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.