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.