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  #1  
Unread February 11th, 2005, 07:08 PM
George Silberschatz George Silberschatz is offline
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Default Reading 2/10/05: Cyclical psychodynamics and contorl-mastery theory

The next article that we will be discussing is an attempt to integrate Wachtel's concept of cyclical psychodynamics and control-mastery theory. The paper, by Suzanne Gassner, can be found here: http://controlmastery.org/studygroup/index.htm
(you will need adobe acrobat reader to download it).
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  #2  
Unread February 21st, 2005, 03:25 PM
patsywood patsywood is offline
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Default thoughts on Suzanne Gassner's paper

I really appreciated Suzanne Gassner making her paper “Control-Mastery Theory and Cyclical Psychodynamics: Commentary on the Weiss vs. Wachtel and DeMichele Dialogue” available for those of us in the SFPRG group to read and think about. I had a number of thoughts about it, especially the discussion of Ruth, but wanted to be careful not to quote anything from the paper to respect the admonition on the front of the paper to not cite or quote material from the paper. I also wanted to acknowledge that Dr. Gassner, as the therapist, certainly has a greater understanding of the patient she treated and that my thoughts are based largely on my rudimentary understanding of the case and in this way, are subject to error. As we all know, it can be very different when we are in the room with a client than when we are discussing the case from an outside perspective.

I really appreciated the clarity with which Dr. Gassner described the differences in position between Control Mastery theory (CMT) and Cyclical Psychodynamic theory (CPDT). Her discussion of both the Rand and Tom cases beautifully illustrate the elegance with which the CMT model explains the ways that these therapies unfolded as well as the progress that was made. In contrast, it is not as clear how CPDT might explain the process and outcomes in these two cases.

What I found myself somewhat confused about was the discussion of Ruth’s case. Here was a client who, upon pursuing legal redress and losing the case, falls into a protracted depression. In that process, she continues to come to therapy but none of Dr. Gassner’s efforts to encourage her or make “pro plan” interpretations of her experience seem to make much difference. I would argue that part of what is going on here sounds like a powerful, biologically-mediated depression and that this organic process interacted with Ruth’s psychological issues complicating the treatment process. It seems likely that, given Ruth’s strong family history of depression, therapeutic change is going to be a more involved process than we might expect in a more straightforward, “neurotic” depression. In neurobiology, there is some empirical evidence for a “kindling” model of depression that has found that over the course of a lifetime of someone who experiences recurrent major depressive episodes, later major depressive episodes tend to be more intense and appear to be triggered by less severe environmental events compared to earlier episodes (Post, 1992). Also, one study found that women with family members who had affective disorders were significantly more likely to respond to stressful events with a depressive episode compared to those with no genetic loading for depression (Kendler et al., 1995).

What is striking – and I have certainly experienced this at times with clients – is that Ruth, as she is described in this depressive episode, appears unresponsive to the therapist’s interventions in her experience of her pain and seemingly oblivious to the treatment. Dr. Gassner states here that it did not appear that the patient was actively testing at this point in the treatment at all but simply sinking into a deeper, more intractable-seeming depressive episode.

I find myself wondering two things here: First of all, I wonder if organic processes such as more biologically-driven symptoms of depression don’t undermine more “normal” testing processes slowing down what would be considered more usual and expected therapeutic progress. This isn’t to say that working to disconfirm pathogenic beliefs in those who are higher on the continuum of having more organic syndromes is unimportant to treatment. It just means that the biological processes have to be treated and managed in addition to the psychological aspects of treatment and that especially in the acute phase of the illness, the psychological processes may be more difficult to access and counteract. Second, I wonder if what Dr. Gassner describes in this part of the treatment with Ruth was more of an entrenched and prolonged passive into active testing sequence (superimposed on the more organic symptoms) that Ruth was presenting to the therapist. Perhaps the depressive episode provided the opportunity for Ruth to intensify the testing of Dr. Gassner in her therapy. There are certainly historical precedents in Ruth’s life for this potential testing sequence: she had a mother who was severely depressed and inconsolable. Ruth was the child who felt omnipotently responsible for her mother’s happiness and well-being and who upon her father’s death, dropped out of college to return home to tend to her very impaired mother. From what Dr. Gassner describes this sounded like one of Ruth’s central traumas - one that interrupted her developmental steps of launching from her family-of-origin, establishing her own independent life and finishing her studies at college (a goal which perhaps also embodied her deepest hopes and dreams). That Ruth reenacted this trauma with her therapist in the course of experiencing this brutal and seemingly unrelenting depression makes sense in terms of her history and is in line with Ruth testing Dr. Gassner around this very traumatic experience with her mother. If Ruth was not testing in this part of the treatment, wouldn’t she have just attempted and/or completed suicide, relied solely on medical treatments and/or left treatment altogether? But Ruth did none of these – instead she intensified her participation in the treatment (coming daily instead of twice a week which is a huge commitment for her to make) and slowly, with Dr. Gassner’s help, her depression remitted.

Embedded in this early trauma are key pathogenic beliefs that Ruth appeared to hold. These included beliefs that she didn’t get to have an independent life, that she is destined to be miserable and that she failed her mother by not being able to make her happy. Dr. Gassner’s decision, in response to finding that her usual therapeutic efforts were not effective in alleviating Ruth’s intense symptoms, was to utilize behavioral interventions. This placed her in the position of being a strong authority for Ruth experiencing small daily pleasures for herself. This “treatment of attitudes” was eventually very effective in that Ruth’s depression slowly lifted (in a matter of weeks she was feeling better) and she was able to resume greater function in her life. Ruth also told Dr. Gassner later on that in a subsequent depressed episode, she pulled herself out of it by relying on these same behavioral steps that she had been encouraged by Suzanne to take.

As I read this case presentation, it strikes me that two things were critical in this part of the therapy in helping Ruth to get better. Both involved the therapist passing key tests that, I believe, Ruth was presenting to the therapist. The first involved a transference test. Dr. Gassner, in Ruth’s time of crisis, did not give up on her as others had done in her life (her husband, her prior therapists and analysts, friends, and her father through his death) by distancing herself. As Ruth became more depressed and more inconsolable, Dr. Gassner increased the intensity of the treatment from twice a week to daily sessions. I imagine that this provided a lot of evidence for Ruth that Dr. Gassner believed that she could get better and that the therapist was willing to do the maximum possible to help Ruth to do this. One might argue that any therapist would have done this. I disagree. Many therapists would have perhaps checked in more frequently with Ruth but seeing a patient daily is a more heroic effort than is the norm. In this position, Dr. Gassner was embodying something important for Ruth. She was embodying a confidence that Ruth could get better, that as her therapist, she was going to be there providing a scaffold for Ruth through the intense storm of her depression and she demonstrated an ability to tolerate Ruth’s intense negative affects and profound hopelessness- something Ruth had difficulty witnessing and tolerating in her mother as a child.

The second type of testing that I believe might have been going on here and that was clearly exacerbated by her depression was this extreme intense passive-into-active testing sequence where Ruth was acting inconsolable and unreachable. Here the therapist, upon finding that her interpretations and usual encouragement were no longer effective, implements behavioral interventions insisting that Ruth allow herself small daily pleasures. It is interesting that within a few weeks of introducing this, Ruth was feeling better which empirically suggests that these interventions were effective. What implementing these interventions did was to counteract the powerful negative pull of the passive into active tests. In this sequence, Dr. Gassner became a strong authority for Ruth getting better by “taking charge” of the treatment. She modeled and encouraged a confidence that Ruth could experience more pleasure even in this bleak period. Finally, she helped Ruth to explore the great difficulty she had allowing herself these small pleasures and in this way, Ruth was able to look at some of her own self-imposed inhibitions against enjoying even small things in her life.

What I wonder is why would Ruth get better within weeks of trying to follow these behavioral interventions? I would suggest that Dr.
Gassner’s “therapy of attitudes” was “pro plan” and thus effected a subsequent improvement in Ruth because it helped disconfirm or at least lessen the grip of Ruth’s grim pathogenic beliefs that she had to suffer by sacrificing her life for her mother and live a life of misery like her mother.

So while I would argue that while in Ruth’s case the CMT and CPDT interventions might look very similar on the surface, the underlying formulation to explain them would be quite different. In CMT, we would posit that Ruth had a strong motivation to not be as miserable as her mother and to not continue to sacrifice herself through this pathogenic identification with her mother. To achieve this, Ruth took advantage of this depressed episode to reenact one of the key traumas in her life with Dr. Gassner; this involved her giving up her independence by suffering and being intensely inconsolable like her depressed mother. As she became more and more depressed, intensified by her strong biological vulnerability to depression, Ruth was hoping that her therapist would not give up on her in spite of her negativity and could “take charge” in a way that her father was never able to intervene with her mother. This taking charge involved the behavioral interventions Dr. Gassner insisted Ruth implement in the treatment.

CPDT, on the other hand, would argue that Ruth did not necessarily have a plan to get better but was trying to get the therapist to collude with her in her neurotic, intense and painful reenactments. As the goal of CPDT is to not collude with the cyclical psychodynamics, a therapist might rely on behavioral interventions to effect therapeutic change in this client. Wachtel might also be more likely in this instance to interpret Ruth’s depression as a reenactment of past history which, given the intensity of her depression, would not be particularly effective. So as Dr. Gassner points out, both CMT (treatment by attitude) and CPDT models might use a behavioral strategy with Ruth that would look relatively similar.

My question for CPDT would be why, if Ruth’s primary motivation was to find a therapist (and others in her life as well) who would simply collude with her neurotic cyclical psychodynamics, would she persevere in treatment the way she did? The experience in that depressive episode in the therapy sounded both wrenching and excruciatingly painful. Perhaps Ruth continued because she didn’t feel she had any alternatives. Perhaps she persevered because she was intensely lonely and the relationship provided support – however ineffective it may have felt to Ruth at times. Or perhaps, as CPDT might posit Ruth was highly motivated to compulsively reenact traumatic dynamics and thus sought a therapist who would provide a sanctioned foundation for this experience. But, in my mind, none of these explanations fully explains Ruth’s perseverance in the therapy through such a difficult period.

While Ruth likely experienced tremendous ambivalence about getting better and felt profound hopelessness at times that she could ever have a happier life, it still seems more plausible to me that a part of Ruth was motivated to free herself or at least, reduce the negative impact that her pathogenic beliefs had on her life. To do this, she needed to have a therapist who wouldn’t actively retraumatize her. The only way she could insure this was to test the therapist over and over again. This culminated in this intense passive into active reenactment that interacted with her biologically mediated depressive episode. While the testing in this sequence may have been obscured by the organic symptoms, I believe it was present none the less. And in this process, as Dr. Gassner “took charge”, Ruth was able to feel better. It is also important to note that the form that this testing sequence took was shaped by the prior work Dr Gassner had done with Ruth as well as the strong need Ruth had to disconfirm or reduce the intensity of her pathogenic beliefs.

I imagine many of Ruth’s prior therapists, unlike Dr. Gassner, may have given up on Ruth as “unanalyzeable” or “resistant” earlier on in the testing process of the therapy. Dr. Gassner didn’t do this even though the treatment felt daunting at times. What she did do was to hold the hope for Ruth that she could have a better life and this, I believe, resonated with Ruth’s own deep desire to be happier and to experience less pain in her life. It is interesting that in spite of prior failed treatments, Ruth had repeatedly sought out additional therapists. This suggests to me that she really wanted to get better and wasn’t just seeking to assuage her loneliness or find a place to simply reenact traumatic, neurotic dynamics as CPDT would argue. She kept on persevering through great pain and difficulty to find a therapist/s who could help her feel better and this included intensifying her therapy with Dr. Gassner through this very painful, seemingly intractible period of depression. Ruth’s “plan” to get better may have felt very inaccessible to her and manifested in what appeared to be tremendous ambivalence towards the treatment at times but in spite of this, Ruth kept coming every day to see Dr. Gassner. Are these the actions of someone who just wants to reenact cyclical psychodynamics? I would say that this perseverance was not just motivated by a desire for immediate relief, but was instead fueled by Ruth’s ardent and deeply held desire to have a better life for herself. Her determination to go after this goal is manifested in Ruth’s willingness as a patient to commit to a more intense therapy with Dr. Gassner at a time when she didn’t feel that any help was going to make things better for her. This suggests that Ruth found something very important and compelling in her therapy with Dr. Gassner. In CMT we would explain Ruth’s persistence in the face of such difficulty as her unconscious plan to get better resonating with Dr. Gassner’s pro plan interpretations and treatment by attitudes that, in turn, freed this patient to feel that she could persevere through this difficult working through experience.

References


Kendler, K., Walters, E., Neale, M., Kessler, R., Heath, A. & Eaves, L. (1995). The structure of the genetic and environmental risk factors for six psychiatric disorders in women. Archives of General Psychiatry, 52, 374-383.

Post, R. M. (1992). Transduction of psychosocial stress into the neurobiology of recurrent affective disorder. American Journal of Psychiatry, 52, 999-1010.
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  #3  
Unread February 23rd, 2005, 08:36 PM
Cynthia Shilkret Cynthia Shilkret is offline
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Default Re: Reading 2/10/05: Cyclical psychodynamics and contorl-mastery theory

I was impressed by Suzanne's thoughtful and clear attempt to demonstrate the importance of plans in treatment. However, I don't think that clinical examples, no matter how compelling to us, will convince clinicians who have a different theory of why patients behave as they do. This is especially true when there is a great deal of overlap between the predictions made by the different theories. For example, I'm sure that Wachtel would agree that Suzanne's cases had good outcomes, and he might even agree with the techniques that she used. But he would probably still feel that he could explain her results without accepting the idea of the patient's plan. A stronger demonstration of the plan concept would require something like George's research on "key tests." If examples could be isolated in which control-mastery theory predicts one outcome and Wachtel predicts another, and the results support the control-mastery explanation, it would be harder for Wachtel (or anyone) to discount the control-mastery explanation. This may not be possible using clinical examples alone. It may require the kind of empirical research that has been carried out by various members of the group.

Cynthia (& Bob) Shilkret
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  #4  
Unread March 12th, 2005, 06:16 PM
Paul Wachtel Paul Wachtel is offline
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Default Re: Cyclical psychodynamics and contorl-mastery theory

I am very puzzled how Patsy Wood can persistently see cyclical psychodynamics as “arguing that Ruth ... was trying to get the therapist to collude with her in her neurotic, intense and painful reenactments,” or that she was as attempting to “simply reenact traumatic, neurotic dynamics,” or was “ highly motivated to compulsively reenact traumatic dynamics and thus sought a therapist who would provide a sanctioned foundation for this experience.” This virtually stands cyclical psychodynamics on its head. The very essence of the cyclical psychodynamics view is irony, the idea that what we end up getting tangled in again and again is often THE VERY OPPOSITE of what we are seeking but is a nonetheless predictable irony that results from the way that vicious circles play themselves out. I have repeatedly distinguished, for example, the cyclical psychodynamic emphasis on irony with the classical Freudian notion of the repetition compulsion, precisely because I do NOT posit that the patient is unconsciously “trying” to perpetuate the pattern. This is so central to the cyclical psychodynamic point of view that I am startled that Wood would attribute the opposite view to me. But in thinking about how this strange mispercpetion could happen, I think maybe an interesting and important idea/distinction may be introduced. Perhaps the confusion derives from the following sentence in Wood’s comment: “CPDT, on the other hand, would argue that Ruth did not necessarily have a plan to get better but was trying to get the therapist to collude with her in her neurotic, intense and painful reenactments.” It seems that Wood assumed that if I do not emphasize the idea of a”plan” per se, then I MUST assume that she is intentionally trying to get the therapist to collude with her. The paper with Annette DeMichele spells out why, although I find myself in enormous agreement with control-mastery theory in so many ways, I am nonetheless not inclined to conceptualize in terms of the patient’s “plan,” but rather, in terms of the patient’s fears and hopes. Among other things, these latter terms, especially if used together, highlight more the centrality of conflict.
For extrinsic reasons I have come late to this discussion, and so will be trying to “catch up” with it bit by bit. I am commenting first on Patsy Wood’s contribution because it is the first I am seeing, but I am sure I will have more to say as I further absorb myself in this exchange.

Paul Wachtel
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  #5  
Unread March 14th, 2005, 03:55 PM
patsywood patsywood is offline
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Default Re: Cyclical psychodynamics and contorl-mastery theory

Hi Paul

I sincerely apologize for so misconstruing Cyclical Psychodynamic Theory in my discussion of Suzanne's paper. I must admit I have read very little of your work and clearly need to read you much more thoroughly before I make any further comments. Patsy Wood
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  #6  
Unread March 14th, 2005, 09:01 PM
Paul Wachtel Paul Wachtel is offline
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Default Re: Cyclical psychodynamics and contorl-mastery theory

Hi Patsy,

I don't know if you came upon the other thread in which I too apologized, because I felt my reaction to what I do think was a misperception was nonetheless much too strident and ill-tempered. If you do get to read more of cyclical psychodynamic theory, I'd be interested in what your perception is.

Paul
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