The Psychodynamic Diagnostic Process: Nancy McWilliams

This lecture by Nancy McWilliams delves into the intricacies of psychodynamic diagnosis, exploring the complexities beyond the DSM and offering insights into therapeutic approaches for various personality types. Here’s a summary of key points with timestamps for your reference:

Levels of Personality Functioning (1:00):

  • McWilliams emphasizes the importance of considering different levels of personality functioning, ranging from high-functioning to psychotic.
  • High-functioning (neurotic to healthy): Individuals exhibit good attachment security, engage in reflective thinking, and can manage complex emotions.(1:00)
  • Borderline: Characterized by intense emotions, unstable relationships, and difficulty tolerating frustration. Therapists need to set clear boundaries and provide consistent support. (2:00)
  • Psychotic: Individuals grapple with severe anxiety and may experience delusions or hallucinations. Treatment focuses on symptom management and building a sense of safety. (3:00)

DSM vs. Psychodynamic Approach (4:00):

  • McWilliams critiques the limitations of the DSM, arguing that it overemphasizes categorical diagnoses and neglects individual context and complexity.
  • Psychodynamic diagnosis, in contrast, considers a person’s history,temperament, defense mechanisms, and attachment patterns to provide a richer understanding. (5:00)

Therapeutic Considerations for Different Personalities (6:00):

  • Obsessive-compulsive: Helping them find healthier ways to manage anxiety and intrusive thoughts, rather than focusing on eliminating obsessions entirely. (6:00)
  • Depressive: Exploring the underlying causes of their self-criticism and encouraging them to develop healthier coping mechanisms. (7:00)
  • Self-defeating: Recognizing the pattern of seeking help while sabotaging progress, and setting clear boundaries to prevent manipulation. (8:00)

Qualities of a Good Therapist (50:00):

  • Caring and empathetic: Building a genuine connection with the patient is crucial for effective therapy.
  • Humble and willing to learn: Therapists should be open to feedback and continuously seek to improve their skills.
  • Interested in the patient: A genuine curiosity about the patient’s experiences fosters a deeper understanding and better treatment.

McWilliams emphasizes the importance of individualizing therapy based on a patient’s unique personality and level of functioning. By moving beyond the limitations of the DSM and adopting a psychodynamic approach, therapists can provide more effective and meaningful support.

Note: This summary provides a brief overview of key points. For a more comprehensive understanding, watching the full lecture is recommended.

Francesetti: Gestalt Therapy, an Engine of Change.

This lecture was given by Gianni Francesetti in Madrid on 22nd Sept 2023 at the European Association of Gestalt Therapy conference.

This article is a work in progress…. These are my notes and personal reflections on this lecture.

@ 10:30 On the topic of “Boring.

Francesetti begins by explaining that he has tried to make his speech less “boring”. He then says, “Boring is not so bad, maybe.”

He will mention this phenomenon of boredom — which I find noteworthy due to personal experiences as someone who often gets bored myself and working with clients who feel chronic boredom as a practitioner — later on in this lecture.

Field perspectives in Gestalt therapy: there is a growing interest in the field perspectives in the current psychotherapy universe. This has much to do with current clinical issues. Frank Staemmler (2006) writes about the concept of ‘field’.

What does “Field” mean? Is it different for each person, or is the feel a “common” dimension?

@13:15 The speaker mentions that different people use the term “Field” differently, and even the same author may use different meanings of the word field, that a definition needs to be made. I tend to think that perhaps this is precisely what the term is about. The field is an all-encompassing concept, and all meanings of the word field are valid and useful to psychotherapeutic work.

@13:59 Is the field different for each person or is it a common dimension in a given situation?

The field as organism-environment contact/unity, and the key historical influencers to the concept of field theory in Gestalt psychotherapy.

@ 35:20 What are the clinical issues we are facing today?

Case study

Psychopathology, just like life, is a fractal.

References

Francesetti, G. (2023). Gestalt therapy. An engine of change. Lecture EAGT Conference on 22 Sept 2023. Madrid. retrieved from https://youtu.be/dSIGs2bbwGU?si=cQGEKwFSDBMZFTbo&t=506

Staemmler, F. (2006). A Babylonian Confusion?: On the Uses and Meanings of the Term ‘Field’. British Gestalt Journal15(2), 64.

The change moments in psychotherapeutic practice 

The challenge with humanistic psychotherapy today is to realize the philosophical con­cepts and theory put into practice. How do we see an I-thou moment in a therapy ses­sion? 

My personal conviction in this topic is borne by the fact that I have experienced change moments – as a client of psychotherapy. Over the years, I have also been able to tell if these change moments had a lasting effect, or if they were just cathartic or tempo­rary because of suggestion and coercion. Perception of from the client’s point of view recorded over lifetime (a couple of years), may be essential aspect of psychotherapeutic process research. 

The process of defining the healing I-Thou moments (Buber, 1936) in psychotherapy often gets lost in language. What some call the transcendental phenomenon (which I have in this paper related to an aspect of Clarkson’s framework), is also called “miracle moments” (Santos, 2003), “sacred moments” (Pargament, 2007), and “moments of meeting” (The Boston Change Process Study Group, 2010). 

What is typically experienced in this moment is typically described like this: “Every therapist knows that there are some special moments in psychotherapy. I experi­ence them as “sacred moments” when immediate realities fade into the background, when time seems to stand still, when it feels as if something larger than life is happen­ing. In these moments, I believe, a meeting of souls is taking place. This was one of those times” (p. 6). 

I had the benefit of attending a presentation at a Gestalt Associates Los Angeles (GATLA) Summer Residential in Lisbon this year which discussed this very topic of defining these moments of encounter. Entitled, I-thou moments in psychotherapy, the study is the result of meta-analyses of psychotherapeutic literature and interviews with therapists. Hence it was found that these I-thou moments: 

  • are memorable, exists in psychotherapy and appears every now and then.
  • are recognizable, significant events.
  • is based on the quality of dialogue.
  • short lasting (in seconds).
  • is rare.
  • is mutually experienced.
    During these moments 
  • perception gets narrowed.
  • there is an unusual level of understanding and acceptance of the other
  • there is experience of being on the edge of something spiritual.

These moments lead to long term change in the therapy and result in motivation for the client to further therapy work. It strengthens the alliance, and has no negative affects (unlike transference relationship). It is also a qualitatively viewed process, and is often arises from sharing of heavy topics and staying long enough at an oftentimes uncomfortable place. Playing the role “I am the therapist, you are the client” prevents these moments from happening. The challenge in studying these moments is the very fact that in trying to grasp the moment, that moment is lost (Pernicka, 2016).

References

Buber, M. (1936). Ich und Du. Berlin: Schocken.

Pargament, K. (2007). Spiritually integrated psychotherapy: Understanding and addressing the sacred. NY: Guilford Press.

Pernicka, M. (2016, July). I-Thou moments in Psychotherapy. Lisbon, Portugal.

Santos, A. M. (2003). Miracle Moments: The Nature of the Mind’s Power in Relationships and Psychotherapy. iUniverse.

The Boston Change Process Study Group. (2010). Change in psychotherapy. NY: W. W. Norton & Co. .

What’s behind the transforming power of dialogue?

Dialogue is a means of making contact, and it is a form of action that goes beyond ver­bal communication. That which lies intrinsic in an I-Thou contact? Is it a phenomenon we understand as empathy? This phenomenon is in itself a concept that leaves much to be discussed. In the context of this paper I’ll refer to Schmid (2001). This paper entitled Comprehension: the art of not knowing, gives a perspective of Buber’s philosophy in the context of psychotherapy, which is useful for this section of this paper (there are also parts of this paper which I have reservations about, which I will also discuss). Schmid states in the beginning that empathy is an “innate (inter-) personal quality” that reaches “beyond identification and interpretation”. It is the act of allowing oneself to be impressed by the other, while expressing oneself in an authentic way in the presence of the other. 

This way of explaining the empathic in a contact with the other is, whether through verbalized or symbolic communication (i.e. body language, a look in the eye or simply “being there”), empathic contact means to put aside the need to use the other person for any personal gratification at all. This means to be there with the other person without feeling as if one has to interpret the identity of the other or the need to establish one’s own identity in the presence of the other. There is no goal in such a contact but a process of “being there”, being authentically present, as an individual, and inviting the other to be there as well as an authentic person. This contact is at a transpersonal level.

Read also: Empathy and Buber’s I-thou

References

Buber, M. (1936). Ich und Du. Berlin: Schocken. 

Buber, M. (1970). I and Thou (Kindle ed.). (W. Kaufman, Trans.) Charles Scribner’s Sons.

Gadamer, H. G. (1975/1960). Truth and method . (G. Barden, & J. Cumming, Trans.) NY: Seabury. 

Schmid, P. F. (2001). Comprehension: the art of not-knowing. Dialogical and ethical perspectives on empathy as dialogue in personal and person-centred relationships. Empathy, 53-71.

Staemmler, F.-M. (2009). The willingness to be uncertain: Preliminary thoughts about intepretation and understanding in Gestalt Therapy. In L. J. Hycner (Ed.), Relational approaches in Gestalt Therapy (pp. 65-110). NY: Gestalt Press.

Healing through dialogue is an eminently hermeneutical phenome­non indeed

“Healing through dialogue is an eminently hermeneutical phenome­non indeed.”

Gadamer, quoted in Staemmler (2009, p. 65). 

The psychotherapeutic alliance is a dialogue which is action. Through this dialogue, understanding takes place. This understanding comes about through a hermeneutic pro­cess. This process requires the authentic inclusion of the self of the therapist. 

Staemmler goes on to emphasize that in the process of understanding, one needs to be asked to ask authentic questions, bearing in mind the tendency for therapist (per­haps to hide his/her own shame) of not being authentically available to the client by asking pseudo-questions, which includes pre-prepared list of questions or repetitive questions like “how do you feel?” without actual curiosity. Pseudo-questions also in­clude questions that predestine their answers. Authentic questioning requires the bring­ing into the open what is unexpected, with the knowledge that the client has the answer. This means that the therapist needs to be open to listening, and living with the uncer­tainty of the answer that he/she is given. This requires that the therapist relinquishes any control over the client’s answers and meaning-making, and this includes predicting what the client’s answer should be before even asking the question. 

This relinquishing of control in dialogue leads us away from Buber’s “I-it” and towards the “I-Thou” way of relating. Incidentally, this forms the “symmetrical” aspect of the psychotherapeutic alliance as discussed earlier described by Altemeyer, and con­nected to Clarkson’s the person-to-person relationship (point 4) and the transpersonal relationship (point 5). 

Another way of understanding the “I-It” form of understanding is “to claim to understanding the other better than she or he understands herself or himself”. Looking closely this can also be seen as an abuse of professional power “disguised as benevo­lence” (ibid. p. 91-92). The consequence to such behavior to the profession is the dis­trust caused by fear of the client from being misinterpreted and misjudged. 

That which happens in an authentic I-thou dialogue is a mutual exchange. This happens in the “between”. Gadamer, in agreement with Buber: “The dialogue has trans­forming power. When a dialogue succeeds, something remains for us and in us, which has changed us” (ibid. p. 93). “Dialogue that succeeds”, is no ordinary dialogue, but that which is inclusive of the self and the other. Converse to the ‘I-It’ way of relating, it exists, as Carl Roger’s is noted to have explained, “without any techniques, means, aims or intentions” (Schmid, 2001). This kind of dialogue is what Buber terms the ‘I-Thou’. This is the dialogue with transforming power. 

This is the transformative contact which many schools in psychotherapy strive to establish in the therapeutic hour. I use the word ‘strive’ to give meaning to the elusive nature of such a healing contact, and the powerful benefits in the event when such con­tact happens.

What’s behind the transforming power of dialogue ?

References

Buber, M. (1936). Ich und Du. Berlin: Schocken. 

Buber, M. (1970). I and Thou (Kindle ed.). (W. Kaufman, Trans.) Charles Scribner’s Sons.

Gadamer, H. G. (1975/1960). Truth and method . (G. Barden, & J. Cumming, Trans.) NY: Seabury. 

Schmid, P. F. (2001). Comprehension: the art of not-knowing. Dialogical and ethical perspectives on empathy as dialogue in personal and person-centred relationships. Empathy, 53-71.

Staemmler, F.-M. (2009). The willingness to be uncertain: Preliminary thoughts about intepretation and understanding in Gestalt Therapy. In L. J. Hycner (Ed.), Relational approaches in Gestalt Therapy (pp. 65-110). NY: Gestalt Press.

Hermeneutic circle of understanding 

The phenomenological attitude of  putting aside, or bracketing, theories and pre-conceived ideas in favor of un­derstanding the client does not mean the absence of interpreting. It also does not mean that therapists should not have pre-knowledge and theoretical understandings. It is im­possible for anyone, therapists included to not interpret. According to Heidegger, “from the very beginning our essence is to understand and to create comprehensibility.” To interpret and understand is to be human (Staemmler, 2009, p. 65). At the same time, it is through our pre-understandings that we can have any understanding at all. 

For this understanding to be authentic, and not based on blind interpretations of theory, what counts is the attitude towards gaining this understanding. According to Gadamer (Gadamer, 1975/1960), the German word for “understanding” (Verstehen) is also used in the sense of a practical ability (e.g., er versteht nicht zu lesen, “he can’t read”). This is the understanding when one goes beyond simply acquiring scientific knowledge— when one gets well versed in something, like understanding a text, or, in the case of therapy, the client. In efforts to access this kind of understanding, Gadamer writes, one would have “the accomplished understanding (that) constitutes a state of new intellectual freedom” (p. 251). Gadamer likens all such understanding to be ulti­mately self-understanding (sich verstehen). What this means is that understanding in this attitude is a dynamic process of self-involvement. Gadamer explains how when reading words written by someone else for example, the reader projects his/her own meaning for the words as he/she encounters them. As one reads or listens further, one has expectations for what meaning is to come, new meaning then emerges and expecta­tions are revised according to what meaning emerges further. This is the process of un­derstanding the subject matter through self-reflection and reinvestigation of the subject. 

Heidegger (1971), in his writings on what and how art is, says, “What art is should be inferable from the work. What the work of art is we can come to know only from the nature of art” (p. 18). Heidegger adds that in discovering a piece of art, we are lead to a circle of questionings. While we are tempted to avoid this circle, we cannot avoid it if we are to understand that “The artwork is, (…), a thing that is made, but it says something other than the mere thing itself is, allo agforeuei. The work makes pub­lic something other than itself; it manifests something other; it is an allegory. In the work of art something other is brought together with the thing that is made… The work is a symbol” (p. 19). Through this circle of learning and self-reflection, Heidegger de­veloped the concept of the hermeneutic circle. 

Gadamer quotes Heidegger in Being and Time, “(The hermeneutic circle) is not to be reduced to the level of a vicious circle, or even of a circle which is merely tolerat­ed. In the circle is hidden a positive possibility of the most primordial kind of knowing, and we genuinely grasp this possibility only when we have understood that our first, last, and constant task in interpreting is never to allow our fore-having, fore-sight, and fore-conception to be presented to us by fancies and popular conceptions, but rather to make the scientific theme secure by working out these fore-structures in terms of the things themselves” (p. 269). Heidegger defines here the attitude towards authentic inter­pretive understanding. This attitude requires the interpreter to have an awareness of the self, and the prejudices (or fore-having, fore-sight and fore-conception). Gadamer states: “all correct interpretation must be on guard against arbitrary fancies and the limi­tations imposed by imperceptible habits of thought, and it must direct its gaze ‘on the things themselves’.” In the context of psychotherapy, the gaze should be directed on the client and what is happening in the alliance. “For the interpreter to let himself be guided by the things themselves is obviously not a matter of a single, ‘conscientious’ decision, but is ‘the first, last, and constant task’.” In other words, it has to be an attitude towards the understanding process. “For it is necessary to keep one’s gaze fixed on the thing throughout all the constant distractions that originate in the interpreter himself” (p. 269). Gadamer adds that the process of understanding texts— and we can translate this to the verbal and non-verbal communication of the client— involves projection on the part of the interpreter: “He projects a meaning for the text as a whole as soon as some initial meaning emerges in the text.” This projection is necessary in order to make meaning of what emerges— “the initial meaning emerges only because he is reading the text with particular expectations in regard to a certain meaning”. It is the working through of this projection and constantly revising the understanding as new material emerges, “is un­derstanding what is there” (p. 269). It is also worthwhile to note that Gadamer found it important “… to distinguish the true prejudices, by which we understand, from the false ones, by which we misunderstand.” However at the beginning of the Hermeneutic pro­cess it is difficult to tell one from the others (Staemmler, 2009, p. 86).

References

Gadamer, H. G. (1975/1960). Truth and method . (G. Barden, & J. Cumming, Trans.) NY: Seabury.

Heidegger, M. (1971). Poetry, language, thought . (A. Hofstadter, Trans.) Harper Perennial.

Staemmler, F.-M. (2009). The willingness to be uncertain: Preliminary thoughts about intepretation and understanding in Gestalt Therapy. In L. J. Hycner (Ed.), Relational approaches in Gestalt Therapy (pp. 65-110). NY: Gestalt Press.

A mental health horror story — is there truth to this fiction?

This is a story about the consequence of not understanding the client in the mental health profession. 

It is necessary to emphasize the importance of understanding and the dangers of misunderstanding caused by pre-conceived ideas. Stammler (2009) cited a story written by Gabriel Garcia Márquez (1994), which I find interesting to relate: 

A young woman, whose care breaks down on a country road in the pouring rain and who tries to get a lift to the next telephone. After a long time, the driver of a van picks her up. In the van are a group of sleeping passengers covered with blankets. As she is cold and wet the woman gets a blanket too. 

After a while the van stops. Together with the other passengers she gets out and enters a building. She meets a woman in uniform and tells her she wants to make a phone call. She is ordered to join the other women in the communal dormitory. Sudden­ly awake to the fact that she is in a psychiatric hospital, she tries to escape—to no avail. Her explanations, protests, and attempts to leave the building were unsuccessful; they were answered with force and sedation. The next day she is introduced to the medical director of the hospital. He deals with her in a very friendly and patient manner. She tries to convince him that she has only come to make a phone call and repeatedly de­mands to be permitted to call her husband and inform him of her whereabouts. The doc-tor speaks to her in a fatherly voice saying “Everything in due course”—and finishes the conversation. 

A few weeks later she manages to send a message to her husband. The price is high; she has to give in to the sexual advances of the night nurse. The visit of her hus­band to the hospital from which she expects her liberation begins between him and the medical director. The latter explains to the former the mental disease of the wife. He talks of the states of excitation, vehement outbursts of aggression and fixed ideas (espe­cially the one to make phone calls); further treatments as well as the sympathetic coop­eration of the husband for the sake of a positive course of the disease are strictly indi­cated

After having been informed in this way, the husband sees the wife. He soothes her, encourages her, tells her that she will soon feel better, and promises to come to visit with her on a regular basis. At first she is perplexed; then she starts to rave and to scream like a maniac. On her husbands next visit, she refuses to see him. The doctor says to him calmly, “that is a typical reaction, it will pass” (p. 68). 

This almost true-to-life horror story tells us what can happen to clients who slip into dependency on professionals for solutions, and end up being labelled by their diagnoses and misunderstood. It highlights the problem of non-active listening on the part of the professional who engage themselves in analyzing without consideration for what is real­ly happening with the client. Therapists who are fixated on their pre-conceived theories tend to adopt a one-theory-fits-all, which deprives the client of exploring his/her own meanings. This mirrors what Reich was trying to explain with the case studies discussed above: where the therapist was too busy at doing the job of analysis to see-and-hear the client. In the story above the staff at the psychiatric hospital were so busy at being “pro­fessional” that they lost sight of seeing the client, not realizing that the client was not really meant to have been there. This is compounded by the influence professionals have on the public who hold the professional in often too high regard. This kind of mis­use of professional status breaks the ethical code of doing no harm: “In providing ser­vices… (psychotherapists) bear a heavy social responsibility because their recommen­dations and professional actions may alter the lives of others” (European Association for Psychotherapy, 2002, p. §1.1.a). 

Why do such oversights also happen in psychotherapy? Is this what we do on a daily basis in psychiatry? Diagnosing children with ADHD, depression and prescribing psycho pharmaceuticals without first attempting at understanding the pathological field in which the patient resides?

Reich writes of this kind of failure to recognize what is really going on with the client (e.g. transferences), and being too much in need of being complimented (from others and also by the self) : “Un­doubtedly, this can be traced back to our narcissism…” (Reich, 1945/1984, p. 25). Which leads us back to the reality that psychotherapy is about understanding the client and the process of which requires the therapist to first understand themself.

Reference

European Association for Psychotherapy. (2002). Statement of Ethical Principles. Retrieved 2016, from European Association for Psychotherapy: http://www.europsyche.org/contents/13134/statement-of-ethical-principles

Márquez, G. G. (1994). Strange Pilgrims. London: Penguin.

Owen, I. R. (2015). Phenomenology in Action in Psychotherapy.

Reich, W. (1945/1984). Character Analysis (3rd ed.). (M. H. Raphael, Ed., & V. R. Carfagno, Trans.) NY: Farrar, Straus and Girouy. 

Staemmler, F.-M. (2009). The willingness to be uncertain: Preliminary thoughts about intepretation and understanding in Gestalt Therapy. In L. J. Hycner (Ed.), Relational approaches in Gestalt Therapy (pp. 65-110). NY: Gestalt Press.

Unconscious feelings and countertransference within the Therapeutic Alliance 

To illustrate how a therapist’s emotions towards client, though brought to awareness and allowed to be revealed, can also be mistaken for authentic reaction to the client’s process, a mentor of mine, in a private lecture on experiences of unconscious effects on a therapist in therapy sessions, narrated a rather simple story he entitled, Chanel No. 5: the client, a middle-aged woman had come to therapy to work on very traumatic and emotionally tragic experiences in her life. The therapist found himself deeply moved by her experiences, and would find himself in tears each time she entered his practice. He questioned his emotionality towards the client only weeks later because he, like many would have, assumed that he was naturally moved by the client’s plight. He subsequent­ly noticed the client’s perfume as she entered the office and asked her what she was wearing. ”Chanel No. 5”, she replied, which was the same perfume his beloved mother had worn for most part of her life. 

In the story, the client instilled emotions in the therapist in which the therapist was unaware of. This gets interpreted somewhat inaccurately at first until the therapist was able to come to a self-awareness. This kind of experience faced by therapists is termed by Freud in a 7 June 1909 letter to Carl Jung, as countertransference, to which Freud explains, “(s)uch experiences, though painful, are necessary and hard to avoid. (…) (W)e need to dominate ‘countertransference’, which is after all a permanent prob­lem for us; they teach us to displace our own affects to best advantage. They are a ‘blessing in disguise’” (Freud, 1909). The unconscious nature of countertransference makes it difficult for the analyst to differentiate between the analyst’s own unresolved difficulties and emotional reactions and impressions that come to the the therapist’s consciousness that are activated by the projective identification of the client. 

While unlike Freud and Klein who considered strong countertransference feelings to have negative affect on analysis and something analysts should work on by gaining more insight into themselves instead, many analysts like Bion have found usefulness in the phenomena. Therapists of the intersubjective and relational schools share counter­transference that they have (and are aware of) as a means to bring authentic contact to the alliance. 

Awareness of therapist’s countertransference is supportive to the therapeutic process 

Countertransference, with awareness, supports rather than interferes with the therapist’s work. Freud’s mention of the need to “dominate” countertransference, can be taken as a call to be aware of dealing with the emotions within the alliance rather than rejecting them and becoming emotionally detached. Heinmann (1950, p. 81) considers this use of countertransference as “one of the most important tools for his/her work. The analyst’s counter-transference is an instrument of research into the patient’s unconscious” as a means of bringing to consciousness of the client what he/she does (consciously or un­consciously) to “get under the analyst’s skin”. How can the awareness of countertrans­ference experienced by the therapist be an advantage to the therapeutic alliance?

“(T)he analysis of the transference, i.e., that part of it which deals with the breaking down of the resistances, constitutes the most im­portant piece of analytic work.”

Wilhelm Reich, 1945/1984, p. 5

The answer is explained by Racker (1953) who acknowledged that the therapist may react emotionally to a patient’s enactments or behavior or personality, but he/she is not prevented from “identifying him/(her)self intellectually with his/(her) defense mecha­nisms and object images”. When the therapist is aware of his/her own emotional reac­tion, this countertransference is actually instrumental into “bringing to his notice a psy­chological fact about the patient” for the feelings helps the therapist to detect the pres­ence of the client’s psychological games. Even though the countertransference feelings are neurotic, the therapist who is aware of this is able to react with understanding. For this understanding to be possible, Racker adds, the therapist has to first analyze and overcome his/her own situation and be able to identify him/herself with the patient’s ego. Within the therapeutic alliance and hour, the patient reenacts and recreates situa­tions that are recurrent in his/her daily situations. These undisclosed and undetected activities, is an unconscious means of avoiding the therapeutic process, and thus “prompted by a desire to retain a defensive organization and probably to recruit the ana­lyst into its personnel” (Britton, 2003, p. 77). In order for the impasse to be broken and the “enactments” to discontinue and therapeutic work can progress, Britton suggests that “until the enactment is recognized and described, the belief system that lies behind it cannot be disclosed, but, at the same time, until the patient’s beliefs that drive it are disclosed the enactment will continue” (Mawson, 2011, p. 4-15). 

Transference and countertransference is a phenomenon in the therapeutic alli­ance, Racker’s comment— quoted also in Britton (2003, p. 55)— highlights the attitude towards acceptance of this human condition and working with it’s existence in psycho­therapeutic relationship: “The neurotic (obsessive) ideal of objectivity leads to repres­sion and blocking of subjectivity and so to the myth of the … ‘analyst without anxiety or anger’ The other neurotic extreme is that of drowning in countertransference. True objectivity is based upon a form of internal division that enables the analyst to make himself (his own countertransference and subjectivity) the object of his continuous ob­servation and analysis” (Racker H. , 1968, p. 132). Objectivity, in many respects, is the priced commodity in psychotherapy. If the therapist is caught up in countertransference and is unaware of the fact, his/her endeavors to work with the clients in an objective manner would be unproductive. 

Objectivity as a concept itself needs some careful consideration. For this we can turn to Maturana & Varela (1980): “(O)bjective knowledge seems possible and through objective knowledge the universe appears systematic and predictable”. Objective knowledge, according to the authors, seems possible. It is prized for the very fact that it gives the impression of predictability. When things are systematic and predictable, we feel safe. The authors go on to explain: “Yet knowledge as an experience is something personal and private that cannot be transferred.” The explanation for this is that objec­tive knowledge must be created by the listener. The listener understands and the objec-tive knowledge appears to be transferred (p. 5). The therapist therefore needs to be aware of this phenomenon: that the information being shared between him/herself and the client is experienced and mentally processed by both parties. The reality is, howev­er, that the assumption that common understanding is achieved is only apparent. 

The benefit of keeping this in mind to the therapist is that he/she will be constant­ly on guard and self reflective of his role as observer. The therapist as an observer is part of the system (in this case the client) in which he/she is observing. Since he/she communicates with the client and the client communicates back, and the client is also the observer in return. “Anything said is said by an observer” (p. 8). The observer can­not but interact with the system; the observer is also observed. 

The observer, if self-reflective, is also able to observe him/herself. So in the ther­apeutic setting, the therapist has the work of observing two individuals: the client and himself. What is achieved is a hermeneutic and cyclical process of understanding. This is discussed later in the paper. Maturana & Varela explains this as such: “If an organism can generate a communicative description and then interact with its own state of activity that represents this description, generating another such description that orients towards this representation…, the process can in principle be carried on in a potentially infinite recursive manner” (p. 29). 

This back-forth movement of allowing experiences (via emotions) to occur and then stepping away from the self in acknowledgment and understanding of what has arisen. This acknowledgment of “what-is” happening at the moment describes what Gestalt therapy literature describes as the paradoxical theory of change (Beisser, 1970), whereby healing change happens not by forcefully eliciting change itself (in this case, by repression or ignorance), but by understanding and acknowledging what is happen­ing to the self at the moment. Through assimilation of the situation, in the case of a countertransference effect encountered by the therapist, the therapist is able to under­stand what is going on in him/her. The clarity of this self awareness and acceptance empowers the therapist to overcome and make informed choices. Self-awareness has much to do with being in contact with the self, existentially, in the here-and-now. This is a phenomenological attitude in observing what-is in the present in contact with the client, while being conscious of one’s own biases. 

With the awareness of the self as observer, there will also be an awareness that the other person is different; the other person actually processes his/her own objective knowledge. We will be able to appreciate that there is room for questioning and discuss­ing the ‘facts’ and ‘truisms’, and to investigate the differences between the self and the other. Resnick (2016) tells us that it is the differences between two individuals that ini­tiate the contact. Without awareness and acceptance of these differences—as often hap­pens when people operate in confluent relationships— there is no sense of the other person for who he/she is. Confluent relationships result in the feeling of loneliness in the presence of others, because there is a push for consensus and the authentic presence of persons are thereby not felt. In therapy, this kind of relationship happens when client tries to please therapist and therapist tries to help client. Both try to find compliancy without first looking at the differences. The result is often an alliance without real con­tact.

References

Beisser, A. (1970). The paradoxical theory of change. In Gestalt therapy now (pp. 77-80). https://static1.squarespace.com/static/572d003b40261d2ef97e5b0b/t/59d64989bce1767a9d98ebbb/1507215754788/G+Paradoxical+Theory+of+Change.pdf

Britton, R. (2003). Sex, death, and the superego: Experiences in psychoanalysis. Karnac Books.

Freud, S. (1909). Letter to Jung. The Freud-Jung Letters. Princeton University Press.

Heimann, P. (1950). On counter-transference. The International Journal of Psychoanalysis.

Maturana, H. R., & Varela, F. J. (1980). Autopoiesis and cognition: The realization of the living. London, England: D. Reidel Publishing.

Mawson, C. (2011). Introduction: Bion today—Thinking in the field. In Bion Today.

Racker, H. (1968). Transference and Countertransference . London: Karnac.

Reich, W. (1945/1984). Character Analysis (3rd ed.). (M. H. Raphael, Ed., & V. R. Carfagno, Trans.) NY: Farrar, Straus and Girouy.

Resnick, R. (2016). New Contemporary Gestalt Therapy Demonstration Films. Vimeo.

Breuer & Freud’s pioneering concept of the psychotherapeutic alliance

Psychotherapy in practice differs from many other areas of medicine, particularly with regard to the patient-therapist relationship.

It has been observed that Breuer’s work documented by Freud paved the way for the less authoritarian attitude of the doctor who knows everything and opened the door to a different kind of therapeutic relationship (Bocian & Staemmler, 2013; Grubrich-Simitis, 1997). Freud wrote in the early days of psychoanalysis of his revered mentor, Jean-Martin Charcot, whose research on Hysteria and its treatment method of hypnosis greatly influenced Freud as a young practitioner, “Charcot, however, did not follow this path towards an explanation of hysteria […].” (Freud & Breuer, 1893). The work of Charcot, notwithstanding, greatly influenced Freud’s transition from neurology to psychopathology (Grubrich-Simitis, 1997, p. 12- 13). Freud acknowledges the contribution of Charcot’s work towards bringing to scientific importance the study of Hysteria, that in having successfully inducing hysterical paralyses in hypnotized patients, Charcot proved that the hysterical paralyses were “the result of ideas which had dominated the patient’s brain at moments of a special disposition” (ibid. p. 13).

Freud’s own studies on Hysteria with Breuer, however, demonstrated the importance of a change in the approach towards the therapeutic relationship in the development of the understanding and healing of a psychological condition. When Freud met Breuer, who became his friend and mentor, Breuer was already in his fifties and was a reputed medical practitioner and experimental physiologist. Breuer had already worked with Bertha Pappenheim, better known as Anna O., in 1880 to 1882, some 3 years before Freud went to study with Charcot. Studies of Hysteria (Breuer & Freud, 1955) were written in 1895, 15 years after the said therapy, and the client by then was known to have been cured of her symptoms. Breuer had, together with his patient— who suffered severe hysterical symptoms and who is often regarded as “highly gifted, and the true discoverer of therapeutic reconstruction”— uncovered the dynamics of mental pathology. Unlike the Charcot school, Breuer used hypnosis “not for the purposes of crude behavioural suggestion but as a route to the memories of pathogenic traumatic experiences that were not accessible to the patient in the waking state” (ibid. p. 21).

Relying on the doctor to carry out treatment while the client remains the passive recipient with the goal of attaining catharsis through hypnotic suggestions, Freud exerts, may not amount to a cure, but a suggestion of a cure. In the case of Breuer’s work with Ms. Pappenheim – in listening with interest to her narratives—the therapist and client were able to investigate the actual events in the client’s life that precipitated the neurotic outcome; this is more than just the knowledge of the existence of psychic disturbance, as Charcot describes it, that is behind the symptoms and desensitizing through hypnotic suggestion. This step of gaining a clear understanding required much more effort, attention and empathy on the part of the practitioner (Freud & Breuer, 1893). Early expert critiques of the Studies of Hysteria reflected Freud’s sentiment of his own work, “[…] it still strikes me myself as strange that the case histories I write should read like short stories and that, as one might say, they lack the serious stamp of science. I must console myself with the reflection that the nature of the subject is evidently responsible for this, rather than any preference of my own (Freud & Breuer, 1895)” (Grubrich-Simitis, 1997, p. 19). With this admittance, we are led to the understanding that procuring a cure requires the abandonment of impersonal scientific learning, but an engagement with the client on a personal level that is different from the conventional attitude of that time, whereby treatment is based on empirical proofs (i.e. what is considered “stamp of science”).

[…] it still strikes me myself as strange that the case histories I write should read like short stories and that, as one might say, they lack the serious stamp of science. I must console myself with the reflection that the nature of the subject is evidently responsible for this, rather than any preference of my own.

Sigmund Freud in Freud & Breuer, 1895

Here we get a glimpse of Freud’s dilemma. He had found a good healing technique, but alas, it did not seem to conform to certain scientific procedures. It is also added that he who “wishes to plumb and describe the mental cannot completely escape the creative writer’s methods of conceiving and describing, however rigorous the will to cool, sober objectivity” (Grubrich-Simitis, 1997, p. 19-20). In many ways, we still find ourselves in a similar situation today, in our discourse on Psychotherapy Science.

That which is more worthwhile to learn from the case of Anna O. is, however, not found in Breuer’s account alone, but that the “psychodrama that took place in Breuer’s treatment, (…), gave Freud raw material for his theories of the Oedipus complex, identification, transference and countertransference, repetition compulsion and acting out (Britton, 2003, p. 8). As if to prove the significance of this first case, Freud (1914) himself reviewed this case 20 years later, pointing out to us to this unique— and often ethically treacherous— aspect of the psychotherapeutic alliance. The word “treachery” is carefully used to emphasize the fact that the danger is insidious and that special attention is necessary to notice and avoid its consequences. In order to investigate a treacherous situation in a relationship, however, we need to understand what lies in it.

References

Bocian, B., & Staemmler, F. M. (2013). Kontakt als erste Wirklichkeit. Zum Verhältnis von Gestalttherapie und Psychoanalyse. EHP-Verlag Andreas Kohlhage.

Breuer, J., & Freud, S. (1955). Fräulein Anna O, Case Histories from Studies on Hysteria. In V. I.-1. In The Standard Edition of the Complete Psychological Works of Sigmund Freud.

Britton, R. (2003). Sex, death, and the superego: Experiences in psychoanalysis. Karnac Books.

Chew-Helbig, N. (2017). The Psychotherapeutic Alliance and Change: A discussion on the healing aspects in a psychotherapeutic relationship. Bachelor Thesis.

Click to access Helbig_2017_Bachelor_Thesis-nh-s-p.pdf

Clarkson, P. (2003). The Therapeutic Relationship. London: Whurr Publishers.

Grubrich-Simitis, I. (1997). Early Freud and late Freud. Reading a new studies on hysteria and Moses and monotheism. (P. Slotkin, Trans.) NY: Routledge.

Power Differences in the Psychotherapeutic Alliance

Although there are different nuances within different psychotherapeutic approaches, the difference in attitude towards the client-therapist power difference can be divided into two very broad groups— symmetric and asymmetric following terminology used in Altemeyer (2013):

  1. The symmetric aspects of the relationship: In what is considered the humanistic approaches to psychotherapy, the therapist’s work is to be there as a companion to the client, to work with the client in partnership sans analyzing, judgment and oftentimes “helping”, but instead providing unconditional positive regard towards the client. For this to be achieved, there must exist a coming together of\ two authentic individuals as in Carl Roger’s person-centred psychotherapy approach that is “contact-building and acknowledging quality and empathy— without any techniques, means aims or intentions” (Schmid, 2001, p. 1).
  2. The asymmetric aspects of the relationship: Within psychiatry, and some archaic versions of the psychoanalytic/psychodynamic schools, the therapist is often expected to be the one more empowered to help the client, as a medical doctor would with his/her patient, providing analysis and nurturance, working on the interpretation of transference or dreams and the therapist’s countertransference reactions, and being a guiding figure to the client (Scharf, 2016, p. 50-55). Similarly, in behavioral & cognitive therapies, the client relies on the therapist for instructions, to set agendas, to give structure to the therapy and provide assistance for forming new experiences

Both standpoints are necessary for therapy to work. The therapist is a trained professional and has the theory behind them as tool to help the client through difficulties. Hence the therapist is the doctor and authority – and hence professional authority— with regard to psychotherapy. Concurrently, the healing process brought about through psychotherapy comes from the empathic alliance that the therapist builds into the relationship.

How then, if all approaches are viable, do we resolve these seemingly conflictual ideas of the nature of the psychotherapeutic alliance?

We can get an answer by referring back to the five-relational Clarkson framework, we may see that the asymmetric aspect or the relationship actually belongs to the first three parts of the therapeutic relationship: the working alliance (point 1), the transferential/ countertransferential relationship (point 2), and the reparative/developmentally needed relationship (point 3). The therapist’s role in these aspects of the relationship is clearly defined, and the switching of roles between therapist and client in this regard is inconceivable. The psychotherapeutic relationship must remain, on this level, an asymmetric one since the therapist has the defined role of the one who nurtures, helps the client with analysis and is the one being paid to do the job. The therapist takes on an egalitarian stance when he/she gives attention to the mutual relationship and helps the client to experience his therapeutic observations.

In the relational approaches of psychotherapy, however, the therapist helps the client to focus on the here-and-now and actively reduces the power inclination within the relationship; this with the intent to engage with the client on a more emotional and experiential level (Altemeyer, 2013). From this vantage point, we can see that the fourth and fifth aspect of the alliance— the person-to-person relationship (point 4) and the transpersonal relationship (point 5)— comes into play. With this understanding, we may be able to appreciate how and why all modalities of psychotherapy schools work: because each of the 5 levels of the alliance is (albeit in different measures and emphases) present in the relationships. We may be able to also understand why psychotherapeutic approaches over time evolve from analytical to relational and vice versa. Approaches evolve because therapists, through their experience working with their clients, have realized the need to modify their attitudes dynamically towards the therapeutic alliance in order to be effective in helping their clients.

The symmetric aspect of the relationship is important to consider– i.e. the person-to-person aspect (point no.4) and the transpersonal relationship (point no.5)— and to show that this symmetric therapist-client relationship is unique to psychotherapy and different from other healing or counselling professions. In most schools of psychotherapy, we are expected to reach into the intersubjective aspect of the relationship, which will be explained in this paper (Chew-Helbig, 2019) as the implicit material (i.e. what is between the lines and not necessarily said), whereas in counselling the focus is on the explicit material (i.e. what is being openly discussed). The symmetric aspect of the relationship is the part of the alliance that brings about enduring change in psychotherapy.

Read in this post about this part of the alliance that is actually the foundation of Freud’s work— that which Freud, through Breuer, discovered and proved to be the way to actually cure what is actually a psychosomatic condition known as Hysteria. Further discussions will move deeper into the whys and hows of what this unique aspect of the relationship actually does to alleviate the patient’s symptoms.

Click to access Helbig_2017_Bachelor_Thesis-nh-s-p.pdf

References

Altemeyer, M. (2013). Die Wiederentdeckung der Beziehung: Ein Paradigmenwechsel im Psychoanalyitschen Gegenwartsdiskurs. In B. Bocian, & F.-M. Staemmler (Eds.), Kontakt als erste Wirklichkeit. Zum Verhältnis von Gestalttherapie und Psychoanalyse (Kindle ed.).

Chew-Helbig, N. (2017). The Psychotherapeutic Alliance and Change: A discussion on the healing aspects in a psychotherapeutic relationship. Bachelor Thesis.

Chew-Helbig, N. Analyzing a Gestalt Psychotherapy Session Using the Helbig Method of Dialogue Analysis (HELDA). URL: https://nikhelbig.at/wp-content/uploads/2019/05/NICOLE-HELBIG-PRINTING-copy.pdf

Clarkson, P. (2003). The Therapeutic Relationship. London: Whurr Publishers.

Scharf, R. (2016). Theories of psychotherapy and Counseling. Concepts and cases. (6th Edition ed.). MA, USA: Cengage Learning.

Schmid, P. F. (2001). Comprehension: the art of not-knowing. Dialogical and ethical perspectives on empathy as dialogue in personal and person-centred relationships. Empathy, 53-71.

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