Monday, 25 November 2013

Review of Jon Frederickson's 'Co-Creating Change: Effective Dynamic Therapy Techniques'

(Draft of review - European Journal of Psychotherapy and Counselling, Vol 16, Iss 1, January 2014, pages 90-93.)

Jon Frederickson

With this book Jon Frederickson provides the most comprehensive, useful, and best-written overview yet of the techniques of Intensive Short-Term Dynamic Psychotherapy (ISTDP). The work is organised into three sections. The first outlines the therapy model and considers how to establish an effective therapeutic focus and procedure. The second allays anxieties that ISTDP can be too intensive with four chapters on building capacity in fragile patients. The third discusses how to help those (highly resistant) patients most in need of the intensive methods on offer.

Whilst his model is largely faithful to Davanloo’s ISTDP, we nevertheless hear a lot of Frederickson’s distinctive voice throughout, perhaps best epitomised in his highly active, firm, compassionate yet pleasingly cheeky blocking of his patients’ tactical and projecting defenses. (‘You thought the hospital was persecuting you, but... [it’s] Your self-persecution and self-attack [that’s] making you feel worse. The bad news is this: you are hurting yourself. The good news is that, since you are the one doing it, it could be entirely under your control.’ (p. 326)). A nutshell version of Frederickson’s vision of psychopathology might be: Feelings are the fundamental way we understand the world (ch.1). But feelings can give rise to painful anxiety when their expression is felt to threaten an essential attachment relationship (ch. 2). We therefore automatically and unconsciously deploy defences, keeping inner and outer reality at bay, but then lose our ability to make sense of the world and act freely and adaptively (ch. 3). The therapist’s job is to build tolerance for, attention to, and causal understanding of, feeling and anxiety (ch. 5), and to do this by facilitating a careful focus on the visceral experience of and impulses associated with feelings. The defences to be worked on include both those tactical strategies that keep the therapist (use of cover words, distancing, evasiveness, generalisation, undoing etc.), and the repressive defences that keep feelings, at bay (ch. 4).

For fragile patients – who use splitting, projection onto the therapist, etc. – Frederickson invites us to gradually build their anxiety-tolerance by repeatedly helping them achieve self-understanding, turn against their defences (ch. 8) and challenge backfiring (i.e. anxiogenic) defences (i.e. projection) by promoting reality testing (ch. 7). The patient’s agreement that it is their will to examine their feelings (ch. 6) facilitates the therapist’s job of holding them to the therapeutic task and challenging their resistance. For highly resistant patients he provides a panoply of techniques to defuse the projection of will, block attempts to keep the therapist out, and forcefully yet kindly undermine the patient’s superego pathology (ch. 11). In particular this involves questioning the patient’s identifications with judgemental part-objects which lead to character defences (self-judgement), transference resistance (judging others) and projection of superego (believing that you judge me) (ch. 11).

Here are some themes that I found exemplary and which capture something of Frederickson’s unique voice: i) His ongoing psychodiagnostic focus on the patient’s level of anxiety, enabling him to titrate the dose of therapeutic intervention so that anxiety is neither too low (‘anxiety is a good sign, signalling that unconscious feelings are rising’ (p. 21)) nor overwhelming (ch. 7). ii) His addressing character defenses / superego pathology by pointing out the function, the pathological nature of the self-relation, and the cost, of the associated behaviours (ch. 12). iii) His consistent identifying, clarifying, confronting and blocking of the patient’s defences (e.g. of self-attack or of projection) in the session (‘…defense interruption is an act of compassion toward the patient’ (p. 7)).

iv) The constant reintegrating and mobilising of the resistant patient’s will when they become helpless or project their will to change onto the therapist or when addressing transference (‘There is no law that says you have to reveal yourself to me. You have every right to maintain this wall, but then I will remain another useless person in your life’ (p. 103)). v) His powerful use of mirroring to deactivate projective character defenses, returning resistance to its individual intrapsychic origins and at the same time building the alliance (‘Pt: I’m not totally committed to the therapy. Th: Although [your emotional health] is your goal, you are letting me know you are not that committed to you. And the good news is you can be as committed or as uncommitted as you want to be to yourself.’ (p. 391)). vi) His reminder to not misguidedly do the patient’s work for them, depriving them of the opportunity to develop in their self-agency (‘Frustration in the therapist is often a sign of resistance in the patient’ (p. 440)).

Significant in ISTDP is its focus on repressed anger and guilt towards primary caregivers. Frederickson tells us (ch. 1) he will consider the significance of the range of emotions in psychopathology, but more than 95% of the cases considered involve suppressed anger as the psychopathological culprit. My own view is that this, along with Davanloo’s belief that not just anger but suppressed murderous rage and guilt are usually the real culprits (ch. 14), is psychopathologically unrealistic, but since this involves critique of ISTDP rather than of the book I shan’t develop it here. Another possibly restrictive aspect of the book is, despite its title talk of ‘co-creating change’, its total focus on active therapist-led defense deactivation, rather than on mutual connection or the positive provision of the right soil structure in which personalities can grow beyond their fixations.

The reviewer’s notes for this journal describe its audience as philosophically informed; here then are a few philosophical criticisms. First I fussily note Frederickson’s sometimes impoverished ontology, which appears to have room only for ‘objects’ and ‘concepts’. Several times he tells us that ‘Since the superego is a concept, it cannot act.’ (p. 357). However whilst it is not an object, and whilst we do indeed have a concept of ‘superego’ – and of ‘table’ and ‘agent’ – it is surely not itself a concept, but rather a psychological structure, which is to say, a coordinated set of emotional and behavioural dispositions.

Second I note his insistence that, e.g., ‘Defenses are our conditioning, not our essence.’ (396), or ‘The patient’s resistance is not a “part” of him. It is merely an automatic, habitual pattern of behaviour’ or ‘A defense has as little to do with a person’s being as a leech has to do with the leg it is sucking on’ (286). It is unclear what the logical status of such remarks is supposed to be. Are they intended as empirical facts? If so we might note that the concepts of our being or selfhood are not always thought of as exhausted by our existential freedom, basic feelings and non-habitual actions, but instead as including those diverse conditioned habits of behaviour that constitute character. Alternatively we might settle this by stipulation, i.e. simply rule that defences aren’t here to count as aspects of true character. In that case we should perhaps then also acknowledge that we are in the terrain of a particular psychodynamic value system, not simply reporting facts about psychological functioning.

A related issue, to do with fact versus construction, came up several times for me throughout the book and also from watching Frederickson’s teaching videos. Frederickson talks, say, of helping a patient tease apart their anxiety and their feelings, or defuse from their superegos, or experience real but buried murderous rage. But it wasn’t clear to me how to motivate a reading of the therapeutic techniques as uncovering pre-existing psychological structures or feelings over a reading which takes them to be creating new psychological structures or creating new and helpful (but perhaps not truthful) experiences (e.g. of murderous rage). He advises, for example, that it is useful to ‘Refer to a ‘critical mechanism in her mind’ ‘habit’ ‘thought pattern’… Some wonder if this may be a useful way to talk to the patient but an inaccurate description. I would suggest it is accurate.’ (p. 288). However no criteria are provided for adjudicating between realist and constructivist takes on this. A key feature of ISTDP is its use of imaginary ‘portrayal’ to facilitate access to buried rage. Frederickson quotes himself asking a patient ‘If that impulse went out on him, if you were out of control like a wild animal, how do you picture that impulse going out onto his body?’ (p. 446). My own feeling, for what it’s worth, is that this could be a leading question creating extravagant, rather than de-repressing buried, anger. Of course this may be a matter of me being too English, rather than of Frederickson creating hysteria. The real question, however, is whether Frederickson’s model has the conceptual and practical resources to make the distinction at the psychological level of explanation.

To end let me return to the myriad merits of the book. I am aware of no comparable work offering a real sense of how to embody intensive dynamic therapy. It not only details psychopathological understanding and therapeutic technique but, like the best kind of master class with its own compelling examples, brings both to life within the reader.