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

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The Film “Ordinary People”

• https://www.youtube.com/watch?v=F7SA5xLOoWo [minute 7:30 to end of clip]

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Can Anything Surprising or Unexpected Still Occur in Therapy?

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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.

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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.

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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.

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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).

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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.

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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).

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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).

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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.

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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).

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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.”

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Narrative Therapy

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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.

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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.

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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.

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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.

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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.”

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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.

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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.

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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.

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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).

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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.

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Depiction of the Integration of What Has Always Been

The Film “9 ½ Weeks”• https://www.youtube.com/watch?v=e9zctBOL

K_E

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Creating a Therapeutic Space for Discovery

• How, and under what conditions, does discovery occur in psychotherapy?

• “Therapeutic space” is seldom considered.

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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 thiscontext, is liberation via awareness of whatis (integration).

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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.

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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”).

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The Patient’s Capacity to Self-Observe

I propose that the main therapeutic task is to activate the patient’s

self- observing capacities, in order to set the stage for recognition.

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A Focus on Preparing the Patient’s Mind

• 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!

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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.

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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.

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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.

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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.

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Questions

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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.

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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.

James Tobin, Ph.D.Licensed Psychologist PSY 22074220 Newport Center Drive, Suite 1Newport Beach, CA 92660

Assistant Professor of Clinical PsychologyThe 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