Saturday, 22 April 2017

cmt

Joe Weiss
I've been looking at a little of the writing on Control Mastery Theory - the approach to psychotherapy developed by Joseph Weiss, later in collaboration with Harold Sampson, and disseminated by Alan Rappoport, George Silverschatz and others. It's a simple model (ugh, that word 'model' that hides so many conceptual sins in clinical psychology) and, if we are to have a simple model, it surely describes better than most any other some of the central features of the psychotherapeutic process.

And yet I find myself reading through Frank Cioffi's eyes. (Cioffi, the marvellous critic of Goffman and Freud, with the keenest of eyes for, and wittiest of pens for recording, the latently pseudo-empirical.) For CMT, it seems to me, offers much by way of 'posits', but provides little sense of what it would be to confirm or disconfirm these. So we're left wondering if what we meet with here are really hypotheses, or axioms, or what.

The real worry I have is that they are axioms masquerading as hypotheses. And that's a real worry because such masquerading is typically cultish, because it shrinks one's sense of the possible, and because it bamboozles natural human communication.

Frank Cioffi
(I'm not trying to overlook the benefits of having a simple system to organise one's thought and experience and interaction. Perhaps some people really would be better off with such a system? (Rappoport, for example, tends to write as if therapists will be lost without a system which provides a far greater degree of reduction than I could ever find comfortable.) Maybe I'm naive in believing most of us can outgrow such needs and return to a richer, more diverse, more fluid encounter with our own and one another's minds.)

The main move in CMT that interests me is a tendency to offer something we can all recognise as sometimes done or occurring, in psychotherapy, as if it were always done or occurring. Because the normal criteria for that something are clearly not going to be present all the time, the tendency can be to suggest that this is because the something is unconscious. Yet it confuses matters to use the concept of the unconscious thus. Not because we cannot find very decent uses for it. But because, if we want to know what it can mean to say that A is Xing even when A is not aware of or disposed to avow that he is Xing, it does not help us to say that A is Xing unconsciously. Sure, fine - but what are the criteria, the ascription conditions, for that? What counts for and what counts against ascribing X to A?  Unless you can give us some kind of answer to that question then it's not clear to me that you're really yet saying anything in maintaining that A is Xing. (Explanationism, in the philosophy of psychology, suffers the same lacunae: we are told that an unconscious or subconscious Xing is the best explanation of the consciously available behaviour Ying, and that's all very well but gets us nowhere until we are told what it is to un/sub-consciously X. It won't do to be told 'well, it's the same as to consciously X except the subject is not aware of it!' For what it is to 'consciously X' is in part to avow that one is Xing etc etc.)

You've been owed an example for too long. Here's something from the San Francisco Psychotherapy Research Group Website:
Control Mastery Theory embraces the idea that patients consciously and unconsciously regulate their own treatment. They work in therapy to disconfirm their crippling pathogenic beliefs. Patients are made miserable by these beliefs and are highly motivated to disconfirm them. Patients think unconsciously about their problems, and make and figure out plans for disconfirming these beliefs. Symptoms such as compulsions or inhibitions can now be understood as efforts to avoid dangers foretold by the pathogenic beliefs. One way that patients work to disconfirm their pathogenic beliefs is by testing them in relation to the therapist. This is a way for patients to reevaluate the reality upon which the dangers predicted by the pathogenic beliefs are based. In testing, a patient acts in accordance with his pathogenic belief. Patients engage in testing behaviors in order to ascertain if conditions of safety are sufficient enough for making their beliefs conscious.
Now how would we distinguish whether that, or the following, was right?
Out of Control Theory embraces the idea that patients come to therapy with emotional pain, anxiety and behavioural dysfunction which they either can't understand or can't control. They have a range of unconscious, semi-conscious and conscious pathogenic beliefs, sets of expectations, complexes, schemata, phantasies and wishes in terms of which we can understand their habitual thoughts, feelings, fantasies, behaviours, and relationship patterns. Because patients are often not adequately aware of their mental states,  and/or because they may not recognise their possible falsity, they typically enact them unintentionally in the therapeutic relationship. Yet so long as the therapist pays attention this is all super grist to the therapeutic mill. What keeps the therapeutic work in the zone of the complexes is not, since he is unaware of them, the patient's drive to test them out, but rather the therapist's skill in noticing and drawing them out, the absence of small talk, the activation of the transference, the closeness of the therapeutic relationship, etc. Fostered by his own reflection on unexpected experiences in and out of therapy, fostered by the therapist's transference interpretations, and fostered by the therapist's love and care, the patient increasingly recognises that he has latent fears and wishes and that they are not as inevitably sound as he expects. Because of all this the patient comes increasingly to acknowledge some of his own unrealistic desires for control and mastery, both of his emotional experiences and of his relationships. Sometimes he takes a punt on his expectations being unfounded or merely self-fulfilling, and risks a new way of relating to his therapist or to other significant others. If things go well he comes to be able to tolerate more of his diverse drives and wishes, acknowledge his all-too-human failings, withdraw his projections, be more vulnerable and loving, make reparations when required, notice and desist from his self-thwarting depressive and avoidant defences, man up, etc. Sometimes the all-too-human therapist gets in the way of this progress, but when therapy goes well he can be a helpful aid, confidant, testbed, reality check, support, recognition provider, confessor, and caregiver.
We all recognise, I think, that patients do sometimes test their therapists. But CMT invites us to think that this is the form that many or most interactions in therapy take. And it invites us to think that progress is made when therapists pass tests. But what about all the times when patients don't test their therapists? And what about the times when the testing is itself pathogenic? When testing needs not to be passed but to be called out?

'Oh', the CMT therapist might say, 'calling someone out on their testing is just another way of passing the test. The test was whether you would take a stand against such behaviour. This is what we call 'passive into active' testing. The patient is behaving badly, but what they are hoping is to learn how to resist such bad behaviour as they themselves were subject to.'

But what are the grounds for saying that the patient was testing the therapist in their behaviour? It won't do to move straight to 'well, this explains really well why they are doing it', for explanations are only good to us if we understand them, and it is an understanding of what it means, here, to talk of testing that we are after.

There is a use of 'test' or 'try' - as in 'trying/testing my patience' - which is largely non-intentional. It is one which would fit the situation just envisaged (when the patient projects guilt into the therapist, for example). But it is not one which fits the CMT therapist's model - since it is, qua test if not qua evacuation, non-intentional. We are not here after evidence; we are after an understanding of what the evidence is said to be for. And none is forthcoming.

I'm not trying to say that we can't think of myriad instances in which a child or a patient benefits, calms down, feels safe, when their boundary-testing and omnipotence is successfully stood up to, when their bluff is called. But is this really going to provide the general framework for psychotherapy in general? Nobody, and certainly not the CMT therapist, thinks that.

Friday, 21 April 2017

sit yourself down in the right place and you won't ever need to go anywhere

When the concept of 'internal relation' is used to overcome a dualism, used to overthrow a depiction of a situation which makes it look like we need to find a way to relate two separate phenomena (mind and world, rule and application, thought and object, order and execution, etc) then we cannot but applaud it. Yet it seems to me that, notwithstanding, the dose of conceptual medicine it provides is often sub-clinical. 

Take the outside of the white disc and the inside of the black circle: O. It is, as Wittgenstein suggests, nonsensical to talk about the fitting of the disc in the circle when the boundary of the disc is defined, given, by the circle. Good, yes, right. They are not related as two separately definable or defined phenomena. But then does it really help us to say that they are instead related internally?

What is it that are related here? Objects or concepts? (This is a doubly terrible question.) Well, one thing is for sure: it is not that we have here two objects which are related by being 'brought under a unifying description'. There is no more fundamental designation of these alleged two objects than 'this disc defined by that circle'. 

No, the designation doesn't unify; we do better to say that we have here one figure, and that we can focus on certain features of this figure. There are two sides to a coin - we cannot peel the sides off from the singular coin to which they belong without their ceasing to be sides. 

The problem with the 'internally' answer to the 'how are they related?' question is that it fails to completely take apart the assumption that here we do indeed properly meet with a 'they'. It's a bit like  (to borrow again from Wittgenstein) answering 'Mr Nobody' to the question 'Who is in the room?' where there isn't anyone in the room. We could speak like that, but we both know it simply disguises the out-of-place-ness of the question. 

The only reason it looks like we meet here with a 'they' is that we have started talking as if that is what we have here. But we don't, so we shouldn't. Sit yourself down in the right place to start with and you won't ever have to go anywhere.

We get this kind of thing all the time in philosophy. 'What makes it the case that 2+2 is necessarily 4?' Bad question - this whole 'makes it the case?' way of speaking already presupposes that we here have to do with two separate phenomena (2+2, and 4) which are by some or other means, you tell me, joined up. But, no, it is not the Platonic objects or the rituals of human life that 'make' this the case. Rather what is the case is that we have such a singular ritual as adding 2 + 2 and calling this '4'. One phenomenon, one rule, one coin, one O, and no thing to relate to any thing else.

How are the morning star and the evening star related? They are not related or unrelated. There is no 'they'. There is one star with two names. ... How are the two names related? ... Well, what kind of relation did you have in mind in your question which asks about how names are related? I can't yet think what you're talking about.


Tuesday, 4 April 2017

the inner, the outer, the unconscious

Our thinking about the unconscious harnesses itself with beguiling readiness to the inner/outer picture which we've otherwise worked so hard to overcome. I'm thinking of how easy it is to imagine that unconscious emotion is inner emotion which is not yet finding its way to outward expression. That defences are inhibitions on voicing and otherwise expressing. Or even that they are inhibitions on some kind of (philosophically invented) 'inner access' to our own inner emotional state.
P M S Hacker

I've no desire to rehearse the critique of the metaphysical inner/outer, and correlative epistemological self-access, picture here. Peter Hacker has conclusively done this to death many years since with his Wittgensteinian work in the philosophy of mind. Let's instead start with a reflective appreciation of the immanence of mentality in behaviour and ask ourselves where this leaves our conception of the dynamic unconscious.

According to Maurice Merleau-Ponty, dynamic unconsciousness is best understood as a latency. This seems promising to me. My desire is, sure, not reducible to, but nevertheless not somehing other than, my expressions of it. The unconscious is an atypical black hole in the texture of my expressive emotionality. And this emotionality has its very being in its enactions, which enactions may be shrunken or expansive, simplistic or finely nuanced. And, since we are here eschewing the inner/outer picture, shrunken or widely ramified and nuanced expressivity is of a piece with shrunken or ramified and nuanced emotionality itself. 

Defences are typically against the shame of having this or that desire, experience, feeling, thought. It is when the accepting balm of the shadow of Thou is cast over me by you that I can thaw, expand into my own latent emotionality. Now there is relief, since the blockage - not in merely outer expression or self-knowledge, or in some separable quotient of the emotion called, tautologically, the feeling of the emotion -  is undone and I can once again body forth in my relatedness. Now I can go on. Now my emotions can actually take shape as such.

M Merleau-Ponty
Now I can make sense again - not in the sense of making reflective sense of my feelings (best leave that to the psychologist), but in the sense in which I, in my feelings, can now develop in them, and a merely immanent possibility of intelligible being - of relating with sense to a world - is back on the table as something more than immanent, as something which may now actually take shape and take up space. My ability to make sense is the same as my ability to move again, to unfold here and there,  to enact meaning in my self-becoming in the context of this and that relationship.

Freud's energic metaphors - which he somewhat psychotically did not recognise as such - capture well, I believe, the experience of defensive blockages on affective becoming. For when we cannot body forth with an affective intentionality, all that we may have left by way of expression is something denuded of intentionality. For example, a sense of pressure, of dampening, of physical symptoms (we cannot cry but perhaps even so water spills from our eyes.)


Monday, 3 April 2017

why defend?

I used to think that emotions which remained unconscious inevitably did so because to feel them is in itself too painful. The idea lies behind the common canard that 'people need their defences'. Anger or sadness or guilt are too much - in the sense that the pain they generate is too much, and the anxiety about feeling this pain is too much. Thus the defences which kick in and which stop us from feeling the emotions are defences against the intrinsic and anxiogenic pain of the emotions.

One of the clinical facts the standard view rather ignores is that it is often a relief to someone to have a defence lifted. You often see this in the clinic: sure, after the defence against sadness is relinquished, the patient feels sad, but yet he is not unhappy to be so, can bear it just fine, etc.  Frankly: it is a relief, and on being reacquainted with oneself thus it also feels healing and integrating. In truth I still believe that the standard view obtains when we meet with psychosis: reality is too painful and so the defences of delusion, mind-dismantling, and autistic retreats are indulged. But I've come to doubt its adequacy in many neurotic cases.

What strikes me as true in neurotic cases is that the becoming, bodying-forth, of emotions is anxiogenic not because of the pain of the emotions but because of an expectation of oneself not being accepted in such emotions, or a feeling that even to oneself one is unacceptable for having such emotions. The anxiety, I am proposing, is essentially social. The anxiety is more often a matter of shame or guilt: I shouldn't be feeling this feeling. Or it's the fear of rejection and the complex nexus of resentment and trepidation and self-doubt and rage that is characteristically bundled up with that.

In the clinic the patient is enabled to body forth into this or that feeling because she gets an inkling of acceptance and understanding of herself in her feeling from her therapist.