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  • Chris Allan is a clinical psychologist and Director of the Psychology Clinic at the University of Wollongong. He has a strong interest in both cognitive and psychodynamic therapies and an ongoing fascination in the interaction of technology and psychology. His interests are varied and include martial arts, playing guitar, cooking, chess, clothes, poetry and computer gaming. He is married with two children two dogs and a budgie.

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Gary Fulcher

And sometimes a cigar is in the mirror. By this, I mean that Dr X appears to be full of hatred, pettiness, shame & despair, but I would like to see the evidence that all human beings are so imbued & I refute the claim that all therapists share this situation with all their clients. I think he also misses the point that most "psychotherapists" miss - that is that CBT is a methodology, not a way of working with clients. Successful therapists of all models require the micro-counselling skills to establish relationships with their clients that are mutually beneficial. When that happens clients come back & engage in therapy, when it doesn't, they don't. So good CBT requires exquisite "deep listening" so that the contingency management is woven into a strong therapuetic relationship that can withstand the stress of methods such as exposure or affect-laden processing of great power. The constant accusation that CBT is purely mechanistic is simply faulty & its perpetuation is defensive.

DrX

Dr. Allan,

Thank you for your generous comments on my post, 'On Conservatives, Fundamentalists and Psychotherapists ( http://tinyurl.com/yjd63e ). I am most grateful to you for your choice for the 'money quote.' The sentiments expressed in the paragraph you selected reflect important aspects of a larger perspective that I consider essential to empathy. As one very wise supervisor helped me to recognize several years into my training, if we are in the habit of unflinching introspection, there is nothing in the client with which we will not find a degree of familiarity, however unpleasant such personal acquaintance may be.

Rather than distance ourselves from the client and the client's material as if it is personally alien to us, I believe it is essential to recognize both the humanity and dignity of our clients as ‘beings’ who are like ourselves. All too often, clients experience neither of these fundamental recognitions when psychotherapists fail to recognize their shared humanity with their clients.

Underlying the porous division between manifest awareness and the more disturbing aspects of unconscious perception, human beings carry an implicit sense of self-alienation and alienation from others. This division might be described as the separation of tolerable mental constructions from unwanted, disowned perceptions. An approach to client’ communications arising from an appreciation for the existential alienation that is endemic to our selective, limited human consciousness can be of great value to the client. The psychotherapist’s honest and proper regard for this division as the normal and broken state of human affairs, helps to contain a great deal of the client’s anxiety about the emergence of troubling unconscious perceptions, particularly when those disturbing perceptions are associated with the therapist.

When the psychotherapist is game for deep, honest, ongoing exploration of the emerging client narrative, even when that narrative holds unpleasant implications for the therapist, the therapist implicitly conveys to the client that the therapeutic endeavor holds the possibility of addressing the endemic human sense of alienation. Latent meanings of client communication are generally neglected precisely because they serve to reduce anxiety associated with troubling unconscious perceptions by disguising those perceptions. As such, they are at the core of the endeavor to address the most troubling aspects of the client’s divided inner life and, thus, call out for the psychotherapist’s attention. When these communications address mistakes in our work, whether it is in the management of a client’s request or in some other intervention error, we would do well to recognize that clients often reveal the most troubling aspects of their perceptions of our work in symbolic form.

The example I provided in my post was intended as an alternative approach to the study of patient reactions to the therapist’s management of a request to self-disclose. My description does not represent an approach to which I adhere in some rigid or limiting way in my own work. It merely intended to bring into relief, the importance of attention to the latent supervisory meanings of client communication that appear to have been completely neglected in the original study. The approach I described in my post represents one facet of approaches that have been discussed by others, chief among them, Robert Langs and Merton Gill. In my own work, I actively grapple with continuing uncertainty that is influenced in no small measure by Heinz Kohut’s work and Stolorow’s intersubjective conceptualization of the therapeutic relationship. I don’t regard my uncertainty as a problem. I regard it as essential to my own ongoing transformation and to that of the client, as well.

Dr. Allan, I am tempted, here, to apologize for preaching to the choir since I have no reason to assume any fundamental disagreement on your part. I’ll refrain, however, from apologizing because I see nothing wrong with preachers and choirs speaking with one another every so often.

I enjoy reading your blog regularly and I intend to review it in my own blog when I catch up on my plan to regularly review the sites in my blog roll.

Regards,

Dr X
http://drx.typepad.com

DrX

Dr Fulcher,

Thank you for taking the time to respond to my post. I realize that Dr. Allan mentioned Cognitive Behavioral Therapy, but I did not mention CBT or any particular theoretical approach in my post. I did lament the commonplace lack of interest in the latent meanings of client communication, as well as what I regard as the defensive lack of interest in unconscious processes within the psychotherapeutic community. I am not sure, then, why you’re in a fuss over my post. If your approach encompasses an 'exquisite' attentiveness to both the latent and manifest meanings of client material, I would applaud rather than lament your work.

The author of the study in question appears to have relied exclusively upon manifest client feedback to evaluate therapist handling of self-disclosure requests. If you are accustomed to listening with an 'exquisite' attunement to multiple levels of client communication, at minimum, I would have expected you to agree with my criticism of the study design, if not my larger criticism of the profession’s growing neglect of dynamic unconscious processes. Other than Dr. Allan’s comment, was there something that caused you to assume that I had judged CBT to neglect unconscious processes or that I had declared CBT a mechanistic approach? I do appreciate the informal, personal quality of exchange that we have available to us in this kind of forum, but it would be helpful if you would direct me toward some of the CBT literature on unconscious processes and latent meaning in client communication that you might rightly assume I have missed in my own study.

I also gather from your assessment of the pathology behind my post that you recognize countertransferential activity ('sometimes a cigar is in the mirror') and defensive projection as parts of mental life. I would be very curious to learn about how you deal with these phenomena when their manifestations impede the therapeutic progress of your clients, particularly when the client resists awareness of these phenomena. I assume, from your comments that you don't believe that you have any unconscious activity, so I'll settle for an understanding of how you manage these alien phenomena in your clients.

As for my own notions of exquisite listening, Patrick Casement has written extensively on the supervisory aspects of unconscious client communication (On Learning from the Patient; Further Learning from the Patient, The Analytic Space and Process; Learning from Our Mistakes: Beyond Dogma in Psychoanalysis and Psychotherapy). Casement is unusually frank and courageous in his coupling of explicit patient material with his own internal supervisory processes as he presents his inevitable mistakes as a finite, limited human being who must always grapple with his own defensive operations. Casement rejects illusory certainties in all forms (including the defensive use of theoretical dogma), while embracing the uncertain nature of awareness that is essential to non-defensive clinical work. I highly recommend any of Casement’s books, but I believe that his first, ‘On Learning from the Patient’ (1985; London: Routledge, http://tinyurl.com/y7shfk ) represents an extraordinary contribution to the therapeutic literature. It is an invaluable work for therapists who are unfamiliar with the unconscious supervisory aspects of client communication.

Respectfully,

Dr. X.

Dr. Coughlin

I just finished reading Dr. X's article and I must say that I find Gary Fulcher's reaction to be absolutely bizarre. Where did Fulcher detect "hatred, pettiness, shame & despair?" Did we read the same article by Dr. X? I expected to find some ogrish portrayal of patients and therapists when I jumped to Dr X's post. Instead, I found a thoughtful, compassionate discussion suggesting that we listen to the deeper elements of our patient's reactions to our interventions. Who could disagree with that proposal?

Chris Allan

Picking up from Dr Coughlin’s line:

Instead, I found a thoughtful, compassionate discussion suggesting that we listen to the deeper elements of our patient's reactions to our interventions. Who could disagree with that proposal?

While I agree with Dr X’s call for a deeper listening to the client’s material it odes raise some interesting issues. These are issues that psychodynamic therapies have struggled with in various ways since their beginnings. Time, insight and countertransference

The first of these is time. We need time to listen for the deeper meanings and lots of it or at least I do. Sometimes a client has to repeat themselves in many different ways in the content across sessions before I hear the underlying theme/wish/need.

In short term work it is not like I don’t hear or see some of the deeper stuff but I chose not to work with it and often do this by acknowledging its presence and suggesting it may be something the client may want to reflect on in therapy when they have more time (flag it, tag it and bag it). It is only when the deeper stuff is an active part of resistance to the therapy that it needs to be explored in shorter term therapy. By shorter term therapy I am thinking of the standard 8 to 12 sessions. We also need to recognise that we may use this as an excuse for the therapist in not listening or sitting with the deeper stuff that may for example reflect fears about our ability to contain or hold the client’s material.

If we don’t have time does it make any difference whether we acknowledge the deeper material or maybe a better question is what difference does it make to the client or the therapist in the short or long term. Personally I think it does but other commentators on this post appear to take a different stance.

The second is the ability of the client to listen to themselves (insight). The client group I work with, borderline personality disorder often have extreme difficulty listening to themselves and present initially in therapy actively acting out both within and outside the room. The deeper material may be literally rammed down your throat (projective identification). The client may have an ability of only a few seconds to tolerate or re-own the projection. This client’s in my experience are unable to tolerate even short periods of silence and have extreme difficulty with classical technical neutrality and require more active neutrality (aka family therapy).

Thirdly is the issue Dr X talks about in some depth and this is how prepared is the therapist able to tolerate and hold the client’s material particularly when it intrudes on their own material they have difficulty tolerating.

One of my first supervisors had a wonderful saying which I appreciate more and more as I grow older:

Never underestimate the power of just being there (for your patient).

No better exemplified than the Peter Sellers movie of the same name Being There. The longer you work with a client the more difficult this maxim is to apply. Dr X’s call for listening more deeply is a good one but you have got to like hard work.

psychoa

I'm coming a bit late to this conversation I realize but I wanted to respond briefly to what Chris says here about our needing "time to listen for the deeper meanings and lots of it." I can't agree more. It's what, for me, makes the idea of an 8 to 12 session treatment unimaginable. It's also what makes the frequency of sessions such a key feature of psychoanalysis and much of the reason I so prefer doing that kind of work to seeing people once a week.

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