Читать книгу Making Sense Together - Peter Buirski - Страница 8

There are four ways a student can learn to do psychotherapy from any theoretical perspective. First, and perhaps the most important, is being in your own psychotherapy conducted from your desired perspective. The second, and indispensable for learning to practice intersubjectively, is being supervised from that perspective. Third, attending classes or lectures on the topic is valuable but in itself is insufficient. The fourth is reading books and journal articles about the treatment process.

Reading alone is insufficient to learn how to practice. You wouldn’t go to a dentist who only read a book. But reading can have a positive cumulative and organizing effect, pulling together and enhancing our understanding and building on what has been learned from the other three experiences. Readings offer a context for holding internal dialogues and dialogues with colleagues. While the first three, the experiences of personal treatment, supervision, and classes, all build on relational engagement with those more knowledgeable about clinical practice, reading is a solitary activity, and we hope that this book will be a valuable addition to the first three.

Making Sense Together, first edition, was published in 2001. Most other books or journal articles explicate the intersubjective perspective by focusing on the application of theoretical understanding to unusual or difficult cases. This new edition will focus on conveying the important ways that practicing intersubjectively can be applied across a wide range of psychological troubles.

The history of the talking cure really originated with Freud. Freud was a physician, and even though he came to recognize that nonmedically trained people could become qualified psychoanalysts (Freud 1926), the medical model under which he was trained came to dominate our thinking about the psychotherapy process. It wasn’t until the 1980s that nonmedical practitioners could be accepted for full psychoanalytic training without a waiver by the American Psychoanalytic Association, and that acceptance occurred only after a group of psychologists filed and won an antitrust lawsuit. Even the term “psychotherapy” has medical undertones as it implies that talking “therapy” is an intervention to be delivered by the psychotherapist and received by the patient. In other words, relief is found through a one-person application as though it could be absorbed in the bloodstream like a pill. This one-person model (see Stolorow’s foreword; Mitchell 1988; Skolnick & Warshaw 1992) defines the treater as an expert on the condition of the treated and fails to appreciate that the intersubjective field, where the reciprocal relationship between the two participants is a joint venture of two people making sense of one, is itself a powerful agent of change (Orange 1995).

A one-person model seeks objective truth, but it does not privilege the transforming potential of the relationship. One-person models may be a suitable approach for short-term, solely solutions-based, and problem-focused therapies, and they are made particularly helpful when disseminated by a warm, empathetic, understanding therapist. But one-person models are also problematic and, if left unexamined, can lead to harmful and narrow-minded pathologizing. One-person models also lead therapists to believe that they are actively fixing, helping, and being a productive and skillful authority on solving the problems for which people come to us seeking help. When dealing with the complexities of the psychotherapy relationship and the inevitable and rich intersubjective field created within this two-person context, believing one is knowledgeable and certain may feel reassuring. But this is where things can get risky if we’re not careful. The therapy space is not intended to be one where we, as therapists, seek fulfillment of our own unmet needs. Of course, we will have many reactions and positive experiences along our journeys as therapists and will often find therapy relationships to be inherently therapeutic for ourselves. However, we must ask ourselves if what draws us to a one-person therapy model, where we are the expert on the other person’s experience, is in the service of mitigating our own anxieties and doubts about the uncertainties of our practice.

So what about this two-person approach? A two-person perspective describes a way of working that values, promotes, and implements the interactions and relationship formed between the two unique subjectivities of the participants. It recognizes that truth is not uncovered or found but is co-constructed in the relationship. The intersubjective perspective has been described by Stolorow and Atwood (1992) as a contextual model. It describes the coming together of two or more worlds of subjective experience to create a field where each party contributes, although not necessarily in equivalent weight, to the mutual influences both bring to bear on the relationship. The relationship is understood to be co-constructed by the participants, as opposed to the one-person model, which does not consider the relationship to be instrumental in affecting the individuals, nor does it allow for the aspects of both individuals to be instrumental in affecting the resultant relationship. Unlike the “working alliance,” where the patient is expected to identify with the analyzing function of the analyst (Greenson 2019), a two-person approach instead values the relationship itself as an agent of change. Regarding the intersubjective field, it is not uncommon for both participants to feel they are participating in and benefiting from the relationship (Magid & Shane 2018). The relationship may indeed be therapeutic for both.

Here, the focus is on two people making sense of one. This makes the work thrilling, surprising, and challenging. In a sense, each pair is tasked with making it up as they go along, experiencing themselves with the other and the other with themselves. Importantly, within the intersubjective field that is co-constructed by the participants, the subjective experience of each person is unique, and therefore, each relationship is unlike any other. There is no model or manual that can be followed as the relationship unfolds. One size does not fit all. Since each relationship is unique, the course of the relationship and of the therapeutic experience will be different. We need to bear in mind that each therapy relationship and each session will follow its own course depending on what unfolds within the hour within each unique dyad. No two therapists would create identical processes, although both could lead to satisfying though somewhat different outcomes.

You can see that we have been struggling with using familiar words such as “therapist” and “patient.” Although there may be simplicity in using these terms to communicate roles, there’s no escaping the fact that these words are derived from the medical model that distorts what transpires in the therapy relationship for each participant. A therapist is someone who provides a treatment to a sick patient. For example, from the perspective of the medical model, all conditions of measles derive from infection by the measles virus. Everyone who has measles has it for the same reason anyone in the history of the world has had it. When we are working with experiences of depression, or anxiety, or other troubles that would bring someone to meet with us, we have to appreciate that all depressions and anxieties are unique to the person suffering from them. We believe that self-experiences like shame, fear, or worthlessness are rooted in what has happened between us and those around us growing up. It follows that each story of how one has come to experience themselves is unique and that each process of transforming this self-experience must be unique as well. No two depressed or anxious people are the same, and their depression or anxiety cannot be understood or transformed in the same way. There is no vaccine for shame or worthlessness, nor is there one for depression or anxiety. While psychotropic medications can provide important relief from painful symptoms of depression or anxiety, organization of experience, the underlying themes and patterns of relating, are typically untouched by this.

It is widely known that outcomes of medication interventions can be influenced by the placebo effect. The placebo effect depends on the belief systems that both physician and patient hold in the efficacy of the medicines. Interestingly, the placebo effect, as it results from a shared belief system between physician and patient, can be conceptualized as the product of a shared relational experience, an intersubjective field, constructed by the two involved parties.

Of course, it is apparent that avoiding the medical model terms of “therapist” and “patient” does present some locution difficulties. If we don’t refer to them as patients, how do we regard those who come to us to discuss their troubles, and how do we name ourselves who engage with them? We are both people who engage with each other in a relationship for our own reasons. This can be awkward in discussions with colleagues, and “patient” might be a convenient shorthand. The Merriam-Webster dictionary states that the word “patient” derives from the Latin word “sufferer” and therefore it could be a suitable shorthand. But while most of us may not be familiar with Latin, neither are most of the people we engage with. But the words “patient” and “therapist” are so ingrained in the traditions of our work, professional literature, and our culture that it is hard to excise them. So, when we use these words, we, our co-participants, and our readers need to perform the mental trick of separating ourselves and the way we think of ourselves from the one-person medical model. While this argument may seem too precious or obsessive, we strongly believe that the medical model has infiltrated our thinking in both obvious and insidious ways and therefore deserves attention even with regard to the language we use.

As we have been discussing, one of the main variables that the people with whom we engage often find so beneficial is the relationship that forms between us (Stern 2017). In many cases, our relationship may be one of the healthiest relationships they have ever had because we work to truly understand their pain and their strengths, are present with them just as they are, without judgment or our own agendas. As Donna Orange (2010) has stressed, we need to acknowledge our own fallibility and hold our theories lightly. We work to get to know the other and toward a mutual understanding of how they have come to be the way they are. If all goes well, our relationship will hopefully be experienced as reparative and growth promoting, perhaps for both of us. Measles, obviously, is not brought on or treated by the relationship between the physician and patient.

As we have described above, the relationship formed between the two participants is likely to be healthier than any relationship the person has had before. From the intersubjective perspective, the power of the relationship is one of the main factors that promotes change (Norcross & Lambert 2019; Norcross & Wampold 2019). In fact, many of the people who seek out a relationship with us do so out of an unconscious desire to find in us a person unlike those of their formative years. Most people who seek out a relationship with us have never experienced a dependable person who can offer the developmentally needed selfobject experiences of consistent attunement, empathy, mirroring, understanding, and caring. Whatever their manifest presenting problems, on a deeper level, people are longing for the needed developmental selfobject experience missing or inconsistently provided in their childhoods. Finding this absent but needed relationship is instrumental in their forming new ways of understanding themselves and healthier ways of relating to others.

Children have limited tools to counteract insensitive treatment by caregivers or to elicit needed selfobject experiences from them. It would be the rare child who could say to themselves, “I am stuck with inadequate or abusive or traumatizing caregivers.” The most common explanation children form for their misattuned or malattuned treatment is to conclude that they themselves are at fault. This may be the only explanation they are capable of reaching as recognizing caregivers as flawed can threaten the very existence of a child dependent on those caregivers. Children often make sense of their experience by concluding that if they were better behaved or attended more to their caregivers’ needs, then they would have felt loved and valued. They often conclude that not feeling lovable or valuable must be due to their own failings or inadequacy.

People are more similar than different. It might seem that everyone we talk to has organized their experiences around feeling unlovable, worthless, damaged, unheard, and unseen. While there are great commonalities to the way people who seek us out have organized their experience, the particular conditions or relationships with caregivers are unique to each person’s formative experience. Two people may have similar organizing principles, but they were formed in their unique experiences with caregivers.

These organizations of experience, that we will discuss in more detail in chapters 9 and 10, are hopefully disconfirmed by the new, attuned, caring relationship and the deeper understanding of themselves that they experience with us. As an outcome of the relationship formed, people will hopefully reorganize their experience to include the fact that someone can indeed understand them and care for them. Of course, it is not easy to reorganize one’s long-standing view of oneself, one’s organization of experience. Often a person will rationalize that they are being treated differently by us because they pay us or it is our job to understand and care about them. This effort to preserve their organization of experience can be strong and persistent, but through meeting together over time and promoting new understanding, this too may be transformed by the positive effects of the relationship with us.

Magid and Shane (2018) argue that empathy is more than a listening function; that is, we are more than just a receiver in the transmission-receiving analogy where the sufferer transmits and the listener receives their verbalizations. Empathy necessarily involves the person of the empathizer. Referencing Stolorow, Atwood, and Orange (2002), Magid and Shane maintain that “the impact of the analyst’s subjectivity, rather than being confined to countertransferential impediments to empathy, constitutes a ubiquitous and unavoidable dimension of the analytic relationship” (p. 251). This clearly points to the relationship at the heart of the empathic experience.

Freud wrote in letters to Fleiss and Jones that psychoanalysis is a cure by love. By this, it seems Freud was referring to the patient’s transference love for the analyst. But more recently, analysts have been writing about the transformative importance of the analyst’s care or love for their patients. McWilliams (2004, pp. 157–61) gives a strong account of the place for “psychoanalytic love” in the transformative process. Perlitz (2019) has written, “The analyst’s affection for her patient is the most important emotion for the success of a treatment” (p. 432). We now appreciate that in addition to attuning to affect and putting words to affective experience, the analyst’s care and love for the other make a significant contribution to the transformative process.

Additional chapters added to the first edition focus more directly on practicing intersubjectively. Chapter 9, on listening and responding intersubjectively, explores the first three contributions to the transformative process, attuning to affective experience, putting words to affective experience, and the caring new relationship with us. Chapter 10, on co-constructing a developmental narrative, addresses the fourth important experience that promotes transformation in the therapeutic relationship, developing together an understanding of how the person has come to be the way they are.