Shirah Vollmer MD

The Musings of Dr. Vollmer

Therapeutic Actions

Posted by Dr. Vollmer on November 5, 2013

The never-ending question of how does psychotherapy work hinges on two answers. One group states that the new “relationship” is curative, as it creates a new template for expectations and love. The other group says that the relationship establishes a foundation in which understanding can grow, and through understanding of one’s past, one can move through a journey of relinquishing unconscious guilt and thereby make better decisions for future endeavors. Needless to say, both can be operative simultaneously, and also needless to say, neither can be proven with scientific inquiry. Further, it is not, nor has it ever been, one size fits all, where the therapeutic action for one patient is not the same therapeutic action for another. To continue on with our ignorance, we, as professionals, can also never state with certainty how we help people, but rather we are left to educated speculation, which is unsettling to all. What psychoanalysts agree upon, but which yet again is a guess, is that the search for unconscious thoughts, feelings and behaviors is the “royal road”. That this search, given that nothing is definite, involves a struggle, by both the therapist and the patient, is inherent in the work. Manual-based therapies, implying that only the patient struggles, is antithetical to our (psychoanalytic psychotherapists) understanding of therapeutic actions. Psychoanalytic literature speaks to an “intense” relationship, but I prefer to characterize the therapist/patient relationship as “deep and messy”.

Returning to the idea of an unconscious, one then separates out these notions into unconscious wishes and fantasies (which can be partly conscious and partly unconscious, at the same time), and unconscious defenses, such as over-eating, which again, can have both conscious and unconscious elements. There is also unconscious assumptions in every relationship, which Freud termed transference, where every connection is a re-visiting of old relationships. In other words, teachers, bosses, administrators, remind us of parental figures, and so we confuse past with present and thereby do not appreciate the nuances of new relationships. Searching for unconscious meaning is the “royal road” and yet some theoreticians argue that there should be no “road” as the journey is not linear, and so the notion of a path is too psychologically constricting. Bushwhacking captures psychotherapy, as there is no trail to follow.

Laney, fifty-one, came in with a dream this morning. “I went to bed thinking about the LAX shooting, and then I dreamed  that I was kidnapped at gunpoint. In my dream, I was thinking about the movie ‘Twelve Years A Slave’ even though I did not see it. I was wondering the airport looking to people, hoping that someone would see in my eyes that I was with a kidnapper. I then started to think about Elizabeth Smart. In my dream I was thinking about her-so weird.” She continues, “I was just so shaken by the LAX rampage that, in my dream, I kept experiencing terror and uncertainty. I thought I would never be free and I thought I would never see my family again. I woke up so frightened and ill-at ease. ” Now, if I were thinking ‘in the transference’ as some might say, then I would wonder aloud with Laney whether she felt that I did not “see” her. Perhaps her dream meant that there were deep misunderstandings between us, and as such, she could never enjoy her family, the way she hoped to, when she first started psychotherapy.

Yet, another route to helping Laney is to stay with her feelings and highlight how scared she is feeling right now, that she has no agency over her destiny; that her dream was a symbolic representation of how trapped she feels, in general, and that no one outside,  looking in, can see that. The technical question in my mind is to decide whether I should tie it to our connection, or I should help her understand herself, independent of how she feels with me. Child Psychoanalysts describe this latter technique as helping the patient label their feelings, in a similar way that a mother helps her child understand his affects. A child who has a tantrum who hears “I know you are angry and tired,” is going to  have deeper understanding of himself, than a child who hears “stop crying.” So, too, psychotherapy tries to help patients understand themselves through the adage, “name it to tame it.” Saying “I feel scared” can diminish the feeling of being scared, or so the theory goes. Fred Pine PhD says that the words “are translations of the inchoate, of the unspoken and unthinkable.” Words make stories, and stories make sense, of experiences, like Laney’s dream, which, on first inspection, felt weird, and hence incoherent. Giving coherency is another way of understanding therapeutic actions.

Perhaps there is a third path that I can take with Laney’s dream, at the risk of being “intellectually freighty,” as a colleague of mine, describes some of my posts. Maybe I need to show up for Laney by being on time, by listening carefully, and by providing her a safe arena in which to share her dream. Maybe, as Winnicott says, the “holding environment” of my office is enough to let Laney explore her own meanings, and that my job is to provide the soil, so she can determine her own growth-path. Franz Alexander MD called this the “corrective emotional experience,” providing a safe harbor, where there was none before. Yet, the safety in the relationship sounds good, but it is not always experienced, and so I cannot trust that Laney has that feeling in our work together. In other words, what I am assuming is therapeutic, may be experienced by Laney as uncaring, depriving, and withholding. There is a never-ending balance between support and challenge. Too much support gets boring and stuck, whereas too much challenge can cause the paralysis of overwhelming anxiety. I am reminded of a fictional patient, who after ten years of working together says, “I think I am ready to tell you the story about the clerk at the post office.” I chuckle out loud and say “you think you are ready?” highlighting both her hesitation and the ‘why now’ provocation.  Feeling supported, and preparing to be challenged is a dynamic, changing, field, and as such, one cannot easily pinpoint therapeutic action.

Perhaps, reliability is the therapeutic action, for some patients, with what Ernst Kris called “strain trauma.” A child who grows up with a consistently unreliable parent may be healed by the consistency and regularity of psychotherapy, independent of what goes on in the session. Even if the value of the predictability of psychotherapy is never discussed, one could argue that this new experience, helps the patient understand his need for structure, given the absence of it, as a child. This narrative may not have to take place for therapeutic action to happen. Feelings of loss and separation are layered over by feelings of rock-hard stability. Dr. Pine calls this the “non-specific effect” of psychotherapy.

“The capacity for surprise,” Dr. Pine says, is yet another therapeutic action, since it implies an openness to hearing new ideas, new experiences, and a fluidity of thought, where the patient’s words are not fitting into a theory, but are allowed to create a new experience in the therapist. The goal, Dr. Pine says, is to “draw on” but not be “controlled” by theories of the mind. This is a nuance of work which is hard to teach, as the message here is to tell therapists to see which idea “bubbles up” and then to use those bubbles to guide the work, as opposed to listening to how the patient’s word fit into a theory of the mind.

So, therapeutic action, like psychotherapy itself, is a series of dilemmas, a series of struggles for the psychotherapist to decide what, how and when to comment on the material, the relationship, or the connections to historical events. This deep and never-ending set of dilemmas, represents the love present in deep therapeutic work. So, to my mind, it is this “love” that is likely to be the summation of the therapeutic actions in psychotherapy. This “love” cannot be put into a manual (?manualized), as the lack of a map, is the key to its’ success.

2 Responses to “Therapeutic Actions”

  1. Shelly said

    Wow, this piece really is different for you. Usually you write in shorter blog format. You put one idea forth and give an example. In this piece you put out many different psychological ideas, then tie them up in the end. It is hard for me to know exactly where and how to comment. Two ideas came to me while reading it: First of all, in your description of Laney’s dream and her fears–what if anything made you think that any of it had to do with you? What gave you the impression that perhaps you didn’t “see her?” Of course, I know nothing about this fictional patient, but my gut reaction would tell me that her fears and her dream had nothing at all to do about your relationship but had to do with her feelings about her life. My second point has to do with the word “challenge” in psychotherapy. You “challenge” your patients when you feel they are ready. What if the therapist constantly challenges the patient and never ever supports them? Doesn’t this make the patient feel stressed, angered, feel blamed, small, shamed and humiliated? Would you call challenging the patient psychotherapy? I call this abuse.

  2. Ashana M said

    i’m inclined more to a third point of view, which is a bit more complex in the sense that I see it as several elements coming together One of these derives from assumption that the skills necessary for managing oneself and engaging in relationships are learned, and we mostly learn these skills by imitating other people. A therapist can explicitly teach some of these skills, but more than that, therapy provides an opportunity to see other skills being demonstrated as the therapist manages his or her own emotions and the relationship with the client. In addition, therapy also an opportunity to practice these skills, including one the client may know but not have much opportunity to safely use, which is actually just using language to make sense of emotions and experiences. In addition, therapy can provide a space where the client can construct a more coherent world-view that accommodates important life events, including traumatic ones, but this doesn’t always happen and it probably needn’t. Creating a coherent world view does need to happen, but it doesn’t need to happen in therapy. This view is not entirely different from your view. For example, labeling feelings is one of those self-management skills. But people who don’t think much about themselves seem to cope just fine with their lives and are about as content with themselves as the rest of us, so I don’t think labeling feelings is especially important because it provides a deeper understanding of oneself, but simply because it’s a skill that seems to be useful in regulating emotions–it engages your systematic, effortful processing system and gets it working on a solution, which shifts your attention away from the problem and towards an appropriate response. Without that, your attention tends to stay focused on the problem, as if your own mind still needs to get the message that there’s a problem to pay attention to.

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