considered normal
it is impossible to delineate what would be considered pathological.
The most comprehensive model of development that I know of is
Ken Wilber's "full-spectrum" model of growth and development.
Probably the best place for the reader to begin to get into the
richness and complexity of Wilber's thought would to start with
Transformations of Consciousness (Wilber, Engler, &
Brown 1986). In important concept in Wilber's model is that the
Western psychology only provides a limited view of human development.
Both Eastern and Western spiritual traditions describe the development
of consciousness beyond mental and rational thought to spiritual
intuitive knowledge. A basic idea put forth in his book is the
distinction between treating "hysterical" (neurotic)
symptoms and treating "common unhappiness". The distinction
comes from a famous quote from Freud which appears at the end
of Studies in Hysteria where Freud says:
Thus, Freud's early view of cure using psychoanalysis, all be
it a major undertaking, only addressed symptom relief. It did
not address the broader issues of pervasive human suffering. Indeed,
Western psychology as a whole offers only a truncated view of
human development which offered little hope of treating common
unhappiness. Psychologies of higher consciousness, i.e. Buddhism,
offer, the prospect of transcending common unhappiness.Unfortunately,
Freud pathologized higher states of consciousness, confusing them
with regressive oceanic states. He fell into what Wilber calls
the "pre/trans fallacy":
This brings us to Wilber's full spectrum model. Wilber states:
Wilber gives three major components of development:
His idea of basic structures comes from what has been called the
Great Chain of Being. Different versions of this idea give different
numbers of structures, i.e. matter and spirit, or matter, mind
body, and soul. Wilber gives ten basic structures:
(The above list was taken from Wilber in Wilber, Engler, &
Brown 1986, p. 69-74.)
Wilber goes on to explain the distinction between the basic structures,
outlined above, and transition states of self development:
Spelling out the implications of Wilber's model is a major undertaking.
However, considering higher the stages of development that he
outlines broadens our view of human development and gives the
possibility of positive psychological health as contrasted to
health being an merely the absence of pathology.
Generic psychotherapy seeks commonalties about the causes of psychological
dysfunction which are considered by the various therapeutic orientations.
It is important to keep in mind the distinction between nosologies
(classifications) of illness, such as the Diagnostic and Statistical
Manual of Mental Disorders DSM IV
which does not purport to catalogue causes of illness,
and theories of the causes the disorders. When one approaches
the study of theories of illness sorting out the layering of classification and process
becomes essential. A diagnosis emerges from relating clusters
or syndromes of internally felt (symptoms) and/or externally observed
(signs) to frequently observed patterns of disorder. The signs
and symptoms of the dysfunction are what is seen on the surface.
The theories are efforts to relate the felt and observable patterns
to some underlying process which give rise to them. Diagnoses
are not treated, people are. We do not treat an obsessive
compulsive or a depression. We do treat a patient who happens
to be feel depressed, or who gets caught up in compulsive rituals.
Thus we start with the patient's complaint. Then we try to figure
what is producing the complaint. That is, what underlying or overriding
processes are at work which emerges as the complaint, or in many
cases the complaints. Some important theories of illness
are:
Genetic and or congenital factors are very important factors which
have to be seriously considered in the understanding of any psychological
disorder. An in depth exploration of genetic or congenital conditions
is beyond the scope of this psychological approach. However, helping
the patient or client adapt to the limitations and redefine the
meaning of organic limitations is a central part of psychotherapy.
As with genetic and congenital factors, organic dysfunction has
to be recognized and given its full and due consideration in the
understanding of the impact that it has on psychological functioning.
The study of organic illnesses is beyond the realm of this work.
Nevertheless, working with the patient to adjust to the particulars
of organic impairment is very much part of a psychotherapeutic
intervention. An important area has to do with learning to recognize
the distinction between errors in brain functioning and the efforts
to cope with them. For example, some depressive disorders may
have to do with mood alterations which are the result of faulty
serotonin uptake. Learning to separate the depressed mood itself
from seeing the mood as an indication of self worth (I am no good
because I get depressed so often.) is very much the province of
psychotherapy.
Just as it is necessary to thoroughly take into account organic
factors, it is recognized that each of us functions in a cultural
surround. No individual can be adequately understood without a
deep appreciation of his or her cultural roots. However, cultural
concerns is not a central focus of generic psychotherapy. Indeed
one of the goals of a generic approach is to find a set of theories
which is global and cross cultural. This search does not deny
the richness, complexity, and importance of cultural diversity.
However, there is a set of basic human functions which is expressed
differently in the various cultures. Thus, I am trying to differentiate
the cultural stylistic differences from the essential psychological
processes. This is like the function argument distinction.
For example, the function addition requires two arguments,
i.e. 2,3 (2 + 3 = 5). Psychologically, the function self
esteem regulation calls for cultural arguments, i.e. machismo.
Machismo may be considered normal and healthy in one culture and
hugely dysfunctional in another. Nonetheless, the cross cultural
function, self esteem regulation, operates regardless of the specific
cultural values by which it is expressed. Loosing sight of the
logical level distinction between
the function and its argument can be the cause of much confusion
and controversy. In this case, self esteem regulation (the function)
is seen in all cultures. The particular values and attitudes which
are highly regarded (the argurments) may change from one culture
to another.
The most fundamental definition of trauma that I know is Freud's
conception of ego overload. The essential idea is that the ego
is being continually bombarded by stimuli. The ego acts as a "reducing
valve" which regulates the felt intensity of the stimulation.
When the intensity of the stimulation threatens the integrity
of the ego the situation is felt as being traumatic. In classical
psychoanalytic theory the stimuli may come from the outside in
the form of environmental stimulation. In addition there are stimuli
which come from the inside, the instincts, sex, aggression, and
the instincts of self preservation. In self psychological terms,
when the cohesion, stability and/or positive affective coloration
of the sense of self (Stolorow & Lachmann, 1980)
is breached, the self is threatened, and some kind of defensive
reaction is made. By this definition there is a whole range of
intensity of trauma. Maxi trauma include life threatening situations
of wars, natural disasters, and serious physical or sexual abuse.
Less obvious trauma include a whole range of personal hurts which
are felt as threats to feeling good about oneself (narcissistic
injury). It is also possible to be traumatized by the intensity
of ones own rage or sexual impulses. These responses are often
complicated by moral injunctions against aggressive and sexual
actions. Nevertheless, the power of a wish to kill a parent or
a child may have all the psychological impact of being threatened
with ones own death. Repression of
these impulses and or memories is an important source of symptom
formation.
It is important to note that development often does not
proceed equally across the whole range of physical-intellectual-social-emotional-vocational
development. i.e. One can have a serious genetic handicap and
yet develop high levels of intellectual capabilities. There are
spiritual leaders that have incredible psychic powers, but who
have difficulties with intimate personal relationships. Although
genetic, organic, cultural, social, economic, and traumatic factors
may distort development, a serious class of developmental derailments
emerge from repeated empathic failures that parents impose upon
their children. Alice Miller's Drama of the Gifted Child
(Miller, 1983) chronicled
the subtle abuses that children suffer at the hands of their parents'
narcissism. An important
developmental sequence has to do with the child having to adapt
to the parent's needs. Normally it is the parent who has to be
empathic to the child's needs. Unfortunately, parents frequently
have unresolved needs of their own and require their children
to provide them with emotional support. In order to maintain the
bond with the parent, the child sets its own needs aside and learns
to accommodate to the parent.
Thus the child either rebels at the cost of straining the bond
with its caretakers, or develops "structures of pathological
accommodation" where "sequestered nuclei of an archaic
self are preserved in conflict with, or in isolation from, the
unresponsive self objects" (Brandchaft, 1988 p.
135) In simpler language, the child splits off from its authentic
self and tries to please the parent by giving the parent what
he or she needs--at the cost of its own legitimate needs.
The notion of pathologies coming from excessive agency or excessive
community come from Wilber's ideas about holons.
Briefly, a holon is a whole which is part of larger wholes and
in turn contains smaller wholes. For example I feel myself to
be a separate reasonably autonomous individual. However, I am
part of a family which is part of a community. I am also aware
of having parts of myself--my body, my thoughts etc. I can believe
that I am so independent that I can disregard the concerns and
feelings of the people that are close to me. This could produce
a macho, or strong silent type mentality, which might be considered
a pathology of too much autonomy. The women's movement has been
eloquent in raising our consciousness to these patterns of relating
Jordan et al 1991.
Conversely, codependency is excessive community. That is, excessive
reliance on a family member, typically a spouse, to provide a
sense of self cohesion, stability, and positive feeling about
oneself. In simple language the person is overly dependent and
becomes seriously destabilized when their partner does not provide
them with a strong calming presence.
One of the best examples of state shifting is viewing an ambiguous
figure. Consider the Necker Cube. . .
As you look it is likely that you see the figure going either
up to the left or down to the right. When you see it one way it
is impossible to see it the other way. The one view locks out
the other. There is a tendency to get stuck in one of the views.
The ambiguous figure is a good metaphor for illustrating how we
tend to fall into old patterns and shift, sometimes unpredictably,
from one mode of responding to another. Sometimes we may feel
open, happy, and free. At other times we are constrained, anxious,
and tight. Each of these states seems to have a grip on us. When
we are open it is hard to think that we could be closed. When
we are tight and anxious it is hard to believe that the tension
will ever dissipate. It is difficult to change from the one state
to the other simply by an act of will. We tend to get "stuck"
in the one mode or the other. Predicting when there will be a
transition from the one state to the other does not appear to
be feasible.
Life is a grand ambiguous figure that we are continuously trying
to organize into meaningful configurations. There are clear adaptive
advantages to being able to form stable views. When you are driving
down the road you want to have clear stable vision. Indeed, we
become frightened when our percepts shift unaccountably or uncontrollably.
However, if your view did not get updated rapidly you would quickly
be in danger because you might be out of touch with changes in
the external reality. Similarly we tend to have specific views
of the people close to us. As we develop we may not update our
views to reflect what is happening currently. Thus, some forms
of illness can be seen as being chronically stuck in a maladaptive
state and not being able to shift to a more adaptive view. Moods
are another good example of states. When we are happy and enthusiastic
everything seems bright and it is hard to think of the dark side.
Conversely when you are depressed it is difficult to see the world
and yourself positively.
The following list is at the core of generic psychotherapy. These
are the basic concepts which can be found across the various therapeutic
modalities and orientations.
Undoubtedly the most important factor in any kind of psychotherapy
is the relationship. What is meant by the term "relationship"
and how it has a therapeutic efficacy are crucial questions. Essentially
the patient feels that a relationship is established when h/she
feels and believes that it is safe to disclose and explore aspects
of his or her self that are painful, shameful, and/or troublesome.
At best, coming for treatment is something of an insult because
there has been some difficulty with the usual way the patient
has been handling his or her life. Building a relationship implies
creating a safe space where the client can reveal more and more
of his or her authentic self. Fundamentally, the relationship
has to do with being in contrast to doing. The quality
of connectedness which permeates the relationship is more important
than what is done to or with the patient. In order for the relationship
to grow the therapist has to suspend his or her own personal concerns
and focus empathically on the client. Empathy has been called
"vicarious introspection". This requires the therapist
to be receptive to the patient and tune into the patient's shifting
inner experience and nuance of meaning. This process enables the
therapist to furnish profound understanding of the client's plight.
The therapist's understanding validates the patient's value as
a person who is genuinely suffering. It is very supportive and
reassuring to have someone truly understand your struggle. The
therapist's insight imparts a sense of competence. The patient
gets the feeling that at last I have found someone who hears and
believes me. This experience is reassuring and confers a sense
of hope. In its best form a sacred space is created in which the
therapy pair can relate to each in an I-Thou rather than
in an I-It manner.
Just what the therapeutic efficacy of the relationship is a major
question. There is nothing new to the insight that compassion
and love are healing. Something positive happens when two people
connect in a caring way. There is a distinction between healing
and therapy. Healing is a natural process. The healer provides
conditions under which homeostatic and growth processes can flourish.
Therapy has much more to do with technical intervention which
is directed to the mechanisms of the dysfunction. Lawrence LeShan
made a contrast between the gardener and the mechanic. The gardener
cultivates organic growth. The mechanic repairs broken parts.
There is a major distinctions between the therapies which make
the relationship (the transference) a major focus, the psychoanalytic
therapies, and the behaviorally oriented therapies which are more
symptom focused. In the behavior therapies once the relationship
"is established" it recedes into the background and
attention is centered on changing specific troublesome behavior
patterns. In the analytic therapies the relationship, or more
technically, the unfolding of the transference, is fundamental.
The objective is to establish conditions in which earlier relationship
patterns reemerge directly in the experience of relating to the
analyst. Then it becomes possible for the patient to see how he
or she is structuring the relationship in ways that repeat earlier
patterns of dysfunction.
Kohut stated "...the basic therapeutic unit of psychoanalysis
[consists] of the two steps understanding and explaining"
(Kohut 1984 p. 102). Clearly,
if the therapist fails to understand and/or can not convey his
or her understanding in terms that are meaningful to the patient
the therapeutic process will founder. Relationship is crucial
but insufficient. In Bettelheim's words, "Love is not enough".
Indeed, understanding and explanation help to create the
relationship itself. The therapists understanding is what guides
the therapeutic interventions. Explanation is a broader concept
than interpretation. Interpretation, in the narrower sense, has
to do with pointing out unconscious thoughts and wishes. Explanation
covers a much wider range which can include all kinds of cognitive
restructuring.
The meaning that we give to a thought, an event, a relationship,
a wish, etc. has a profound effect on how we will react to it.
For example, a patient who is subject to panic attacks thinks
when his heart begins to pound thinks that he is having a heart
attack. Thinking that he is in the midst of a fatal catastrophe,
his heart begins to beat even harder and he starts to hyperventilate,
sweats and gets dizzy. He thinks his demise is at hand. He rushes
to the cardiologist, is examined, and his heart is found to be
in good condition. The doctor says, "There is nothing the
matter with you, it is only your nerves". The doctor reframes
the situation. The meaning that the patient was giving to his
symptoms is restructured from a fatal illness to a psychological
reaction. A referral is made to a psychotherapist. Exploration
with the therapist reveals he has become excessively vigilant
to his own physiological reactions. He has developed a positive feedback
loop. The thoughts that he has about his bodily sensations (their
meaning) is that there is something terribly wrong with him. This
thought frightens him, and the thought in turn intensifies
his somatic reactions. The cognitive restructuring helps the patient
to reinterpret his physical sensations. The patient learns to
say to himself, "When my heart beats hard it does not mean
that I am getting a heart attack". The discussion of servo systems
indicated that the referent controls the output of the system.
In psychological terms, as he comes to realize that he is not
in danger, his physiology quiets down. The psychotherapist may
then help him to see that bodily reaction was in response to an
unconscious conflict rather than a heart attack.
The above example is a very simple circumscribed specific symptom
focused situation. Actually cognitive restructuring is a major
aspect of most forms of psychotherapy. How we think about ourselves,
others, our jobs, etc. etc. occupy us most of waking hours. These
thoughts can bring about intense emotional reactions. The ideas
frequently structure what we regard as real and important. Most
of us are deeply identified with our thoughts and with the way
that we think. Thus altering the way that we think changes the
way we react to our view of ourselves and of the world.
Desensitization can be used to treat a broad range of problems
that people bring to therapy. One of the most essential dynamics
in symptom formation are the defenses erected against pain, memory
of pain, and or anticipation of pain. Here pain is being used
in the most general sense, physical pain, fear, anxiety, depression,
shame, guilt, etc. Most people operate on the pleasure principle
where they try to maximize pleasure and avoid pain. Thus a major
goal of therapy is to help patients learn to relate to their pain
differently. However, there is an important distinction between
pain and suffering. There is no way to go through life without
experiencing pain at times. Suffering is the meaning that is given
to pain. If I have a pain in my left arm, I can think it is from
working out too vigorously, and not be concerned about. I have
the expectation that it will pass of its own accord, and I don't
pay much attention to it. If I think that it is referred pain
from my heart and that I am having a heart attack, my reaction
is likely to be one of alarm and great concern. The sensation
of the pain, itself is the same. The meaning is very different.
My suffering is much greater in if I think I am having a grave
illness. So a major aspect of desensitization is altering the
meaning that the client gives to his or her pain. What needs to
be done in order to alter the meaning is a major therapeutic issue.
An important class of interventions which alter the meaning of
symptoms has to do with exposure and response prevention. This
approach is most clearly worked out by the behavior therapists.
Treatment of the phobias provided the simplest and clearest examples.
Consider a patient with a germ phobia who has the compulsion to
wash his or her hands after any possible exposure to germs. In
the proceedure of exposure and response prevention the patient
is instructed to hold a dirty object. The therapist instructs
to patient not to wash his hands. The response of washing
hands is blocked and the patient is told to remain with the anxiety
that is generated when he refrains from washing. If the patient
is willing to comply with this procedure, he finds that his anxiety
dissipates after a while even though he does not wash his
hands. This process of exposure to the dreaded stimulus and preventing
oneself from responding in the symptomatic manner has the effect
of desensitizing the patient to the feared object. Thus it can
be seen that process of desensitization alters the meaning that
the feared objects have for the patient.
The procedure of exposure and response prevention is found in
other kinds of therapy, although it is called by other names.
In classical psychoanalysis the patient is instructed to free
associate. The patient is told to lie on the couch, turn his or
her attention inward, and tell the analyst exactly what is happening
as it is occurring. Freud would tell his patients, "We are
on a train together. Your have the window seat. Describe the passing
scene to me". Freud did not believe that the associations
would simply be a stream of random gibberish. Rather as the patient's
defenses let down the underlying drives and wishes would start
to assert themselves. Classical psychoanalytic theory is based
on the notion of a conflict between the repressed sexual and or
aggressive instincts and the prohibitions against expressing them.
Avoiding germs, snakes or horses, has to do with avoiding external
things. It is easy to see if the patient is approaching the dreaded
germs. A more difficult case is to create conditions in which
the patient faces his own sexual or aggressive impulses. There
are two aspects concerning facing internal fears. One, admitting
them to oneself, and two, admitting them to the analyst. Thus
as the patient was free associating there would be blocks in the
flow of associations. The patient would fall silent, or would
engage in any one a great variety of resistances (anything that
would distract him or her from truthfully reporting the immediate
flow of what is coming into awareness). Resistances occur when
something would emerge into consciousness that disturbed the patient.
The patient would have a conflict about admitting it to himself,
and/or the analyst. The patient might then drive it out of awareness
immediately, and repress or deny that it happened. Or the patient
might do any one of a great number of things to divert attention
from the troublesome thought, image, emotion, and or bodily sensation.
In any case the outcome would be a break in the unrestricted flow
of associations. This was a signal for the analyst to step in.
The analyst might just note that there has been an interruption,
or possibly make an interpretation about what he thought the patient
may be reacting to that caused the disruption. All of these technical
maneuvers were designed to help the patient become exposed to
the feared material. And if the patient were able to continue
the free association, the very act of free associating would in
effect prevent the defensive response. Thus in a psychoanalytic
framework we have exposure and response prevention, which has
the effect of desensitizing the patient. The patient then has
a choice of how to respond. He or she does not have to react in
previously automatic and often unconscious ways. In learning theory
terms, the link between the stimulus and the response is altered.
Exposure and response prevention is brought to an elegant height
in a vastly different tradition, Buddhist mindfulness meditation.
In this tradition the instruction is stark--just sit and allow
yourself to observe whatever comes to consciousness, and
simply witness what happens without trying to change or
alter it in any way. Like free association this is very easy instruction
to give and an extremely difficult one to follow. One of the great
differences between mindfulness meditation and free association
is that what happens in the mindfulness practice is not immediately
told to the analyst. The meditator is much more on his or her
own and does not get the immediate kind of feedback that is possible
in analysis. Further, it is easier to avoid the conflicts about
sharing the details of his experience with some one else. Of course
the meditator has to deal with the teacher, but scrutiny of the
relationship is not central to the process as it is in the analysis
of the transference in psychoanalysis. In addition, the typical
meditation teacher is not trained in analysis of resistance. So
like any other approach, it has a limited range of applicability.
To truly follow mindful practice requires great discipline and
ego strength, qualities that many patients who come to treatment
do not have. It is a very powerful practice. All distractions
are removed and one is faced directly with the range and intensity
of his or her inner condition. That is, one is focused in his
or her inner states of being. The meditator comes to see how thoughts,
feelings, and bodily sensations arise and pass away. He or she
is repeatedly exposed to painful experiences, but he does not
act to make the pain go away. Thus, this procedure is a pure form
of exposure and response prevention. Although being mindful can
and should be carried over into practical daily living, solo meditation
practice is different from living in the rough and tumble of intimate
relationships, which bring the frustrations of many practical
worldly concerns. A possible danger is that one will retreat into
spiritual practices as a way to bypass troublesome unresolved
developmental tasks, i.e. intimate committed relationships, and/or
a stable career.
A generalization from this is that exposure and desensitization
is rather situation specific. One can achieve blissful inner states,
but become rattled by the demands of a unsympathetic boss or spouse.
The Buddhists claim that it is possible to achieve a state which
transcends the usual kinds of state specificity. This is a beautiful
ideal and, but I have yet to meet such a realized person.
Making the unconscious conscious is a major focus of psychoanalysis.
In Freud's early formulation he equated the id with the unconscious
and gave his famous directive "where id was, there ego shall
be" (Freud, 1933,
SE:1953 vol. 22 p. 80). More generally however, if you are unaware
of something it is not possible to deal with it effectively. So
the notion of making the unconscious conscious has extensive applicability.
What is meant by the term--unconscious is an important issue.
Wilber (1980) gave five kinds of unconscious:
The most difficult form of making the unconscious conscious has
to do with treating the submergent-unconscious. This is the dynamic
unconscious, Ucs. In this case the thought, wish, or impulse
is locked out of awareness by a conflict which results in the
sustained repression of the thought, wish or impulse. Returning
a repressed thought to consciousness involves much more than merely
pointing out something to the patient. In Freud's schema if something
were preconscious it could readily be brought to consciousness
by making an deliberate effort to retrieve it. On the other hand,
if there were repression the material is forced into the system
Ucs. Simply refocusing attention and trying to recall the
material would not bring it to awareness. An interpretation
and/or working through the resistances which are engendered by
conflicts which produced the repression in the first place is
necessary. However, simply trying to make the unconscious conscious
is generally insufficient. Freud's famous dictum, "Where
there is Id let there Ego be", did not address many important
issues, i.e. structural deficits.
As indicated above in Wilber's classification there are levels
of consciousness which go beyond the range of awareness that is
ordinarily addressed in Western psychology. Helping make the emergent-unconscious
conscious has been the role of the spiritual disciplines. However,
sometimes these levels do emerge and there is a growing interest
in the spiritual development. Not pathologizing the higher levels
nor confusing them with the prepersonal developmental levels is
important. An important interface between psychotherapy and spiritual
practice is mindfulness training. Mindfulness is sustained open
awareness of whatever is happening at the moment. At least initially,
mindfulness work is not so much making the unconscious conscious
as it is making the conscious conscious. Most of the time
we are thinking about our experience rather than simply
experiencing it directly. We are often lost in thought and running
"on automatic". Thus, we are not actually conscious
of the is-ness of what is happening. Learning focus of
attention and sustaining mindful choiceless awareness is an important
gateway to enable the emergent-unconscious raise to awareness.
Literally catharsis means to purge. Psychologically, it has to
do with vigorously letting out of feelings. Very simply, getting
something off of my chest makes me feel better. The notion of
catharsis is related to abreaction which is the process of releasing
repressed memories and their associated feelings. This process
releases pent up feelings, and restores a sense of equilibrium.
Although "getting it out" leaves one feeling relieved,
the long term therapeutic effect tends to be limited. A very good
example is of pent up anger. Freud in his metapsychological paper
on repression indicated that strictly speaking affects are not
repressed. When we do not feel an affect it is simply un-activated.
It is not repressed, and is not pent up. More accurately
what is repressed are memories and wishes. If one has truly repressed
memories or conflictual events, becoming aware of the memories
and the feelings associated with them can be extremely helpful.
Experiencing the memories and the feelings associated with
them gives one a sense of release, relief, and of being rebalanced.
It is my impression that what is the more lasting therapeutic
ingredients in abreaction have to do with acceptance, and exposure
and response prevention. An empathic therapeutic relationship
expands the domain of what is considered safe and acceptable.
The therapist is seen as a strong accepting presence who can tolerate
disturbing thoughts, wishes, and affects. The therapist encourages
the patient to move toward painful memories and affects. Often
patients are afraid of either spinning out of control or of getting
stuck in a painful affect state. So they do not want to approach
the dreaded matters. The therapist's sustaining acceptance and
interpretation of the conflict and anxiety laden material encourages
the patient to allow experience here-to-fore repressed of suppressed
memories, wishes, and feelings. Finally, the patient allows the
full intensity of the feared or previously unacceptable thoughts
and feelings. Seeing that he or she is able to tolerate the intensity
of the affect and that it dissipates rather escalates out of control,
enables the patient to move toward and through the discomfort
rather than away from it. Also realizing that the therapist is
able to accept the outburst reassures the patient that he or she
is an acceptable person who can has the strength cope with the
conflict. Thus, the catharsis per se is part of a much
larger process. Unfortunately, there is a tendency to focus on
the drama of the catharsis rather than the patient work which
creates the conditions for it to happen.
Much has been said about the efficacy of "getting out feelings".
This is especially true when it comes to expressing anger. There
is the concern about getting high blood pressure or some other
symptom if the anger is held in. Indeed, an important theory of
depression is that it is anger turned on to oneself. Although
repressed anger may result in various symptoms, and the expression
of the anger relieves the symptoms, I believe that the value of
"catharting" the anger is often over rated. First, the
experience of getting extremely angry can be traumatic. Many patients
are disturbed by the intensity of their own anger. Even
though at times it can be a relief to express anger, getting angry
and sustaining anger is clearly a stress. It is very important
to be in touch with ones anger and to know how to appropriately
assert oneself. Knowing that you feel angry is crucial--expressing
it is a matter of judgment. In cases of chronic anger the issue
is much more what continues to generate the anger, than
the catharsis of the anger itself. One can be angry forever without
ever coming to terms with what is leading one to feel so irate.
Thus, catharsis my help one feel better but the effect of the
catharsis is likely to only be temporary.
The idea of optimal frustration and transmuting internalizations
comes from Heinz Kohut's work on restoring the self. :
He gives a three step progression in treatment:
These steps require some elaboration. the first step has to do
with what the psychoanalysts call establishing "the transference".
There is a distinction between establishing rapport and
establishing a transference. Rapport is a feeling of comfort
and confidence that one develops with the therapist. The rapport
may be rather superficial and have more to do with the likeability
and/or charisma of the therapist than with a reactivation of the
patients earlier modes of relating. When a transference is soundly
activated, the patient's psychological state and mode of relating
shifts from adult patterns to earlier varieties. (1) The therapist
is no longer thought of as merely being a helpful person, and
something special happens in the relationship with the analyst.
Earlier longings, hopes, and fears emerge with some intensity.
The patient wants something from or with the analyst. Love, protection,
support are yearned for, (2) but the analyst does not actually
provide what the patient seeks. This failure to give the patient
what the patient wants is the frustration that Kohut discusses.
(3) However, the analyst recognizes the patient's desires, understands
their importance, and is able to respond empathically to the patient's
wishes and needs. For example, the patient expresses upset at
the thought that the therapist is going away on a vacation. The
patient's wish is that the therapist not abandon him. The therapist
does not forego his vacation, and thus frustrates the patient.
However, the therapist understands how seriously upsetting his
absence will be for the patient, and the situation is discussed
fully. The process of (1) going through the frustration, and (2)
of being understood, and of having his feeling validated, (3)
enable to patient to be more accepting of his own concerns in
part by making the therapist's compassionate exploration of his
feelings part of his own repertoire for soothing himself (the
transmuting internalization).
The concept of optimal frustration has been questioned by a line
of important reconsideration by the intersubjective self psychologists.
Bacal 1985 stated:
Major sources of psychopathology are repression, regression, and
developmental arrest. Repression has to do with having awareness
dynamically blocked by a conflict. The techniques of making the
unconscious conscious treat repression. Regression implies that
one has developed adequately but has retreated to earlier modes
of behaving in response to conflict or trauma. Developmental arrest
implies that development has never taken place in the first place.
It is sometimes difficult to distinguish regression from developmental
arrest. It is also important to recognize that development does
not necessarily proceed uniformly across all areas of growth.
For example, some one may be highly intellectually developed and
have great difficulty in intimate emotional relationships. However
one thinks of it, there a clinically important class of problems
has to do with some aspect of ones functioning being out of sync
with his or her chronological stage of development. The notion
of unblocking implies that there is some kind of obstruction.
If the obstruction can be cleared away then development can proceed
normally. I am not sure that unblocking developmental arrests
can be addressed directly. The unblocking emerges as the treatment
progresses. The patient has to become aware that there is some
kind of blockage. The patient has to troubled by the arrest enough
to want to change it. Finally, some kind of structure building
is needed in order to create the behavior patterns, attitudes,
and skills which forester the new growth.
The self psychologists speak of the cohesiveness, stability and
the affective coloring of the sense of self. The qualities that
I experience as cohesive or stable or that I feel good or bad
about have to do with my identifications. i.e. I am a psychologist,
a man, a father. All the roles and physical, emotional, cultural
and intellectual attributes that I assign to myself can be thought
of as my identifications. The mechanism of identification has
to do with taking on the characteristics of some important figure
in ones life. i.e. I am like my father. Altering who or what I
feel I am can be a crucial ingredient in change. Unconscious identifications
can have far reaching effects on ones behavior and sense of well-being.
Making these identifications conscious and altering ones attitudes
about them is often an important ingredient in therapy.
An important sequence of shifts of identification was given by
John Weldwood . The essential line of development has to do with
moving from being embedded and identified with ones experience
to dis-idenfifying with experience.
Education, as such, has had a bad name in psychoanalytically oriented
therapies. Usually when people come for therapy it is because
the usual processes of education have failed. Most people know
what is good for them. They have been repeatedly told what will
help them. Nonetheless, they have a hard time doing what they
know will help them. If they were able to utilize the education
that they have had, they would not come for treatment. Indeed,
a depressed patient once said, "Depression is when you can't
do what you know will help you". However, to the extent that
the problem is simple ignorance education is the treatment of
choice. Further, elements of education are to be found in all
forms of treatment. The patient has to be instructed on how to
be a patient and on what to do in order to make the therapy work.
As with education, suggestion has not been well regarded by analytic
therapists. Indeed, one of the great concerns among the early
analysts was to clearly differentiate suggestion from interpretation.
How much an interpretation is a suggestion is an important question.
If a patient has unconscious sexual wishes, by definition the
patient is truly unaware of his or her libidinous desire. If the
analyst makes the interpretation, "You would like to have
sex with your mother", how does the patient know that the
analyst is not simply putting ideas in his mind (making a suggestion).
The traditional answer to this question has to do with the way
the patient responds. If the patient has a strong emotional response
and memories of loving attachment to his mother emerge, then it
is not likely that the analyst is simply suggesting something
to him. The analyst has made a connection which has brought the
wish to consciousness. This is not suggestion in the sense that
the therapist is attributing a wish to the patient that the patient
does not have. However, there are times when patients overlook
alternative courses of actions or different ways of seeing situations.
In these cases suggestion of alternatives can be beneficial. Suggestion
does come in many shades. The thesaurus gives the following shades
of meaning for the word suggestion: proposal, idea thought advice,
proposition, recommendation, council, bid, and exhortation. I
suspect that all of these meanings are used at one time or another
during the course of an extended therapy.
Feedback can be thought of from several points of view. First,
feedback is essential for almost any kind of control. This can
be clearly seen in motor behavior. If I try to stand up I need
the position cues which come from my muscles and joints to tell
me the position of the various parts of my body. If I am anesthetized
or neurologically impaired and do not have these cues my coordination
will be impaired. Similarly in the social situation of a therapy
session, the patient and the therapist are continually giving
each other verbal and non verbal cues about how they are reacting
to each other. These responses are a form of feedback which each
uses to guide his or her behavior. In a very real sense the patient
and the therapist are regulating each others behavior by continually
giving indications of how each is responding to the other. Second,
in a more limited sense, feedback can be thought of as the interventions
that the therapist makes. Comments, reflections, interpretations,
suggestions, etc. are forms of feedback that the therapist employs
to help the patient gain a fuller view of him or herself. We tend
to focus on the discrepancy between what we want and what we feel
we are getting. We are less concerned with what we ourselves do.
Thus feedback from the therapist helps us to see our own blind
spots. It is central to any kind of therapy. For a more formal
discussion of feedback see Servo Systems and Feedback.
Site Maintained by William Dubin, Ph.D. wd16@columbia.edu
Theories of Development
When I have promised my patients help or improvement by means
of a cathartic [early psychoanalytic] treatment I have been faced
by this objection: 'Why, you tell me yourself that my illness
is probably connected with my circumstances of my life. You cannot
alter these in any way. How do you propose to help me then.' And
I have been able to make this reply: 'No doubt fate would find
it easier than I to relieve you of your illness. But you will
able to convince yourself that much will be gained if we succeed
in transforming your hysterical misery into common unhappiness.
With mental life that has been restored to health you will be
better armed against that unhappiness. (Studies on Hysteria
written with Josef Bruer in 1893. SE Vol. 2
p. 308)
A major therapeutic confusion among various theorists stems from
what I have called the "pre/trans fallacy" (Wilber 1980)
which is confusing of pre-rational structures with trans-rational
structures simply because both are non-rational. This confusion
runs in both directions: pre rational structures (phantasmic,
magic, mythic) are elevated to trans-rational status (e.g.,
Jung), or trans-rational structures are reduced to pre-rational
infantilisms (e.g., Freud). It is particularly common to reduce
samadhi (subtle or causal subject-object identity) to autistic,
symbiotic, or narcissistic-ocean states. Likewise Atman, the one
universal Self, is confused with the monadic-autistic ...self.
...In my opinion, such theoretical and therapeutic) confusion
will continue to abound until the phenomenological validity of
the full spectrum of human growth receives more recognition and
study.
I have...attempted to develop an overall or spectrum model of
psychology, one that is developmental, structural, hierarchical,
and systems-oriented, and that draws equally on Eastern and Western
schools. Vis-à-vis psychopathology the conclusion I reached
was that the spectrum of consciousness is also a spectrum of (possible)
pathology. If consciousness develops through a series of stages,
then a developmental "lesion" at a particular stage
would manifest itself as a particular type of psychopathology,
and an understanding of the developmental nature of consciousness--its
structures, stages, and dynamics--would prove indispensable to
both diagnosis and treatment (Wilber, Engler, & Brown, 1986,
p. 66).
A simple metaphor may be useful to explain this distinction. The
basic structures themselves are like a ladder, each rung of which
is a level in the Great Chain of Being. The self (of the self-system)
is the climber of the ladder. At each rung of that climb, the
self has a different sense of identity, a different type of morality,
different set of self-needs, and so on. These changes in the sense
of self and its reality, which shift from level to level, are
referred to as transition structures, or more often as the self-stages
(since these transitions intimately involve the self and its sense
of reality.
Thus, as the self climbs from say, rung 4 to rung 5, its limited
perspective at rung 4 is replaced by a new perspective
at rung 5. Rung 4 itself remains in existence, but
the limitations of its perspective do not. This is why the basic
structures of consciousness are more or less enduring structures,
but the self stages are transitional, temporary, or phase-specific
(Wilber, Engler, & Brown, 1986 p. 76).
Theories of Illness
Genetic and/or Congenital
Disorders
Organic Disorders
Cultural Constraints
Trauma
Developmental Derailments
Every phase in a child's development is best conceptualized in
terms of the unique psychological field constituted by the intersection
of the child's evolving subjective universe with that of its caretakers....Pathogenesis,
from this intersubjective perspective, is understood in term of
severe disjunctions or asynchronies that occur between structures
of subjectivity of parents and child, whereby the child's primary
developmental needs do not meet with requisite responsiveness
from (self) objects. When the psychological organization of the
parent cannot accommodate the changing phase specific needs of
the developing child, then the more malleable and vulnerable psychological
structure of the child will accommodate to what is available.
(Atwood & Stolorow, 1984,
p. 69)
Excessive
Agency or Excessive Community
State Shifting
Theories of Therapeutic
Action
Relationship
Understanding and
Explaining
Cognitive Restructuring
(Reframing)
Desensitization -- Exposure
and Response Prevention
Making the Unconscious
Conscious
Catharsis
Structure Formation
Via Optimal Frustration and Transmuting Internalizations (Kohut)
...we can return to the question of just how psychoanalysis
cures...The most general answer that self psychology gives to
this question is a simple one: psychoanalysis cures by the laying
down of psychological structure.
And how does this accretion of psychological structure take place?
The most general self psychological answer to this second question
is also simple: psychological structure is laid down (a) via optimal
frustration and (b) in consequence of optimal frustration, via
transmuting internalization (Kohut 1984,
p. 98-99).
Structure Formation Via Optimal Responsiveness, Optimal Provision
and Optimal Gratification
Unblocking
Developmental Arrests
Identification Shifting
Education
Suggestion
Feedback
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