- 1. Promoting the Patients Capacity to Suffer: A Revision of
Contemporary Notions of Psychotherapeutic Aim James Tobin, Ph.D.
Licensed Psychologist PSY 22074 220 Newport Center Drive, Suite 1
Newport Beach, CA 92660 949-338-4388 Assistant Professor of
Clinical Psychology 601 South Lewis Street Argosy University
Orange, CA 92868 714-620-3804 1
2. Case VignetteSupervision Vignette # 1 2 3. Evidence-Based
Practice Evidenced-based practice and managed care. Symptom
reduction and progress: the standard of care. If progress doesnt
occur, something is wrong with the psychotherapists abilities or
the treatment provided or both. 3 4. Enormous Pressures on
Therapists-in-Training Not only to diagnose, intervene, and help,
but to cure (the helping profession has become the curing
profession). Traditional notions of abstinence have practically
been forgotten. The proliferation of pantheoretical notions of the
working alliance/relational theory often dont correspond to
treatment outcomes. 4 5. The Helping Profession, the Curing
Profession Therapist in training place enormous expectations on
themselves, many of which are misguided (see xxxs paper Mistaken
Beliefs of Beginning Psychotherapists), and many of which come from
unresolved historical issues re: treating/healing a pathological
caregiving figure. These characterological predispositions fit
nicely with the current environment of symptom reduction and
positive outcomes. 5 6. The Therapists Role: To Help Relieve the
Patients Suffering Assumptions and beliefs about therapeutic action
and the therapists role: coping and resilience. Relieving the
patient of his/her suffering we want to help the patient feel
better and do better. This is a narcissistic need, both personally
and professionally (we have a vision for the patient). 6 7. What
are the Liabilities of This Way of Thinking about the Therapists
Role? ? 7 8. Case VignetteSupervision Vignette #2 8 9. What are the
Liabilities of This Way of Thinking about the Therapists Role? 1.
Affirming the patients subjective. 2. Avoiding CT and
identifications (neutrality is a hyper-focus). 3. The therapy space
is ordinary, not extraordinary, highly restricting what the
therapist does with the patient and feels about the patient
(featured in Stanley Kubricks films The Shining and 2001: A Space
Odyssey). 4. The therapist is largely inhibited and the patient is
objectified! 9 10. The Curative Mindset = Inhibition Chad Kellands
recent quote: You mean we can tell the patient what we really
think? 10 11. The Curative Mindset Often Causes a Collusion of
Resistance These are interactional resistances [that make the]
psychotherapeutic work [revolve]s around noninsightful symptom
relief, inappropriately shared defenses, enactments and
gratifications (Karlsson, 2004, p. 570). Karlsson (2004, p. 569)
elaborates: both [therapist and patient] unconsciously avoid
understanding because they fear the understanding will create too
much psychological pain. 11 12. Role Assignments in the Therapeutic
Dyad Collusions of resistance not only have to do with avoidance of
pain, but also with pressure to stay in accordance with role
expectations. Therapist (omnipotent healer) and patient
(healing/healed). The illusion each holds can be viewed as really
one in the same: the role assignments will continue to be
maintained and compatible. 12 13. Two-ness and Disillusionment The
inevitable reality of the two-ness of the human condition (puts
pressure on the role assignments). Both clinical vignettes feature
the emergence of two-ness disillusionment begins. The anxiety leads
to the need to keep things ordinary (inhibitions about the
extraordinary). 13 14. Ordinary vs. Extraordinary The therapeutic
dyad colludes in resistance vs. the extraordinary (roles are
maintained; illusion is upheld). The need to keep things ordinary
is very strong and present even in more subtle clinical
interactions and intrapsychic experiences (what is intuited). The
phenomena are largely dissociative in quality. 14 15. Paralleling
Dissociations in the First Vignette The patient dissociated from
the full reality of his experience (he did not see his own
accountability). If he did not dissociate, his suffering would be
immense. The therapist dissociated from the obvious comment
emerging within her (out of her two-ness) to maintain a role (to
prevent the patients suffering). Full contact with experience is
not possible (illusions are maintained). 15 16. Given This All,
What is the Therapists Role? Here are My Recommendations: 1. The
therapist must help the patient come into full contact with the
reality of his or her experience and learn from it. 2. This will
likely cause the patient (as well as the therapist) incredible
suffering both must bear. 3. The main therapeutic activity is to
detect dissociated material (internally and relationally) as it
occurs and offer it to the patient in the form of what Renik calls
logical thinking or alternative constructions of reality the
patient compares/contrasts the therapists constructions with
his/her own. 16 17. Given This All, What is the Therapists Role?
Here are My Recommendations: 4. The art of therapy involves the
therapist learning how to move seamlessly back and forth between
empathizing with the patients narrative (their illusive appraisal
of reality) and proposing alternative perspectives and areas of
inquiry (potential for disillusionment); how to do this delicately
so that learning is not traumatic! 5. This involves role
flexibility, i.e, shifting between the ordinary and the
extraordinary, always being a two and knowing when and how to
reveal your two- ness (C.K.) 17 18. Therapists in Training:
Problems of Exhibition and Inhibition Some novice therapists claim
their two-ness too aggressively: a problem of exhibition (too
little neutrality/poor tact/overly permissive role-playing). Others
are reluctant to embody their two-ness and to use it as Renik
advises: a problem of inhibition (hyper- neutrality/overly
heightened tact; overly restricted role-playing). 18 19. If the
Extraordinary Can Be Entered Into. There will emerge the gradual
and nontraumatic accumulation of knowledge facilitated by a good
enough mother and the holding environment she provides (#4). This
is Winnicotts notion of therapy being a transitional play space, a
safe arena of exploration in which illusion/fantasy (what is
dissociated) is gently and delicately replaced by the reality of
experience (the therapist works to move the patient from
dissociation to a more realistic appraisal and acceptance of
experience). 19 20. Shame is Gradually Replaced by Regret Gradually
increasing the patients (non-dissociated) contact with experience
alters shame-based defenses, replacing them with regret
(learning/suffering) (theme of the film Magnolia). What patients
most need is location of the intuitions about reality that have not
received adequate confirmation or support from others (#4, p. 365).
Shame is nothing more than the patients dissociated intuitions
about what actually happened that were also avoided or denied by
others. 20 21. An Essential Paradox Our patients need to suffer
what they have dissociated and not yet learned (the therapist
detects dissociated material); paradoxically, the therapist cures
by helping the patient suffer. For Freud, the goal of therapy is
determin[ing] the role we play in our unhappiness and the role
assigned to fate (Thompson, p. 149).** hysterical misery into
common unhappiness (Breuer & Freud, 1893-1895/1955, p. 305). 21
22. Supervision as Suffering The supervisee avoids multiple
contacts with experience in therapeutic interactions with patients
(including traumatic identifications), frequently colluding and
dissociating. The supervisor is in conflict vis--vis the
supervisee: he wants her to learn but not to suffer. This leads to
an ongoing battle over staying in the ordinary (Kubrick) vs. moving
into the extraordinary that exists throughout the course of
supervision. 22 23. Supervision as Suffering To the extent to which
the supervisee can tolerate holding/containing the supervisee, and
does not remain too rigidly attached to a role vis--vis the
supervisee, he will capitalize on extraordinary moments as they
emerge (not collude in resistance or dissociate from them) and non-
traumatically offer them to the supervisee for exploration. This
involves enormous sensitivity to the supervisees shame-based
defenses. 23 24. Supervision as Suffering The supervisor will also
be open to the supervisees capacity to pick up on dissociations
emanating from the supervisor, and not to respond defensively when
the supervisee raises them. All of this models a way of being (an
alternative view of therapeutic function) to the supervisee she can
then enact with her patients. 24 25. Supervision as Suffering The
two-ness of the supervisee is a reality the supervisor can never
deny this will cause the supervisor to exhibit when he would
otherwise prefer to inhibit, and vice versa. This teaches the
supervisee that the supervisor is able to suffer for the sake of
her learning, just as the supervisee must suffer for her patients.
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