Therapy that goes well is much harder to discuss than therapy that fails. Usually, when someone presents at a case conference, the discussant looks hard for ways to humiliate the presenter; failing this, the discussant usually shifts to a matter of his/her own personal interest---something that makes the discussant look good and by inference shows that the presenter is lesser. The therapeutic work presented by Dr. Edmund is so good, and Caroline's improvement so rewarding, that I have been struggling for weeks to find something useful to say. Nonetheless, Gil Levin has pestered me with such tenacity that I am forced to make some (hopefully interesting) comments.
I'd like the reader to consider an irreverent question: If you excise from the last paragraph in this case report the words "the central themes or core pathogenic beliefs against which she had to struggle," the only phrase in which Dr. Edmund uses the language of Control Mastery Theory, would you have thought even once about the therapist's school of therapy?
The therapist concerned with developmental issues might see Caroline's behavior, affective instability, relational style, and sexual confusion as typical of the toddler era, and might understand the therapist's work as deeply empathic support offered while the patient completed the work necessary to travel through this period of development. It must have been difficult for Dr. Edmund to maintain her sense of self as a good selfobject (a nurturant person who acts as an external modulator of another's affect) while Caroline dealt with the seductive behavior of her peers in NA and AA. Yet the result was excellent---Caroline learned the difference between true empathy and pseudoempathy, and grew rapidly within the embrace of a therapist who was both interpreter and exemplar.
In the early days of psychoanalytic practice, we therapists were attacked by lay authorities for our supposedly prurient interest in the patient's activities, thoughts, and emotions around sexual matters. Today, a therapy that never discusses sexuality is more the exception than the rule, and nearly everybody takes for granted the simple fact that sensible contraception (and now awareness of sexually transmitted diseases) makes sex an arena within which a host of fantasies, images, hopes, affect management scripts, "conflicts," and relational skills are played out in relative comfort. The skilled therapist is not a moralist who imposes a standard of behavior as a grid or exoskeleton (did you know that moral suasion was the core of phrenology?), but one who interferes only as Dr. Edmund suggested---when play places the patient at previously unforseen or unknowable risk. Here, too, the therapy was exemplary, for the therapist encouraged her patient to enjoy sex as a private expression of her own personal wishes and interests. Carl Schneider has written about his work with a young woman whose rampant promiscuity turned out to represent a script for the disavowal of shame; as Schneider's patient learned to experience shame over a normal range from mild to extreme, she stated eloquently how much she loved the ferocity of the blush she now experienced when guys made comments about her past sexual exploits. Able to experience normal shame, she could maintain her personal boundaries with much greater skill. How close this is to Caroline's experience of therapy! Contemporaneous with Caroline's movement away from toddler era affectivity and sexuality was her acceptance of normal shame and her newly found ability to undo her disavowal of parental shamelessness.
Near the end of this instalment of the case, Dr. Edmund mentions that Caroline felt "suicidal" and lapsed into the kind of sexual behavior more characteristic of an earlier period in her treatment. It should be clear to anyone who understands the concepts of interaffectivity and the idea of unwanted affective resonance, that Caroline's empathic wall was inadequate to handle the unmodulated affect ambient in the world of her parents. The experienced therapist knows that the occasional suicidal threat is more a message about unbearable density of affect than a wish to die, just as the occasional use of street drugs and sexual explosion are ways of managing affect. A stormy past usually precludes a calm and well-modulated psychotherapy.
But I return to my original question: Does the therapist's avowed theoretical orientation have very much to do with the patient's success in treatment? My own answer is based on the observation that no "caregiver" (mother, of course) can soothe a child to a level calmer than her own. The limiting factor in the degree of change or growth possible for a patient is not the school within which the therapist was educated, but the wellness or maturity to which that therapist has grown. I think it was Maimonides who said that "an angry teacher cannot teach, and an angry student cannot learn." So it is for each of the nine innate affects. Our own ability to manage and modulate our own affects, our ability to live in the world with the fewest possible preconceptions about whatever path is correct or necessary for the other, and our willingness to present ourselves as lifetime learners rather than authoritarian experts---these attributes often mark the truly gifted therapist. Nearly every day someone asks me why I haven't promulgated a "school" or "system" of therapy based on affect and script theory, and I answer that schools and systems are what the outsider detects in the expert, not the basis of an education. Freud was not a Freudian, Milton Erickson was not Ericksonian; I never saw Wolpe do anything other than what seemed obvious to him at the moment, just as Mike Basch worked from his soul rather than the system he taught us. Therapeutic systems are the armature around which we build the sculpture of our selves, but they have little to do with the way we work when grown up.