Saturday, 1 May 2021

psychotherapy's moral bite: on deactivating the projection of will

What distinguishes the master therapist? I've long suspected that an important aspect of such a therapist is her moral seriousness. By that phrase - moral seriousness - I mean something quite specific. Rather than define it I'd like to first say what I don't mean by it, and to then allow the sense of it to emerge from an example. 

So, what I don't mean is moral shrillness, or moralising, or a failure of empathy, or an absence of the light touch, or an inability to take oneself less than seriously (i.e. a failure of what Jonathan Lear calls irony.) 

And now the example. It's from a recent blogpost by Jon Frederikson; Frederikson is a particularly lucid and thoughtful exponent of ISTDP (Intensive Short Term Dynamic Psychotherapy). One of his trademarks is what ISTDP calls 'deactivating the projection of will':

Pt: "I don't want to dig too deep today because I'm in a precarious personal equilibrium."
Th: I have no right to dig into anything you don’t want to dig into. That’s why I have to ask you what you want to dig into that you think would be useful to you.” [Deactivating the projection of will.]
Pt: I don’t want to dig into anything.
Th: It’s your therapy, so you can dig as much or as little as you want. [Deactivate the projection of will.] If we don’t dig into anything, what will be the result for you?
Pt: I won’t get anywhere.
Th: So it sounds like you are at war with yourself: wanting to get somewhere and not wanting to get somewhere. What’s that like to notice that struggle within yourself? [Point out the struggle he faces within himself. There is no struggle between the two of you.]
Pt: "I'm afraid if I connect too much with how exhausted I am, I will just fall down."
Th: That makes complete sense. Would it make sense to look under the exhaustion to see what it might be covering up? [Exhaustion is not something we want to explore since the patient would only become depleted. We might test whether exhaustion is functioning as a defense and invite the patient to look under it.]
Pt: “I don’t want to look at my issues too closely today because I’m balancing lots of things and I feel fragile.”
Th: I have no right to look at any of your issues unless there are issues you want to look at that you think would be helpful to you. That’s why we need to find out what you want to look at that you think will be helpful to you. [Deactivate the projection of will.]
Pt: I feel fragile.
Th: How so? [If the patient is fragile, naturally we want to know so we can assess his strengths and weaknesses. Or the patient may not be fragile. We can’t know unless we assess.]
Pt: I didn’t sleep well last night.
Th: And the fragility? What are the signs telling you that you might be fragile?
Pt: “I’m afraid if I let myself feel how tired I am I won’t be able to go on.”
Th: That makes sense. Shall we look under this tiredness and see what it might be covering up?
Pt: Covering up?
Th: Yes. Would it make sense to look at a specific example where this tiredness comes in, so we could see what it might be covering up? [Invitation to engage in the therapeutic task.]

Now Frederikson doesn't describe his intervention in moral terms. He focuses, quite properly, on the character of the defense and the apt means of blocking it in the service of the therapeutic work. But it seems to me that the extract warrants a moral redescription, and that such a description will reveal something important about what's going on.

The first thing I want to note is that the projection of will is, in a sense, quietly abusive. I don't say this to make a big thing of it - it is often just a little thing - but to highlight an essential aspect of its character. 

So: I come to my therapist's consulting room but then, rather than stay in touch with my wish to know myself better and do the work of therapy, I regress and in effect say 'I want to be here but I don't want to do the work'. Except if it'd actually been said like that, then the patient would at least have been owning the contradictoriness of her action and her thought. Yet instead of owning the contradiction, she secretly disavows her wish to do the work whilst still coming to therapy. The contradiction is a living, rather than a thematised, one.

The therapist is after all a professional, is someone who does her job because she enjoys exercising her skills. And the patient who says he doesn't want to work in the session is depriving them of the opportunity of actually earning their living by plying their trade. (Imagine going to the dentist and saying, 'oh don't worry I'll pay you for your time, but today I just want to sit and chat'... It's not cool.)

For a patch of time some years ago, when a couple of patients habitually turned up late and apologised for it, I found myself saying something like 'Well as for me I was very happy reading my book; and I'll still be paid; it's surely only your own time you're wasting.' The reason I'd give myself for saying this was that I wanted to help them see what they were losing because of their actions, as well as to help myself avoid slipping into a 'oh that's quite all right, please don't worry about it', people-pleasing, overly empathic, state of mind. No doubt it was sometimes of help in those ways. But it truly failed in at least five respects. First, in saying it I failed to acknowledge the fact that I do my job because I find it rewarding - not just because it's how I earn my living. In this way what I said was disrespectful to myself: I wasn't noticing that I was being deprived of the opportunity to be the professional I am. (Of course, properly understood, the discussion of the lateness was also precisely an opportunity to engage my professional skills! But y'know, and to make an analogy: being abused by a narcissist is also an opportunity to develop one's self-possession - it doesn't mean we should thank them for it.) Second, by implying that it really was of no more value to me than my book, it devalued the therapeutic work that the patient and I were doing together and potentially also the patient. Thirdly, it failed because it deprived the patient of a chance to have a healthy experience of repentance, an apology being heard, blame being aptly apportioned, and forgiveness being given. (Experiencing true rupture repair, as opposed to competitive grudge-bearing, is majorly important for many patients since their early environment provided them very little opportunity for internalising healthy regulative moral ideals.) Fourthly it tanked because it rather prevented meaningful investigation into the meaning of the lateness. And finally it failed because it was perhaps something of a passive aggressive vengeful devaluation of the patient. I thought I was being morally serious - but, yeah, I wasn't.

Back to Frederikson on deactivating the projection of will. So, as well as not holding onto her own wish to actually do therapy, and as well as disrespecting the therapist by prima facie depriving her of the opportunity to ply her noble trade, the patient also disrespects the therapist by bending out of shape the moral fabric of their relationship. This projection is in truth a kind of projective identification. The patient not only fails to hold onto his own wish to do the work; he regressively shunts it into the therapist; and now sets up a dynamic in which the therapist is invited to experience herself as opposed to the patient. This is the structural equivalent of going up to an innocent stranger in a bar, nudging them, and then - rather than apologising - acting as if there's now some standing beef between them for which the nudgee is no more responsible than the nudged. The real issue, of course, is what's going on within the nudgee - it's an issue between himself and himself.

It's precisely here that the therapist's moral seriousness is most required. For what she mustn't do is what I described my past self doing above - or, even worse, just ignore the issue or become pathologically 'understanding'. But rather, in a gentle and firm way, she must implicitly call the patient out on what he's doing, and invite him to re-own what he's projecting. This demands the therapist's full self-possession. She must have spotted the projection in play, been able to stand up to it without getting drawn into an enactment, implicitly let the patient know not only that it's happening but that it's not ok, hold in mind the patient's better self's reason for coming to therapy even whilst he's busy disowning it, actively recall the patient to his better self, openly hand back the covertly passed over baton of the patient's will, not be reactive or dismissive, hold true to a dignified sense of her own value (and in this way manifest that moral value we call self respect), hold morally true to a sense of the value of the work, be aware of the patient's genuine struggles and anxieties without letting this awareness become a spurious exculpation, and invite a reparative - 'depressive' rather than 'paranoid-schizoid' position - dynamic. Being 'the adult in the room' is not, we might say, simply a matter of having a certain psychological maturity. Or rather, it is, but such a maturity must be understood as itself ineliminably a moral maturity.

I want to end by noting that it's not only master therapists who have (amongst other signal attributes) cultivated and embody what I'm calling 'moral seriousness'. The other professionals who I'm most aware of embodying it are what we might call master school teachers and master social workers. They deal with difficult and in some ways toxic dynamics not by becoming remote, not by morphing into a perversely uninvolved version of the so-called analytic 'blank screen', not by allowing themselves to get sucked into the dynamics or by becoming 'superior' to their charges. Instead they retain dignity and, without being patronising about it, and without minimising the fact of the disrespect in play, and - without removing themselves from the vital, dynamic, respect-constituted character of the relationship - recall their charges to their better selves.