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. 25 26. References Aron, L. (1991). The patients experience of the analysts subjectivity. Psychoanalytic Dialogues, 1, 29- 51. Bollas, C. (1989). Forces of Destiny: Psychoanalysis and human idiom. London: Free Association Books. Chodorow, N. (1989). Feminism and psychoanalytic theory. 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