integrity as the lynchpin of integration

Orval Hobart Mowrer

The concept of the pathogenic secret and its significance to psychotherapy belongs, in the twentieth century, to the troubled and now largely forgotten American behaviourist Orval Hobart Mowrer. Influenced by Harry Stack Sullivan, Mowrer disagreed with Freud that neurotic guilt was at the core of much psychopathology, instead proposing real guilt as the driver, and de-repression through confession (in Integrity Groups - this was the 60s and 70s...) as the therapeutic solution. Mowrer modelled psychopathology as addiction, and it's perhaps unsurprising that it's in the field of addiction recovery that his work still has some influence.

What does it mean to model pathology as addiction? It means, Mowrer's pupil Bixenstein tells us, that the sufferer indulges in short-term pleasures whilst making herself unaware of their cost. In the kind of psychoanalytic terminology which Mowrer rather eschews, we might say that she represses, or splits off from, her awareness of the cost of her pleasures.

A defence subserving this latter unawareness, one we often encounter in the clinic, is projection. I  can't tolerate my guilt and so I project it into you - i.e. I make you out to be the bad one. Needless to say the projection may in fact - contra Mowrer - be of both real and neurotic guilt. A typical situation is one in which a patient is caught up in projecting the castigations of their superego, or so inexorably reads what the therapist says through the lens provided by the superego that (what is imagined to be a retaliatory) projection can almost feel like a moral duty.

Such projection is most effective when it is subtle, and it is subtle in ways which, I think, make clear just how the integrity group or 'pathogenic secret' concept has little chance of tackling it effectively. Just think of: a partly raised somewhat quizzical eyebrow whilst the therapist speaks; a minutely dismissive shrug just after the therapist speaks; a supposedly urgent question asked for which no answer could be satisfactory; amusement at something the therapist says or does which hovers on the in-between of laughing-at and laughing-with; requests made which exploit the inevitable ambiguities regarding what is reasonable to press for, thereby inviting slack-cutting and the latent queering of the moral pitch of the interaction; frustration at the therapist's incomprehension being expressed which would be utterly reasonable were it not for the fact that information which would have been rather helpful has been held back; conveniently construing the therapist's sincerity as tiresome earnestness so as to avoid the disturbing felt obligation to reciprocate the former; the subtle disowning-of-accountability (e.g. in a strategic use of psychiatric illness labels) in a push for not-quite-warranted-sympathy in how a story unfolds; etc; etc. Think of the sotto voce nature of many of these interactions - how they may be engaged in with a degree of plausible deniability - how the letter of what the patient says may yet be impeccable - how swept along by it one inevitably is. Think of how upsetting it is to have one's loving kindness gently trampled on and how, thank you but no, it's really not par for the course in this relationship just because it has this financial element to it.

The addictive buzz for the patient of such micro-abuse is akin to what we also find with schadenfreude - a sense of vulnerability and haplessness and culpability is relievingly located elsewhere - in the micro-agressed therapist. You are the clumsy insensitive dolt, not I, and if I perpetrate my aggressive relocation of doltishness not so much through the verbal content but, perlocutionarily, through the twisting of the tonal form of our interaction, then hopefully I can get you to suck it up into your self-conception in a way which allows you and I to let me off the hook (and you feeling shit). (A Bionian take on projective identification.) Yet such interactions nevertheless carry the typical cost and share the ongoing dynamic of addictions: they spoil the soil-structure of the relationship, making it unavailable as a collaborative loving resource to be internalised, and the sense of guilt or shame which is projected yet always lurks since it will painfully return unless the defence is maintained. In fact it increases, since the patient now suffers not only his original projected guilt or shame, but now also the additional guilt or shame at having micro-abused the therapist. Without an alternative ethic for relating, the projective besmirching spirals - this is the driver of the addiction to projective identification.

Consider the amalgam of neurotic and real guilt and shame one often finds in such interactions. Here is what in good (if idealising) humanistic spirit one might want to describe as the fundamental situation: at root the patient struggles to tolerate her vulnerability in love and connection. She so readily imagines shame being the apt emotion for so many of her ordinary reactions. She imagines - where by 'imagine' I mean simply the dispositional phenomenon of being inclined to expect - that she in her actual feelings - of upset, disappointment, anger - will be met with a lack of sympathy and understanding. She imagines that she will be met with self-negating criticism, with a 'pull your socks up', or a 'well what did you expect?', or a 'that's typical of you!', or a 'isn't this all rather self-indulgent?' or a 'I hope this teaches you a lesson', or a 'so you shouldn't have got your hopes up should you?', or a 'well clearly you were getting too big for your boots', or a 'stop being a cry baby', or a 'stop attention-seeking', etc. This is neurotic shame that stems from the superego, and is the kind of shame which the therapeutic relationship is designed to deactivate. Yet so powerfully does the superego force its damning message into the fabric of perception itself, thereby generating the negative transference, that the patient experiences such shaming for feeling coming from - or more often lurking unexpressed within - the therapist. And in response to this the patient goes on the manipulative attack. This manipulative attack must be subtle, since otherwise the superego-imbued-'inner'-therapist will add further scorn. Yet it is real and, to the extent that the patient stays in touch with an awareness of the possibility of a different therapist, of one who cares, one genuinely wronged by such put downs and performative beratings, her painful experience of guilt and shame increases.

Before turning to therapeutic solutions let's put one more consideration on the table - concerning how such a superego prevents integration. The goal of therapy, as I understand it, is to allow the patient to suffer/enjoy the full range of her feelings. It is in and through our feelings that we grasp the significance of our significant situations: I grasp what it means when you show me kindness or love, I grasp the significance of the fact that you no longer love me, or that you didn't love me as I had hoped, or that you have been spending more time with someone else, or that nature/fate/God has truly smiled on me with the health and opportunities I enjoy, or that I've been unkind, or that you've traduced my good will, or that I just won't be getting the promotion I longed for, or that you really have died and won't be coming back. We can't meaningfully grasp these things 'with our head' since what that would mean would simply be that we can make the apt reflective inferences when pushed; instead we must grasp them 'in our heart' which means that our reactive dispositions must change. We must experience the vulnerable joys and pains of opening up to another or of knowing that they have closed the door on us. The feeling is the adjusting to the ever-changing realities that befall us, and the task of therapy is the expansion of ego capacity - i.e. the increase in our welcome tolerance of all our feelings (which tolerance is not the same as condoning all the impulses such feelings may engender!). Yet it can be hard to adjust thus, to let the feeling course through the meaningful lived body; it so readily gets shunted off into the merely physiological body, or displaced, repressed, sublimated, projected. But what it most powerfully gets suppressed thus by is an inner critic - the voice which says that the feelings in question are shameful. This is the superego's potent contribution to the failure of integration - i.e. the failure to have ego capacity to suffer all, rather than merely that part condoned by the superego, of one's emotions.

In response to all of this the therapeutic task ought to be clear: it is the replacement of one ethic with another. Replacement of a competitive antagonistic point-scoring ethic with one of loving care, acceptance and cooperation. Replacement of this both within the therapeutic relationship and within the mind of the patient - in how he treats himself. The therapist smiles uncondescendingly, welcomingly, sympathetically, honestly, on the patient's feelings; the patient can now begin to internalise this acceptance, to make space within her soul for more of her pain and delight. Shame and guilt become welcome as opportunities for learning and growth; sadness welcomed as an opportunity for adjustment to loss and for valuing what one had; anger welcomed as a signal that one may have been wronged and a helpful prompt to assertively potent thoughtful reaction and self-rescue; envy welcomed as a clue as to one's forgotten or unrealised ambitions. Emotional feelings, in such an ethic, are calls to us to be, and reminders of the being of, our true selves.

But how can the therapist achieve this if they are the target of projective attack? Isn't that the dilemma we often face? I don't mean so much when one is struggling to not respond in kind, but rather when one's notwithstanding kindness itself will be abused or experienced as shaming or received with scepticism - rather than internalised as the herald of a healthier ethic. (Well, but... don't we already know something of this from the parenting situation? When the toddler is angrily, 'selfishly', unyieldingly carrying on, the parent's job is to be firm and clear and boundary-maintaining and non-retaliatory, to judge when the time is right for waiting this out and when right for thinking about it together.) The therapeutic task, it seems to me, is here several: i) to understand the psychodynamics of the projection, ii) to clearly acknowledge within herself the quality of feeling that patient is projecting, iii) to hold onto the thought of a different ethic, a different way of relating as a real possibility for the patient and between patient and therapist, iv) to firmly yet without retaliation describe what the patient is doing in the interaction, along with a description of the significance of the projected feeling to the patient, and a comprehending-distance-providing description of where this habit of reaction might be coming from in the patient's history, v) a reminder of the cost of adopting this competitive antagonistic ethic to the patient, and vi) a reminder of the possibility of another way of relating, vii) an invitation to the patient to make a step - to take a leap of faith that there exists another way of relating and that there exists, beyond what the negative transference makes available (and this really will be a leap of faith, so all-pervasive is the transference), a different kinder more understanding therapist to be related to.

The therapeutic task, one could say, is to agitate, firmly, kindly, honestly, for a change of heart. Which means the patient withdrawing their projections and apologising. The therapist must be able to hear this apology and take it - and not dismiss it casually with a 'oh that's all right' or a 'don't worry it's all in a day's work'. No, the therapist must be able to hear the confession in a way which acknowledges its deservedness, for without this they will not be able to offer forgiveness: they will not be able to let the patient know that he is no longer resented, that the apology has been accepted, that good relations are restored.

I've met morally deprived patients for whom the above procedure - the restoration of love, and not just the calling of a truce or a conveniently repressive forgetting, after a time of projective distemper - was a revelation. So entrenched had their families of origin been in a tit-for-tat point-scoring blame culture that the very idea of real forgiveness was more bewildering than anything else. Yet what could be more valuable? Not only is the patient then able to cultivate greater ego capacity and a kinder self-relation, not only are they able to have a trial relationship conducted according to a different ethic, one which they will hopefully be able to go on and generalise elsewhere, but furthermore the patient will now be able to swap their depression-engendering guilt for a valuable pride. Not the sinful pride of having an inordinate opinion of oneself, but the valuable anti-depressive pride of knowing that one has done the right thing, that one is making the best of a bad job, or making a good ethical fist of matters, suffering well, taking on the chin what is there to be taken, living with dignity.