Tuesday, 1 August 2017

formulation vs recognition

The rhetoric of the 'scientist practitioner model' we meet with in clinical psychology has for some time now found its way into psychodynamic psychotherapy. I'd like to reflect on some of its language and ask if it's really apt to the therapeutic task. I choose the following textbook at random. Cabaniss et al (2013) offer us their 'describe, review, link' model for creating a psychodynamic formulation: describe 'the patient's problems and patterns', review 'the patient's developmental history', and link 'the problems and patterns to the history using organizing ideas about development': 
'A psychodynamic formulation ... is an hypothesis about the way a person thinks, feels, and behaves, which considers the impact and development of unconscious thoughts and feelings.... Psychodynamic formulations do not offer definitive explanations; rather, they are hypotheses that we can change over time.' 
'One way of thinking about this postulates that these problems are often caused by thoughts and feelings that are out of awareness – that is, that are unconscious. This is called a psychodynamic frame of reference. Thus, a psychodynamic formulation is an hypothesis about the way a person’s unconscious thoughts and feelings may be causing the difficulties that have led him/her to treatment. This is important to understand, as helping people to become aware of their unconscious thoughts and feelings is an important psychodynamic technique.'

'When we formulate cases psychodynamically, we make hypotheses about how people develop their characteristic ways of thinking, feeling, and behaving. Thus, once we have a good sense of the problems and patterns, the next step in creating a psychodynamic formulation is to review the developmental history. The developmental history includes everything that happens during peoples’ lives that help shape their dominant patterns of functioning; that is, the way they think about themselves, have relationships with others, adapt to stress, think, and work and play.' 
'When we take a developmental history, we are guided by these principles:
  • include nature and nurture
  • relationships are key
  • trauma is critical
  • chronology is relevant
  • development is lifelong'
Having described and reviewed the patients problems and history the third step is to 'link' them together. This linkage provides the provisional understanding or 'hypotheses' which is to guide and inform the therapy. Here's an example: 
'How did Dr Z form this hypothesis? It was not magic. Rather, as she learned about Ms A’s problems and patterns, she asked herself a question: 
                  Why does this talented woman have such a low opinion of herself? 
Because she was thinking psychodynamically, she DESCRIBED Ms A as having difficulties with self-esteem regulation that likely reflected unconscious, overly critical perceptions about herself and her abilities. This gave Dr Z a partial answer to her question, but she knew that in order to develop a strategy for helping Ms A with her low self-esteem, she would need to understand how and why these unconscious, maladaptive self-perceptions had developed. To answer that, Dr Z REVIEWED Ms A’s developmental history and, among other things, learned that she had had a difficult relationship with her critical, dismissive mother. She then used an organizing idea about development – that maladaptive self-perceptions are often related to a person’s early relationship with a dismissing, critical parent – to LINK the pattern to the history. By describing, reviewing, and linking, she had formed an hypothesis about why Ms A had such a low opinion of herself – a psychodynamic formulation.'
Once we've got them 'Formulations help the therapist to 'construct meaningful interventions'. These might include: 
  • 'recommending treatment and setting early goals
  • creating a life narrative
  • offering explanation and perspective throughout the therapy
  • consolidating insights as a preparation for termination'

There is much we could take issue with in this. Even if it were clinically intelligible and possible it's hard for me to imagine it being therapeutically desirable. In particular I doubt that bringing such thought to bear on the patient in his presence is either of much therapeutic use or in line with the core values underpinning meaningful therapeutic - or for that matter meaningful human - encounters.

The word which comes to my mind is 'external': the authors' description of the relation of the patient's unconscious thought and feeling to her behaviour, and of the character of the therapist's appreciation of this, strips unconsciousness of its immanence in behaviour (inner causes, posits, etc). The requisite tentativeness of the therapist's suggestions is automatically equated with the therapist not losing sight of the thought that his or her suggestions about unconscious thoughts and feelings are hypotheses. The understanding which the clinician develops is construed as instrumental for his or her clinical activity. Finally the relation of the past to the present is also seen as an external relation between two different phenomena: a childhood trauma, an adult symptom; the clinician's hypothesising about this relation is facilitated by his knowledge of developmental and longitudinal studies.

But what might it mean to say - as I want to say - that a therapist and patient are, in potent analytic therapy, in some sense internally rather than externally related? What might it mean to say too - as I also want offer - that a patient's trajectory towards health is one from an external to an internal relation between himself and his own experience? Isn't all that a crazy mishmash of matters philosophical and matters psychotherapeutic? After all, in therapy we have two separate individuals in the room, etc etc...!

(That, I also want to say, is one of those philosophical reactions which is far too quick for its own good! Be patient!)

In therapy - and in much of interpersonal, moral, life - we have an essential need for recognition. The patient needs the therapist to be able to offer her recognition. Recognition in (and not just of) her distress. Recognition that ways of feeling and forms of behaviour which appear to the patient to be untoward, symptomatic, undesirable, foreign, forms which merely assail, are in fact intelligible moments in the living of a human life. To be honest the patient doesn't need to know that they are causally intelligible in terms of their traumata or what-have-you, although that may be interesting (perhaps too interesting...) or helpful. Such a form of explanation, in fact, still leaves the patient in an external, unassimilated, relation to her symptoms.

When I show you recognition, that is when my relation to you comes aptly under the concept of ethical recognition, then I take you and your experience and your action as humanly intelligible. Where by 'humanly intelligible' I mean: intelligible as such, being experiences that we 'get', that we can 'relate to' as meaningful in themselves. We can understand this immanent intelligibility best through examples. For example: you cut your finger and it hurts; your girlfriend leaves you and you are distraught; someone calumniates you and you are angry; someone praises you justly for what you and you are delighted. To react thus is to be living what we take to be a human life.

The patient however comes along with suffering which she does not understand. She perhaps hopes that the therapist will somehow help her get rid of it. The depressed person feels flat, unmotivated, suicidal, etc. The obsessional feels assailed by impulses that are not experienced as his own, ones he cannot endorse. The phobic feels scared of what she knows ought not to be scary to her (because it is not dangerous). And so on. The clinician may be able to understand how these developed - they may be able to understand the patient's symptoms - but in the sense I'm interested in here this does not mean yet an understanding of the patient. In the sense I reserve for it here, to understand the person is rather to offer an understanding of her symptom which restores human intelligibility to it. Not, for example, that we can understand the causal development of your obsession, but that it becomes once again something you understand as an expression of your will. This is what we call integration, and such integration (where id was there ego shall be - in Jonathan Lear's helpful take on Freud's dictum) is the correlative of another's recognition - recognising in the sense of acknowledging rather than identifying someone.

So this is one thing which it means to say that a patient's relation with her symptom is external whereas that with her emotional experience is internal. In the latter case the experience is her own not in the sense that it happens to her but that it is a moment of her agency. Therapy restores this internal of-a-piece-ness of the symptom with the patient's will; in this way they turn from patient to agent.

What about the apt relation between therapist and patient being, as I unperspicuously claimed, internal rather than external? Here my claim is that when we offer another recognition, when we encounter them as (we might say as) subject rather than object, our response to the other is an intimate corollary of them in their meaningful experience. The comparison here is between i) two independently crafted shapes that happen to fit together and (to borrow an example from Wittgenstein) ii) the inside of the black circle and the outside of this disk: O. If my will is internally related to my experiences in a way in which it is not related to that which befalls me, and if the therapist's recognition offers me a reacquaintance with what of myself is in truth immanent within my symptoms (where id was there ego shall be), then when the therapist offers an 'interpretation' what is happening is they have offered me an avowal. Offered something which can become a living moment of my will. When this happens the therapist and the patient are 'of one mind'. The therapist helps 'restore the patient to himself'. Le mot juste is offered to which the patient may say 'yes that's it!', pick it up, use it, and so on.

The clinical psychologist tends to portray the tentativeness of the apt therapeutic suggestion as making a statement in the form of an hypothesis rather than of a fact. I think this mischaracterises the relation between the imposing versus the respectful therapeutic word. (For example, sometimes the therapist might have to take a strong stand against the patient's defences, offering the mot juste in rather forceful terms. To do any less may be to fail to respect the patient as a locus of potential agency.) What is more to the point is the need to not impose one's will if one is to do anything that could even count as offering recognition. Thus if I tell you what you think I am not doing you justice. Since in telling I am claiming to speak from the phenomenon. Yet here I am making it part of my will, rather than allowing for you to own it within your own.

Finally, consider the difference between an understanding of a symptom as a present day causal product of a trauma (or what have you), something concatenated down and an understanding of it as the (until now disavowed) voicing of (say) a trauma. In the former case the two are related externally: one explains the other. In the latter it is internally related: one is of a piece with the other. We come to see what before was a mere symptom as the ongoing expression (in the sense of the pressing outwards, the very living enactment) of a humanly (not: of a psychologically) intelligible moment in someone's life.