Diagnosis or Plan Formulation?

Susan is a 45 years old woman who asks for my help because she feels depressed. She is overweight, has never had a significant love relationship, does not have any close friends, does not work very much, her income is pretty low and she lives with her old and sick parents, taking care of their health. She says that she cannot go and live by herself because she does not have the necessary money and cannot leave her parents alone. She says that she has no hope of finding a better job because she does not think she is a good enough worker – though my impression is that she is sensitive and clever.   She says that she wants to get better but has lost any hope of finding a man who can fall in love with her and adds that her life arrangement cannot be changed. I am her third therapist.

 

David is a 40 year old man who lives with his girlfriend and her 6 years old daughter and works in a small company. He has had 11 years of psychotherapy and for 6 of these years he has also taken medicines for his depression and anxiety. Moreover, for several years he has suffered of a paraphilia and in different periods of his life he has suffered also of compulsions: he had to plan and check several times all he did, from everyday tasks such as making the bed to work tasks and decisions. All of his psychic life is centered around the idea of being worthless, inadequate and less capable than all the people he knows. He thinks that he is too introverted and slow, too passive and not “cool” enough to be liked by the right people. For this reason, he feels depressed and becomes very anxious any time he needs to deal with a new task.

 

Sara is a 28 years old woman who sought therapy because she felt very depressed after the ending of a relationship she had hoped that could have become a real love story. Apart from crying very often because she thought that the ending of her relationship was her fault, biting her fingers and make them bleed, and having difficulties to sleep, Sara has lots of good friends, is a very good worker, loves her job and practices a lot of sports. She spendt most of the sessions of her first year of therapy crying and accusing me of being a liar: she has no hope of finding another man who will be as good as the lost one, and she accused me of being deceptive when I disagreed.

All these patients, when they started therapy, met the criteria of a depressive disorder. Susan also believed she had attention-deficit disorder; David met also the criteria of a generalized anxiety disorder, an obsessive-compulsive disorder and a paraphilia, a dependent personality disorder and showed also significant traits of a narcissistic personality disorder.

But … are these diagnoses in some way useful for planning their treatment? Does it make any sense to think that these patients need similar treatments, maybe empirically supported, for overcoming their depression? May we think that the multiple problems of David, and of so many other patients, should be considered as different and independent problems, each one to be treated per se with a different EST?

My response is: no. The psychic condition of a human being is not a puzzle of unrelated pieces of psychiatric diagnoses. It is the outcome of their stories and of their adaptation efforts. So, let’s try to make sense of their problems looking at the core elements of their plans.

 

Susan grew up in a family full of violence, suffering, and emotional blackmail. She was the younger child, and her father had been physically violent with her mother and siblings, but not with her. Her mother lost one of her children when Susan was very young and asked her to spend their time together in order both to alleviate her grief and to protect her from her violent husband. One of her sisters decided to share with Susan the “secret” of being abused by one of their brothers. Both an older brother and an older sister during adolescence developed psychiatric problems. Because of all these traumas, Susan grew up with strong survivor guilt toward her siblings and mother and strong feelings of separation guilt toward her parents, which have prevented her from developing a life of her own and severely affected her self-esteem. Even now, she feels guilty at the idea of leaving her parents’ house and not taking care of them anymore (her mother used to say to her: “If you were not with me, I would die”); moreover,  she feels that she got more from her parents than her brother which , has caused deep resentment, pain and rage in him.  She tests her pathogenic beliefs mainly with behaviors which show her compliance with her pathogenic beliefs, hoping to find someone that will support her right to have a life of her own.

From a certain perspective, it would be crazy not to be depressed while keeping on living a life such as the one she is living. It is her life that needs to be changed and to do so she needs to disprove her pathogenic beliefs and to overcome her guilt.

 

Daniel’s problems come from the fact that his mother, since he was very young, used to compare him with his older sister finding him always inadequate and inferior. It was she who had always told him that he was too slow, introverted and not “bright” enough for having a successful life. His mother was always insensitive to David’s suffering and complaining, saying that she was simply trying to help him become a better person. And now Daniel is convinced that his mother is right, and he is able to point to evidence of this fact. When confronted with a new task, he becomes very anxious and his anxiety negatively affects his performance, and this becomes further evidence of the fact that he is not adequate, which makes him feel depressed. He cannot sleep because he needs to “prepare” himself for any problem he might have to deal with the following day, and his paraphilia seems to be an expression of this same basic theme: in order to get excited, he needs to be humiliated by a prostitute with a phallus while he touches her socks or sucks her (plastic) penis. The core of his pathology is his self-hate, and he tends to propose transference tests by compliance and passive-into-active tests hoping to find someone who believes in him and is not too upset by his devaluations.

 

Finally, Sara has been deeply affected by the continuous fights among her parents, and by the fact that she has been able to find her way in life and leave her parents’ apartment while her younger chronically depressed brother continues living with their parents and does not seem to have any aspiration or life goals. Because of her strong survivor guilt, whenever a possible love story comes to an end Sara becomes depressed because she believes that she will always be alone or that she needs to learn to be content with an unsatisfying relationship. Her problems relating with men are an expression of an identification with the worst aspects of her parents, identification which comes out of her survivor guilt. She needs a strong and optimistic therapist who is able to stand her pessimism and criticism.

 

I think that Plan Formulations, even such rudimentary ones, are much more useful than a DSM or psychiatric diagnosis for understanding the nature, origins and meaning of the difficulties of our patients, and they provide a much more precise guide for treating them. It is also clear that, on the basis of the formulation of their plans, each of the above described patient needs a quite different kind of treatment in order to overcome her/his “depression”, and a quite different attitude from the therapist. Susan needs a strong, supportive but relatively detached therapist who helps her overcome her separation guilt and change her life; David needs a strong and accepting therapist who is able to appreciate him and help him to overcome his powerful self-hate; and Sara needs a therapist who seems to be independent, lucky and happy and helps her in legitimating her own happiness and her right to have a satisfying love relationship.

 

Plan Formulations, much more than diagnoses, enable us to understand and treat our patients; they help us in being more empathic and sensitively attuned to their needs, and provide a useful  map whose efficacy is empirically supported.

 

Some Reflections on Falling in Love

From the perspective of Control-Mastery Theory, we fall in love with a person if their appearance, manner, character, behavior, attitude or other features, seems able to disconfirm the pathogenic beliefs that obstruct our desire for sexual pleasure, recognition, appreciation, love, intimacy etc. (Sampson, 1994; Bader, 2002). The specific features that s/he should have are, of course, shaped by the the particular features of the emotionally relevant experiences and people of our life. In this post, I would like to start from these ideas and reflect on some kinds of falling in love that I have often observed in my clinical practice (De Luca, Gazzillo, 2018).

Antony, a gay man in his thirties, for the first five years of our treatment was unable to have a satisfactory relationship primarily because of the men he tended to fall in love with. In fact, a necessary feature that a man had to have in order to make him fall in love with him was that he had to be basically rejecting. I clearly remember one time when the man Antony was in love with declared his interest to Antony: in that same evening, my patient understood that he actually did not like that man anymore -- he was too feminine, i.e. weak.

The basic fantasy which drove him when he fell in love was, as he named it, “the Superhero fantasy”: Antony fell in love with “objectively beautiful” and basically rejecting men who gave him some positive feedback, even if minimal and equivocal, because his feelings were aroused by the perspective that, at the end, these beautiful and emotionally unavailable men would have fallen in love with him, and would have been able to appreciate and “save” him, just like a Superhero, when he was in pain.

We understood that an experience such as this one would have disproved his strong belief of not deserving appreciation and care, and would have “given a different ending”, quoting his word, to the childhood experiences of deprecation and indifference he experienced with his father.

The kind of falling in love Antony was a victim of derived from a deep need to master this relational trauma, but (for several different reasons), actually re-traumatized him: the men Antony fell in love with never reciprocated his feelings and ended up confirming again his pathogenic beliefs.  Thus, Antony’s self-hate and disloyalty guilt toward his parents were reconfirmed and strengthened. However, at the basis of Antony’s falling in love there was the idea that the man he chose would have given him what he always needed and never received from the father.

Oscar, a patient in his forties, tended to fall in love with women who all shared the same features: low self-esteem, good intellectual capacities and a whole series of painfully unfulfilled aspirations. When he fell in love with them, Oscar became completely dedicated to these women; he adored them and tried to make them happy and fulfilled by his love. Over the course of therapy, we were able to understand that he saw his traumatized childhood self in those women and tried to give them the kind of treatment that he would have liked to receive. They reminded him his suffering self in need of love, and his falling in love with these women was an expression of his desire to give them what they (and he) always needed.  Falling in love was an attempt to master an old trauma: he never felt that his parents -- particularly his mother -- really understood him and loved him for who he was. Falling in love with these women represented Oscar’s effort to disprove one of his basic pathogenic beliefs.  The problem was that these women were not his suffering self, and in many cases did not need what he gave to them, and so Oscar ended up being frustrated and saw his pathogenic beliefs confirmed again. He was not able to make these women happy and felt that they did not love him. Many times, during his treatment, I thought about  Lacan’s  famous aphorism: “Loving means to give something that you don’t have to someone who does not want it”.

Chiara, a patient in her twenties, repeatedly fell in love with men that she thought had skills that she wanted to acquire but feared she could not develop. She fantasized, for example, that being the girlfriend of her piano teacher would  help her to acquire (in an osmotic process) his playing ability, and this ability would in turn help her obtain the appreciation she never had by “other people”.

This kind of fantasy reflected a painful mix of self-hate and survivor guilt.  Chiara felt undeserving and worthless but the fantasy also expressed her powerful desire to overcome her feelings of worthlessness – feelings that stemmed from a deeply abusive relationship with a violent and disturbed mother. Needless to say, she tended to choose men who shared with her parent a cynical and arrogant attitude -- men who were basically unable to love her or to help her.  Even though her falling in love with these men was fueled by an attempt to master her trauma, Chiara saw her pathogenic beliefs repeatedly confirmed in the relationships with these men. This kind of falling in love was based on the idea that together with these men she would acquire what she always wanted.

Another variant of this situation is exemplified by Francesca, who tended to fall in love with men that she thought were clever, bright, open minded and bohemian, all features that her mother had taught her to love in men.  By having such relationships, she hoped to fulfill her mother aspirations, making her happy and proud of her.  The problem was that these men ended up being a bitter disappointment: what had initially seemed to be a shining armor was ultimately revealed as papier mache.  At that point Francesca felt hurt and depressed, thinking that those men were as weak and inconsistent as her father had always been for her mother.  Her survivor guilt had its triumph, and her doubts about her value remained the same.

These kinds of observations make me think that it is not rare for people to fall in love with someone when they feel that that specific person will enable them to master their deepest trauma and disconfirm their core pathogenic belief. This is the reason why we often tend to fall in love with people who remind us of our old traumatic others or our old traumatized self.  The similarities between our (potential) partners and our traumatizing others or traumatized self help explain why it is often so easy to fall in love with the “wrong” people.  Relationships that are based on the premise that together with the other person we will acquire what we always needed, often have unhappy endings because the other person is in general much more complex and less perfect than they initially seem. S/he has much more than the qualities and features we choose him/her for, and some of these other qualities and features can give rise to troubling incompatibilities. By contrast, we can also see why it is so incredibly mutative when we fall in love with the “right” person.

In summary, my hypothesis is that when we fall in love, what we are looking for is an experience of redemption from our old traumas and core pathogenic beliefs.  A similar point was implicitly noted by Wilfred Bion (1961, 1970) when he connected the basic assumption of pairing with the feelings of hope and messianic expectation.

References

Bader, M. (2002). Arousal. The Secret Logic of Sexual Fantasies. Thomas Dunne Books, New York.  

De Luca, E., Gazzillo, F. (2018). Note sull’innamoramento per persone narcisiste ed emotivamente poco disponibili. http://www.cmt-ig.org/note-sullinnamoramento-persone-narcisiste-ed-emotivamente-poco-disponibili-emma-de-luca-francesco-gazzillo/ 

Sampson, H. (1994). Repeating pathological relationships to disconfirm pathogenic beliefs. Commentary on Steven Stem's “needed relationhsips”. Psychoanalytic Dialogues, 4:3, 357-361, DOI: 10.1080/10481889409539024.

Bion, W.R. (1961). Experiences in groups. Routledge, New York.

Bion, W.R. (1970). Attention and interpretation. Taylor and Francis, New York.

 

 

 

Italian CMT Training Program

How we teach CMT in Italy

Following a request received by my friends and consultants Geroge Silberschatz and Marshall Bush, in this post I am going to describe the training that a person who becomes part of our Control Mastery Theory Italian Group (CMT-IG) has to follow in order to become a CMT practitioner.

We accept in our group people who are graduated in psychology or in medicine, but we are open to consider even applications from people with other degrees related to other helping professions, such as degrees in education or social work.

In the first year of membership, new members pay 450 euros, and in the second year the membership fee is 300 euros per year (400 euros for the founders).  

The very first year of training is dedicated to learning the theory. Each new member attends 14 three hours seminars dedicated to the following themes:

1)      An overview of CMT (Francesco Gazzillo)

2)      Adaptation, safety and mastery: basic motivations, unconscious functioning, interpersonal relationships and beliefs (Francesco Gazzillo)

3)      Traumas, pathogenic beliefs and pathogenic schemas (Francesco Gazzillo)

4)      Guilt and shame (Francesco Gazzillo)

5)      Testing (Francesco Gazzillo)

6)      The patient plan and the Plan Formulation Method (Francesco Gazzillo, Federica Genova)

7)      Assuming the right attitude, passing tests and giving pro-plan communications, following patients coaching activities (Francesco Gazzillo)

8)      Dreams, fantasies and sexual fantasies according to CMT (Francesco Gazzillo)

9)      Treating severe patients from a CMT perspective (Francesco Gazzillo, Roberta Alesiani)

10)  CMT and academic counseling (Giuseppe Stefano Biuso)

11)  CMT and children, family and couple therapy (Valeria Crisafulli)

12)  CMT and the clinical work with adolescents (Guido Bossa, Carmela Cicalese)

13)  CMT and social work (Sveva Angrisani)

14)  Questions, doubts and new perspectives (Francesco Gazzillo)

The first year of membership

Before attending the seminars, our members are assigned to read the book How psychotherapy works (Weiss, 1993), while at the end of each seminar we give them several papers to be studied (see the list below). During the theoretical course, each member reads the chapters of the book Fidarsi dei pazienti (Gazzillo, 2016) related to the concepts that will be addressed in the following seminar. In order to have access to the final theoretical exam, each member needs to have attended at least 12 seminars.

The theoretical exam that trainees need to pass in order to have access to the clinical supervision groups of the second and third year of our training consists in writing a brief essay (5 to 10 pages). In this essay, they have to explain a CMT concept within the context of the theory and add some clinical exemplification of the same concept.

The second and third year of membership

After this first theoretical year, each member has access to the second step of our training: s/he has to attend 80 hours of clinical group supervisions in two years. These supervision sessions, aimed at learning how to apply the theory, are held on two consecutive Tuesdays of each month, and each meeting lasts 2 hours. During the first Tuesday, one member has to present the transcriptions, or detailed clinical notes, of the first two-three sessions of a new case together with the formulation of the plan s/he developed. The role of each supervision group, coordinated by one of the founders of our Association, is to assess the goodness of the plan formulation on the basis of the clinical material presented. In the second Tuesday of that month, the same member who presented the clinical material at the previous meeting has to bring one or two sessions of the same patient, from any period of his/her therapy; the aim of this second encounter is to check the correctness of the plan formulation and of the clinician communications on the basis of the reactions of the patients to the therapist interventions.

At the end of these two “clinical years”, every member who attended at least 60 hours of clinical group supervisions has access to the final exam: s/he has to read the transcriptions of the first three sessions of a patient unknown to her/him and to formulate the patient’s plan; then, s/he has to read another session of the same patient and has to write down the communications s/he would have given to that patient according to her/his plan formulation.

If a person wants to have also individual CMT supervision, s/he is free to choose one of the senior member of our association to have them, and we have established a fixed fee (45 euros) for them.

The writings of both the theoretical and the clinical exam are evaluated by the eight founders of our Association.

Other activities

After having passed the theoretical exam, each member can take part in our study groups; so far, five groups are active:

1)      Empirical research on CMT concepts (coordinated by Francesco Gazzillo)

2)      CMT in academic counseling (coordinated by Giuseppe Stefano Biuso)

3)      CMT in children, family and couple therapy (coordinated by Valeria Crisafulli)

4)      CMT in clinical work with adolescents (coordinated by Guido Bossa and Carmela Cicalese)

5)      CMT in social work (coordinated by Sveva Angrisani)

After having passed the clinical exam, each member can start a new study group if s/he finds at least three people interested in that topic. The aim of each of these groups is to study a particular topic from a CMT perspective and publish papers on that topic.

Each member can also propose the publication of her/his CMT writings on the section “Idee” (Ideas) of our website. Each paper proposed for publication is evaluated by the 8 founders of our Association and can be accepted, rejected or accepted after the requested modifications are done.

These are the basic elements of our training.

15)   

Preliminary reading

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

Basic book

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

Adaptation, safety and beliefs

1.      De Luca, E., Mazza, C., Gazzillo, F. (2018), Mente razionale e inconscio adattivo/Rational mind and adaptive unconscious. In CMT-IG (2018), Esplorazioni teorico-cliniche. Il primo anno del CMT-IG/Theoretical and clinical explorations. The first year of CMT-IG. Edizioni CMT-IG, Roma, pp.58-76

2.      Genova, F., (2018), La biologia della sicurezza/Biology of safety. In CMT-IG (2018), Esplorazioni teorico-cliniche. Il primo anno del CMT-IG/Theoretical and clinical explorations. The first year of CMT-IG. Edizioni CMT-IG, Roma, pp.77-106.

3.      Sampson, H. (1990), The problem of adaptation to reality in Psychoanalytic Theory. In Contemporary Psychoanalysis, 26(4), pp. 677-691. http://dx.doi.org/10.1080/00107530.1990.10746685.

4.      Sampson, H. (1992), The role of "real" experience in psychopathology and treatment. In Psychoanalytic Dialogues, 2(4), pp. 509-528.

5.      Silberschatz, G. (2005), The Control-Mastery Theory. In G. Silberschatz (a cura di), Transformative Relationships: The Control-Mastery Theory of Psychotherapy (pp. 3-23). New York: Routledge.

6.      Weiss, J. (1990), The centrality of adaptation. In Contemporary Psychoanalysis, 26(4), pp. 660-676.

7.      Weiss, J. (2005), Safety. In G. Silberschatz (a cura di), Transformative Relationships: The Control-Mastery Theory of Psychotherapy (pp. 31-42). New York: Routledge.

Pathogenic beliefs, affects and interpersonal guilt

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

2.      Curtis, J.T., Silberschatz, G. (2005), The Assessment of Pathogenic Beliefs. In G. Silberschatz (a cura di), Transformative Relationships: The Control-Mastery Theory of Psychotherapy (pp. 69-92). New York: Routledge.

3.      De Luca, E., Mazza, C., Gazzillo, F. (2018), La centralità dell’adattamento: funzionamento motivazionale e moralità tra neuroscienze, psicologia evoluzionistica e Control-Mastery Theory/The centrality of adaptation: motivational functioning and moraliry accordinf to neurosciences, evolutionary psychology and Control-Mastery Theory. In CMT-IG (2018), Esplorazioni teorico-cliniche. Il primo anno del CMT-IG/Theoretical and clinical explorations. The first year of CMT-IG. Edizioni CMT-IG, Roma, pp16-57.

4.      Fimiani, R., De Luca, E., Rodomonti, M., Fazeli Fariz-Hendi, S., Nicolais, G., Gazzillo, F. (2018), Note sullo sviluppo del senso morale/Notes on moral development. Rassegna di psicologia, XXXV, 1, pp. 29-39

5.      Gazzillo, F., Gorman, B., Bush M., Silberschatz, G., Mazza, C., Faccini, F., Crisafulli, V., Alesiani, R., & De Luca, E. (2017), Reliability and validity of the Interpersonal Guilt Rating Scale-15: A new clinician-reporting tool for assessing interpersonal guilt according to Control-Mastery Theory. In Psychodynamic Psychiatry, 45(3), pp. 362-384.

6.      Gazzillo, F., Gorman, B., De Luca, E., Faccini, F., Bush, M., Silberschatz, G., Dazzi N. (2018). Preliminary data about the validation of a self-report for the assessment of interpersonal guilt: The Interpersonal Guilt Rating Scales-15 s (IGRS-15s). Psychodynamic Psychiatry, 46, pp.362-384.

7.      O' Connor, L.E. (2002), Pathogenic beliefs and guilt in human evolution: Implications for psychotherapy. In P. Gilbert, & K.G. Bailey (a cura di), Genes on the coach: Explorations in evolutionary psychotherapy (pp. 276-303). New York: Routledge.

8.      Silberschatz, G., & Sampson, H. (1991), Affects in psychopathology and psychotherapy. In J. Safran, & L.S. Greenberg (a cura di), Emotions, Psychotherapy, and Change (pp. 113-129). New York: Guilford Press.

9.      Weiss, J. (1997), The role of pathogenic beliefs in psychic reality. In Psychoanalytic Psychology, 14(3), pp. 427-434.

 

Patients unconscious plan

1.      Alesiani, R., Villa, D., Pieri, A., Boccalon, S., Gazzillo, F. (2018), L’importanza dei primi colloqui nella CMT/The relevance of intake sessions in CMT. In CMT-IG (2018), Esplorazioni teorico-cliniche. Il primo anno del CMT-IG/Theoretical and clinical explorations. The first year of CMT-IG. Edizioni CMT-IG, Roma, pp.108-121.

2.      Bossa, G. (2018), Adolescenti e genitori: sviluppo sano e problematiche secondo la CMT/Adolescents and their parents: normal development and problems according to CMT. In CMT-IG (2018), Esplorazioni teorico-cliniche. Il primo anno del CMT-IG/Theoretical and clinical explorations. The first year of CMT-IG. Edizioni CMT-IG, Roma, pp.204-215.

3.      Crisafulli, V. (2018), Il metodo per la formulazione del piano in età evolutiva (PFMda)/Plan Formulation Method for the developmental period (PFDMda). In CMT-IG (2018), Esplorazioni teorico-cliniche. Il primo anno del CMT-IG/Theoretical and clinical explorations. The first year of CMT-IG. Edizioni CMT-IG, Roma, pp.190-203.

4.      Crisafulli V., Rodomonti M. (2018), La formulazione del piano di coppia (PFMc)/Plan Formulation Method for Couples (PFMc). In CMT-IG (2018), Esplorazioni teorico-cliniche. Il primo anno del CMT-IG/Theoretical and clinical explorations. The first year of CMT-IG. Edizioni CMT-IG, Roma, pp.174-189.

5.      Curtis, J., Gazzillo, F. (2018), Discussione sul concetto di piano di Joseph Weiss/A discussion on Josef Weiss plan concept. In CMT-IG (2018), Esplorazioni teorico-cliniche. Il primo anno del CMT-IG/Theoretical and clinical explorations. The first year of CMT-IG. Edizioni CMT-IG, Roma, pp.323-343.

6.      Gazzillo, F. (2018), Note sull’ascolto in ottica CMT/Notes on clinical listening from the CMT perspective. In CMT-IG (2018), Esplorazioni teorico-cliniche. Il primo anno del CMT-IG/Theoretical and clinical explorations. The first year of CMT-IG. Edizioni CMT-IG, Roma, pp122-128.

7.      Curtis, J.T., & Silberschatz, G. (1986), Clinical implications of research on brief dynamic psychotherapy, I: Formulating the patient's problems and goals. In Psychoanalytic Psychology, 3(1), pp. 13-25.

8.      Silberschatz, G. (2008), How patients work on their plan and test their therapists in psychotherapy. In Smith College Studies In Social Work, 78(2–3), pp. 275-286.

9.      Watchel, P.L., & Demichele, A. (1998), Unconscious plan or unconscious conflict? Commentary Joseph Weiss's Paper. In Psychoanalytic Dialogues, 8(3), pp. 429-442.

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

11.  Weiss, J. (1998), Unconscious plans and unconscious conflict. Replay to commentary. In Psychoanalytic Dialogues, 8(3), pp. 443-453.

Tests, interpretations, attitude and coaching

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

2.      Gazzillo, F. (2018), Differenziare i test da passivo in attivo: per compiacenza e per ribellione/Differentiating passive-into-active tests: by compliance and by non compliance. In CMT-IG (2018), Esplorazioni teorico-cliniche. Il primo anno del CMT-IG/Theoretical and clinical explorations. The first year of CMT-IG. Edizioni CMT-IG, Roma, pp.161-166.

3.      Gazzillo, F., Genova, F., Fedeli, F., Bush, M., Curtis, J.T., Silberschatz, G. (2018), Patients unconscious testing activity in psychotherapy: a theoretical and empirical overview. Manuscript submitted for publication.

4.      Sampson, H. (2005), Treatment by attitudes. In G. Silberschatz (a cura di), Transformative Relationships: The Control-Mastery Theory of Psychotherapy (pp. 111-119). New York: Routledge.

5.      Silberschatz, G., & Curtis, J.T., (1986), Clinical implications of research on brief dynamic psychotherapy, II: How the therapist helps or hinders therapeutic progress. In Psychoanalytic Psychology, 3(1), pp. 27-37.

6.      Silberschatz, G., & Curtis, J.T., (1993), Measuring the therapist’s impact on the patient’s therapeutic progress. In Journal of Consulting and Clinical Psychology, 61, pp. 403-411.

7.      Weiss, J. (1992), The role of Interpretation. In Psychoanalytic Inquiry, 12(2), pp. 296-313.

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

 

Dreams and sexual fantasies

1.      Bader, M. (2002), Arousal. The secret logic of sexual fantasies. Italian edition published by Raffaello Cortina, Milan, 2018.

2.      Messina, I., Gazzillo, F. (2018), Un sogno ben analizzato in ottica CMT/A dream well analyzed according to CMT hypotheses. In CMT-IG (2018), Esplorazioni teorico-cliniche. Il primo anno del CMT-IG/Theoretical and clinical explorations. The first year of CMT-IG. Edizioni CMT-IG, Roma, pp.167-172.

3.      Weiss, J. (1993), L'uso dei sogni da parte del terapeuta/The therapist’s use of dreams. In Weiss, J. (1993), How psychotherapy works. Process and technique. New York, Guilford, pp.142-166.

4.      Weiss, J. (1998), “Bondage fantasies and beating fantasies”. In Psychoanalytic Quarterly, 67(4), pp. 626-644.

Treating severe disorders and working in specific settings

1.      Biuso, G. S. (2018), Come funziona il counselling universitario/How university counselling works. In CMT-IG (2018), Esplorazioni teorico-cliniche. Il primo anno del CMT-IG/Theoretical and clinical explorations. The first year of CMT-IG. Edizioni CMT-IG, Roma, pp.254-290.

2.      O' Connor, L.E., Weiss, J. (1993), Individual psychotherapy for addicted clients: an application of Control-Mastery Theory. In Journal of Psychoactive Drugs, 25(4), pp. 283-291.

3.      Pryor, K. (2005), A long-term therapy case illustrating treatment by attitude. In G. Silberschatz (a cura di), Transformative Relationships: The Control-Mastery Theory of Psychotherapy (pp. 121-151). New York: Routledge.

4.      Shilkret, C.J. (2006), Endangered by interpretations. Treatment by attitudes of the narcissistically vulnerable patients. In Psychoanalytic Psychology, 23(1), pp.30-42.

5.      Weiss, J. (1996), The second century of psychoanalysis. In Psychoanalytic Psychology, 13(2), pp. 251-258.

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.