The Local Level (and the negotiation toward a path of shared intention)

The candidate/presenter in the Continuing Case Conference started out warning the class that in taking process notes she had gotten confused about who had said what. It turns out that this comment would foreshadow the theme of the session.

The patient had cancelled, due to her work schedule, an appointment with her specialist for a medical concern that warranted follow-up. The therapist had already been concerned about the patient’s possible, serious medical problem, but had not before said anything to the patient about her worries. In this session, the therapist makes her concern explicit, then asks a couple of questions: do your parents know? Were there other reasons to cancel besides work? After this interchange there was some silence. The patient commented that she will bring a letter she is writing to the next session so that the two will have something to discuss. The therapist offered to discuss the process of the letter’s composition. The patient declined, saying she would bring it in when completed. More silence. The therapist inquired if the silence is experienced as a punishment [there is a history of the patient’s mother giving the patient the ‘silent treatment’ when angry at the patient.] The patient says she used to feel that way with the therapist but not anymore. [a new way of being together had already transpired]

The therapist then says she has something she would like to discuss [the patient has offered something, the letter, to bring in to discuss, now the therapist reciprocates, as the two move along the same path toward shared intention ---to not ‘suffer in silence?’], a recent session that had an effect on the therapist and possibly on the patient, but worries she (the therapist) will be too much like the patient’s mother, always setting the agenda. The patient asks if it is appropriate to ask what are the therapist’s feelings about the patient. The therapist explains that what is between them is ‘fair game’ to discuss, and using the word “mutuality,” discloses relief that she (the therapist) is not “crazy” (a word and worry often used by the patient) for they both are on the ‘same page’ about having accidently seen each other in public places. The patient is happy about this mutual understanding but says she prefers the word “solidarity” to “mutuality.”

The class mused about the colloquial (in the therapist’s city) connotations of the word ‘solidarity’ which includes ‘an otherness to our togetherness.’ The class --  aware of the patient’s fears that her Self and her agency would be subsumed under the mother’s -- noted how the patient helps co-create the boundaries between herself and her therapist. The class discussed how a new way of being together [the patient can assert her own agency for the therapist can reflect and make explicit her own contributions to enactments], that is, a change in implicit relational knowing is slowly being forged despite the therapist being pulled into micro-enactments to be concerned, advise, participate, or intrude. The crux of the negotiation has been about moving toward a shared intention. 

The gestalt or arc of the session had been the slow, steady, quiet negotiation around ‘Can we be close and still be separate?’/ ‘May we be close and I not have to subsume my Self and my agency?’  (the theme) While it may have seemed to the therapist and to the class that not very much was happening in the session, it turns out -- as the Boston Change Process Study Group notes -- that change in implicit relational knowing can also, maybe usually, occur even in the quieter moments, and not only in the moments of heightened affect (now moments) and their potential, subsequent moments of meeting.

Change in Psychotherapy: A Unifying Paradigm. (2010). The Boston Change Process Study Group. New York: Norton.

Fittedness and Implicit Relational Knowing: What is Mutative

In co-creating fittedness, the therapist and the patient implicitly move toward a shared intention. In a beautiful explicit, concrete example, a colleague shared how she and a pre-teen, female patient were drawing a story together on a large whiteboard [an example of the therapist joining or following the patient]. After awhile, the young patient became embarrassed and moved away from the shared task, but then, looking over her shoulder and seeing the therapist still drawing, the patient returned to the whiteboard for some finishing touches [an example of the patient joining the therapist]. That is, the two moved closer and closer toward a shared intention. Moving toward a greater ‘fittedness’ leads to an increased coherence within the dyad, which, in turn, expands implicit relational knowing.

Expanding implicit relational knowing widens the possibilities of how to behave with one another and enriches the repertoire of relational patterns. Likewise, flexibility increases, as does the hope for spontaneity. This is mutative. This is change. Change opens the way to insight, when, after comfortability with a new way of being with an other, one notices that and how things are different.

This is to say that change precedes insight, not follows it.

The Boston Change Process Study Group [BCPSG] has turned psychoanalytic thinking on its head in another way with their explication of how relational patterning is primary and the foundation of psychological life, while conflict and defense are secondary. They cite attachment patterns at age twelve months (seen in the Strange Situation) as evidence for the presence of conflicts and defenses based on relational experiences (because the infant has already apprehended what to expect from the caregiver). For example: an infant with avoidant attachment has learned it cannot count on the caregiver to soothe it when distressed and so appears to have little affect [defensive] while seeking objects to soothe itself; or, conflict is evident in disorganized attachment where the infant reaches for its mother while simultaneously backing away from her.

Change in Psychotherapy: A Unifying Paradigm. (2010). The Boston Change Process Study Group. New York: Norton.

Continuing Case Continues? and disruptions, and continuity of sense of self

There was today in class a lot of confusion on the instructor’s part. Even if we get past the limitations imposed by differing accents, by the teleconferencing connection, and by this instructor’s hearing impairments, there remains that the instructor could not sort out when the presenter was talking about what occurred in the session explicitly between patient and therapist and what was being related from the presenter’s mind as hypotheses and as background information about the patient and the treatment for the class to know. [To this instructor’s relief, the instructor was not the only one confused about ‘what is going on around here’ in the class.]  So we decided to discuss together what was going on. [Unfortunately, the presenter was not able to get through the session she had looked forward to presenting; a melancholy choice: choose one, lose the other.]

By addressing in class the process instead of content, we were able to glean some useful ideas.

Quoting one classmate, we could ask: What belongs to whom? Whose ‘language’ is spoken? (whose desire? [a topic of the earlier course]) and Who am I?, all of which might relate to the patient, the patient vis a vis her parents, the therapeutic dyad, and to the class. This same classmate noted that the disruptions might be related to the session (as well as to the presentation), specifically to the possible dissociated self states of the patient coming into the session, threatening continuity of self and of session. Another classmate noted a possible dilemma between fusion and individuality for the patient, that is, the patient experiences an attachment as having to lose the self or part of the self if she is to maintain a connection. (The presenter confirmed this with an example from the session). There is also the Adult Attachment Interview research which found an incoherent narrative is indicative of insecure attachment, which the patient here certainly experienced with her intrusive mother. Lastly, the instructor’s repeated attempts to clarify what the presenter was saying caused not only too many  interruptions (discontinuity) but also had the presenter feeling scrutinized just as the patient had felt so micromanaged by her mother.

All this by way of saying what the reader already knows: process is as important, maybe more so, as content; class process may reveal valuable information about the patient’s inner life; parallel process exists; instructors need to be more mindful of how her desire affects the presenter’s; and much more.