Joe's Boston Talk

    Control Mastery (Broitman)

    Joe's Boston Talk
    by Joe Weiss, 6/26/97

    I am posting Joe's latest talk given this year in Boston- hope you all enjoy reading it!

    For a number of years my colleagues and I have been thinking about the question: How does psychotherapy work? We have investigated this question in various ways, including the careful study of case reports and the reading and re-reading of the process notes and transcripts of psychotherapies. We have developed a number of hypotheses about therapy that we have now tested and refined by numerous quantitative empirical research studies.

    I will begin with a brief summary of our views.

    We assume that the patient's problems stem from certain unconscious beliefs which we call pathogenic. These beliefs are grim and frightening. They may adversely affect the patient's self-esteem and they may prevent the patient from successfully pursuing certain adaptive desirable goals such as success, happiness, or a good relationship. The patient unconsciously wants very much to solve his problems. He suffers unconsciously from his pathogenic beliefs and he is powerfully motivated unconsciously to disprove them. He works to disprove them by testing them with the therapist, hoping that the therapist will pass his tests. For example a person who unconsciously believes that he is unattractive and likely to be rejected may test this belief by talking about stopping therapy in the hope that the therapist will show him that he (the therapist) wants him to continue in treatment. The therapist's task follows from above. It is to help the patient in his efforts to disprove his pathogenic beliefs and to pursue the goals forbidden by these beliefs. Unconscious Mental Functioning We assume that a person has powerful non conscious cognitive capacities. He is able to non consciously assess reality and to make and carry out decisions and plans. Our views are supported by the research of academic cognitive psychologists such as Lewici. Their research has demonstrated that a person's nonconscious thinking in some contexts is much more rapid and sophisticated than his conscious thinking. He can solve problems nonconsciously that he cannot solve consciously and that can never learn to solve consciously. He becomes conscious of the solutions to the problems but not of the processes by which he obtained them. A person also exerts control unconsciously over his repressions. He represses mental contents such as painful memories, motivations, affects, and ideas as long as he assumes that their becoming conscious would endanger him. He brings repressed contents forth when he unconsciously decides that he may safely experience them. The observation that a person unconsciously controls the access to consciousness of repressed material is illustrated by the phenomenon of crying at the happy ending. For example, Louise, a woman in her late thirties, many years ago suffered the death of her two year old son. She was overwhelmed with grief and repressed it, and in doing so, she repressed the memory of her son to the point that she could no longer recognize him from his picture in the family album. Nine years later she had another son from a second marriage. When this son was brought to her room in the hospital, Louise burst into tears and for the first time in years brought forth memories of her first son. According to my explanation the birth of her second son made up for her previous loss and reduced her sense of overwhelming grief. This made it safe for her to remember her sadness and her sense of loss. An important point here is that Louise was surprised by her sudden weeping and by her suddenly becoming conscious of the memories of her first son. She did not consciously decide to bring the sadness and the memories to consciousness. She brought these forth when she decided unconsciously that she could safely experience them. A patient in therapy also regulates his repressions. Like the person who cries at the happy ending he brings forth repressed mental contents when he unconsciously decides that he may safely experience them. Psychopathology As I already stated, the patient's problems are rooted in pathogenic beliefs. The patient acquires these in infancy from traumatic experiences with parents and siblings. These beliefs are about morality and reality. For example a patient whose parents failed to protect him developed the belief about reality that he was not going to be protected and the moral idea that he shouldn't be protected. The patient's pathogenic beliefs may be extremely compelling. They are acquired very early in life at a time when the future patient considers his parents to be absolute authorities. The infant and young child has no prior experience by which to judge is parent's teachings and attitudes. Moreover, he needs them to survive and he must learn to adapt to them. Our definition of belief is broad. We count as beliefs structures that are non-verbal and that may never have been conscious. The beliefs of the infant and young child are not encoded in words. They are stored, according to Stern, as RIGS, that is Repetitions of Interactions Generalized. Even after a person has developed language he still continues to acquire non-verbal unconscious beliefs. Beliefs are almost always accompanied by affects. A person who believes that the world is a dangerous place is anxious and tense. A person who believes that he is likely to succeed is optimistic and cheerful. Sometimes the patient's affects lead him t his repressed beliefs. For example a patient first became aware through his anger to his parents that he believed his parents had mistreated him. We refer to the mental structures underlying psychopathology as beliefs rather than fantasies to emphasize that they are about reality, and that they are grim and painful rather than wishful. Freud followed this usage in his discussion of castration anxiety. He consistently wrote that castration anxiety stems from a belief or conviction and not from a fantasy. The belief in castration as Freud wrote about it is from our point of view an excellent example of a pathogenic belief. Freud assumed that the belief in castration is unconscious and that it may give rise to psychopathology. He also believed that it is acquired by normal processes of inference from traumatic experiences, such as from castration threats and the sight of the female genitals. Moreover the belief in castration is grim and not wishful. Here are some common pathogenic beliefs: I am bad and unworthy. Nothing I do will work out. If I am strong, I will hurt my parents. If I leave my parents, I shall upset them. If I am demanding, I will burden my parents. Anything I achieve is at the expense of my parents; therefore I should not achieve much. (This is the belief behind survivor guilt.) If I am friendly, I will be rejected. The Therapeutic Process Our theory of the therapeutic process follows from the above. It is the process by which the patient works with the therapist consciously and unconsciously to change his pathogenic beliefs and to pursue the goals forbidden by them. The patient works to change his pathogenic beliefs by testing them with the therapist and by using the therapist's interpretations to learn that he suffers from pathogenic beliefs and that these beliefs are false and maladaptive. He tests the beliefs by carrying out trial actions, affects or assertions that, according to the beliefs, should affect the therapist in a particular way. He hopes that the therapist will not be affected as the beliefs predict. If the therapist does not react in accordance with the beliefs, the patient may take a small step toward disproving the beliefs. He will also feel safer with the therapist. As we have demonstrated in our research, the patient reacts immediately after the therapist passes a test or offers a helpful interpretation: 1) He becomes less anxious. 2) He becomes bolder. 3) He becomes more insightful. 4) He experiences what he is talking about more fully. The patient also reacts to interpretations by changes in his pulse rate, skin conductance and body movement. We studied these changes in a thirty year old depressed woman who is married to a graduate student at the University of California. (This study as carried out by Stewart Ablon and Nnamdi Pole with the help of Lynn O'Connor). The therapy, as the patient knew in advance, was for 16 sessions. The patient and her husband were both Mexican and had two children. She wanted to go to graduate school but was held back by several pathogenic beliefs. She believed that she would surpass her husband and so hurt him. She also believed that it was unfair and disloyal to her mother to have children and have a career. She believed that her mother had wanted a career but sacrificed herself by staying home to take care of the children. Throughout the therapy, we kept a record of the patient's pulse rate, skin conductance, and body movement. We also video taped her. The segment shown in this transparency is from session 13. The patient in a previous session had stated that she was planning to quit a rollerbladding group because her husband was joining it and would be a better skater than she. In session 13, the therapist said that she might have a lot of fun rollerblading and might be a better rollerbladder than her husband and that she would be quitting the group in order to protect her husband's self-esteem. Before the therapist finished the sentence, the patients pulse rate, body movement, and skin conductance all declined. This shows the patient was relieved by the interpretation and so felt safer and more relaxed. She also changed her facial expression. He face became relaxed and she look thoughtful.

    However, though the patient was relaxed as shown by physiological measures, she dismissed the interpretation by saying the rollerblading was silly. However, she said a moment later that her mind had gone to a different place. She then described her feelings of watching her mother die six months ago. She wanted to share her mother's pain. She wanted to put herself in her mother's place. She felt she was betraying her mother by living. She also stated that she did not quite understand why she was saying these things. Later in the hour, she returned to the topic of her husband. He is very brilliant but a little disorganized. She had the thought thinking about his disorganization that she might have an easier time getting a dissertation done. I would like to make two points about this: 1) the patient reacted nonconsciously to the interpretation by becoming relaxed before she consciously acknowledged the value of the interpretation. 2) The interpretation set off a chain of thought about disloyalty and guilt. First to her mother and then to her husband. This chain of thought was carried out partly nonconsciously. As the patient noted later, she was not aware of the connection of her concern about her husband and her concern about her mother.

    The patient was given the Beck Depression Inventory every 4 sessions. This measure shows that she had a moderately severe depression at the beginning of the therapy and was not depressed at the end of the therapy. She made especially rapid progress after session 13.

    The Unconscious Plan The patient in therapy works in accordance with a simple, unconscious plan which tells him in a very broad way which direction to go. It tells him which problems to tackle at any one time and which ones to defer. In making this plan, as in making a conscious plan, the patient takes account of many things including his strengths and weaknesses, his opportunities, his anxieties, and the personality of the therapist. In making the plan he is especially concerned with avoiding danger and retaining a sense o safety. The idea of an unconscious plan seems counter-intuitive to many therapists. However, as Miller, Galanter, and Pribram have argued forcefully, it is almost impossible to conceive of psychological behavior that is not done in accordance with a plan. The idea of unconscious planning applies to patients who seems to have no direction. Such a patient may be testing the therapist as a part of his working towards a particular goal. An example of this has been reported by Renik (1995) who, however, did not refer to the patient's behavior as testing. When Renik told his patient that she seemed to meander without purpose, the patient answered that she was attempting to assure herself that Renik would not impose his agenda on her.

    The idea that patients are motivated to solve their problems is supported by evolutionary psychology. It is implausible that evolution would produce the kind of mind that Freud postulated in his early theory 1900, 1911-1950. A person with such a mind would be severely handicapped in his efforts at adaptation. He would be at the mercy of powerful fluid unconscious forces over which he had little or no control and he would not be well suited for survival.

    Evidence of Planfullness is supplied by infant research (Stern, 1985). According to Stern infants after birth begin to make and test hypotheses about their care givers in an attempt to learn how to develop a secure relationship with them. Their behavior s described by Stern is like the testing carried out by adults in therapy. The infant's behavior does not depend on language or a highly developed conscious mental life. The infant's behavior demonstrates that from the earliest stages of life the human as adaptive goals and works to obtain them.

    We have found support for the plan concept from our own research. We found in numerous cases that interpretations that our judges assumed should help the patient to carry out his plan (referred to us as pro-plan interpretations) tended in fact to help the patient to do so. After such interpretations the patient became more relaxed, bolder, and more insightful. However, the patient did not react that way after interpretations that our judges assumed should not help the patient in his efforts to carry out his plan.

    Mrs. G. I will give a case example illustrating a patient's plan. Mrs. G., a professor of Art History, began analysis suffering from the belief that unless she complied with the analyst, she would upset him. She felt endangered by this belief. She feared she would feel compelled to comply with the therapist and so follow bad advice or accept false interpretations. Therefor Mrs. G decided unconsciously that she must begin by working to feel safe with the therapist. She set out to assure herself that she could safely disagree with him.

    Mrs. G had acquired in her childhood relations with her father the belief that she must agree with men lest she hurt them. Mrs. G's father (and to a lesser extent her mother) had been perceived by her in early childhood as possessive and vulnerable. According to the patient, her father had been intensely involved with her. He had been pathetically eager for her to admire him and to accept his opinions even in trivial matters.

    When Mrs. G disobeyed her father or disagreed with him even in small things, he would become upset. A vivid example of this occurred when Mrs. G was 6 years old. Her father had asserted that a horse never takes all of its hoofs off the ground even while galloping. Mrs. G responded by showing her father a photograph from an encyclopedia of a horse galloping with all of its hoofs off the ground. He became very upset, whereupon Mrs. G felt guilty about showing him up and went to her room depressed.

    At the beginning of her analysis, Mrs. G worked unconsciously by testing the analyst (and, by the same tests, her pathogenic beliefs) in order to disconfirm the pathogenic belief that if she were assertive with the analyst she would hurt him. For example early in these sessions, Mrs. G spent part of an hour making fun of the analyst for having his name on the office door. She complained that its presence there exemplified his bad taste. A few weeks later she complained that the noise made by men working down the hall was disturbing her. She thought the analyst should ask them to stop working, and when he did not she accused him of being a Caspar Milquetoast.

    Mrs. G was anxious or tense while criticizing the analyst, and her voice became shrill. If, however, the analyst did not appear defensive, Mrs. G would assume that she had not hurt him and would relax. Moreover, she would remain relaxed for several sessions. While relaxed, she would be more cooperative. She would also bring forth new material, as, for example, new memories of having hurt her father.

    She reacted in much the same way to the analyst's telling her that she was afraid of hurting him. She could use these interpretations in her efforts to disprove her pathogenic beliefs (we call such interpretations "pro-plan interpretations"). In my opinion, she would have been upset by the interpretation "You are afraid to trust me". This would have been an "anti-plan interpretation". She would have experienced it as confirming her belief that the therapist wanted her to agree with him and s she would have felt endangered.

    After about six months of analysis, the patient became convinced that she could disagree with the analyst without hurting him. This enabled her to cooperate with him and to feel fond of him. She could feel safe in cooperating with him once she knew that she could disagree with him. Also, after six months Mrs. G. brought forth a sexual fantasy of being spanked by the therapist. She could express the sexual fantasy of submission when she knew that she did not have to submit.

    The Case Specific Approach

    The therapist's approach and attitude to the patient are case specific. They depend on the therapist's assessment of the patient's particular pathogenic beliefs and goals and also the patient's ways of testing his pathogenic beliefs. For example, if the patient's primary belief is that he should be rejected, the therapist may be helpful if he is friendly and accepting. If the patient's primary belief is that he will be intruded upon or possessed by the therapist, the therapist may be helpful by maintaining a sense of formality and a relatively strong frame. I will now discuss the therapy of a patient that illustrates a case specific approach. In this example, the analyst's reaction to a major test was crucial to his passing it and indeed to the success of the analysis. Miss P.

    Miss P., a professional woman in her mid-thirties, came to analysis because she was unable to make friends or form intimate relationships. She was inhibited by a powerful fear of rejection. In childhood she assumed that the little interest her parents sowed in her expressed not affection but duty. The analyst, who considered Miss P.'s fear of rejection to be her paramount concern, tried to show her that he cared about her. He accommodated her frequent requests for schedule changes, took pains to answer her questions, and showed a lively interest i the various topics she introduced. The analyst also interpreted Miss P.'s fear of rejection. Miss P. agreed with this interpretation, seemed to feel calmed by it and confirmed it by examples from childhood and everyday life. However, she did so without experiencing the loneliness, sadness, and humiliation that are usually part of the experience of being rejected.

    During the first three years of her analysis Miss P. made slow progress. She achieved a better position at work, made a few friends, and began to date. Then one day in the fourth year of analysis Miss P. announced that she planned to stop treatment in tree months. She stated that she had achieved what she had come for. The analyst reacted by implicitly opposing Miss P.'s stopping. He interpreted it as motivated by her fear of rejection. He told her that she was afraid he would reject her and so was planning to reject him first, that she was afraid she was a burden on him, and that she assumed she did not deserve more help from him. Miss P. again seemed pleased. She told the analyst that his interpretations made sense. However, she was not helped by the interpretations to experience affectively her sense of rejection Moreover, she persisted in her plan to stop. Then, as she came close to her deadline, she responded to the analyst's questions by acknowledging that she was not sure why she was so determined to stop. The analyst urged her to continue until she understood more about this. She grudgingly agreed to continue until she understood more about her plan to stop treatment.

    A few days later Miss P. brought forth poignant memories of maternal rejection. She became intensely sad while reporting these and wept during most of the analytic hour. Though these memories were painful the patient did not re-repress them. Rather, she kept them conscious and used them to understand herself. Nor did Miss P. threaten to stop treatment again. She continued in analysis for four more years and was helped considerably by it.

    In her test of the analyst Miss P. made it easy for him to reject her and difficult for him not to do this. She assumed that if the analyst did not care about her he would take the line of least resistance and permit her to stop. Miss P. was moved by the analyst's urging her to continue. She began to feel cared for, and this made it safe for her to bring forth her memories of rejection. Her experience of the analyst's concern for her was crucial for her to feel safe with him. A central part of Miss P.'s analysis was the analyst's reaction to her rejection test. Before the analyst passed this test, Miss P. thought of him as dutiful but unconcerned about her. She did not feel accepted. Her pathogenic belief was not changed. he did not consider it safe to expose her sadness to him. She would have felt all the more hopeless and ashamed if her expressions of sadness had been met by indifference. If the analyst, out of concern for Miss P.'s autonomy, had remained neutral while she was trying to decide whether or not to quit treatment, he would have failed her test. She would have left treatment not much helped and with her pathogenic belief that she deserved to be rejected confirmed by the analyst's permitting her to stop. Nor would the analyst have protected her autonomy, for although Miss P. could not acknowledge it and indeed was not conscious of it, her wish to continue treatment was more powerful, more adaptive, and more central to her personality than her wish to stop.

    Another illustration of the value of a case-specific approach occurred in the analysis of a patient whose psychopathology and analysis are analogous to those of Miss P. Miss P. experienced her parents as rejecting; she developed the belief that she did not deserve to be accepted; she gave the analyst a powerful rejection test; and she brought forth new and significant memories after the analyst passed this test. The patient presented below experienced his parents as failing to protect him; he developed the belief that he did not deserve protection; he gave the analyst a powerful protection test; and he brought forth new memories of being unprotected after the analyst passed this test. Some analytic patients especially during the opening phase of treatment feel endangered by any interpretation. They equate the analyst making interpretations to a parent lecturing them, pulling rank, limiting their freedom, or giving them unsolicited advice. With such patients (and indeed with all patients) the analyst's first priority is to help the patient to feel safe. Therefore the analyst should refrain from interpretation or use it sparingly until the analyst receives some indication that the patient no longer is endangered by it. Until then the analyst may communicate by passing the patient's tests and by his overall approach. If the analyst helps the patient by non-interpretive means to feel less endangered so that the patient becomes less defensive and develops insights on his own, the analyst may add to the patient's developing self-knowledge by providing the patient with explanations that help him to organize this knowledge. For example, if the patient brings forth a traumatic childhood experience, the analyst may point to the pathogenic beliefs he inferred from this experience and show him that he is still struggling to change these beliefs.

    Mr. T. C.

    Before his first interview with Mr. T. C. the analyst had heard from the referring family physician that Mr. T. C. was depressed and having difficulty working. Mr. T. C.'s parents, siblings, and wife all worked hard themselves and all were worried about is not working. However, during his first session Mr. T. C., a computer programmer, who knew that the analyst had been informed by the referring physician of his difficulty working, did not talk about this problem. Instead he chatted informally about the computer he saw in the secretary's office. He talked about its capabilities and discussed various programs that the secretary might find useful. He also talked about several friends and acquaintances whom the analyst knew.

    The analyst became aware that Mr. T. C. was doing the same thing in analysis as in everyday life, that is, making a point of not working. The analyst was tempted to point this out. However, he suspected the patient's wife and parents had been nagging hi to work, that he resented this, and that he was testing the analyst to determine whether the analyst would also try to induce him to work. Therefore the analyst decided not to question him and indeed not to offer any interpretations until the patient gave some indication that he wanted to be helped interpretively. The analyst simply showed interest in whatever topic the patient introduced. In Mr. T.C.'s second session he continued to talk in the same vein as in the first. He looked very comfortable. He took off his watch and glasses. He took out his wallet and keys and put them on a chair in the office. He also draped his legs over the arm of the chair. He made a joke about not liking to feel constricted. About two weeks after Mr. T. C.'s first session the analyst received a call from the referring physician stating that Mr. T. C. was feeling better and beginning to work more enthusiastically. (Mr. T. C. made no mention of his working.) The analyst inferred from this that he was on the right track and continued his non-interpretive approach. Over a period of time the patient began to talk more freely about himself. After several months he talked about the high value he placed on a sense of freedom. He stated that he felt constrained by a schedule and he linked his need for freedom to the constraints his parents had placed on him. They worked all the time and were uncomfortable when he did not. If he watched T.V. they would remind him of tasks that he had not completed. At this point the analyst told Mr. T. C. that he had apparently accepted his parents' opinion that he should work all the time and was now struggling against believing this. Mr. T. C. seemed pleased and agreed. As a consequence of these and other comments the patient became less averse to interpretation. Though the analyst continued to treat the patient mainly by his attitude, he made a number of comments designed to help Mr. T. C. fit his memories and his current problems into a broad explanatory framework, thereby enabling him to understand himself better and to see himself more sympathetically. Mr. T. C.'s difficulty working was rooted in the pathogenic belief that he should work very hard and should not enjoy leisure or freedom. In childhood he had felt so burdened by his parents' insistence that he always be working that he had become averse o doing any work. In his analysis he feared that the analyst would insist that he work continuously on his problems and so confirm his pathogenic belief that he should not feel free in treatment to talk about whatever he wanted. When the analyst did not insist on his working Mr. T. C. permitted himself to become more relaxed both in his everyday life and in his treatment. As he felt more free and began to enjoy his leisure he found work less burdensome.

    I will report now on a research study carried out by Polly Fretter, a member of our group, which demonstrates shifts in the patient's level of experiencing in response to the therapist's interpretations. Fretter's study was carried out on the transcripts of 3 sixteen session psychotherapies. I will briefly describe the steps Fretter took in carry out the research. 1. First Fretter had a group of judges determine the patient's plan. They did this from the transcripts of the intake in the first therapy session. They reached a reliable agreement about the patient's pathogenic beliefs, goals, how she would test the therapist, and the insights that would help her reach her goals. 2. Fretter then had another group of judges remove from the transcripts all the therapist's interpretations. She then gave them to a new set of judges in random order along with the patient's plan formulation. She asked the judges to rate each interpretation for the degree to which it should help the patient to carry out her plan. In other words, she asked them to decide to the degree to which each interpretation was pro-plan. 3. Fretter then removed from the transcripts a one minute segment of the patient's therapy from just before each interpretation and from just after each interpretation. 4. Fretter then presented the segments in random order to another set of judges who were asked to rate each segment on the experiencing scale. This scale measures how fully the patient is experiencing what she is talking about. High indicates lack of defensiveness and correlates very closely with measures of insight. The judges did not know whether the segments they were rating came from before or after the interpretation. Nor do they know what part of the therapy the segments came from. 5. Fretter then correlated the Planfullness of each interpretation with the degree of the shift in experiencing from before the interpretation to after the interpretation. 6. Fretter then calculated the average Planfullness of the interpretations for each therapy hour and the average degree of shift of experiencing from before each interpretation to after each interpretation for that hour. The correlation's were very high. They range from 0.6-0.8. 7. Fretter also showed that for these 3 cases, the ratio of pro-plan to anti-plan interpretations predicted the outcome. Specifically it predicted the rank order of the outcome as measure 6 months after the termination of the therapy. The patient with he highest proportion of pro-plan interpretations had the best outcome and the patient with smallest proportion of pro-plan interpretations had the worst outcome. Of course outcome studies on 3 patients have really no statistical significance.

    Conclusion The patients suffer from unconscious pathogenic beliefs. They are highly motivated to work in therapy to disprove these beliefs. They work throughout therapy by testing the therapist. They work unconsciously in accordance with an unconscious plan. The therapeutic process is the process by which the patient works with the therapist to carry out the plan.

      • Control Mastery Theory as General Psychology by Vic Comello, 7/2/97
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