Sometimes Confrontations are Needed

In talking with several American and Italian colleagues, sometimes I have had the impression that confrontations[1] were considered a therapeutic tool which should not be used by clinicians working from a Control-Mastery Theory perspective. Or, along the same line, that the sense of safety that we should ensure for our patients prevents us ipso facto from using confrontations in our clinical work. Confrontations, in fact, may make the patient feel temporarily less safe when first received, but eventually they can enhance the patient’s sense of safety and lead to important therapeutic progress. In this brief post I will try to illustrate this point.

If we read carefully what Weiss (1993) writes about the analysts’ use of their authority with patients (ibidem, pp. 50-54), and in particular if we read the case of Geoffrey B. (ibidem, pp.51-52), it is clear that there are circumstances where confrontations are very useful, if not required. In the treatment of this man, the analyst “confronted repeatedly the patient with his self-destructiveness. However, the patient provocatively continued to be promiscuous. Finally, the analyst told Geoffrey that unless he stopped his promiscuity, he (the analyst) would discontinue the treatment”. And, as if he were rebutting the above mentioned misinterpretation of the safety principle, Weiss adds: “The patient became angry, wept, and berated the analyst for his failure to maintain an “analytic” attitude. However, rather than stopping treatment, he stopped being promiscuous. Also, he became more secure and more trusting in the analyst, and he retrieved several of his parents’ failures to protect him from self-destructive sexual behaviors” (ibidem).

From this brief example of a passed protection test, we can see how we must ensure our patients’ unconscious sense of safety, but this unconscious sense of safety can be sometimes reached only after a period when the patient feels anxiety, pain and rage, feelings which are common in the testing phases of therapy. The more reliable signs of greater safety felt by our patients, in fact, are not their conscious feelings of ease during the sessions, but their capacity to work towards reaching their goals, their ability to become more involved in the therapeutic work and relationship (for example remembering previously warded-off memories), and their testing the clinician more boldly (see also Weiss, 1993, pp.131-132). Finally, the case of Geoffrey B. told by Weiss also shows how the patient’s sense of safety can, in certain circumstances, be strengthened by a confrontative attitude.

When are confrontations useful?

On the basis of my clinical experience, I would say that confrontations may be useful when patients, because of their pathogenic beliefs and unconscious guilt, want to do or are doing something which is clearly self-destructive, or are avoiding doing something which would be clearly positive for them. And this is often true with severely traumatized patients and with patients who tend to act out.

When patients tell or show us that they are doing something self-destructive, they are generally testing our willingness and ability to protect them in the hopes of disconfirming the pathogenic belief that they do not deserve to be protected. In this situation, being confrontational means passing their protection tests. This occurs frequently with patients who suffer from addictions, substance abuse, sexual promiscuity, suicidality, severe anorexia, other self-destructive behaviors or behaviors which could put other people and the therapy at risk. In cases such as these, it is often necessary to put as a conditio sine qua non for starting or continuing therapy, that the patient will not act out these behaviors and, if needed, will complete a hospitalization or a recovery or detoxication program. About these points, the utmost firmness is often needed, together with a clear explanation of the reasons why these conditions are being put in place. The patient must be given every reassurance about the availability of the therapist to support the patient in dealing with and understanding her/his painful feelings and their origins.

 

One month after the beginning of her therapy, Rita, a patient who had been a poly-drug abuser and heroin addict, “decided” to quit her detoxication program because of the discomfort she felt due to the side effects of the drugs they were giving her. When she told me this, I urged her to continue her program and to talk with the medical director about these side effects. And I added that I would not continue to see her in therapy if she quit the program. During most of that session, Rita was very angry with me: she thought that I was not taking into account her point of view and her discomfort, and that I did not trust her enough. I stuck to my position, and the only positive thing Rita was able to find in my words was the possibility of negotiating with the medical director what could be done about the side effects of her meds. With her mother, this had always been impossible. At the end of the session, she accepted my conditions reluctantly. And when, six months later, she completed the detoxication program, she felt proud of herself and said to me “thank you for your firmness”. She thought that she did not deserve protection because her mother used to shout at her but never really protected her.

In other moments of her therapy, Rita posed protection tests mediated by a passive-into-active strategy. In other words, she could abruptly become as aggressive, devaluating, and contemptuous towards me as her mother had been with her. And even on some of these occasions, after more than one year of therapy, I had to be confrontational with her saying something like: “You cannot behave in this way here. Stop it. I am not going to stand these your-mother-like behaviors”.

Another variant of her passive-into-active testing me was her presenting herself as being in pain during the session and not using any of my communications and attitudes to feel better. In those moments, I could feel empathically her suffering, and at the same time I felt that she was somehow blaming me for it while I was put in a powerless position. At those times, typical of the second and third year of her therapy, the best way for me to help her overcome those states was to say: “If you want to keep on feeling so, it is up to you”. After these communications, Rita was in general relieved and started to talk with me about her mother making her feel guilty for her suffering without giving her any opportunity to relieve her mother’s suffering.     

 

However, being confrontational may be useful also in circumstances which do not imply testing, or even in circumstances when confronting the patient may imply failing some test for the sake of protecting her/him in reality.

Consider the following examples:

Chiara, a patient in her twenties suffered for a strong self-hate.   During a session she received a text message from one of her friends inviting her to come over and spend some time together. On one hand, Chiara wanted to go on with her session, but on the other hand she was so afraid that saying no to her friend would jeopardize the relationship that she was strongly tempted to leave the session and meet her friend. I showed her how that behavior derived from her pathogenic belief that no one truly loved her or was interested in her, and that in order to not lose the people she loved, she always had to comply with them. She agreed, but thought that this was really true in the case of that friend. So she told me that she wanted to leave the session to reach that friend. At that point, I said to her: “You do not have to go. If you leave, you will never find out if your fears are true or not, and I am sure they are not”. Chiara accepted my point of view, but I had to repeat what I thought several times, and then I reminded her of several situations in her past when she had renounced very important things in her life because she felt she needed to comply with the people she loved in order not to lose them. Chiara kept on being afraid for several hours that she was about to lose her friend. But when this girl phoned on the following day, she felt a deep sense of relief: she understood that she had been in the grip of a pathogenic belief.

     In this case, I do not think that Chiara was testing me; she was simply acting according to one of her pathogenic beliefs. However, my confrontation helped her become aware of her pathogenic belief and helped her work on disproving it, and on many occasions she reminded me how useful it was that I told her not to go.

 

Serena, a patient in her thirties who had always lived with her parents and has so far been unable to complete her professional training, during the third year of her analysis was able to find an institute which would have enabled her to complete her degree in one year. Serena had changed high schools three different times, universities twice, and training institutes three times, each time for a different reason. A few months after she started her new training program, she said to me that she was thinking of moving to anther town because she could no longer stand the chaoticness of Rome. When she said this to me, she was clearly anxious and afraid that I would object to her resolution. I was aware that she was presenting a transference test of her separation guilt – the main reason why she had not been able to move from her parent house. However, I thought that it was more important that she complete her training and start to do the work she had studied for. In other words, I thought that her resolution had a very important self-punishment component deriving from her strong survivor guilt and triggered by the possibility of completing her training and starting to working. For this reason, and being aware that I was somehow failing her separation guilt test, I said to her: “I know that you are going to be upset by my words, but I think now it is very important that you complete your training and start to work. Your moving to this other city will create several difficulties in completing your program, so I think you should stay here. When you complete your training, you can go wherever you want. I am not saying this because of the therapy, we could go on via Skype. But it is time for you to complete your training”. She was as disappointed and angry as I had suspected she would be and left the session without a resolution.

After a couple of weeks, she had to go to that town for a different reason, and when she came back she said she had been quite disappointed by it. A few months later, Serena left her parents house and went to live with a friend. One year later she completed her training, and we were able to work through her survivor guilt more deeply.

 

David, a patient in his thirties who suffered from deep self-hatered, used to always follow the same pattern in relationships with women. He first took them out for wonderful dinners in the best restaurants of Rome. Then he tried to seduce them by being smart, nice and joyful. Then he spent the night with them and did his best to make them happy and to satisfy them. After some time of treating women this way, David started to feel tired and to run out of money. Being afraid that these girls would not have loved him if he showed his “normal self”, he stopped replying to their phone calls and text messages. When these girls then showed their disappointment and anger over his not responding to their communications, he saw their reaction as confirmation of his self-hatered and thought he was right in thinking that nobody could love him for who he really was.

After he told me several times about relationships which followed this pattern, I decided to say to him: “Look, the problem is not that you are a jerk or a despicable person, but that you act like a jerk and a despicable person. You do so because you are afraid that no girl would love you if she discovered how you really are, but the way you behave will always push girls to think that you are a jerk. Your “solution” is the problem, not your true nature. So, stop acting in this way!” David was interested in my words, took them into account and mused about them when he felt that he should “disappear” with a new girl. He continued to be afraid that it would have been worse to show who he really was. However, slowly but progressively, he started to reveal his true self to women.

 

To sum up, confrontations sometimes may be needed, but they have to be delivered within a warm and generally supportive therapeutic relationship; their aim should always be to protect patients, and they have to disconfirm some of the patients’ pathogenic beliefs. Finally, it is particularly important that the overall attitude of the therapist while confronting the patient be pro-plan – i.e. different from the attitude of traumatic caregivers and from the attitude that the patient had with her/his traumatic caregivers during her/his development.

Confrontations are sometimes needed, but they should be protective and always pro-plan, even if they may sometime fail some testing dimension of patients’ communications and behaviors.

 

References

 

Weiss, J. (1993), How psychotherapy works. Process and technique. New York, Guilford.

 

 

 

 

 

 

[1] Within this context, with confrontation I mean interventions delivered by therapists using all their authority and aimed at stopping or pushing the patient to do something.

What therapists can make of their feelings within the session

At least since the seminal paper on countertransference published by Paula Heimann in 1950, it is quite well known in dynamic psychotherapy that the emotional reactions stirred up by patients in their therapists, together with the thoughts which go along with them, may be a relevant source of information.

However, there are broad divergencies among the different schools and authors about the relevance to be given to these elements for understanding and treating patients. This wide array of opinions goes from those authors who think that therapists’ feelings are expressions of the therapist’s intrapsychic dynamics and unresolved conflicts that need to be controlled by self-analysis [Freud (1910) and Melanie Klein (1957)] to those who thinks that they are a particularly sensitive tool for understanding patients’ unconscious [Heimann herself and Henrich Racker (1968)]; from those who think that there are “objective” emotional reactions to some patients in some phases of their therapies (Winnicott, 1949), to those who believe that countertransference (as well as transference) is inevitably a co-construction of both the patient and the therapist – an intrinsically intersubjective and idiosyncratic “co-transference” (Donna Orange, 1995). Which is the position of Control-Mastery Theory in this debate?

In How psychotherapy works, Weiss (1993, pp.80-84) talks about the therapist’s affective responses to a patient as one of the elements which may contribute to the understanding of the patient plan, and his clinical examples show how these feelings may be:

1)      Something that patients may push us to feel because of their pathogenic beliefs, but that they hope we won’t need to feel (for example, out of his survivor guilt a patient may push us to feel brighter and more effective than himself);

2)      Something that patients felt during their traumatic experiences and that they hope we could teach them how to better manage (for example, a patient who had to take care of a very suffering mother and felt overwhelmed by her pain can make us feel overwhelmed by the task of relieving her suffering);

3)      Something that patients hope that we will feel and show so as to disconfirm their pathogenic beliefs (for example, a patient who needs a relaxed and casual interaction because he needs to have disconfirmed the belief that people need him always to work hard and be productive may relate to us in a funny and informal way);

4)      Something that patients are afraid that we (also) will feel, because if we will, this would be a confirmation of their pathogenic beliefs (for example, a patient with strong feelings of self-hate may test us in such strong ways that we are tempted to reject him).

As it is possible to see from these brief examples, if on one hand a CMT therapist may use his/her feelings for understanding patients’ goals, pathogenic beliefs, traumas, and testing strategies, on the other hand therapist feelings are a slick tool if taken in isolation. In fact, they can push us to act both in a pro-plan and in an anti-plan way even though they typically say something about what is happening in the patient’s mind.  In some cases they are mostly an expression of our idiosyncratic way of reacting to some part of the patient material or some facet of his personality. I can easily recognize in myself, for example, an idiosyncratic irritation when I deal with passive and complaining patients. For these reasons, we can say that our own feelings may be useful for understanding patients, but we do not have to be guided by them in our responses to patients without considering also our own psychic functioning and the patient plan.

Clare, a patient in her twenties afflicted by a strong self-hate deriving from severe mistreatments at the hand of her mother, often behaved in session in a quite chaotic and aggressive way, stirring up in her therapist feelings of irritation and the impulse to reject her; the therapist thought that these reactions were similar to the reactions that the patient said her family members and high school friends often had with her, and it was clear that if the therapist had acted out these feelings he would have re-traumatized the patient. The therapist’s emotional response in those moments provided a useful hint for hypothesizing the patient traumas, pathogenic belief and testing strategy (transference test by compliance); but they were a very poor guide for his conduct. However, in other moments she was so sincere, open, and engaged that her therapist felt a deep affection and admiration toward her, feelings that when communicated to the patient, were a powerful disconfirmation of her self-hate (transference test by rebellion). They were something that the patient wanted the therapist to feel and show.

Alexander, a patient in his forties afflicted by  strong separation guilt, used to complain and claimed to be very distressed any time his therapist had to miss a session; this behavior stirred up in his clinician a mix of guilt and rage but showing these feelings would have re-traumatized the patient as they would represent a failure of his passive into active test. They were something the patient had often felt in his life, and he was hoping to learn from the therapist how not to be overwhelmed by these feelings. On the other hand, when the patient seemed to be pleased that the analyst had enjoyed his vacations, he stirred up in the therapist very pleasant feelings, which made the patient happy because he experienced it as a disconfirmation of his separation guilt (passive into active by rebellion). He was giving to his therapist something he wanted to receive for himself.

From these very short and schematic examples, we can easily see how patients’ traumas, pathogenic beliefs and testing strategies may affect therapists’ emotional responses with the mediation of the therapist’s idiosyncratic functioning. For this reason, therapist feelings and idiosyncratic thoughts may be very useful for understanding patients only when taken within the broader context of all the therapist knows about the patient and his treatment and without neglecting the peculiarities of her/his own psychic functioning. In other words, we do not have to neglect what we feel and think while being with a patient, but this should not be the basis of our clinical decisions. The patient plan, and the clinician understanding of the elements of the plan the patient is working on in each specific moment of the treatment, should be the main guide of our clinical decisions.

Toward our own and our patients’ feelings we should be as sensitive as a well-tuned violin string, but we must make sense of our vibrations within the overall symphony of the patient material. Our brains are wired to be pre-reflectively attuned with other peoples’ emotions and intentions (Rizzolatti, Sinigaglia, 2006), and our reciprocal interpersonal motivational systems are structurally paired (Liotti, Fassone, Monticelli, 2017), but as therapists we must make sense of the emotions we feel working with a patient within the context of our own idiosyncrasies and, above all, within the context of the patient’s plan.

We should be aware and accept anything we feel and think, but we have to tame our reactions so that they will be pro-plan.

 

 

References

 

Freud, S. (1910), The future prospects of psycho-analytic therapy. Complete Psychological Works of Sigmund Freud, Vol. 11

Heimann, P. (1950), On counter-transference. The International Journal of Psychoanalysis, 31, 81-84.

Klein, M. (1957), Envy and gratitude. London (UK): Tavistock Publications Limited.

Liotti, G., Fassone, G., Monticelli, F. (2017), L’evoluzione delle emozioni e dei sistemi motivazionali. Raffaello Cortina, Milano.

Orange, D. (1995), Emotional Understanding: Studies in Psychoanalytic Epistemology.  New York: Guilford, 1995.

Racker, H. (1968), Transference and countertransference. London: Hogarth Press.

Rizzolatti, G., Sinigaglia, C. (2006), So quel che fai. Il cervello che agisce e i neuroni specchio. Raffaello Cortina, Milano.

Winnicott, D.W. (1949), Hate in the counter-transference. The International Journal of Psychoanalysis, 30, 69-74.

 

Attitude as a means to test and as a means to cure

In my opinion, one of the more useful ideas that CMT has given to clinicians and researchers, and one of the ideas which still deserve a lot of attention and more empirical study, is the idea that the attitude of a patient may be one of her/his possible testing tools, and that the attitude of the clinician can be a powerful therapeutic tool.

Let’s start from the patient attitude as a testing tool. In his book How psychotherapy works, Weiss (1993) dedicates an overall paragraph to “Testing with attitudes”, and here he writes: “there are therapies in which the patient, instead of attempting to disprove his pathogenic beliefs by discrete tests, attempts to disprove them by displaying a persistent attitude that serves the same testing function (…) The therapist … should develop an attitude toward him that is designed to help the patient disprove his pathogenic beliefs” (p. 102). So, the attitude displayed by a person may be a consequence of their pathogenic beliefs, of the affects associated with them, and of the strategy s/he developed to test them in the hope that reality will disconfirm them. Consequently, we can infer some of the nuclear pathogenic schemas of a patient by analyzing their more pervasive or frequent attitudes.

A few brief examples may be of help: one of my patients suffered from strong self-hatred derived from the severe mistreatments and devaluations she experienced at her mother’s hand.  A few months after the beginning of therapy, she started to show a very warm and outgoing attitude toward me, an attitude that she had tended to show when she felt safe with someone.   She was very sensitive to my reactions because she was always afraid that I too could reject her and felt very relieved when she saw that I appreciated and reciprocated that attitude. So, we can conceptualize that attitude as a transference testing by rebellion.

Another patient of mine who suffered from intense omnipotent responsibility guilt, was always very polite, precise, and self-controlled  both in therapy and with any other person with whom she was not very close. When she was a child, her mother used to tell her that she had to behave well because she did not want to be considered a bad mother by other people. This patient used to smile happily when I was ironic about her being always on time and very precise in paying me at the end of the very last session of each month. And we both laughed when, for the first time, she forgot to pay me that day. So, we can see her polite, precise, and self-controlled attitude as a transference testing by compliance. She wanted to see if I, as the mother, need her to always behave well, hoping that I did not.

A third patient spent the first eleven months of her three time a week psychotherapy accusing me of being a liar and an ineffective therapist,  saying that she was wasting her time and her money without any hope of having her depression solved. But, at the same time, she kept giving me hints that her symptoms were progressively disappearing. She was repeating with me the devaluing and complaining attitude of her father, who always said to her that she was not good enough and that any hope of a happier life was doomed. During that period of her therapy, the only way I could productively interact with her was by jokingly reminding her, here and there, of some of her father mottos: “You should have done that, but now it’s late” or “Well, in any case this is not enough”.  Her attitude was a passive-into active testing of me.   

One final example: A patient who suffered from deep feelings of survivor guilt was always very appreciative with me and was always happy when she saw that I appreciated her (incidentally, she started trying this supportive approach with the other people she loved). She grew up in a family of suffering and unsatisfied people who were completely unable to support each other and who criticized any manifestation of self-satisfaction as a sign of arrogance and any sign of loving as a sign of “do-goodism” and “weakness”. In her being appreciative toward me, and in enjoying my appreciation of this attitude, she was trying to give herself and me a new experience: this attitude was a passive-into-active test by rebellion.

Given these premises, we can see how the concept of pathogenic schemas can help us to understand personality, and personality disorders.

Now, let’s think about the other side of our topic, the clinician’s attitude as a curative factor. The basic idea suggested by Weiss is this: if patient attitudes may be testing tools, passing these kinds of tests requires the therapist to demonstrate attitudes that are optimal responses to them. To do so, the therapist must understand which pathogenic belief is being tested by that attitude and which testing strategy is expressed by it.  So even about this topic, what to do depends on a good enough formulation of the patient plan: the therapist attitude should be as “case specific” as any other element of the therapy. And if we want to be a little more precise, we could say that a pro-plan attitude is an attitude which is (1) the opposite of the attitude assumed by the caregivers during the traumatic episodes and/or interactions that gave rise to the pathogenic belief tested by transferring, and (2) the opposite of the attitude assumed by the patient during those traumatic episodes and/or interactions, if the pathogenic beliefs developed are being tested in a passive-into-active way (Angrisani, Gazzillo, 2017).

Though initially sketched out by Weiss in several passages of his writings, it is Harold Sampson (2005) who, in one of his best papers, Treatment by attitude, writes more systematically about the curative potential of the therapist attitude:

“Treatment by attitude is not ordinarily a rote, mechanical, or formulaic process. Nor is it a contrived or inauthentic process. It is based on personal judgements, sensibilities, and beliefs that reflect the therapist’s convictions about how to help the patient. The intervention may be planned and premeditated as well simultaneously spontaneous and genuine, not unlike many ordinary interactions in everyday life (e.g. a teacher giving special attention to a particularly insecure student).  Finally, treatment by attitudes is usually understandable in terms of familiar human experience (…) [It]often takes place outside the conscious awareness of either the participants … [and can be considered] a way of following closely and understanding [the patient]” (ibidem, pp. 114-118).

How is it possible that an attitude assumed by the therapist as part of his or her effort to be pro-plan can simultaneously be spontaneous and genuine?  I think that this is possible because correctly understanding and formulating the patient plan entails the ability to put oneself fully in the patient’s shoes, to experience the main events of the patient’s life from her/his perspective, and to emotionally understand how and why the patient developed their particular obstructions and testing strategies.   From a complementary perspective, the plan formulation of a patient is a powerful tool for deepening and refining the empathy of the clinician. This is the reason it is very possible to be deliberately pro-plan while also being spontaneous. 

It is worth noting that, particularly with patients with severe personality disorders, being able to deliver “unusual treatments” (Weiss, 2005) mainly conveyed by the clinicians’ attitude may be the key to success (Pryor, 2005; Shilkret, 2008; Gazzillo, Mellone, 2016). In fact, if the overall attitude of a patient is an expression of her/his core pathogenic beliefs and testing strategies --  i.e. the core of her/his personality --developing a pro-plan attitude is also a way of  helping the patient to modify their troublesome personality patterns.

Finally, if we think about all the mistakes that every therapist makes, especially when relying on a flawed theory of psychopathology and psychotherapy, we could be easily surprised by the fact that psychotherapy is nonetheless useful.  I think that our patients can forgive our mistakes if we make them with an attitude that is “good enough”.   A helpful (pro-plan) attitude can be our savior, particularly in difficult times.

 

References  

 

Angrisani, S., Gazzillo, F. (2016), Scegliere il giusto atteggiamento. In Gazzillo, F. (2016), Fidarsi dei pazienti. Introduzione alla Control-Mastery Theory. Milano: Raffaello Cortina pp.141-156.

Gazzillo, F., Mellone, V. (2016), Note sui disturbi gravi della personalità alla luce della Contro-Mastery Theory. In Gazzillo, F. (2016), Fidarsi dei pazienti. Introduzione alla Control-Mastery Theory. Milano: Raffaello Cortina, pp.241-275.

Pryor, K. (2005), A long-term therapy case illustrating treatment by attitude. Silberschatz, G. (2005). (ed.), Transformative relationships: The control-mastery theory of psychotherapy. New York: Routledge, pp. 219-235.

Sampson, H. (2005), Treatment by attitudes. Silberschatz, G. (2005). (ed.), Transformative relationships: The control-mastery theory of psychotherapy. New York: Routledge, pp.11-120.

Shilkret, C. (2008), Endangered by interpretation. Treatment by attitude of the narcissistically vulnerable patient. Psychoanalytic Psychology, 23, 1, pp.30-42.

Weiss, J. (1993), How Psychotherapy Works. Process and technique. Guilford, New York.

Weiss, J. (2005), Safety. Silberschatz, G. (2005). (ed.), Transformative relationships: The control-mastery theory of psychotherapy. New York: Routledge, pp. 31-42.

 

 

  

 

 

 

 

 

 

 

Review of PATHOLOGICAL IDENTIFICATION, by Steven A. Foreman, MD Psychoanalytic Psychology 2018, Vol. 35, No. 1, 15–30 Reviewed by Peter Schumacher, MFT

Joseph Weiss developed and wrote about his ideas for many years before they coalesced around a key psychoanalytic understanding that eventually gave birth to what we know today as Control Mastery Theory.  In an early paper (Weiss, J. 1968), he discussed a comparison between two competing contemporary models of psychoanalytic process.  The two models, “progressive stripping away” and “progressive integration,” were each used to provide an overall perspective on the changes that occur in analysis.  The first and more popular model, stripping away ­­— or “successive uncovering” it was sometimes called — was akin to the analogy of peeling an onion; peeling away successive layers of mental life, and analyzing each new layer as it appeared.  At the time, this was widely considered a helpful orienting model of psychotherapeutic process.  It allowed the clinician to have a working analogy, and a perspective from which important questions could be examined and resistances could be addressed as they successively emerged.  This led eventually to the final goal of the analysis, the core of the onion, as it were, being interpretation of fantasy that was related to early primary process.  This analogical model had its limitations, however, in that it could take years to know if actual patient progress were being made in any given analysis because there was no specific indicator of forward movement.  Not to mention that the human psyche is complex, and doesn’t easily lend itself to being compared with an onion.

The second model, progressive integration, builds on the first but with a twist.  Instead of working with resistances and penetrating deeper and deeper into layers of warded-off material, the clinician works with emerging material to allow for an integration of warded-off contents, resulting in “progressive acquisition of new capacities.”

Joseph Weiss saw the benefits of the integration model as a description of what he was to later call “mastery.”  As a person integrates warded-off contents, over time she or he becomes more able to consciously regulate attitudes, feelings, and behaviors that previously were unavailable or unconsciously expressed as painful repetitions.

Both models were about bringing forth unconscious material, but Weiss pointed out that the model of progressive integration added an important new feature, leading to a significant contribution to the practice of psychotherapy.  Weiss saw that the integration model allowed for the formulation of a practical theoretical construct of progress in therapy.  Patient progress was described in the paper as a “change in the transference and recovery of new memories.”  Progress in therapy can now be observed immediately following an intervention or interpretation.  This paper was a major development in psychoanalytic and psychotherapeutic thinking, and, as noted earlier, was the foundation of Control Mastery Theory.

Steven Foreman makes a similar step forward with his paper on Pathological Identification.  Using the concept described by Joe Weiss to understand the problem of repetition or reenactment of parental pathology, Foreman points to an aspect of attachment behavior that gives identification new meaning within early attachment patterns, which has important implications for psychotherapeutic technique.

Using clinical examples to illustrate what the process looks like, Steven Foreman clearly and articulately lays out the relationship between early childhood trauma and adult repetition of problematic behavior.  He also distinguishes the more “destructive” pathological identification from the “normal” psychological process of identification with a parent figure.

Joe Weiss used Neiderland’s term “survivor guilt” to explain painful pathological identifications, where the child would feel something akin to survivor guilt if he or she would surpass the parents in areas where the parents were deficient.  According to Weiss, in order to avoid feeling guilt about outdoing parents, children imitate problematic parental behaviors, feelings and attitudes, and in this way hold themselves back, thus protecting the parents from shame and reinforcing attachment.  Weiss used the term “unconscious guilt” to describe this phenomenon.  Foreman, in noting that the guilt Weiss referred to was potential guilt, recognized that guilt was not the primary emotional process driving the dynamic in early attachment.

Steven Foreman saw that the primary emotional driver of attachment was not guilt, or the fear of guilt, but the powerful motivation to be “empathic, caring and protective” toward parents and parent figures. When children imitate problematic parental behaviors and attitudes, they may fear the repercussions of doing better than the parents, but primarily children want to protect the parents from their own critical feelings about the parents.

This change in emphasis, from avoidance of guilt to feelings of protection for the parents, presents us with a new and practical theoretical construct that has important implications for treatment.  Foreman, by following patterns in case material like Weiss much earlier, realized that patients do not relate as easily to interpretations focused on avoiding guilt as they do to interpretations and interventions focused on protective feelings for their parents.

This also intuitively makes sense.  Interpreting avoidance of guilt feels more accusatory than interpreting protective feelings for the parents.  This shift gives the clinician both a clearer picture of the etiology of psychopathology and a very useful perspective from which to structure helpful interpretations and interventions.  Additionally, Steven Foreman outlines specific strategies for utilizing technique based on this model of psychopathology in four sequential steps.  This paper is a major advance in both developmental theory and theory of psychopathology.

References:

Niederland, W. G. (1981). The survivor syndrome: Further observations

and dimensions. Journal of the American Psychoanalytic Association,

29, 413–425.

Weiss, J. (1968). Stripping Away and Integration: Two Perspectives on the Therapeutic Process.  Unpublished paper.  San Francisco Psychotherapy Research Group archive.

Why therapists choose CMT

At the beginning of the 2018 first theoretical seminar on Control-Mastery Theory of the Control-Mastery Theory-Italian Group (CMT-IG), I asked the twenty-five new members of our Association to explain the reasons they decided to become CMT practitioners. Most of them were already practicing psychotherapists, others were completing their training in some other form of psychotherapy,  a few were psychologists that still needed to become psychotherapists, and most of them were in analysis or had completed some other form of personal psychotherapy.

Deciding to become members of the CMT-IG, they decided to dedicate at least three years of their life to learn CMT, first from a theoretical and then also from a clinical perspective, and to dedicate at least part of their professional life to use and expand our approach, without any other “practical” gain apart from becoming CMT practitioners. For this reason, I was quite curious about the reasons of their choice.

Most of the new members of our Association had learned something about CMT by listening to the lessons on CMT that I teach in Sapienza University during my course in Dynamic Psychology, or to the seminars on CMT that I have in several Master Programs in psychoanalytic psychotherapy or in cognitive psychotherapy.

Following, I will report their replies, grouping them in a way that seems sensible to me. George Silberschatz, John Curtis, Marshall Bush and I have found these reasons instructive.

The positive qualities of the CMT theory

The theory is clear and straightforward.

It is flexible and, at the same time, precise.

It is integrative, i.e. it enables therapists to use techniques of different approaches within a coherent and unified frame.

It provides a way to understand and plan both psychotherapy and social work within a unified theoretical frame.

CMT helps to make sense of the patient experience

It helps the clinician to see the world through the patients’ lenses.

It enables us to make sense of the patients’ psychological conditions and needs quite rapidly.

It helps to make sense of the patient history and of its consequences.

It gives clear practical implications on how to work with a patient.

The case-specificity of CMT clinical approach

It puts the patient’s needs ahead of the therapist model.

It is case-specific, not disorder specific.

 

The way CMT affects the clinical work

It enables the clinician to make sense and "use" therapeutically the patient-therapist relationship;

It supports the therapist in being bold and authentic when needed.

It legitimizes more directive and protective interventions, which are "forbidden" in classical psychoanalysis, if they are in line with the patient plan.

It pushes the therapist to take position, supporting the patient’s healthy goals and contrasting her/his pathogenic beliefs and schemas. In other words, the therapist does not need to always be neutral.

It enables us to understand why some interventions or actions, which are considered 'wrong' in a classical psychoanalytic perspective, actually work.

It helps to understand the reasons why some therapies, which theoretically are supposed to be effective, do not actually work.

The empirical foundation of CMT

Its concepts are empirically tested and testable.

Its effectiveness is empirically grounded.

The optimism of the theory

CMT supports the clinician’s trust in the adaptive capacities of the patient.

It stresses pro-social motivations and unconscious higher mental functioning.

It enables the clinician to work well with patients who do not behave as they are supposed to behave in therapy.

It helps the therapist to have a more positive view of very difficult patients, and even in the worst moments of a psychotherapy.

It enables therapists to help even apparently “untreatable” patients.

And finally, CMT helps the therapist to better understand themselves.

There is much more that could be said about each of these points, but for now I will leave that to the reader. What I would like to stress is that our theory seems to be appreciated because it is useful for understanding and treating patients and because it is strongly ingrained in both clinical reality and empirical research.

CMT Dreaming

As already seen in several previous posts, at the core of our model there is the idea that both our conscious and unconscious mental functioning is highly sophisticated, aimed at adaptation and regulated, at its basis, by the safety/danger principle. This means that we want to pursue pleasurable and healthy goals but are frequently obstructed in this task by the difficulties of reality and by our pathogenic beliefs, the deep and long-lasting traces of our developmental traumas. Starting from these premises, it is not difficult to hypothesize that also our dreams, the product of our night-time unconscious mental functioning, are an effort at adaptation. Saying it in the simplest way, our dreams are messages we send to ourselves by which we try to develop and test our policies for solving unresolved problems (see also Bargh, 2017). And dreams serve this function whether or not the dreamer remembers them. As said by one of my patients: “I like dreams, even because when I dream I do not have to try hard to understand what my mind is dealing with. The dream says this to me”.

Dreams are never trivial; they address the main concerns of a patient, even if s/he is not able to understand their meaning. People dream about problems they have not been able to resolve so far, and may dream also about problems they do not feel able to face in their conscious awareness because their pathogenic beliefs make them feel in danger. So, a person may “reveal more self-knowledge and may see things more clearly in his dreams than in his waking-life” (Weiss, 1993, p.142).

Dreams have an overarching adaptive function. We may have dreams aimed at mastering traumas, at providing corrective emotional experiences (similar to the wish fulfilment dreams), or dreams aimed at soothing and consoling oneself.   Self-punishment dreams are quite common, as are those that warn or encourage the dreamer.   There are dreams in which we muse on our problems and develop insights into possible solutions.

The fact that dreams are thoughts expressed by visual images and are experienced as something that is happening to us, not as something felt as produced by us, make them an enormously powerful tool -- much more powerful than an abstract thought.  In our dreams we can use different narrative styles (realistic novel, sit-com, narrative, prophecy etc.) and a wide range of rhetorical figures (irony, reductio ad absurdum, hyperbole, repetitions etc.) to convey important messages or themes. Finally, even the comments that the dreamer makes in recounting the dream or the associations to it are frequently relevant for understanding it.

But if dreams have an adaptive function and can be understood as a message that a person is sending to him/herself, why is it often so difficult for the dreamer to understand them? First of all, because it is not always clear to the awakened dreamer which is the problem or concern his/her dream is dealing with and the attitude s/he may have toward that problem while dreaming.  Second, as adults we are in general less accustomed to think in visual terms.  Third, dreams take place in a in a very particular state of mind, sleep, which is naturally dissociated from the lucidly wakeful state we are in when reflecting on the dream and trying to understand what it means. Finally, dreams may be hard to understand because, consciously or unconsciously, they may be heavily disguised.  There are many reasons for such disguises; consider, for example, a person who wants to warn himself about a danger while consciously needing to deny that danger.

In order to understand the meaning of a dream a therapist should consider both its context (what the patient was talking about before telling the dream, what is happening in therapy and in in the patient’s life when s/he has this dream) and the associations that the patient makes about the dream and its various components. We may think about the interpretation of a dream as something like the task of giving a caption to a cartoon (Weiss).  It is helpful to shift from the idea of interpreting a dream to the idea of exploring it (Paul Ransohoff). And we should not forget that dream interpretation is just one part of psychotherapy, and not always the most relevant.  We can make sense of a patient’s dreams only within the following context: when a patient reports a dream, it is possible that s/he is testing us, or tells us a dream because we passed an important test, or maybe s/he is coaching us with it. In psychotherapy, we can rely (also) on dreams for understanding the goals the patient wants to pursue,  the pathogenic beliefs s/he is trying to disprove, the  policies s/he is considering and which kind of relationship s/he wants to have with us.

Just one example. A patient in his thirties was working through the loss of his father.  He was trying to understand if he should follow his father’s teachings about the centrality of social status in life or follow what he thought to be important and “true”. At the same time, he was trying to understand if he should have complied with the requests of a couple of friends who could have been useful to him in term of status or if he should have broken off the relationship because they had disappointed him and were increasingly distant from him. During a session, he told me this dream:

 

I was with that couple of friends near the walls of a very old town, probably a town from the ancient Roman period or from the Middle Age. We have to go to a bookshop, but following one of these friends we lost our way and were not able to find the bookshop. A that point I realized that the bookshop was in the center of this town, while my friends thought that it was in the outermost part. I see some broken keys on the ground, and I thought that they had been broken by my two friends lack of care.

 

     The basic message of this warning dream, which is expressed like a prophecy, is that he could find his "center", the "key" of his future only if he does not comply with the teachings of his father and with the requests of those friends. And this is what he did in the following year. This dream was very important for the patient, who went back into his mind several times in the following years when he felt confused or anxious about what to do.

 

References

 

Bargh, J. A. (2017), Before you know it: The unconscious reasons we do what we do. New York: Touchtone.

Weiss, J., Sampson, H., & the Mount Zion Psychotherapy Research Group. (1986). The psychoanalytic process. New York: Guilford Press.

Weiss, J. (1993), How psychotherapy works: Process and technique. New York: The Guilford Press.

 

 

 

How to be effective

The different psychotherapeutic approaches and schools tend to attribute the effectiveness of their treatments to different kinds of interventions and communications. Apart from the relevance attributed to therapeutic alliance and empathy, which are recognized as central or at least useful by virtually all the researchers and practitioners of our field, and whose effectiveness can be taken for granted (Lambert, 2013; Wampold, Imel, 2015), the differences among the theories of technique of the different schools of psychotherapy are often huge. From Socratic dialogue to transference interpretation, from support to specific homework, from the authenticity and congruence of the therapist to the use of exposition with response prevention exercises, from skill training to mentalization enhancing communications, each school has its own specific tools that are purported to be effective. But the empirical evidence supporting them is generally weak (and frequently there is no research evidence available at all).

In this regard, Control-Mastery Theory is different. First of all, there is no specific technique or manual descending from our theory.  Instead, there are practical indications that are broad enough to be applied by therapists with various theoretical backgrounds and styles yet precise enough for working in a “case specific” way with each different patient. The second great difference between CMT and many other approaches is that the therapeutic indications of CMT have a solid empirical basis, i.e., they are “empirically validated” (for a review, see Silberschatz, 2005; 2016). What are these indications?

We can describe them in three different ways that are substantially equivalent:

1)      Helping patients to feel safe with us;

2)      Disproving patients’ pathogenic beliefs;

3)      Helping patients to carry out their plan.

As we have seen, according to CMT psychopathology stems from painful, grim pathogenic beliefs developed as adaptions to traumatic environments and events.  These pathogenic beliefs make the patient feel endangered if s/he tries to pursue healthy and pleasurable goals, and for this reason patients are powerfully motivated to disprove them. Each communication and intervention that helps the patient to disprove pathogenic beliefs and to feel safe in pursuing her/his goals is, ipso facto, therapeutic (Weiss, 1993). 

But the more precise way of helping a patient to get better is developing, and following, a good formulation of her/his plan (Weiss, 1994; Curtis, Silberschatz, 2007). In fact, as we have seen in the previous post, patients, other than being powerfully motivated to disprove their pathogenic beliefs and pursue their goals, have also a more or less detailed plan about how to do it.  They test their pathogenic beliefs in specific ways; look for a specific kind of relationship with their therapist; want to understand their specific pathogenic beliefs including their origins and manifestations; want to master the trauma that are at their basis. Consequently, we may define “therapeutic” as anything which helps the patient to

(1) become clearly conscious and feel legitimate, capable, and supported in pursuing his/her goals without feeling too guilty, afraid, ashamed, and so on;

(2) become clearly conscious of pathogenic beliefs,  their origins, functions, and consequences, and ways of disproving them;

(3) become conscious of the traumas that are the basis of these beliefs and how to better master them, thereby retelling her/his own life history in a less guilty form.

(4) Along the same lines, a relationship is therapeutic in so far that  it is corrective, i.e. if the patient experiences that her/his tests are passed, and if the clinician demonstrates an attitude that is different from the attitude of the traumatic parents and from the attitude that the child adopted toward them (Sampson, 2005; Gazzillo, 2016).

Following the plan of the patient, being sensitive to the patient’s reactions, and being responsive to her/his coaching (Bugas & Silberschatz, 2000) provides a way of understanding if we are on the right track.  The plan formulation is also a useful guide for determining whether the patient is looking for a treatment that is based largely on interpretations (Shilkret, 2008), looking for a concrete help vs. finding her/his own way to solve problems, wants a silent or talkative therapist, wants an intimate or distant relationship, and so on.

If we want to be of help, we must be pro-plan. All the rest is commentary.

 

References

 

Bugas, J., & Silberschatz, G. (2000), How patients coach their therapists in psychotherapy. Psychotherapy, 37(1), pp. 64-70.

Curtis, J. T., & Silberschatz, G. (2007). Plan Formulation Method. In T. D. Eells (eds.), Handbook of psychotherapy case formulation (2th ed., pp. 198– 220). New York: Guilford Press.

Gazzillo, F. (2016), Fidarsi dei pazienti. Introduzione alla Control-Mastery Theory. Milano: Raffaello Cortina

Lambert, M. J. (Ed.), (2013). Bergin and Garfield’s handbook of psychotherapy

           and behavior change (6th ed.). New York, NY: Wiley.

Sampson, H. (2005), Treatment by attitude (pp.111-120). In Silberschatz, G. (edited) (2005), Transformative relationships. The Control-Mastery Theory of Psychotherapy. New York and London: Routledge.

Shilkret, C. (2008), Endangered by interpretations. Treatment by attitude of the narcissistically vulnerable patient. Psychoanalytic psychology, 23, 1, 30-42.

Silbershatz, G. (2005), An overview of research on Control-Mastery Theory (pp.189-218). In Silberschatz, G. (edited) (2005), Transformative relationships. The Control-Mastery Theory of Psychotherapy. New York and London: Routledge.

Silberschatz, G. (2016), Il fondamento empirico della Control-Mastery Theory: le ricerche sulle psicoterapie. In Gazzillo, F. (2016), Fidarsi dei pazienti. Introduzione alla Control-Mastery Theory. Milano: Raffaello Cortina, pp. 123-240

Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate:

         the evidence for what makes psychotherapy work (2nd ed.). New York,

         NY: Routledge

Weiss, J. (1993), How psychotherapy works: Process and Technique. New York: Guilford Press.

Weiss, J. (1994), The analyst’s task: to help the patient carry out his plan. Contemporary Psychoanalysis, 30, 2, 236-254.

 

 

 

 

Helping patients to obtain what they want by formulating and following their plan

Looking back at what happened during a psychoanalysis or  psychotherapy, it is common to notice that the treatment was all basically centered around one or a few themes. Each patient worked toward reaching one or few goals, was obstructed by one or few fears, and tended to deal with those fears in a limited number of ways. Moreover, with hindsight we notice that each patient dedicated some periods of therapy to work on a theme, and other periods on other themes or on the same theme from another perspective. And, if we want to be honest, we should add that these same “pathogenic schemas” do not completely disappear even after a successful treatment; they “lose their grip”, become less strong and pervasive, but somehow remain and tend to appear again in moments of distress, even if they do less harm. So, we have the impression that the therapeutic process was much more ordered and focused than one could have thought while it was happening. How to make sense of this fact?

The answer to this question becomes obvious if we consider this problem according to the adaptive unconscious hypothesis: patients come to psychotherapy with a plan, even if this plan is in general unconscious. Many people may consider this hypothesis implausible because they think that the unconscious mind cannot be very organized, or because they believe that it is the therapist who establishes the course of a treatment.  However, both systematic clinical observations and careful empirical studies show that this is not the case (Curtis, Silberschatz, 2007). As every human activity is regulated by a plan indicating its goal as well as several possible strategies of achieving  it, so it is for psychotherapy (Weiss, Sampson, & The Mount Zion Psychotherapy Research Group, 1986; Weiss, 1993; Weiss, 1998). What are the elements of this plan?

Given that a patient seeks psychotherapy because s/he is not able to do or feel something that s/he would like to do or feel, the first element of a plan are the healthy and pleasurable goals that the patient would like to pursue with the help of the therapist. They can be conscious or unconscious, explicitly conveyed by the patient or implicit, concrete or abstract, but they are by definition healthy and pleasurable; if the patient declares unrealistic or self-destructive goals, what s/he is actually conveying are pathogenic beliefs that the patient is testing.

If the patient has been not able to reach those goals so far it is because s/he is obstructed by her/his pathogenic schemas, and these are the second element that s/he will try to communicate to us.  While interacting with patients, a CMT clinician tries to infer and formulate not only what the patients wants but also their pathogenic schemas, which are typically unconscious due to  repression,  dissociation or because they are stored as procedural rather than declarative knowledge. And among these pathogenic schemas, those related to their interpersonal sense of guilt often play a particularly relevant role. Patients want us to know them because they want our help to disprove them.

During the initial interviews patients tend also to tell us – and we should always investigate –the more important events of their life that led to their pathogenic schemas, and relational experiences that shaped their way of conceiving themselves, other people, and the world. In other words, patients tell us their traumas and try to convey to us their impact on their psychic life. They talk about them because they want our help to master them, and if they do not talk about them, we can speculate about their nature based on the patient narratives and from how they relate to us. This is the third element we need to delineate for understanding the patient plan.

As seen in a previous post, patients try to disprove their pathogenic beliefs by testing them in their important relationships, and they can test them in different ways. During the first interviews they try to show us -- both in what they say and in how they relate to us -- their typical testing strategies, and the reactions that they hope we will have. In other words, they will try to help us understand their needs so that we will react appropriately to their communications, actions, and attitudes.  Consequently, we should ask ourselves how they want us to behave in order to help them and the kind of attitude they would like us to have. This is the fourth element of a patient plan.

Taken together, these elements enable us to understand the kind of insights that may be of help to our patients.   In other words, they try to help us see what they need to understand about themselves in order to feel better and overcome their painful feelings, inhibitions, and symptoms.

Sometimes patients seem to have a quite precise plan for their therapy, one which may specify the pathogenic schemas they want to deal with initially and which will be deferred; other times their plans are something like a “rough draft” pointing to a certain direction and suggesting a favorite way to proceed, but in an open and flexible way. In either case, patients coach (Bugas, Silberschatz, 2000) their therapist so that they can better understand the elements of their plan, and they often try to adapt their way of testing to the peculiarities of the therapist and her/his approach.

To develop a formulation of a patient plan the therapist should rely on what happens during the early sessions, paying attention to the elements described above and to the therapist’s  emotional reactions to the patient as well as all the information s/he has about the patient.   Therapists should think about their patients in everyday terms, as we think about other people in our life. And therapists can check if their hypotheses are correct by asking themselves if the formulation is able to explain most or all of what they know about the patient.  Therapists should also rely on the patient’s reactions to her/his interventions as a way of determining if s/he is on the right track.

Finally, thanks to John Curtis and George Silberschatz we have an empirically validated Plan Formulation Method (PFM; Curtis, Silberschatz, Sampson, Weiss, 1994) which assists us in reliably explicating and describing the plan of our patients. This is the “manual” we need to follow in order to be most helpful to our patients. 

 

References

Bugas, J., & Silberschatz, G. (2000), How patients coach their therapists in psychotherapy. Psychotherapy, 37(1), pp. 64-70.

Curtis, J. T., & Silberschatz, G. (2007). Plan Formulation Method. In T. D. Eells (eds.), Handbook of psychotherapy case formulation (2th ed., pp. 198– 220). New York: Guilford Press.

Curtis, J. T., Silberschatz, G., Sampson, H., & Weiss, J. (1994). The Plan Formulation Method. Psychotherapy Research, 4, 197–207.

Weiss, J. (1993), How psychotherapy works: Process and Technique. New York: Guilford Press.

Weiss, J. (1998), Patients' unconscious plans for solving their problems. Psychoanalytic Dialogues, 8(3), pp. 411-428.

Weiss, J., Sampson, H., & the Mount Zion Psychotherapy Research Group. (1986). The psychoanalytic process. New York: Guilford Press.

Traumatic Early Bonds Called Guilt

In the last post we saw several reasons why it is so difficult to abandon our own pathogenic beliefs and schemas, even when our experiences disprove them. Among the different factors contributing to this fact, one of the more relevant is unconscious guilt. As Freud (1916, 1923, 1925, 1929) pointed out decades ago, patients punish themselves with their symptoms and problems; and, as suggested by Fairbairn (1952, 1963), their suffering is a function of their bonds with bad internal objects.  According to Control-Mastery Theory, we could add that the strength of unconscious guilt is a good approximation of the strength of these bonds.

Guilt is a painful moral emotion depending on our capacity to feel empathically the distress of another person, on our attributing to ourselves the responsibility for this distress, and on our desire to avoid or repair it (Friedman, 1985). Recent developments in affective neuroscience and cognitive, developmental, and evolutionary psychology (Zahn-Waxler & Robinson, 1995; Bybee & Quiles, 1998; Hoffman, 2000; Panksepp & Biven, 2012) stress that guilt is a function of our altruistic/pro-social motivations (Tomasello, 2016), which are as primary as our egoistical and self-centered motivations. If individual natural selection can explain why we may be so egoistic, our altruism evolved thanks to group selection (Wilson, 2007, 2015): we harbor pro-social altruistic motivations because we are a eusocial species living in groups.  The abilities and motivations that drive us to help another human being have been “rewarded” by evolution because they have promoted the survival and reproduction of our groups.

Guilt stems from fear (of losing the bond with or the love of another person), attachment (to that person), and care (for him or her) (Gazzillo et al., in press; Kochanska, Gross, Mei-Hua & Nichols, 2002).   In contrast to classical psychoanalytic thinking, there is no need to harbor aggressive wishes in order to feel guilty; believing that what you want or do could harm your loved ones or your relationships with them is sufficient to cause guilt. And in contrast to classical cognitive models (e.g., Kohlberg, 1969), contemporary moral evolutionary psychology shows that feeling guilty is not a consequence of complex reasoning, but of an intuitive emotional assessment of the reality we face.

There are six “moral foundations” (Haidt, 2012) that we all share because they are “wired” in our brain and shape our moral sensitivity: we value protection and condemn harm, appreciate loyalty and criticize betrayal, reward equity and punish cheating; we appreciate the respect of legitimate authority and condemn arbitrary subversive actions; we want to be free and disrespect oppressing others and, finally, we feel that our body is to a certain extent sacred and are morally disgusted by its degradation.  Different cultures shape the meaning and give more weight to some of these foundations and less to others, as do our personal experiences -- in particular the early, traumatic experiences that are the bases of our pathogenic beliefs. These beliefs may transform guilt, which is basically adaptive, in a relevant pathogenic force.

Control-Mastery Theory (Bush, 2005; Weiss, Sampson & The Mount Zion Psychotherapy Research Group, 1986; Weiss, 1993) has focused its attention to four families of pathogenic beliefs which give rise to four kinds of guilt: survivor guilt, separation/disloyalty guilt, omnipotent responsibility guilt and self-hate. Survivor guilt refers to a painful emotion that people may experience when they are surpassing important others, believing that they are hurting them by being more successful, happy, fortunate, etc. Separation guilt stems from the fear of harming others by becoming independent and moving away, while disloyalty guilt stems from the belief that being psychologically different from them will be hurtful to loved ones. Omnipotent responsibility guilt involves an exaggerated sense of responsibility and concern for the happiness and well-being of other people, and it is based on the belief that one has the duty and power to save loved ones in trouble. The last kind of interpersonal guilt, self-hate, arises when an individual complies with severely critical, abusive, or neglecting attitudes of important others, often a parent. It describes the feeling of being inherently wrong, inadequate, guilty, and not deserving of love, protection, and happiness. These interpersonal guilt feelings described by CMT are compatible with four of the six moral foundations pointed out by Jonathan Haidt (2012).

Unconscious interpersonal guilt condemns people anytime they try to be separate, different, or better off than their loved ones and anytime they try to give value to themselves and their life. Various childhood experiences give specific meanings to being different, separate, or better off than love ones, but the basic conflict remains the same: am I allowed to pursue my personal and relational wellbeing or must I sacrifice my life to my early love objects?

Finally, according to CMT guilt often supports chronic shame, which is an expression of compliance to shaming parents or identification with shameful parents; in either case, shame is maintained by difficulties in differentiating and becoming independent from or displeasing parental figures.  In other words, the feelings of shame are maintained by guilt toward loved ones.  In a zero-sum game, interpersonal guilt causes us to experience our gain as a loss for the people we depended on, and leads us to sabotage our life out of loyalty and solidarity with the relational vestiges of our past.

 

References

 

Bush, M. (2005). The role of unconscious guilt in psychopathology and in psychotherapy. In G. Silberschatz (ed.), Transformative relationships. The Control-Mastery Theory of Psychotherapy (pp. 43-66). New York: Routledge. 

Bybee, J., Quiles, Z. N. (1998). Guilt and mental health. In J. Bybee (Ed.), Guilt and Children (pp. 270-291). London: Academic Press.

Fairbairn, W. R. D. (1952). Psychological Studies of the Personality. London: Routledge & Kegan Paul.

Fairbairn, W. R. D. (1963). Synopsis of an Object-Relations Theory of the Personality. International Journal of Psycho-Analysis, 44, pp. 224-225.

Freud, S. (1916). Some Character-Types Met with in Psycho-Analytic Work. The Standard Edition of the Complete Psychological Works of Sigmund Freud, (Vol. 14, pp. 309-333). London: Hogarth.

Freud, S. (1923). The Ego and the Id. The Standard Edition of the Complete Psychological Works of Sigmund Freud, (Vol. 19, pp. 1-66). London: Hogarth.

Freud, S. (1925). Inhibitions, Symptoms and Anxiety. The Standard Edition of the Complete Psychological Works of Sigmund Freud, (Vol. 20, pp. 75-176). London: Hogarth.

Freud, S. (1929). Civilization and its Discontents. The Standard Edition of the Complete Psychological Works of Sigmund Freud, (Vol. 21, pp. 57-146). London: Hogarth.

Friedman, M. D. (1985). Toward a Reconceptualization of Guilt. Contemporary Psychoanalysis, 21 (4), pp. 501-547.

Gazzillo, F., Gorman, B., De Luca, E., Faccini, F., Bush, M., Silberschatz, G., Dazzi, N. (in press.). Preliminary data about the validation of a self-report for the assessment of interpersonal guilt: The Interpersonal Guilt Rating Scale-15s (IGRS-15s). Psychodynamic Psychiatry.

Haidt, J. (2012). The righteous mind: Why good people are divided by politics and religion. New York: Pantheon/Random House.

Hoffman, M. L. (2000). Empathy and moral development: Implications for caring and justice. New York: Cambridge University Press.

Kochanska, G., Gross, J. N., Mei-Hua, L., Nichols, K. E. (2002). Guilt in young children: Development, determinants and relation with a broader system of standard. Child Development, 73, pp. 461-482.

Kohlberg, L. (1969). Stage and sequence: The cognitive development approach to socialization. In D. A. Goslin (ed.), Handbook of socialization theory (pp. 347-480). Chicago: Rand McNally.

Panksepp, J. Biven L. (2012), The Archeology of Mind. Neuroevolutionary Origins of our Emotions. New York. W.W. Norton & Company.

Tomasello, M. (2016). A natural history of human morality. Boston: Harvard University Press.

Weiss, J. (1993), How Psychotherapy Works. Process and technique. Guilford, New York.

Weiss, J., Sampson, H., & Mount Zion Psychotherapy Research Group (1986). The psychoanalytic process: Theory, clinical observation, and empirical research. New York: Guilford Press.

Wilson, D. S. (2007), Evolution for everyone: How Darwin's theory can change the way we think about our lives. New York: Delta Press.

Wilson, D. S. (2015). Does altruism exist: culture, genes, and the welfare of others. Boston: Yale University Press.

Zahn-Waxler, C., Robinson, J. (1995). Empathy and guilt: Early origins of feelings of responsibility. In J. P. Tangney & K. W. Fischer (ed.), Self-conscious emotions: The psychology of shame, guilt, embarrassment, and pride (pp. 143-173). New York: Guilford Press.

Beliefs and pathogenic beliefs

In order to adapt to reality, since the very first moments of life (Stern, 1985) we start to develop and test reliable “maps” of our world.  We do it first unconsciously and then consciously, and in developing these maps we pay particular attention the kinds of situations, experiences, and people that make us feel safe or in danger. These “maps” organize our perceptions, cognition, emotions, behavior and they shape our temperament as well as the development of our personality (Silberschatz, Sampson, 1991). They are our guides into the world and describe how we are, how other people are, how the world is and how we must behave in order to reach our goals and to avoid dangers. These maps, which we will call “beliefs”, define our “reality” and “morality” (Weiss, 1993). Our “beliefs” or more precisely, our “system of beliefs”, are not originally expressed in words, so that we have sensorial, motorial, and procedural maps together with verbal maps which tend to be hierarchically structured. We can formulate most of these beliefs as “if…then” structures, and try to make them as coherent as possible.

The beliefs we develop are strongly influenced by the emotional/motivational systems which are active when we first develop them, and even as we modify and build new beliefs throughout life the beliefs we developed as children (and adolescents) tend to be particularly powerful.  Why are beliefs formed in childhood so compelling?  Children are totally dependent on their caregivers and consequently can easily feel endangered: our attachment (and care) needs are stronger than ever, we need to have a good enough relationship with caregivers and will do anything we can to preserve this vital relationship. We need to see our caregivers as strong, good, and wise, and if there is a disagreement we think that we are wrong and they are right.  In fact, children tend to think that the way their parents treat them is the way they deserve to be treated. Thus, the implicit and explicit demands, teachings, and the experiences we had with our caregivers are the foundation of our core beliefs. The beliefs that we develop when we are children are also influenced by our cognitive and emotional immaturity and by the paucity of our experiences.  As children, we tend to put our self at the center of any situation, often give  ourselves more power than we have,  blame ourselves more than we deserve, and  overgeneralize on the basis of very few cases (Weiss, Sampson, & the Mount Zion Psychotherapy Research Group, 1986).

Each of our beliefs is then connected to four possible strategies: compliance (with the parent and the belief), identification (with the parent who “taught” it to us), rebellion (against the parent and the belief) and counteridentification (with the parent who “taught” it to us). These strategies, together with the belief they are associated with and the affects that connotate it, give rise to our “schemas” (Silberschatz, 2005).  

We are very slow in changing our beliefs and schemas (which is basically adaptive) and tend to more heavily weight information or experiences that confirm them (confirmation bias) - particularly for the beliefs that warn us against danger. And there is a subset of beliefs and schemas that we call “pathogenic beliefs and schemas” because they make us suffer, inhibit us, fuel our symptoms, or push us to behave in ways that are dysfunctional. They are generally formulated during our developmental years and their defining feature is that they associate the pursuit of a healthy and pleasurable goal to an internal or external danger to ourselves or to loved ones. Pathogenic beliefs and schemas may be conscious but are generally unconscious either because they are repressed or because they are based on implicit/procedural knowledge.

Pathogenic beliefs and schemas derive from both “shock” and “stress” traumas, and they originated as efforts to adapt to these traumas: we developed them by processes of inference, trying to understand how the trauma happened, what we did to cause it and how we can prevent similar traumas in the future.  However, with the changing of our needs, relationships, and experiences these beliefs and schemas become maladaptive because the negative consequences they have on our lives are too burdensome and painful.  Consequently, even though it feels dangerous, we are deeply motivated to disconfirm them and this is the main reason a patient looks for a therapist.

Just one example: Seeing that my mother looked hurt any time I wanted to spend time with people other than her, I developed the pathogenic belief that the people I love are easily hurt if I do not remain close to them.  As a result of this belief, I may tend to: (1) always stay very close to people I love (compliance) and feel guilty if I do not do so; (2) avoid interpersonal closeness and feel a claustrophobic anxiety when another person wants to be very close to me (rebellion); (3) require people I love to be very close to me and become hurt or angry when they want to be with other people (identification), or (4) convey the message that I do not need loved ones to stay with me and then become anxious or guilty when I sense that they feel that I need them to stay close to me (counteridentification). These could be my pathogenic schemas.

 

References

 

Silberschatz, G. (2005). (ed.), Transformative relationships: The control-mastery theory of psychotherapy (pp. 219-235). New York: Routledge.

Silberschatz, G., & Sampson, H. (1991). Affects in psychopathology and psychotherapy. In Safran, J.D., Greenberg, L.S. (eds.) (1991), Emotion, psychotherapy, and change. New York: Guilford Press, pp. 113-129.

Stern, D. N. (1985). The interpersonal world of the infant: A view from psychoanalysis and developmental psychology. London: Karnac Books.

Weiss, J. (1993). How psychotherapy works: Process and technique. New York: Guilford Press.

Weiss, J., Sampson, H., & Mount Zion Psychotherapy Research Group. (1986). The psychoanalytic process: Theory, clinical observation, and empirical research. New York: Guilford Press.