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.
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.