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Unread February 4th, 2005, 09:01 PM
patsywood patsywood is offline
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Default thoughts on the concept of the patient's plan

Hi Everyone

In reading the dialogue between Joe Weiss and Wachtel in Psychoanalytic Dialogues, I was struck by the reference that Wachtel made to Control Mastery’s tendency to adopt the “positive” view of a given conflict experienced by our clients as a central interpretative stance. Wachtel writes:“Weiss is operating from a dichotomous decision tree in which, if the supposed more classical formulation is unsatisfactory, then his must be right.” Rather than viewing the patient’s appearance of being more relaxed after an interpretation as a passed test, Wachtel observes: “The pleasant surprise alternative – that the patient anticipated rejection and was missing sessions to ward it off but was delighted when it turned out his expectations were disconfirmed – would also lead to his becoming more relaxed and coming more regularly and it would not require making the additional assumption that the patient had this outcome in mind to begin with and was giving the therapist the chance to show he was different.” This suggests a hesitancy on Wachtel’s part to assume the lowered anxiety in the patient’s response was due to the therapist passing a test that reinforced the patient’s preconceived plan as Weiss inferred but rather was simply a result of a more immediate sense of relief on the patient’s part that the anticipated rejection did not occur. To Wachtel, the idea of a preconceived patient’s plan is a leap of faith made by Control Mastery therapists that is not substantiated by any data.

The question then arises, how do we empirically determine a patient’s intent? It seems that there are a number of avenues we have to assess this. One is self-report – the patient actually tells us that she wants to achieve a particular goal. In this case, we might question her intent based on other contextual information we had that disputes that but in the absence of that, we would likely be inclined to believe this patient. Another option is to look at behavior and see how behavior dovetails with statements of intent. If a patient tells us one thing and repeatedly does another, how do we make sense of this empirically? According to Control Mastery theory, we would make sense of it either by wondering if the patient was letting us know by telling us this goal that this was their plan and the behavior was a test to see if we, as therapists, would ignore or give up on the goal. Another possibility is that we might assume that the behavior was evidence of the patient’s true plan and their statement to the contrary was a test to see if we could look beyond the words to help the patient achieve their goal. Another avenue we have to assess planfulness is affect. If a patient tells us with much misgiving something they want we might be more likely to question it than when they tell us something with great enthusiasm. But again, we might be looking for contextual information such as identification or compliance with a parent to evaluate this data as well. In any of these scenarios, there is a strong subjective element to our assessment where as therapists we must infer our patient’s intended plan from data gathered in our patient’s statements, her affect and behavior. In order to make sense of the complexity of all this raw data, we filter that data through our model of how the mind works. For Control Mastery therapists, central to that model is the concept that patients have a conscious or unconscious plan to get better. In this way, we have a kind of tautology: we select out data on the basis of our model and then use that to further justify the model.

In looking at some of the differences between Weiss and Wachtel, there is a similar dialogue in Cognitive Science between the Bandura’s self-efficacy model (1989) and the Powers', control theory, the cybernetic model (1991). The Self –Efficacy model views humans as always striving towards goals, working to eliminate challenges and barriers to their fulfillment of their goals. They do this through as Bandura puts it “emergent interactive agency” that has self-reflective and imaginative elements to it. In this model, an interaction between personality, affect, cognition and environment all drive behavior. The Control Model, on the other hand, views humans as motivated by immediate environmental inputs that are fed through an information processing loop that then determine behavioral outcomes. It is discrepancies between the programmed state and perceived changes in input from the environment that motivate change in the latter model. In this way the control model is based on more immediate inputs whereas the self efficacy model views human motivation as having a more positive goal oriented and therefore planful aspect to it. Bandura writes, “there is a growing body of evidence that human attainments and positive well-being require an optimistic sense of self-efficacy. This is because ordinary social realities are strewn with difficulties. They are full of impediments, failures, adversities, setbacks, frustrations and inequities. People must have a robust sense of personal efficacy to sustain the perseverant effort needed to succeed. (Bandura, 1989).” Put in another way in a later article Bandura (2003) writes: “People are aspiring and proactive organisms, not just reactive ones. Their capacity to exercise forethought enables them to wield adoptive control anticipatorily rather than being simply reactive to the effects of their efforts. They are motivated and guided by foresight of goals, not just be hindsight of shortfalls.”

This tendency to side on the positive side of the conflict humans experience is at the heart of Control Mastery theory. It’s not enough to just “be” with our patients or clients in their conflict, we actually want to act as coaches to move them forward from their state of impasse and this often involves identifying a goal as the plan – we do this either explicitly or implicitly in the way we work with this patient. This focus then provides the momentum patients often need to move through their impasse and inhibitions. This doesn’t mean that we want to be glib about the conflict they find themselves in – between their desired goal and inhibitions from achieving it. Wachtel seems to suggest that the idea of a plan can be dismissive of a patient’s struggle with their conflicts. But I don’t think Control Mastery would endorse this. Often it is initially appropriate and necessary to remain close with our clients in their pain while we acknowledge and validate their discomfort. On the other hand, helping them to move past the impasse and using our authority, our positive beliefs in them, our interpretations and our unflappable stance are all ways that we take a positive stand that our clients can resolve their conflicts and problems and thereby move through them toward “their goals.” This involves assuming that their plan to achieve whatever goal they feel stuck from achieving is a viable one and sometimes the therapist naming it as their plan can be motivating to the patient, even if the plan is only inferred by the therapist (e.g. a reading of their unconscious plan).

It is difficult to get a full understanding of Wachtel’s model of the mind without reading more of his work. In his book, Therapeutic Communication he elaborates on how he views the change process in clients. He draws heavily from Piaget in his explanation which involves processes of assimilation (small shifts in perception and behavior) and accommodation (larger, more global shifts in cognition). Wachtel writes of transference as particularly important in the therapeutic process: “Transference reactions, from this perspective, are best understood as the product of schemas in which assimilation predominates over accommodation. When we describe a patient’s reaction as transferential, we are essentially saying that he accommodates only minimally to the specific qualities of the analyst that differ from his parents, and that the readiness to assimilate the experience with the analyst to schemas associated with previous experiences from early figures in his life can override many fine (and not so fine) points of difference. But the perspective provided by considering transference in the light of Piaget reminds us that the transference reaction cannot be purely assimilative. There must be some accommodation as well (Wachtel, 1993).”

It is this latter statement that coincides more with a Control Mastery model with an emphasis on more planful change. Nevertheless, if we consider how Wachtel may regard the patient relative to a plan concept, the process of assimilation and accommodation is a slow, usually lawful process that takes time and would likely involve staying with the client more in the immediate experience of his conflict/s rather than making inferential statements about where he might be going (the idea of the patient’s plan). Such interpretations would likely be received by the patient, in Wachtel’s scheme, as counterintuitive and premature and are therefore less effective in moving them towards change. Indeed, Wachtel states in Psychoanalytic Dialogues: “Patient’s way of living will almost inevitably lead again and again to experiences that seem to “prove” their validity, for, acting on the basis of those beliefs, patients will elicit behavior from others that is compatible with their expectation. In that sense, these “unrealistic” beliefs become “realistic” in the context of a patient’s cumulative life experience. A therapeutic approach that does not acknowledge this odd quasivalidity will not feel as experientially on target to the patient and will therefore be less effective in helping the patient to develop an alternative valid worldview that is more expansive and affirmative of the full range of her psychological possibilities. (Wachtel, 1998).”

While I don’t discount Wachtel’s perception that for some patients it is imperative to stay close to their experience because their readiness for change is more conflicted, I also feel that, at times, the infusion of the therapist’s energy and enthusiasm for their ability to change can provide important momentum for the patient to move through their impasses as the Bandura Self-Efficacy model implies. In this way, the therapist does play a key role, at times, in putting words to the plan for the patient as part of the therapeutic work. So as therapists, we infer subjectively what that plan is, based on our experience of the patient, put a name to the plan and often find that the patient responds in a positive way.. Still there may be times when the therapist naming the plan may feel premature to the patient. In this instance we are not likely to see a positive response from the patient. Perhaps as Wachtel implies it is premature. It may also be the case, however, that later on in the treatment it becomes clear that the therapist naming the plan up front may have served as an incentive to the patient in spite of their earlier rejection and discounting of it. In this way the Weissian view more explicitly promotes the accommodation processes that Wachtel feels need to emerge more organically through repeated interpretations of the transference in his cyclical psychodynamic model.

So where does this leave us relative to the plan concept? It seems difficult ultimately to prove the existence of a patient’s plan except through their self-report. Otherwise, as therapists, we are can only infer it from their behavior, their affects and their transference reactions to us or by observing where the patient ends up as treatment goes on. The question then becomes, is it useful to infer a plan? Are there circumstances where the therapist making such an inference would actually be harmful to the patient? I would argue that most patients are comforted by knowing that they have a plan in mind - that their behavior, affects and statements have a more underlying meaning that is adaptive and makes sense for their lives. That patients can’t articulate their plans sometimes is no evidence that they don’t exist – they may be unconscious plans in this case. However, there maybe times when the conflict the patient finds herself in is so intractable and complex that for the therapist to identify her plan to resolve the conflict and interpret this for her might feel hurtful and premature. In these instances, a more measured approach on the therapist’s part that adheres more immediately to the patient’s experience may be valuable and effective.

Patsy Wood

Last edited by patsywood; February 6th, 2005 at 05:20 PM.
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