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How Psychotherapy Works |
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Practitioner’s Information |
Stanley Moldawsky |
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In some ways it is presumptuous of me to try to answer this questions since scholars through the ages have struggled to answer that question. For Freud, it was insight that produced change. Unfortunately, this can often be just an intellectual understanding with no emotional change. For me, change precedes insight and the person must “live through” the affects in a new relationship in which there is safety to experience oneself. Through the living through process in a therapeutic relationship the formerly repressed affects are integrated and the person begins to change, now enriched by feelings that were unavailable before. This is a slow process in which the therapist’s feelings are significant in helping the patient to unpack. First and foremost regarding the therapist’s feeling is HOPE. The therapist feels hopeful about helping the patient and conveys this attitude in manner and speech. It must be genuine. And the therapist is naturally curious and interested in the patient’s story. This interest is again conveyed by the welcoming attitude in the therapist. (Frank Froman would say, “I’m glad you’re here.”) The therapist is engaging and wants to connect. So many of our patients suffer from attachment disorders and connection is desired but scary to them. The therapist is not scared to connect, indeed she/he wishes to relate. Psychotherapy is a “healing attachment” situation in itself. It encourages the patient to believe in him/herself and heals the original attachment problem. By your entire delivery, you convey that your patient is important. The relationship has always been considered a valuable matrix for change to take place but I am crediting it with more than a matrix. Neuropsychological research is showing that brain changes are taking place within the therapeutic relationship. I am emphasizing the PROCESS rather than the insight to be the crucial variable. The process is what takes place within the new relationship with the therapist as described above. This week Ann, an obese professional woman came to her session and reported the following: “I didn’t want to come today, I don’t want to be here”. “Oh, what’s that about?”, I responded. She didn’t know. I remained silent. She then began to talk about her supervisor whom she disliked. Then she mentioned having lunch with her sister who remarked that when they were kids, and she complained to Mother, Mother would say something like “Just be nice”. My patient was the oldest of 5 children and had been the “caretaker” of them as well as the one who worried about Father’s alcoholic behaviors. She was the good one. She never was “allowed” to get angry. I wondered if she was afraid to be here today because she might be angry with me and that would upset her “good girl” persona. She then began to talk about how angry she was with her husband and she seemed visibly angry. She then talked of how fat she had become and wondered what that had to do with what we were talking about. She thought she soothed herself with food and I thought she was swallowing her anger. Now what happened in this vignette? Before corning to the session she was aware she was reluctant to be here but had no clue as to any feelings about that. I was very interested in her reluctance and encouraged her to open it up. She was not aware where the discussion would lead but feelings of anger arose which she experienced with me. These feelings which we learned had frightened her as a child were being unpacked in our session. The fright, the worry she would be thrown out of my office; we lived through that. What I believe was taking place was an experience of anger toward her Mother via her relationship with me, we helped it be in the present and she survived it. This will be repeated many times in the near future I suspect and each time she will become a tad more comfortable with the anger. As she allows the anger to be felt and does not need to repress it again she will need less soothing and will experience weight loss. That’ s how psychotherapy works. The new relationship with a therapist permits the patient to dare to experience repressed feelings and “live through” the expected punishment, and the new found freedom. As a patient told me this week when I asked her “How does psychotherapy work?”(I was thinking about writing this paper for the IP and wondered what this particular patient thought about what made psychotherapy work for her). “Well, it’s a place where you feel safe and can feel all that pain and get a handle on it”. I thanked her (it seems I got a collaborator). The idea of safety is crucial to me also. In being protected, a person will talk about themselves differently than in an ordinary conversation. Therapy is a very unique relationship. With Ann, we are doing “anger management” which has become a slogan. It makes sense to me that we are not teaching or learning techniques to manage anger but are learning what the anger is really about and helping the person to integrate those feelings so that they can be expressed naturally without fear. Vignette #2. I had worked with Tony for 5 years. After 2.5 years he moved to Florida and we continued 3 times per week on the phone for another 2.5 years. We were successful in working on his obsessive thinking, and his inner critical “voice”, and he was much freer and enjoying his marriage and his son. He spoke fluent Italian and ended therapy by moving to Italy, thereby making an independent move away from me. He had become attached to me and we had worked through some of his early attachment issues so he felt more independent. After two years I received a call from Italy. He wishes to resume therapy to work on things that we hadn’t done enough with. However, he wanted to try once a week; so far we have had 3 sessions. I raised his fee even though the call was more expensive. He started by saying..”1 made a quantum leap in the work we did. I just decided to give up control, the voice is a shadow of itself and I’m on my own here….the separation from you was like death but I’m really different. I don’t have obsessive thoughts anymore. I’m finally an individual. Some times I wanted to call you but I was afraid I’d be rejected. I want passion in my life. I’m tired of feeling guilty.” In the next session he reported his most recent dream. . . “I was with my friend’s father…a billionaire (in reality he was a college professor). I was ashamed of my Father, I was in a crowd…they were all Jewish except me. This girl was rubbing her foot against mine. I sat there and did nothing. She got up and went to the middle of the room and started to get undressed. There was an orgy going on.. I did nothing”. His associations; there is something about incest in the dream. (What makes you think of incest?). “I thought of (an attractive woman who was like a “cousin” to him). It was family for sure”(You were immobile in your dream and she was seductive and inviting). “Yes, even in my dream I’m terrified of sex. My son was screaming in the dental chair. He asked me ‘what will happen to my penis?’” We discuss his fear of castration for his incestuous ideas. We don’t know whether his shame about his Father was seen by him as an attack on his Father. He glorifies him (as a billionaire) in the dream.. There is more to learn here regarding who the castrator is. He was afraid to call me for fear I’d reject him. Am I the castrator? The Jew in the crowd? Interesting sessions ahead as we unwrap these fears, their history, and my assumption of renewed sexual vigor as we move along. How is psychotherapy working here? With the use of a dream and his associations to it we are able to get at underlying feelings, feelings of sexual inhibition, fears of castration, desire for sexual expression. He will “live through” those fears with me as he unravels the affects and their history and I expect him to integrate the sexual feelings eventually. It was part of the unfinished work of our previous therapy. Incidentally, I am convinced that if you have done intensive work over a period of time, telephone therapy is possible. The importance of creating “an island of safety” where your patient dares to risk telling you what is really going on, where you are open to whatever the patient is experiencing and involved so that the patient can use you for projection of fantasies and feelings. To enable your patient to “live through”with you those formerly forbidden feelings in a new supportive relationship enables your patient to mature and change. |
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