Saturday, 13 August 2016

the case of m

Aaron T Beck
When recounting the history of his clinical disillusion with psychoanalysis Beck describes the reactions of two patients. One - the women who generously regaled him with stories about her sex life but whose transference was yet latently dominated by worries of being boring - I've written about before. But the story of the other patient - M - in 1956 - is perhaps less well known. (It gets told in Aaron T Beck. 1993. Cognitive Therapy of Depression: A Personal Reflection. Aberdeen: Scottish Cultural Press.) It seems to me that, despite it forming a lynchpin of Beck's turning away from psychoanalysis, it really cries out for  psychoanalytic treatment. To pre-empt my conclusion, I shall argue here that what Beck was really reacting to was a clumsy form of ego psychology; that cognitive therapy was a better bet in theory and practice than the (ego-psychological) form of psychoanalysis he was trained in; but that a version of psychoanalysis which pays proper attention to the complexity of unintegrated internal object relations is a better bet still. Further, that whilst the task of psychotherapy is integration, there are aspects of Beck's theorising of the mind which work against this. (I know it must seem like I'm trying to give this guy a hard time! But, really, it's not that - I suspect he was a much better and more creative psychotherapist than many of his analytic colleagues, and I value the pragmatism of his approach. It's just that I feel he also did psychotherapy a disservice when he threw the object-relational baby out with the ego-psychological bathwater.)

m

M was a depressed male patient in psychoanalysis who according to Beck followed the fundamental rule - 'of reporting everything that came to his mind. He had learned not to censor thoughts that he was concerned about and not to leave anything out.' M spends much of a session angrily criticising Beck. 'After a pause, I asked him, going according to the book, what he was feeling. He repeated he felt guilty.' Beck surmises that M 'was feeling angry, he expressed anger, and the anger itself evoked the affect of guilt. That is, hostility led directly without any intermediary variables to guilt – one emotion to another.' 'But then the patient surprised me with an observation... that the whole time while he was criticizing me, he was generally aware of another [un-expressed] stream of thoughts such as, “I said the wrong thing … I should not have said that … I’m wrong to criticize him. I’m bad… I have no excuse for being so mean.”'

Beck remarks several times on how surprised he was by the fact that his patient was, in effect, not actually following the fundamental rule. 'This incident constituted my first surprise and also presented me with an anomaly. If the patient was actually reporting everything that came to mind, how could he have experienced a conscious flow of associations and not report it? Further, how could two streams of thought [one conscious, the other preconscious - consisting of what Beck called 'automatic thoughts'] occur simultaneously?'

To conclude, Beck formulates that 'M’s self-critical thoughts were an intermediate variable between his angry expressions and his guilty feelings. The angry feelings did not directly activate guilty feelings but led to self-critical thoughts. ... This notion was contrary to my erstwhile understanding of the psychoanalytic dictum that anger leads directly to guilty feelings. Later, I was to discover that self-critical thoughts could lead to guilty feelings/sadness without there being any preceding anger.'

About this I offer three considerations:

the fundamental rule

There is one rather peculiar feature to Beck's description of the fundamental rule and free association. That is, he tells us that the patient was following it... but also that he wasn't following it. We now know the story: the thoughts the patient struggles to attend to are preconscious and are 'automatic'. According to Beck the difficulty in attention to them comes from the fact that they are fleeting, are on the fringe of consciousness, and that patients are not accustomed to verbalise them.

Well, yes, but... But psychoanalysis has always had a story to tell about why this is. Which is that the patient struggles to attend to such thoughts, or even to allow them to develop into fully fledged conscious thoughts, because they cause anxiety. The ignoring of them is not accidental but rather motivated - by the avoidance of anxiety, shame, guilt, awkwardness, etc.

I return below as to why M would be defended against such anxiogenic thoughts.

intervening variables

Beck tells us that in his opinion M's self-critical thoughts were an 'intermediate variable between his angry expressions and his guilty feelings' and that this was 'contrary to my erstwhile understanding of the psychoanalytic dictum that anger leads directly to guilty feelings'. 

First off, I think we can be confident that Beck didn't believe that anger led to guilty feelings for no reason. It is obvious why someone feels guilty on getting angry: they either realistically or neurotically take themselves to be unreasonable in this. I think we can also be confident that no psychoanalyst has ever thought that hostile feelings lead to guilt feelings for no meaningful reason, but just as a brute reflex.

Michael McEachrane
Second, isn't it just such takings that are given expression in the second stream of thoughts Beck describes? Here we need to remember to distinguish two senses of 'thought' - one is akin to 'belief', another to 'occurrent cogitation'. When someone says 'I think that...' they are probably reporting a belief - i.e. something with a primarily dispositional character; when they say 'I was just inwardly rehearsing what I'd say if...' they are talking of a more Jamesian stream of consciousness. (Michael McEachrane does a super job of showing how these two senses get conflated in CBT to the detriment of the theory.) Here it is surely M's belief that he has traduced Beck that is being expressed in M's semi-conscious inner chatter.

Yet whilst we do well to distinguish two senses of thought, we don't ordinarily do so well, I believe, to distinguish thoughts and feelings. If we take thoughts as merely bits of inner verbiage, and feelings as akin to sensations without any intrinsic intentional content, then we can push ourselves into thinking of them as needing bolstering from one another to make viable contributions to our inner life. But there's no need to take them in such reductive ways. M actually feels bad about his hostile treatment of Beck. There is a unity to this feeling. Defence mechanisms may sever the unity; they need no further help in doing this from a phenomenologically misguided cognitive theory.

internal object relations

What struck me the most on reading Beck's description of M was M's difficulty in managing ambivalence and how this difficulty relates to the structure and task of an analytic session. On the one hand M was angry with Beck (we don't know why); on the other he felt guilty about this. But up till this point in the session he didn't admit (to Beck certainly, but perhaps also to himself) that he felt the guilt. The fundamental rule, I surmise, gave him a novel kind of 'permission' to voice all his angry feelings - that, after all, is 'being a good analytic patient'. But actually he doesn't manage to be a 'good patient' - not because he has been angry, but because he has not also confessed to his guilty feelings. M's mind is not integrated. He can either have one or the other. If both come together - that's when he'd feel too anxious, and, I suggest a la analytic theory, defend against the anxiety by splitting into either his guilty or his angry self.

When M is out in the world, busy being depressed, we may imagine that often he is just aware of the guilt. When he is in the clinic, busy telling Beck with impunity just what he thinks of him, then he will just be aware of the anger. Neither are very helpful by themselves. What is required is integration. Let's assume for the sake of the discussion that Beck didn't really deserve M's anger. (It seems a reasonable assumption!) So now what we are arriving at is an understanding that M perhaps has some natural narcissistic difficulties (i.e. he struggles with not having his 'infantile' needs met in the way he feels entitled to), and that hitherto the only response to the anger that he feels has been an unsympathetic self-berating. 

M has, as yet, nowhere to turn. The situation is familiar to all of us on either side of the couch. He can either identify with his anger, and cut off from his guilt. This is all very well but hardly makes for being an integrated individual. (We all know the kind of spoiled unpersonable scold who is made for by the kind of pseudo-therapy which urges such an affective exchange.) Or he can identify with his guilt and cut off from his anger. Which is also all very well but is a surefire recipe for being a uncongenial depressive miserabilist. (The extreme Calvinist solution, perhaps.) These different positions are characteristically embodied in different internal object relations - either I cow-tow before a nasty superego or I become an all-id sociopath. The significance of the talk of complex object relations here is that we acknowledge the different uncomplementary positions which M is forced into and the relations between these in his psyche which make for associations either of the one stream or of another (which is different than saying simply that some of M's thoughts are best understood as conscious and some as subconscious, and that M just needs attentional training to report the latter), and the need for him to cultivate more benign relations (which means the same as 'integration') between these intrapsychic self-stances.

therapy

At this point what I believe M needs is ... therapy. By 'therapy' I mean, here ... an inwardly transformative encounter with a loving judge. I mean: an experience of engaging with someone who can smile kindly on his anger, know the distress it comes from, know how hard it is to not have what you want, not dismiss or disallow the anger, but yet not thereby condone or give it full rein, not exculpate yet not castigate. As M internalises this relationship he will himself become able to smile on his perfectly human impulses and reactions, engage in a more kind (which is not to say 'more permissive') inner dialogue, allow himself to suffer the pains of not having his needs met without devaluing them, face life with honesty and fortitude and forbearance, forgive himself whilst learning from his mistakes, and learn to shape such of his anger as is valuable into a fruitful assertiveness. That way we find ego where id was; that way M can cultivate a more benign superego, avoid the unenviable choice of being a brat or a misery guts, and grow as an integrated person.