Therapeutic Communication, Paul Wachtel (2011)
One: Rethinking the Talking Cure
Psychotherapeutic texts generally focus on the patient’s words and not the therapist’s words. One focus of this book is that every overt message that the therapist intends to convey (the focal message) also contains a second message (the meta-message)which “conveys an attitude about what is being conveyed in the focal message.” “A comment whose focal message is accurate but whose meta-message is poorly wrought can have an effect similar to that of a potentially curative organ transplant that is rejected by the patient’s body because it is registered as alien.”
We need to pay attention to the patient’s experience of the therapist’s remarks, as transference makes it “likely that the patient’s experience of the comment will differ in certain respects from what the therapist thinks she is conveying.”
Therapist noises are “familiar phrasings that therapists call upon when certain, phrasings that at once convey a blistering sense of professionalism and serve to protect the therapist from further revelation of what she is thinking or feeling.” One way to gauge whether we are using therapist noise is to keep track of our perhaps-to-maybe ratio. When we’re in our “stilted, ‘therapist noises’ stance,” we’re more likely to use “perhaps” than “maybe” (e.g., “perhaps your feeling such and such”).
Two: The Continuing Evolution of Psychotherapy
The Emergence of Affect, Acceptance, and Experience in CBT
There are two trends in recent years that have helped CBT to converge with the psychodynamic tradition.
First, new cognitive therapies have placed more emphasis on affect and accepting the patient’s experience. While CT had long focused on cognitions and rationality, Barlow has stressed the importance of the patient being exposed to his affective experience, and Linehan and Hayes have stressed the importance of accepting the patient’s affective experience.
Traces of these more recently developments could be found in different behavioral therapies in the 1970s. Wachtel observed at the time that these therapies were “in important ways more experiential than most approaches of that era. Instead of talking about what the patient was afraid of or could not handle well, [these therapists] helped the patient to directly experience what he had been avoiding.” “What struck me from all of these experiences was both the clinical sensitivity and skillfulness that these behavior therapists manifested and the degree to which the work promoted the client’s deep and direct immersion in the experiences that had been associated for them with distressing affect.” It is true, as CBT claims, that our perceptions and thoughts affect our feelings, but it’s also true that our feelings affect our perceptions and thoughts (e.g., LeDoux, Damasio, Forgas).
Moving on to psychodynamic therapy, all these focus on the experiences that the patient has “banished from awareness in the course of growing up because they threatened his sense of himself or his sense of who he must be in order not to lose contact with key attachment figures.” But unlike traditional approaches, more recent ones have emphasized, not confronting the patient with his avoidant tendencies, but rather helping him “to accept the tendencies in himself that he has thought or feared were unacceptable.”
Second, there has been the emergence of constructivist cognitive therapy. As Arnkoff and Glass write: “Whereas rationalist cognitive theories assume that the therapist can know the true state of affairs through logic or sensory observation, constructivist theories posit that each person creates his or her reality.”
The Emergence of Relational Analysis
Relationalist “stress relationships between people as the most fundamental organizing theme of the evolving psyche.” Relational writers claim that classical psychoanalysis is a one-person model, as it holds that the analyst is “observing, in more or less objective fashion, characteristics and dynamics that lie ‘within’ the patient and that are bound to be manifested in almost any context.” The analyst, according to this model, himself “is not really a part of the field of observation.” In a two-person model, the analyst believes that what happens in the session is “co-constructed,” “a product of the interaction between two people, each of whom contributes to what happens.”
Wachtel writes that we can similarly talk of one-person and two-person versions of CBT. In one-person CBT, therapists “view themselves as objective observers, standing outside the phenomena they are observing and participating only in the sense that they ‘point out’ what is going on.” There are also CBT therapists “who view themselves as genuine participants in a co-constructed experience.”
Another important development in psychoanalysis has been the idea of self-states. Traditionally, psychoanalysis assumed the existence of “underlying structures or inclinations” that are “largely unresponsive to what is happening in day-to-day life.” According to this view, “daily experiences can affect, say, the ‘manifest’ content of a dream, but the ‘latent’ content remains unchanged.” However, the concept of multiple self-states tells us that there is not just one thing happening beneath the surface but rather “there are many ways of behaving and experiencing that genuinely characterize the person.”
He writes that the notion of self-states is not inherently problematic. “Indeed, the capacity to respond differently to different contexts and circumstances is a hallmark of psychological health; to act and feel the same at a PTA meeting, at a funeral, and in bed with a lover is not a sign of healthy consistency but of psychological disorder. Rather, the phenomenon of multiple self-states is problematic only when those self-states are dissociated from each person, when the person is unable, in one state of mind, to maintain any real sense that at other times he thinks and feels differently.”
Wachtel then summarizes some important facts about the relational model. Analysis “do not so much dig up material that has never been consciously experienced before, or that has been thoroughly banned from consciousness since the day it was buried, as we enable material that has, up till now, been but dimly or occasionally grasped or experienced to be more readily or thoroughly acknowledged, elaborated, and accepted.” Moreover, relational analysts work to both “further the articulation” of dissociated experiences and also “enhance the connections between that articulation and other experiences that have been heretofore mysterious, misunderstood, or difficult to modify. Overcoming dissociation means restoring, or enhancing, the capacity to be moved by what one sees or understands, both in the sense of being moved emotionally and in the sense of being moved to action.”
He continues by writing that good psychotherapists do not “dive beneath the surface of the patient’s experience to tell him (‘interpret’) what he is really feeling.” Rather, they “discover what is being excluded from consciousness by attending in meticulous detail to the patient’s experienced subjectivity.” This type of listening also involves attending to “what does not appear in consciousness, as well as what is muted, experienced without the expected affect, or given a particular spin that seems not to be consonant with how the person is behaving or with other aspects of what he is experiencing.”
Psychotherapeutic texts generally focus on the patient’s words and not the therapist’s words. One focus of this book is that every overt message that the therapist intends to convey (the focal message) also contains a second message (the meta-message)which “conveys an attitude about what is being conveyed in the focal message.” “A comment whose focal message is accurate but whose meta-message is poorly wrought can have an effect similar to that of a potentially curative organ transplant that is rejected by the patient’s body because it is registered as alien.”
We need to pay attention to the patient’s experience of the therapist’s remarks, as transference makes it “likely that the patient’s experience of the comment will differ in certain respects from what the therapist thinks she is conveying.”
Therapist noises are “familiar phrasings that therapists call upon when certain, phrasings that at once convey a blistering sense of professionalism and serve to protect the therapist from further revelation of what she is thinking or feeling.” One way to gauge whether we are using therapist noise is to keep track of our perhaps-to-maybe ratio. When we’re in our “stilted, ‘therapist noises’ stance,” we’re more likely to use “perhaps” than “maybe” (e.g., “perhaps your feeling such and such”).
Two: The Continuing Evolution of Psychotherapy
The Emergence of Affect, Acceptance, and Experience in CBT
There are two trends in recent years that have helped CBT to converge with the psychodynamic tradition.
First, new cognitive therapies have placed more emphasis on affect and accepting the patient’s experience. While CT had long focused on cognitions and rationality, Barlow has stressed the importance of the patient being exposed to his affective experience, and Linehan and Hayes have stressed the importance of accepting the patient’s affective experience.
Traces of these more recently developments could be found in different behavioral therapies in the 1970s. Wachtel observed at the time that these therapies were “in important ways more experiential than most approaches of that era. Instead of talking about what the patient was afraid of or could not handle well, [these therapists] helped the patient to directly experience what he had been avoiding.” “What struck me from all of these experiences was both the clinical sensitivity and skillfulness that these behavior therapists manifested and the degree to which the work promoted the client’s deep and direct immersion in the experiences that had been associated for them with distressing affect.” It is true, as CBT claims, that our perceptions and thoughts affect our feelings, but it’s also true that our feelings affect our perceptions and thoughts (e.g., LeDoux, Damasio, Forgas).
Moving on to psychodynamic therapy, all these focus on the experiences that the patient has “banished from awareness in the course of growing up because they threatened his sense of himself or his sense of who he must be in order not to lose contact with key attachment figures.” But unlike traditional approaches, more recent ones have emphasized, not confronting the patient with his avoidant tendencies, but rather helping him “to accept the tendencies in himself that he has thought or feared were unacceptable.”
Second, there has been the emergence of constructivist cognitive therapy. As Arnkoff and Glass write: “Whereas rationalist cognitive theories assume that the therapist can know the true state of affairs through logic or sensory observation, constructivist theories posit that each person creates his or her reality.”
The Emergence of Relational Analysis
Relationalist “stress relationships between people as the most fundamental organizing theme of the evolving psyche.” Relational writers claim that classical psychoanalysis is a one-person model, as it holds that the analyst is “observing, in more or less objective fashion, characteristics and dynamics that lie ‘within’ the patient and that are bound to be manifested in almost any context.” The analyst, according to this model, himself “is not really a part of the field of observation.” In a two-person model, the analyst believes that what happens in the session is “co-constructed,” “a product of the interaction between two people, each of whom contributes to what happens.”
Wachtel writes that we can similarly talk of one-person and two-person versions of CBT. In one-person CBT, therapists “view themselves as objective observers, standing outside the phenomena they are observing and participating only in the sense that they ‘point out’ what is going on.” There are also CBT therapists “who view themselves as genuine participants in a co-constructed experience.”
Another important development in psychoanalysis has been the idea of self-states. Traditionally, psychoanalysis assumed the existence of “underlying structures or inclinations” that are “largely unresponsive to what is happening in day-to-day life.” According to this view, “daily experiences can affect, say, the ‘manifest’ content of a dream, but the ‘latent’ content remains unchanged.” However, the concept of multiple self-states tells us that there is not just one thing happening beneath the surface but rather “there are many ways of behaving and experiencing that genuinely characterize the person.”
He writes that the notion of self-states is not inherently problematic. “Indeed, the capacity to respond differently to different contexts and circumstances is a hallmark of psychological health; to act and feel the same at a PTA meeting, at a funeral, and in bed with a lover is not a sign of healthy consistency but of psychological disorder. Rather, the phenomenon of multiple self-states is problematic only when those self-states are dissociated from each person, when the person is unable, in one state of mind, to maintain any real sense that at other times he thinks and feels differently.”
Wachtel then summarizes some important facts about the relational model. Analysis “do not so much dig up material that has never been consciously experienced before, or that has been thoroughly banned from consciousness since the day it was buried, as we enable material that has, up till now, been but dimly or occasionally grasped or experienced to be more readily or thoroughly acknowledged, elaborated, and accepted.” Moreover, relational analysts work to both “further the articulation” of dissociated experiences and also “enhance the connections between that articulation and other experiences that have been heretofore mysterious, misunderstood, or difficult to modify. Overcoming dissociation means restoring, or enhancing, the capacity to be moved by what one sees or understands, both in the sense of being moved emotionally and in the sense of being moved to action.”
He continues by writing that good psychotherapists do not “dive beneath the surface of the patient’s experience to tell him (‘interpret’) what he is really feeling.” Rather, they “discover what is being excluded from consciousness by attending in meticulous detail to the patient’s experienced subjectivity.” This type of listening also involves attending to “what does not appear in consciousness, as well as what is muted, experienced without the expected affect, or given a particular spin that seems not to be consonant with how the person is behaving or with other aspects of what he is experiencing.”
According to the relational model, then, “it is consciousness itself that is the royal road to the unconscious. It is through attending to the variable qualities and contents of consciousness, noticing what comes into focus sharply, what is experienced in only a dim or blurry fashion, when the focus and quality of conscious experience shifts, either abruptly or subtly, when the patient’s subjective experience seems wholehearted and when it seems hedged, muted, or affectless, and so forth that the clinician comes to understand the nature of what is being defended against. The consciousness is not so much a hidden realm, fully formed and lying unseen below, but rather an unarticulated set of potentials for fuller experience, a set of proclivities and inclinations that guide and shape experience without the patient’s fully elaborating, acknowledging, or endorsing them. Understanding the unconscious is always an inference based on close study of the vagaries of consciousness.”
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