The Anatomy of Discovery in Psychotherapy: "Something So Familiar, It is Strange"

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In this talk, presented at the Western Psychological Association Annual Convention in April, 2014, Dr. Tobin cautions that the current environment of empirically-based treatment may foreclose on the discovery process psychotherapy affords. According to Dr. Tobin, psychotherapy is most successful when the patient's self-observing capacities are supported by the therapist. If the therapist can avoid narcissistic ambitions and instrumental fictions employed to understand the patient prematurely, the conditions may allow for the patient to connect with dissociated memories, cognitions, and affects. Dr. Tobin utilizes movie clips from the feature films "Ordinary People" and "9 1/2 Weeks" to illustrate his perspective.

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The Anatomy of Discovery in Psychotherapy: "Something So Familiar, It is Strange"

  1. 1. The Western Psychological Association Annual Convention April 25, 2014 The Anatomy of Discovery in Psychotherapy: “Something So Familiar, It Is Strange” James Tobin, Ph.D. Assistant Professor of Clinical Psychology
  2. 2. The Film “Ordinary People” • https://www.youtube.com/watch?v=F7SA5xL OoWo [minute 7:30 to end of clip] 2
  3. 3. Can Anything Surprising or Unexpected Still Occur in Therapy? 3
  4. 4. Evidence-based Practice • An unfortunate consequence of APA’s endorsement of empirically-based treatment approaches (APA, 2006) has been the undeniable “medicalization” of the psychotherapy. 4
  5. 5. Evidence-based Practice • The therapist’s consulting room has been transformed into a rather sterile forum in which the clinician unfurls a series of evidence-based, health-producing interventions targeting the patient’s problems. 5
  6. 6. Evidence-based Practice • Clinical psychology training curricula are structured around evidence-based practice (EBP), which may lead to a regimented, one- size-fits-all approach to clinical practice. 6
  7. 7. The Relational/Interpersonal Movement • Postmodern constructivism gone awry? I would argue that an almost radical focus on CT and enactment has resulted in therapists’ “use of self” leading them to be dogmatic and self-preoccupied (not focused on the patient). 7
  8. 8. The Clinician’s Need to Know • In Between Conviction and Uncertainty: Philosophical Guidelines for Practicing Psychotherapists, Downing (2000) argues that the clinician is guided by a personal epistemology, an organizing schema that serves as a heuristic for understanding patients. 8
  9. 9. The Clinician’s Need to Know • In his review of Downing’s book, Kose (2003) called these heuristics “instrumental fictions,” [which are] “motivated by the conviction or desire to know the truth and provide useful illusions that allow us to work toward the fulfillment of that desire” (my italics, p. 214). 9
  10. 10. The Narcissism of the Clinician • There is also a narcissistic need on the part of the therapist to be helpful, knowledgeable, and capable. • Therapists-in-training are burdened with enormous expectations, many of which are misguided (see Misch’s 2000 paper “Great Expectations: Mistaken Beliefs of Beginning Psychodynamic Psychotherapists”), and many of which come from unresolved historical issues re: treating/healing a pathological caregiving figure (Miller, 1997). 10
  11. 11. The Static Nature of the Consulting Room • So the therapist is oriented toward symptom reduction, being helpful/smart/capable, and personal knowledge schemas; the patient is also oriented toward a rigidity that obstructs something new being discovered. 11
  12. 12. The Patient’s Rigid Narrative • Research and anecdotal evidence suggest that patients typically enter therapy with firm beliefs about themselves, others, and themselves in relation to others (preferred ways of thinking/acting/feeling that are often quite rigid). 12
  13. 13. The Patient’s Rigid Narrative Schema Narrative The common occurrence of a new patient in a first session who says, “My upbringing and family were totally normal.” 13
  14. 14. Narrative Therapy 14
  15. 15. Therapy as Arm-Wrestling • Given these circumstances, it is not surprising that entire therapies can be characterized by the patient and therapist arm-wrestling about whose certainty is more accurate, or, instead, a lack of engagement on the part of the patient. 15
  16. 16. The Patient’s Compliance • These issues often result in the patient merely complying or accommodating (either consciously or unconsciously) to the therapist’s preferences. • This is often defensive on the part of the patient, particularly if there has been significant impingements in the patient’s developmental history. 16
  17. 17. The Alternative: A View of Psychotherapy as Promoting Discovery • In my view, psychotherapy is a medium that makes it possible for the patient to self- observe, explore his/her life experience, and potentially DISCOVER something. 17
  18. 18. Promoting Discovery • Discovery involves the patient’s recognizing something about him- or herself not seen before through the preparation of the patient’s own mind. • The relational aspects of the therapeutic situation prepare the patient for this work, but the therapist’s efforts/brilliance does not constitute the patient’s discovery. 18
  19. 19. Stern • Donnel B. Stern (1997) has broached the issue of discovery in psychotherapy from a relational perspective, illuminating how the therapeutic dyad may arrive at the shore of “unformulated experience.” 19
  20. 20. Stern • In his two important works ,“Unformulated Experience: From Dissociation to Imagination in Psychoanalysis” (1997) and “Partners in Thought: Working with Unformulated Experience, Dissociation, and Enactment” (2009), Stern describes his view of the mutually co-created discovery process in psychotherapy and psychoanalysis. 20
  21. 21. Stern • I don’t view the discovery process as being mutually co-created but, rather, as an occurrence within the patient that the therapist is largely a spectator to – the discovery is a product of the patient’s mind and the setting the therapist has created. • It has very little to do with constructs like countertransference, enactment, use of the self, etc. that dominate the current environment. 21
  22. 22. Discovery Not as Aha!, but as Recognition • I emphasize recognition, not learning or understanding, in my conceptualization of discovery. • Discovery is visceral, not intellectual or academic. 22
  23. 23. Discovery as Recognition • The therapeutic process is a slowly evolving, gradual endeavor in which the patient’s characteristic ways of thinking/acting/feeling emerge, are contacted, and are examined. • As close examination proceeds in sessions, there naturally arises an integration of elements of the patient’s personal identity that was not available before (something is recognized – it is a kind of binding together of disconnected parts). 23
  24. 24. Integration as the Key to Mental Life • What is recognized is not something new, but what has always been (“dissociation”); what has always been finally becomes integrated (moved into conscious awareness). • In this perspective, there is no interpretation, idea, etc. offered by the therapist to the patient that hastens the discovery process; if anything, the therapist’s ideas get in the way of discovery. 24
  25. 25. Depiction of the Integration of What Has Always Been The Film “9 ½ Weeks” • https://www.youtube.com/watch?v=e9zctBOL K_E 25
  26. 26. Creating a Therapeutic Space for Discovery • How, and under what conditions, does discovery occur in psychotherapy? • “Therapeutic space” is seldom considered. 26
  27. 27. Discovery as Awareness of What Is • The main assumption is that the patient is thinking/acting/feeling in ways that are out of his/her own awareness, and, as such, the patient is not liberated. • Therapeutic cure, in this context, is liberation via awareness of what is (integration). 27
  28. 28. The Clinician’s Therapeutic Function • The therapeutic function has more to do with setting the stage/promoting the patient’s capacity to “connect” with what the patient has not seen or recognized about him- or herself. 28
  29. 29. Ambiance • It is not a battle of certainties or agendas, but establishing a therapeutic ambiance which allows the patient to ultimately self-observe what has always been known, but never recognized (the “something so familiar, it is strange”). 29
  30. 30. The Patient’s Capacity to Self-Observe 30 I propose that the main therapeutic task is to activate the patient’s self- observing capacities, in order to set the stage for recognition.
  31. 31. A Focus on Preparing the Patient’s Mind 31 • This involves a different type of activity than what most therapists have been trained to execute: it involves potentiating the patient’s mind, not acting on the patient. • The therapist mainly focuses on observing what he/she recognizes about the patient, in order to stimulate the patient’s self- observing capacities. AND THAT’S ALL!
  32. 32. The Abandonment of Meaning-Making • The therapist consistently attempts to examine the patient’s beliefs and convictions, yet does not arm wrestle the patient with his/her own or throw the patient into a position of defensive compliance. • In fact, all meaning-making is distracting from a focus on the patient’s capacity to self- observe. 32
  33. 33. Foregoing the Clinician’s Narcissism • What is satisfying narcissistically for the majority of therapists must be relinquished; instead, the therapist needs to focus on setting up the conditions in which the patient can most effectively work and helping the patient do the work. 33
  34. 34. Conclusion • The therapist’s attention: (1) observing what one notices about the patient; (2) catching when and how the therapist obstructs the conditions of the therapeutic space. These two activities should be the focus of supervision. 34
  35. 35. Conclusion • I rely on the capacity of the space itself to engender the patient with an ability to use it, and, consequently, his/her own mind long after therapy has ended. • To me, this seems more to the core of what actually happens in “successful” treatments. 35
  36. 36. Questions 36
  37. 37. References • APA Presidential Task Force on Evidence-Based Practice (2006). Evidence-based practice in psychology. America Psychologist, 61, 271-285. • Downing, J. N. (2000). Beyond conviction and uncertainty: Philosophical guidelines for practicing psychotherapists. Albany: State University of New York. • Duncan, B.L. (2010). On becoming a better therapist. Washington, D.C.: American Psychological Association. • Fisher, J.E., & O’Donohue, W. (2010). The practitioner’s guide to evidence-based psychotherapy. New York, NY: Springer Science+Business Media, LLC. • Goodheart, C.D., Kazdin, A.E., & Sternberg, R.J. (2006). Evidence- based psychotherapy: Where practice and research meet. Washington, D.C.: American Psychological Association. 37
  38. 38. References • Kose, G. (2003). Book review [Review of the book Between conviction and uncertainty: Philosophical guidelines for practicing psychotherapists, by J. N. Downing]. Journal of Psychotherapy Integration, 13, 211-215. • Miller, A. (1997). The drama of the gifted child. The search for the true self. New York: Basic Books. • Misch, D.A. (2000). Great expectations: Mistaken beliefs of beginning psychodynamic psychotherapists. American Journal of Psychotherapy, 54, 172-203. • Stern, D. (1997). Unformulated experience: From dissociation to imagination in psychoanalysis. Hillsdale, N.J.: Analytic Press. • Stern, D. (2009). Partners in thought: Working with unformulated experience, dissociation, and enactment. New York: Routledge. 38
  39. 39. James Tobin, Ph.D. Licensed Psychologist PSY 22074 220 Newport Center Drive, Suite 1 Newport Beach, CA 92660 Assistant Professor of Clinical Psychology The American School of Professional Psychology at Argosy University | Southern California Orange, CA 92868 Email: jt@jamestobinphd.com Website: www.jamestobinphd.com Phone: 949-338-4388

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