Here’s one I’ve been sitting on for a while. What does a Shrinky do when they’re having a bad day? Probably not what I’d do.. that’s for sure!
Yesterday I found myself on Twitter having the most fascinating debate with a whole host of clever people but particularly shrinkies @jaypsyd and @janettereinke.
A major critique in my recent readings (mostly humanistic theories) was that psychoanalysis delivers insight without ever achieving “change”. Whereas CBT* delivers short term change without any insight leading to a recurrence of behaviours/general unhappiness/woe in the longer term.
My question(s): Where is the connection between insight and change? What is the catalyst that moves the client from one to the other? What modality of therapy offers this best and how does it manifest in the relationship/process of therapeutic interaction?
And yes – we dug through this in less than 140 characters a pop. Neat, eh?
I think our conclusions ran thusly…
Insight leads to (self) knowledge and (self) acceptance. This (self) acceptance reduces shame, and ultimately creates a desire for change or alternatively, creates an environment conducive to change.
We also discussed the role/definition of shame. @Jaypsyd sees shame “more as a cultural artifact placed atop the psyche” whereas I definitely see it as a developmental issue, potential extant parental issues impacted/exacerbated by cultural influences but then placed upon (projected onto, if you will) the developing child, with each generation compacting the damage previously inflicted by the former.
Or something.
Then I highlighted another critique appearing within the same set of texts, that person-centred therapy is too passive.. that “witnessing” is not enough of a catalyst for change. Which led us to discuss the role of unconditional positive regard and how difficult/challenging it is to maintain.
I’ve been asked (far more often than I’m strictly comfortable with) whether I want to become a therapist. For the reason of UPR alone, my answer is the same as the last panel of this cartoon.
Nuff said.
Seeing as we now have more than 140 characters available to us, please feel free to add any comments on this subject at the bottom of this post.
*Don’t get me started on the lack of longitudinal studies on the magical cure-all that is CBT but if you’re interested, we’ve now seen the first publicly available longitudinal study – and it shows that it doesn’t work. In Sweden, much like the UK and USA they have wholeheartedly embraced CBT at the expense of all other modalities. A recent in-depth study has shown :
(That’s USD $150,516,850,328 or in the UK £95,139,793,241)
elizabethdavid
/ August 29, 2012I wonder if you have considered the Gestalt theory of the Paradox of Change? Briefly, that change can happen only once I can accept fully where/how I am now. Until then I am blocking the possibility of change by wishing I could be different. Within UPR the acceptance, realisation and insights that you refer to can occur, and I’m free to allow what needs to happen to happen. But the change comes from within, (as the Buddhist hot-dog seller said to the man who had asked him to “make him one with everything”, handing over a $20 bill and waiting for the change).
WG
/ August 29, 2012Yes.. this is why Gestalt melts my brain (let alone anything to do with Reichs)
To clarify.. this concepts negates the desire for change, correct? Or does it allow room for desire-for-change, only once acceptance has been achieved?
And you talk of the Buddha (Jaypsyd will love this..) are you suggesting that change flows from acceptance without conscious effort?
Fascinating stuff..
Vanessa
/ August 29, 2012My response from FB:
This isn’t quite fully formulated, but… here goes: I think that insight is what happens *after* you change. Therapy isn’t about insight — it’s about having a different experience with another human being than you’ve had all your life. You learn to *be* in a different kind of relationship, you learn to express your feelings, to recognize the transference, and to notice your resistant walls that you keep up in order to avoid moving forward. In this different kind of relationship, you have insight about yourself in the present, which then makes you see how screwed up things had been for you in your past relationships and why. The insight is kind of a side-effect, not the goal. Did that make any sense?
WG
/ August 29, 2012Does make sense Vanessa – thank you
I think what I’m struggling with is the connection that is assumed by the therapist between “in the room” and “the real world”. ie… I lead/guide/enable/empower (bletch) depending on modality and … ta da! change is achieved in the real world. That’s where I see a lack of connectivity/accountability. I anticipate that in most cases, therapy ends long before any lasting real-world change can be effected.
But that’s another post..
Vanessa
/ August 29, 2012That IS another post. Maybe I’ll write one!
Rebekah
/ August 29, 2012Before I entered school and since, I’ve learned more about therapy from reading and working with the psychotherapists/hypnotherapists at Uncommon Knowledge than from school (where we mainly just talk about theory). And one of the things Unk talks about is giving your client “proof” that change has actually happened, that they’ll be able to carry what they’ve learned in the therapy room into the real world.
You’re right that this is an idea that seems to be lacking from the minds of many therapists.
Jason Evan Mihalko (@jaypsyd)
/ August 29, 2012As much as I love Gestalt therapy (I studied in Cleveland with students of Fritz and Laura), I think it is important to be mindful that Gestalt tends to overlook biological factors and is almost totally absent in discussing the limitations that oppression creates on human potential. The Gestalt focus on I, and self empowerment, generally fails to look at factors that an individual has little to control over.
Change from a Gestalt perspective is generally a change in awareness, perception, or interpretation. At least that is what the Cleveland school would say.The Polsters and Joseph Zinker offered up so many refinements and additions to Perls’ original though. A useful way to think about change from the Gestalt perspective is the cycle of awareness which is is at the heart of the Cleveland school.
Essentially: sensation —-> awareness —–> Mobilization of energy —-> action —-> contact/change —-> withdrawal/satisfaction —-> returning to ground/fertile void
Disorder comes from problems withing this cycle of awareness. Again, the focus is on the self, and what the person is doing/not doing. Fritz and others neglected an analysis of culture, power, oppression, economics, class….
See: http://www.clevelandconsultinggroup.com/articles/emergence-gestalt-approach-to-change.php for a decent articulation of the Cleveland school’s take on Gestalt and change.
WG
/ August 29, 2012Ahhh hello my little lotus dweller.
Yes – have been reading about cycle of awareness.. but does not Gestalt align nicely with your Buddhist tenents .. ie that change/acceptance comes from within – acceptance of what is in order to achieve whatever change is possible?
And yes.. am very aware of the organically-grown, electronically blended concoction that Gestalt practices have become. Tis a big pile of espagettis that I’m working through at the moment.
(but if we’re really going to get into gestalt then I’ll have to get The Silver Cat involved..)
Do you think that Gestalt ignores/diminishes/discounts/disregards the historical context (all that psychoanalytic digging) as well as the current/socio-economic/cultural?
lechatdargent
/ August 29, 2012No
Gestalt is explicitly field theoretical. The field theory in question states: behaviour is a function of an organism in an environment. To understand behaviour, it must be put in context, and the whole point of the concept of creative adjustment is to explain behavioural patterns in terms of adaptation to an evolving lifespace (aka the organism/environment field).
Gestalt doesn’t ignore the historical, it just starts with the here and now, and explores the historical as an organising principle of current experiences. And the gestaltist that ignores socioeconomic, political and cultural factors isn’t a gestaltist.
WG
/ August 30, 2012Ah hello Monsieur le Chat! thank you for joining us
Yes – this is more in line with my understanding.. ie “the field” doesnt have to be present tense only.. however many of the Gestalt texts seem to imply this, or at least are not so clear. (or perhaps I simply misunderstand).
Rebekah
/ August 30, 2012There’s a similar misunderstanding regarding solution-focused therapy. I’ve encountered classmates who believe that SFT completely ignores the past, but you can’t! At the very minimum, you have to at least ask the client what happened (in the past) to cause them to visit you, right?
It’s more that the past isn’t dealt with as much as in theories like psychoanalysis.
WG
/ August 30, 2012But equally, (and I think this is where the “balance” comes in), these are not therapies that lock you in the past, going round in circles gathering “insight”, being interpreted by (let’s face it) one person’s opinion plus stack of dusty books on Freud.
I’d much rather a world that believed that the answers lie within the client and see the therapist as facilitator rather than some kind of captor.
That way.. the therapy might one day end!
Rebekah
/ August 30, 2012EXACTLY.
This is what I was alluding to in another comment, about why it took so long for me to get on this path.
lechatdargent
/ August 30, 2012It’s a bit of a head fuck, but I think the knack is to make this realisation:
There is no such thing as memory, only remembering; and remembering is a present tense activity.
Strictly speaking, my organism/environment field has to be present tense because past and future don’t exist, only now exists. I just understand ‘the historical’ to be an element of my field that operates in the present.
I guess an example would be if I broke my leg as a kid and ended up with a limp. My historical account of having broken my leg way back when is, by itself, fairly irrelevant. What’s relevant is that my history (breaking my leg as a boy) is an active element of my present experience (walking with a limp). So my history operates as a personal myth that puts my present experiences in context.
So it’s untenable to not consider the historical. However, the historical is only relevant in so far as it contextualises what is happening now.
WG
/ August 31, 2012I really like this idea, M.Le Chat.
There is far too much self-doubt around history/memories or how they are interpreted/reflected back to the client by this or that therapist/practitioner. I rather like to consider that one must accept them as they are (bit of Buddhist accepance there for @jaypsyd on his lotus blossom) and deal with them however they impact on the now… so that the present is part or result of the whole narrative.
Not that I am referring to Narrative Therapy (which is a separate thing) as I equally disagree with the externalisation/depersonalisation of events.. bit too much like examining one’s life in a petri dish
recoverynetwork:Toronto
/ August 29, 2012Nice one . Do you have a link / ref for that publicly available longitudinal study ? CBT can be useful – I have found it of some use. It’s just not “the answer” it seems to have been adopted as [like drugs] – no therapy is…there just isn’t one. I simply wish the T in cbt were used to mean “tools” because that’s mostly what it is: a bunch of tools, thinking tools if you like, that a person can learn to use, and use with a little help, a lot of help – or none. Kevin H
WG
/ August 29, 2012yep – you need to click the hyperlink in the body of the text above. That will take you to the reference site (though am sure it will be in swedish).
CBT is like any treatment.. from chemotherapy to spoonbending.. some of it works for some people and when it does (without harming anyone physically, emotionally or financially or indeed in any other way) then that’s marvellous. But saying it works for everything and then foisting it on an entire population as the only option is narrowminded, oversimplistic, led by fiscal rather than humanitarian motivations and.. frankly.. a load of bollocks. As we say here Britain.
recoverynetwork:Toronto
/ August 29, 2012Thnks WG. Yeah! now we’re talking – especially since “bollocks” is my all time favourite word.[but then I am from over there] nothing like it for binding together thought, emotion and visceral somatic experiences, though a punchbag bearing a politicians face does come close….
There’s going to be a session on CBT at the World Hearing Voices Congress in Sept. some of us who hear voices have a violent reaction to being CBT-d upon..
..and spoonbending therapy sounds worth a try- when they’re all bent outta shape like that where do I shove em?
Thanks for the tip on the link ….now all I need is me universal translator, now where did I last have that thing?….
Rebekah
/ August 29, 2012I’ve said repeatedly during my coursework that the reason there are so many theories is because there’s no such thing as a panacea in therapy – no “one size fits all”. Even my professors have stressed that sticking strictly to one theory is limiting yourself and that they and most people they know are “integrative” therapists – you may align yourself with a particular theory, but you borrow heavily from others to meet the needs of a given client.
So, yes. I wholeheartedly agree that this move towards CBT as a cure-all is a mistake.
Jason Evan Mihalko (@jaypsyd)
/ August 29, 2012I think what you describe Rebekah is more an ecclectic therapist–a little bit of this and a little bit of that and if one is lucky, a grounding in one particular theory. An integrative therapist, however, seeks to take two or more theories and meld them together into a stand alone theory. Paul Wachtel is someone that comes to mind who has written a lot about integrative therapy.
I am ow old enough (gasp) that I have seen more than a few “new” theories come into vogue that will treat all of the ills of society quickly, effectively, and better than eanything that has come before. I have come to see that we are all looking at different aspects of the same phenomena–life–and describing it from our own phenomenological perspective. No one is more true, or better, than the other.
Some seem just silly to me. I leave those theories to those who don’t find them silly.
Rebekah
/ August 30, 2012Mm, the way my professor explained it, “eclectic” used to be the term, but it’s frowned upon now (mostly because a lot of so-called “eclectics” were lacking that grounding you mentioned). She definitely used “integrative”. *shrugs* Anyway, I think I’ll call myself a “let’s try a couple things and see what works for YOU” therapist.
I feel a small pull towards Strategic for that reason, but I wouldn’t consider it my primary theory.
“I have come to see that we are all looking at different aspects of the same phenomena–life–and describing it from our own phenomenological perspective. No one is more true, or better, than the other. Some seem just silly to me. I leave those theories to those who don’t find them silly. ”
And there it is.
I recognized a while ago that there’s so much crossover between theories, it’s silly to pigeonhole yourself as a staunch, unwavering follower of any one theory – they’ve all “inspired” (borrowed from, repackaged, influenced, pick a verb) each other. To generalize, the whole theory thing seems to me to be less about “I have a new idea!” than it is “I need to be published, so I’m going to re-dress this older idea!” 
Factor in that studies show therapeutic progress is more about rapport than it is the particular theory used, and I’m left with the conviction that we just have to do whatever’s a good fit for both us (whatever makes sense to the therapist and can guide their actions) and the particular client (whatever will help them move forward).
Jason Evan Mihalko (@jaypsyd)
/ August 29, 2012“Do you think that Gestalt ignores/diminishes/discounts/disregards the historical context (all that psychoanalytic digging) as well as the current/socio-economic/cultural?”
Yes. By definition gestalt respects amd honors the past buy focuses on the here and now. I also think that it hadn’t even occurred to there folks that gave birth to Gestalt therapy that there might be people who were different than them.
With some exceptions, Gestalt folks usually talk about working “on the high side of normal.”
WG
/ August 29, 2012ah but those that “gave birth to it” (..foul image) cannot possibly be comparable to contemporary shrinks.. otherwise all psychoanalytically trained shrinks would be little carbon copy Freuds.
how can anyone choose and train and practice on any modality without themselves incorporating cultural and social elements of their own time/society/background even if just through some variety of involuntary osmosis..?
Rebekah
/ August 30, 2012“how can anyone choose and train and practice on any modality without themselves incorporating cultural and social elements of their own time/society/background”
They can’t. Not if they’re a good therapist (by my definition, anyway). It’s an ineffective therapist who sticks strictly to the “rules” of their theory, never wavering or taking anything else into account. IMO. YMMV.
WG
/ August 30, 2012I wonder Rebekah, if it comes from “choosing” (electing?) a modality too early.. in Freud’s day (pr perhaps just the 50 years after), one chose a master and modelled one’s practice thereupon. My understanding from those in training now that I talk to, is that one gains a wider understanding across modalities (ie a University/Masters type education in “Psychotherapy”) and then elects and refines practice within the chosen field. Of course this field is influenced by whoever your professor/mentor/supervisor is (I refer you to the training stats here http://talesoftherapy.wordpress.com/2012/07/24/pedigree-therapy-tales-361/ )
Which, we hope, will produce a more rounded approach across the board. Or, you know, perhaps not.
Nevertheless, it is true that many practice in a narrow field and do not examine theory across modalities to see what can be of beneficial to them and their practice/clients.
On the other hand, perhaps that’s a British thing.. ?
Rebekah
/ August 30, 2012Hmmm… I think there’s a point in there.
First, though, I have to relate that I don’t feel like I “chose” my theoretical base – it chose me. I did some study into psychology back in high school and early university, but the focus of those classes was in the wrong area to really grab my attention. It was much later – years after I’d earned a BA in English and had been working in “the adult world” for a while – that I was exposed to a much different theoretical approach and had that “lightbulb” moment: “Oh, okay, yeah. THAT makes sense! NOW I could see myself pursuing this as a career.” (There were other factors, too; it was a “perfect storm” time in my life where a lot of things had to click into each other.)
And it’s been interesting going into a graduate program with that base already there, adding onto it with bits and pieces from other theories I’ve had to learn about. I definitely think I’ve had a different experience in the program than some of my classmates because of it.
Overall, though, your comment reminded me of a Twitter conversation Jason and I had one day. As I recall (it’s late, so I might be wibbly here), the crux was that school is where you learn “the rules” and then you graduate and learn how to bend/break the rules – what your personal approach is going to be, how much and when you’re going to listen to those who preach how it “should” be done (say, appearance or office decor or patting a weeping client on the back)… I wonder if it might be said that those who stick to a “narrow field” or allow themselves to be over-influenced by a supervisor’s way of doing things just don’t want to stick their necks out and take their own risks? If that makes any kind of sense.
WG
/ August 30, 2012Completely
Jason Evan Mihalko (@jaypsyd)
/ August 29, 2012I think what I’m struggling with is the connection that is assumed by the therapist between “in the room” and “the real world”. ie… I lead/guide/enable/empower (bletch) depending on modality and … ta da!”
The notion is that when you are working in there here and now (what is happening in the room, in the relationship, in that moment) you are relating and being present I new ways. The assumption (magic?) is that the new pattern of being, relating, and connecting is carried over into relationships outside the office.
WG
/ August 29, 2012there you go with those assumptions again…
i understand the concept of micro/macrocosm.. but still wondering how the behavioural/change transfer occurs, is monitored or demonstrated. I guess now we’re getting into evidence-based practce again and what constitutes “sucessful treatment outcomes” in the final analysis..
Attachment Girl
/ August 30, 2012“The notion is that when you are working in there here and now (what is happening in the room, in the relationship, in that moment) you are relating and being present I new ways. The assumption (magic?) is that the new pattern of being, relating, and connecting is carried over into relationships outside the office.”
Jason, I just wanted to very much agree with this from a client’s perspective. So much of what I learned in therapy was carried out into the world, because I implicitly learned it by relating directly to my therapist and being able to talk freely and examine the relationship. Learning to move closer to him, has taught me to understand why I wasn’t doing that before, the net effect being that I can now move closer in the relationships in which I chose to. And as I have begun to live more fully (IMHO, the goal of an “effective” therapy), I have lost track of the amount of times I have handled a situation, then pulled up short thinking “How did I know how to handle that?” and realized the answer was that I had watched my therapist handling the same situation with me. In some ways, therapy for me was a relationship apprenticing; I learned by being with an attuned other, and emulating what I experienced.
WG, I also found this strip very timely, as I recently put up a post on accepting the :”Not so pretty” parts and in writing it, came to a conclusion very similar to what you wrote in the comments after the strip: “Insight leads to (self) knowledge and (self) acceptance. This (self) acceptance reduces shame, and ultimately creates a desire for change or alternatively, creates an environment conducive to change.” I realized that experiencing acceptance that removed the NEED for change, freed me up to want change and see myself as having the efficacy to enact the changes I wished to.
Last but not least, on a very personal level, I really appreciated this one because of recent experiences on the Crisis line I volunteer on. It;s felt like someone is putting angry juice in the water around here, and I have been through a string of people furious that I am not helping them the way they think I should be. Get kicked in the teeth enough times for daring to volunteer your time and effort to help, and being told what a total S%^& you are for doing so, does lead to wanting to say F*&* it. It was actually a relief to read this one, thanks!
PJ
/ August 29, 2012I just got in from a “bad day”, ending with talking to a friend about how some days you just don’t have the resources, and lo and behold…the perfect cartoon. This cheered me right up.
WG
/ August 29, 2012huzzah! clearly my attunement-o-meter is working on full throttle. Here’s hoping tomorrow is better!
Jason Evan Mihalko (@jaypsyd)
/ August 29, 2012“otherwise all psychoanalytically trained shrinks would be little carbon copy Freuds.”
We still have a analytic folks here in Boston that are busy talking about penis envy. Very much by the Freud book sorts. Though there are contemporary folks too.
“how can anyone choose and train and practice on any modality without themselves incorporating cultural and social elements of their own time/society/background even if just through some variety of involuntary osmosis..?”
Beats me. Well that’s a lie. I have a opinion (on everything). We here in the states often pretend to be color blind…and are blind to white privilege, and priviliege in general. You f therapists have an exceedingly hard time getting out of their box and seeing other world views. Old therapists have a hard time too.
Rebekah
/ August 30, 2012I like your opinions, Jason.
Jason Evan Mihalko (@jaypsyd)
/ August 29, 2012“but still wondering how the behavioural/change transfer occurs, is monitored or demonstrated. I guess now we’re getting into evidence-based practce again and what constitutes “sucessful treatment outcomes” in the final analysis..”
Now you want me to monitor and demonstrate change?? What’s next?
Your question may require a blog post.
WG
/ August 30, 2012Yes – do it!
Karen
/ August 30, 2012WHAT? You mean it’s inappropriate to tell them WTF??! I find that, if I do, I don’t have to worry about insight and change, it happens right there – in the here and now – and before they take that behaviour outside in the real world, they think twice.
WG
/ August 30, 2012I think we’ve combined two questions here for convenience.. not suggesting that the two are related.
Rebekah
/ August 30, 2012Karen, your comment made me laugh.
And made me remember that, although the “WTF” hasn’t been said as such, my own (school-required) therapist has called me on some stuff in that kind of tone of voice.
WG
/ August 30, 2012Is that not what Supervisors are for,…?
http://talesoftherapy.wordpress.com/2010/07/27/supervision-therapy-tales-35/
Rebekah
/ August 30, 2012HA!
I’ll let you know; I’ll be starting a supervised trainee post (if I can line up a site; visiting one next week) in late October.
worldof0iD
/ August 31, 2012It’s my new favourite TT.
WG
/ August 31, 2012thank you my dear
Julie
/ August 31, 2012What an interesting question. For myself, I would compare therapy to a dance studio, in which the different parts of the studio are represented by different aspects of the therapeutic relationship. All dance studios have a full-wall mirror in which to see yourself and what you are doing in order to understand it and improve. In therapy, that mirror is made up of the transference, as well as my therapist’s feedback to me. For example, if I’m constantly convinced she’s getting sick of me, even though there’s no evidence of that (and because it’s therapy, it’s actually OK to ask her about that), I realize it’s a reflection on my own incorrect assumptions which I am carrying around. Dance studios also usually have a barre, which is a support you can use to hold yourself up while you try something new and difficult. In therapy I feel brave enough to go out in life and try something new and scary if I know I can come crying back to my T if it doesn’t turn out well. The third thing all dance studios have is a space to practice in. Because the relational space in therapy is relatively clear, spacious, and safe, you can try relating in different ways from how you have in the past instead of being stuck in the same awkward head-nodding dance you always do at parties.
So there you have it, the dance studio theory of therapeutic change.
Rebekah
/ August 31, 2012That is a FANTASTIC metaphor.