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?

'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.