Rethinking Therapeutic Action, Gabbard and Westen (2003)
Evolving Concepts of Therapeutic Action
3. Addressing the Patient’s Conscious Problem-Solving. “We typically associate ‘directive’ interventions of this kind with the treatment of severe personality disorders who have difficulty with the capacity to mentalize. However, even high-functioning patients can benefit from explicit mutual problem solving. Interventions of this sort, though not classically ‘analytic’, can have two salutary effects.” “[O]ne patient who worked in an academic setting was enraged at her department chair, for reasons both real and transferential, and was heading to his office shortly after a session to confront him in ways that would have been disastrous for her career. The clinician interrupted her plan by both exploring the meanings of her anger and intended self-destructive response (which was in part a reparation for her anger) and by problem-solving ways she could address her concerns with her chair that would accomplish her conscious goals without accomplishing some of the less adaptive unconscious ones.”
Both Interpretation and Support
Both interpretative and supportive interventions can be therapeutic. They reference the Menninger Psychotherapy Research Project, the final report of which was written by Wallerstein (1986). He “examined the treatments of 42 patients and found that supportive strategies resulted in structural changes just as durable as those brought about by interpretive approaches. Calling attention to our own idealization of insight, Wallerstein noted that interpretive and supportive elements are always intertwined, and supportive or relationship aspects of the treatment should not be denigrated.”
Both interpretative and supportive interventions can be therapeutic. They reference the Menninger Psychotherapy Research Project, the final report of which was written by Wallerstein (1986). He “examined the treatments of 42 patients and found that supportive strategies resulted in structural changes just as durable as those brought about by interpretive approaches. Calling attention to our own idealization of insight, Wallerstein noted that interpretive and supportive elements are always intertwined, and supportive or relationship aspects of the treatment should not be denigrated.”
Shift from Reconstruction to the Here-and-Now
Reconstruction has been de-emphasized, “and we spend less of our time digging for buried relics from the patient’s past.” Instead, “much of our focus is on the way the here-and-now interactions between analyst and patient provides insight into the influence of the patient’s past on patterns of conflict and object relations in the present.” “A significant addition to Freud’s understanding is our current emphasis on enactment, role-responsiveness and the various phenomena that fall under the rubric of projective identification (Gabbard, 1995). We now view the analyst as inevitably pulled into the ‘dance’ the patient re-creates within the consulting room — hence the focus on the interactions between analyst and patient in the here-and-now. In this view, transference–countertransference dimensions of the treatment are a primary stage on which the drama of the therapeutic action unfolds, and these enactments are both experienced and interpreted.”
Reconstruction has been de-emphasized, “and we spend less of our time digging for buried relics from the patient’s past.” Instead, “much of our focus is on the way the here-and-now interactions between analyst and patient provides insight into the influence of the patient’s past on patterns of conflict and object relations in the present.” “A significant addition to Freud’s understanding is our current emphasis on enactment, role-responsiveness and the various phenomena that fall under the rubric of projective identification (Gabbard, 1995). We now view the analyst as inevitably pulled into the ‘dance’ the patient re-creates within the consulting room — hence the focus on the interactions between analyst and patient in the here-and-now. In this view, transference–countertransference dimensions of the treatment are a primary stage on which the drama of the therapeutic action unfolds, and these enactments are both experienced and interpreted.”
Negotiating the Therapeutic Climate
As Mitchell has written, “There is no general solution or technique, because each resolution, by its very nature, must be custom designed. If the patient feels that the analyst is applying a technique or displaying a generic attitude or stance, the analysis cannot possibly work (1997, p. 58).”
As Mitchell has written, “There is no general solution or technique, because each resolution, by its very nature, must be custom designed. If the patient feels that the analyst is applying a technique or displaying a generic attitude or stance, the analysis cannot possibly work (1997, p. 58).”
The Aims of Treatment (What Changes)
Psychoanalysis has two main aims: (1) to alter unconscious associational networks and (2) to alter conscious patterns of thought, feeling, motivation, and affect regulation.
Psychoanalysis has two main aims: (1) to alter unconscious associational networks and (2) to alter conscious patterns of thought, feeling, motivation, and affect regulation.
Unconscious Associational Networks
One of the main goals of psychotherapy is to alter components of our mind that remain unconscious, namely (1) unconscious associations between affects and representations, (2) unconscious wishes, (3) unconscious maladaptive beliefs, and (4) unconscious defenses and compromise formations.
Examples of unconscious associations between affects and representations: one patient has feelings of self-loathing associated with representations of the self as bad; another patient has feelings of anger associated with representations of father figures. Example of unconscious wishes: a patient who keeps entering inappropriate relationships and needs to understand what he’s enacting and to develop desires that lead him to more satisfying relationships. “However, we are actually short on both theoretical and technical accounts of how to help people change motives that are highly gratifying, if ultimately problematic — and of precisely what happens to the old motives once the person begins to seek more adaptive goals and objects.” Example of unconscious maladaptive beliefs: “a patient may avoid achievement because he harbors an unconscious belief that others will be hurt by his success.”
One of the main goals of psychotherapy is to alter components of our mind that remain unconscious, namely (1) unconscious associations between affects and representations, (2) unconscious wishes, (3) unconscious maladaptive beliefs, and (4) unconscious defenses and compromise formations.
Examples of unconscious associations between affects and representations: one patient has feelings of self-loathing associated with representations of the self as bad; another patient has feelings of anger associated with representations of father figures. Example of unconscious wishes: a patient who keeps entering inappropriate relationships and needs to understand what he’s enacting and to develop desires that lead him to more satisfying relationships. “However, we are actually short on both theoretical and technical accounts of how to help people change motives that are highly gratifying, if ultimately problematic — and of precisely what happens to the old motives once the person begins to seek more adaptive goals and objects.” Example of unconscious maladaptive beliefs: “a patient may avoid achievement because he harbors an unconscious belief that others will be hurt by his success.”
Conscious Patterns of Thought, Feeling, Motivation, and Affect Regulation
“Clinical experience suggests that focusing primarily on conscious thoughts or feelings (as in cognitive therapy for depression) tends to produce only short-lived changes, and careful examination of the research basis for such treatments supports this view (Westen and Morrison, 2001). Recent research in cognitive neuroscience suggests why this should be the case: implicit processes are psychologically and neurologically distinct from explicit ones, so that targeting only those processes that reach conscious awareness is likely to leave many important associational networks untouched.”
“A prime function of consciousness is to provide the organism with the capacity to override the ‘standard operating procedures’ encoded in implicit associational networks and to ‘reset’ some of the parameters of those networks (the strength of connections among their linked units) through conscious reflection and actions that alter subsequent experience (see Horowitz, 1999). Indeed, experimental research documents show that, when people are not consciously thinking about their motives, they are guided by implicit motives, but when they turn their conscious attention to their motives, their conscious goals—which have very different developmental correlates and origins—tend to regulate their actions (McClelland et al., 1989).”
Targets of therapeutic action: (1) conscious thought processes, (2) conscious affect states, (3) conscious coping skills, and (4) conscious motives.
Regarding (1), a patient “was consumed with thoughts about a man she had hoped would propose and instead spurned her. She spent most of her waking (conscious) moments for the following year ruminating about what she might have said, what he meant when he said particular things, and so forth. Over time, the patient came to understand her tendency to ruminate as a defensive strategy that had once allowed her to cope with the uncertainty of having an intermittently abusive parent. This insight-oriented work aimed at examining the unconscious function of rumination for her, which was tied to its etiology. At the same time, however, the therapist helped her distinguish modes of conscious self-reflection: introspection, aimed at examining experiences in the past or present with an attitude of curiosity, self-exploration and the possibility of change in the future; and rumination, which dwells on the past with an attitude of regret…In fact, this distinction proved very helpful to the patient in regulating spirals of negative affect, as she began to catch herself ruminating and to shift gears by asking herself questions about the functions rumination was serving at those moments (e.g. ‘What am I getting out of this right now?’, ‘What would I be feeling if I weren’t ruminating?’, and ‘What is doing this preferable to?’)... Despite the lack of an explicit theoretical rationale, we suspect that most analysts and analytic therapists routinely call depressed patients’ attention to the way they consciously berate themselves, expect the worst, discount their own abilities, and so forth. Although doing so is unlikely by itself to change unconscious networks, it may well help stop self-defeating spirals and allow patients to make better life decisions, which can in turn impact their future happiness.”
Regarding (2), “Focusing on conscious affect states may involve efforts to alter the frequency or intensity of particular feelings, helping the patient recognize and tolerate contradictory feeling states (e.g. love and hate toward the same person (Kernberg, 1975)), or helping the patient tolerate feelings that are uncomfortable (Krystal, 1977). Much of the time, in fact, patients come in with the explicit goal of reducing aversive emotional states such as anxiety and depression… In this respect, an important goal in many treatments is helping patients learn to tolerate affects such as anxiety enough so that they can use them as signals (Siegel and Rosen, 1962).”
Regarding (3), “Although we may not always target such processes explicitly, changes in conscious coping strategies often provide an index of change, as when a patient begins to show an increased capacity for using humor to cope with unpleasant realities, particularly about the self. At other times, particularly in patients with severe personality disorders who lack basic affect regulation skills, conscious coping strategies may be an essential, explicit target of therapeutic action (see Westen, 1991; Linehan, 1993).”
Regarding (4), “To the extent that these motives are maladaptive or reflect unconscious compromise formations, and to the extent that they may lead people to behave in ways that are ultimately detrimental to their well-being, they should become the target of treatment just as unconscious motives should. More often, of course, our aim is to bring to consciousness motives that are unconscious so the patient can make more informed choices about what he wants to do, what messages he wants to convey etc.”
“Clinical experience suggests that focusing primarily on conscious thoughts or feelings (as in cognitive therapy for depression) tends to produce only short-lived changes, and careful examination of the research basis for such treatments supports this view (Westen and Morrison, 2001). Recent research in cognitive neuroscience suggests why this should be the case: implicit processes are psychologically and neurologically distinct from explicit ones, so that targeting only those processes that reach conscious awareness is likely to leave many important associational networks untouched.”
“A prime function of consciousness is to provide the organism with the capacity to override the ‘standard operating procedures’ encoded in implicit associational networks and to ‘reset’ some of the parameters of those networks (the strength of connections among their linked units) through conscious reflection and actions that alter subsequent experience (see Horowitz, 1999). Indeed, experimental research documents show that, when people are not consciously thinking about their motives, they are guided by implicit motives, but when they turn their conscious attention to their motives, their conscious goals—which have very different developmental correlates and origins—tend to regulate their actions (McClelland et al., 1989).”
Targets of therapeutic action: (1) conscious thought processes, (2) conscious affect states, (3) conscious coping skills, and (4) conscious motives.
Regarding (1), a patient “was consumed with thoughts about a man she had hoped would propose and instead spurned her. She spent most of her waking (conscious) moments for the following year ruminating about what she might have said, what he meant when he said particular things, and so forth. Over time, the patient came to understand her tendency to ruminate as a defensive strategy that had once allowed her to cope with the uncertainty of having an intermittently abusive parent. This insight-oriented work aimed at examining the unconscious function of rumination for her, which was tied to its etiology. At the same time, however, the therapist helped her distinguish modes of conscious self-reflection: introspection, aimed at examining experiences in the past or present with an attitude of curiosity, self-exploration and the possibility of change in the future; and rumination, which dwells on the past with an attitude of regret…In fact, this distinction proved very helpful to the patient in regulating spirals of negative affect, as she began to catch herself ruminating and to shift gears by asking herself questions about the functions rumination was serving at those moments (e.g. ‘What am I getting out of this right now?’, ‘What would I be feeling if I weren’t ruminating?’, and ‘What is doing this preferable to?’)... Despite the lack of an explicit theoretical rationale, we suspect that most analysts and analytic therapists routinely call depressed patients’ attention to the way they consciously berate themselves, expect the worst, discount their own abilities, and so forth. Although doing so is unlikely by itself to change unconscious networks, it may well help stop self-defeating spirals and allow patients to make better life decisions, which can in turn impact their future happiness.”
Regarding (2), “Focusing on conscious affect states may involve efforts to alter the frequency or intensity of particular feelings, helping the patient recognize and tolerate contradictory feeling states (e.g. love and hate toward the same person (Kernberg, 1975)), or helping the patient tolerate feelings that are uncomfortable (Krystal, 1977). Much of the time, in fact, patients come in with the explicit goal of reducing aversive emotional states such as anxiety and depression… In this respect, an important goal in many treatments is helping patients learn to tolerate affects such as anxiety enough so that they can use them as signals (Siegel and Rosen, 1962).”
Regarding (3), “Although we may not always target such processes explicitly, changes in conscious coping strategies often provide an index of change, as when a patient begins to show an increased capacity for using humor to cope with unpleasant realities, particularly about the self. At other times, particularly in patients with severe personality disorders who lack basic affect regulation skills, conscious coping strategies may be an essential, explicit target of therapeutic action (see Westen, 1991; Linehan, 1993).”
Regarding (4), “To the extent that these motives are maladaptive or reflect unconscious compromise formations, and to the extent that they may lead people to behave in ways that are ultimately detrimental to their well-being, they should become the target of treatment just as unconscious motives should. More often, of course, our aim is to bring to consciousness motives that are unconscious so the patient can make more informed choices about what he wants to do, what messages he wants to convey etc.”
Techniques (What Strategies Facilitate Those Changes)
Interventions that Foster Insight
Free Association
“First, as Freud emphasized, it provides a way of seeing defenses in action, occasionally gaining a glimpse behind them (when the patient is associating relatively freely), and observing the circumstances under which resistance emerges (when the patient is not as able to associate freely). Second, and related, free association allows the patient and analyst to explore and map the patient’s implicit networks of association—to work together as cartographers of the mind to create a model of the networks that lead the patient to think, feel and act in the ways he does under various circumstances.”
“First, as Freud emphasized, it provides a way of seeing defenses in action, occasionally gaining a glimpse behind them (when the patient is associating relatively freely), and observing the circumstances under which resistance emerges (when the patient is not as able to associate freely). Second, and related, free association allows the patient and analyst to explore and map the patient’s implicit networks of association—to work together as cartographers of the mind to create a model of the networks that lead the patient to think, feel and act in the ways he does under various circumstances.”
Interpretation
“Interpretation, the second technique, may be directed at any of a number of mental events. These include wishes, fears, fantasies and expectations; defenses and compromise formations; conflicts; transferential patterns; relational patterns observed from patients’ narrative descriptions of interpersonal events that do not have direct analogs in the therapeutic relationship; feelings induced in the analyst by the patient’s interpersonal pressure; and links between thoughts and feelings or between elements of associational networks that the patient has not recognized or wanted to recognize.”
Interpretation that focuses specifically and systematically on transference themes is, of course, one of the hallmarks of psychoanalysis that typically distinguishes it from psychoanalytic psychotherapy. While psychotherapeutic approaches may involve interpretation of transference phenomena, these efforts are often more attenuated, less thoroughgoing and less systematic. Psychoanalysis relies more heavily on an approach that pushes transference understanding to its limits (Gabbard, 2001a; Greenberg, 2001).”
“Interpretation, the second technique, may be directed at any of a number of mental events. These include wishes, fears, fantasies and expectations; defenses and compromise formations; conflicts; transferential patterns; relational patterns observed from patients’ narrative descriptions of interpersonal events that do not have direct analogs in the therapeutic relationship; feelings induced in the analyst by the patient’s interpersonal pressure; and links between thoughts and feelings or between elements of associational networks that the patient has not recognized or wanted to recognize.”
Interpretation that focuses specifically and systematically on transference themes is, of course, one of the hallmarks of psychoanalysis that typically distinguishes it from psychoanalytic psychotherapy. While psychotherapeutic approaches may involve interpretation of transference phenomena, these efforts are often more attenuated, less thoroughgoing and less systematic. Psychoanalysis relies more heavily on an approach that pushes transference understanding to its limits (Gabbard, 2001a; Greenberg, 2001).”
Interventions that Result from the Therapeutic Relationship
First, the therapeutic relationship can be a corrective emotional experience. Second, through the relationship, the patient learns to perform an external function; e.g., a patient might learn to self-soothe through repeated experiences of soothing by the therapist. Third, the patient internalizes affective attitudes from the therapist. “For many patients, this involves tempering a hypercritical superego, as when the patient begins to internalize the therapist’s interested, exploratory stance toward material previously experienced as shameful or otherwise ‘bad’, or when the patient internalizes a more explicitly temperate attitude toward his impulses or actions. This may occur through explicit comments by the therapist as well as through gestures, intonation and other forms of communication that may be registered implicitly or explicitly.”
“A fourth way the relationship can be an active change instrument is through internalization of conscious strategies for self-reflection—that is, when the patient gradually becomes his own analyst. In part, this may occur through simple observational learning processes, although as Fonagy has observed, a crucial avenue for therapeutic change may lie in the patient’s increasing capacity to find himself in the therapist’s mind’ (1999b, p. 51). All of these aspects of internalization are predicated on development of a therapeutic relationship in which the patient feels safe enough to explore his mind in the presence of an other.” Fifth is the identification of prominent transference-countertransference paradigms.
First, the therapeutic relationship can be a corrective emotional experience. Second, through the relationship, the patient learns to perform an external function; e.g., a patient might learn to self-soothe through repeated experiences of soothing by the therapist. Third, the patient internalizes affective attitudes from the therapist. “For many patients, this involves tempering a hypercritical superego, as when the patient begins to internalize the therapist’s interested, exploratory stance toward material previously experienced as shameful or otherwise ‘bad’, or when the patient internalizes a more explicitly temperate attitude toward his impulses or actions. This may occur through explicit comments by the therapist as well as through gestures, intonation and other forms of communication that may be registered implicitly or explicitly.”
“A fourth way the relationship can be an active change instrument is through internalization of conscious strategies for self-reflection—that is, when the patient gradually becomes his own analyst. In part, this may occur through simple observational learning processes, although as Fonagy has observed, a crucial avenue for therapeutic change may lie in the patient’s increasing capacity to find himself in the therapist’s mind’ (1999b, p. 51). All of these aspects of internalization are predicated on development of a therapeutic relationship in which the patient feels safe enough to explore his mind in the presence of an other.” Fifth is the identification of prominent transference-countertransference paradigms.
Secondary Strategies
Change in psychoanalysis primarily comes through “the therapeutic relationship and the acquisition of insight or understanding. In psychoanalytic psychotherapy a variety of other avenues of therapeutic change are common.” Different classes of interventions.
Change in psychoanalysis primarily comes through “the therapeutic relationship and the acquisition of insight or understanding. In psychoanalytic psychotherapy a variety of other avenues of therapeutic change are common.” Different classes of interventions.
1. Confrontation. These can carry implicit or explicit suggestions for change. “For example, many interpretive comments that include confrontive elements call the patient’s attention to patterns of behavior, and particularly maladaptive relational patterns, with an implicit or explicit suggestion that the patterns are problematic and may require change (Raphling, 1995). Indeed, the simple act of exploring one set of associations or issues rather than another provides information to the patient about the aspects of his mental life or behavior we consider worthy of attention and, by implication, the aspects that we suspect are giving him trouble and he might want to work on (see Wachtel, 1993). Even as neutral a comment as ‘I wonder what it means that ...’ implies that there is something to be understood that is worth therapeutic attention and that may require change.”
2. Confrontation of Irrational Beliefs. This intervention can at times be as important as confrontation of problematic behaviors, defenses, or compromise formations. “The examination and confrontation of dysfunctional or irrational beliefs is an inevitable component of any good psychotherapy for depression or anxiety, regardless of the theoretical basis for the treatment, because depressed and anxious mood states recruit ways of thinking that perpetuate dysphoria, and hence need to be addressed directly.”
3. Addressing the Patient’s Conscious Problem-Solving. “We typically associate ‘directive’ interventions of this kind with the treatment of severe personality disorders who have difficulty with the capacity to mentalize. However, even high-functioning patients can benefit from explicit mutual problem solving. Interventions of this sort, though not classically ‘analytic’, can have two salutary effects.” “[O]ne patient who worked in an academic setting was enraged at her department chair, for reasons both real and transferential, and was heading to his office shortly after a session to confront him in ways that would have been disastrous for her career. The clinician interrupted her plan by both exploring the meanings of her anger and intended self-destructive response (which was in part a reparation for her anger) and by problem-solving ways she could address her concerns with her chair that would accomplish her conscious goals without accomplishing some of the less adaptive unconscious ones.”
4. Exposure. “Experimental evidence suggests that the association between internal states (such as shortness of breath) and anxiety about potential panic can, over time, become wired at subcortical levels (involving the thalamus and amygdala), and that these associative links may not be easily amenable to highly verbal, ‘cerebral’ treatments such as psychoanalysis, except to the extent that the patient’s insights into his problem lead him to confront what he is afraid of. Analysts from Freud on have noted that, for phobic patients, little progress will be made unless the patient faces the feared situation (Gabbard and Bartlett, 1998).”
“Patients in psychoanalytic treatments manifest avoidance in many areas of their lives (including the networks they avoid while associating on the couch), and avoidance is self-reinforcing (i.e. it keeps anxiety at bay, which in turn reinforces avoidance of thoughts, memories or situations associated with anxiety or other forms of negative affect). An exposure model can be useful in thinking in object-relations terms about affects associated with warded-off representations, as when a depressed patient actively wards off positive self-representations. Many patients with depressive dynamics fear feelings of pride and accomplishment, and actively ward off both the recognition of others and self-recognition. To what extent this is best addressed by exploring the meaning of the defense, inducing the patient to examine and ‘sit with’ positive warded-off self-representations, or some combination of the two, is an open question. For some patients, it may well be that no amount of defense analysis—or only a very long period of defense analysis, during which the patient may persist in symptoms or actions that have irremediable consequences (such as a junior faculty member on a tenure clock who presents for help with a career-threatening writing block)—will overcome the natural tendency to avoid what is threatening, without more active interventions by the therapist.”
“Patients in psychoanalytic treatments manifest avoidance in many areas of their lives (including the networks they avoid while associating on the couch), and avoidance is self-reinforcing (i.e. it keeps anxiety at bay, which in turn reinforces avoidance of thoughts, memories or situations associated with anxiety or other forms of negative affect). An exposure model can be useful in thinking in object-relations terms about affects associated with warded-off representations, as when a depressed patient actively wards off positive self-representations. Many patients with depressive dynamics fear feelings of pride and accomplishment, and actively ward off both the recognition of others and self-recognition. To what extent this is best addressed by exploring the meaning of the defense, inducing the patient to examine and ‘sit with’ positive warded-off self-representations, or some combination of the two, is an open question. For some patients, it may well be that no amount of defense analysis—or only a very long period of defense analysis, during which the patient may persist in symptoms or actions that have irremediable consequences (such as a junior faculty member on a tenure clock who presents for help with a career-threatening writing block)—will overcome the natural tendency to avoid what is threatening, without more active interventions by the therapist.”
5. Self-Disclosure. “This can be particularly important for patients whose attachment relationships fostered incoherent working models of relationships—that is, whose attachment figures were so unpredictable that the child could not understand or predict their behavior. In such cases, limited self-disclosure can be essential in helping them learn to understand people better, maintaining their trust, and showing them a different model of emotional expression and intimacy. Judicious self-disclosure may also promote mentalization (Gabbard, 2001b), leading to an enhanced reflective function in the patient. For example, by sharing a feeling with the patient, the analyst may help the patient see that his perception of how the analyst feels is only a representation, which can be played with and understood.”
6. Affirmation. “As Killingmo (1989) has pointed out, patients who have experienced severe childhood trauma may experience the therapist’s observations as invalidating the patient’s subjective experience in the same way the patient’s parents did (see also Linehan, 1993). Notions of acceptance and validation have long been central to theories of therapeutic action outside psychoanalysis (Rogers, 1959), and have begun to gain ‘acceptance’ in the psychoanalytic literature with their introduction by Kohut (1971). Empathic validation of the patient’s perspective, however, must ultimately be complemented by an ‘outside’ perspective from the analyst that presents a different view (Gabbard, 1997b; Goldberg, 1999).”
7. Facilitative Strategies. This refers to “interventions that help the patient become more comfortable collaborating with the analyst or therapist to come to understand his inner world. These can range from interjection of the normal social niceties that make anyone comfortable in conversation to the use of humor, educational comments (e.g. explaining to the patient why focusing on what is happening in the room can be useful) and various forms of soothing comments that can be helpful when people are confronting painful, anxiety-provoking or shame-inducing material that they may have kept from awareness—and may otherwise keep from the therapist or analyst—for many years.”
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