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In This Section:
The personal nature of hypotheses
Don't over-pathologize
My matrix of likely explanations
Influences outside the realm of psychotherapy
Addendum: My Personal Clinical Matrix
The human brain is amazingly well designed for understanding others. Your capacity for empathy lets you put yourself in others' shoes and come quite close to understanding the other person's experience as if it were yours. In addition, the human brain is an exquisite metaphor engine for finding one thing that is equivalent to another but expressed in different terms. A hypothesis is fundamentally just that, an expression of subjective experience in different terms. As a result, hypotheses developed from a cookbook will lack richness and close adherence to subjective truth.
DISCLAIMER: Because of the highly personal nature of the work we do, it is best to develop your own repertoire of possible explanations. This matrix is not intended to be universal, but to suggest possibilities. Much of the psychodynamic and analytic literature consists of examples of possible dynamics. Not only that, but there is much, too, in the cognitive-behavioral literature to describe erroneous "core beliefs" that clinicians have encountered. These are all good starting points, but experience probably does the most to fill out each therapist's repertoire. It is our patients who teach us the most. What makes therapy so gratifying to the therapist is that our understanding of each patient is unique. In so many ways, each patient is different from any we may have seen before.
Look for the Least Pathological First
This is a very important principle. We should try to explain what we see using the least pathological explanation first. Only when that one is unsatisfactory should we go to the more pathological. For example, the term "borderline personality" is an "illness" explanation, but, as Judith Herman has pointed out, notions of arrested development and outgrown mechanisms for coping with trauma often offer as good an explanation. In this way, we can avoid applying illness labels to people who may be better described as "stuck" on some emotional or developmental issue that they have not been able to resolve.
In our age, there is a tendency to apply a label then treat the label rather than ther person. Even patients will identify themselves with a label, "I suffer from major depression," and expect that the label will be enough to tell you what to do. These comforting oversimplifications are unfortunate because they set up many unrealistic expectations, but even more serious, they tend to over-pathologise as well. They paint a more serious picture of the problem than may be the case. For example, the major depression of a person in early recovery from alcoholism may simply be that she is used to controlling her environment as a means of coping, and now, deprived of her means of control, is massively uncomfortable. The following list will start with the least pathological.
Broad Categories that May Yield Specific Hypotheses:
Lack of knowledge or inexperience: It is surprising how frequently some misunderstanding of life creates major problems. A patient was afraid of her own power. In childhood she had been afraid of murderous thoughts, not knowing whether she might actually carry them out. She was so afraid that she kept them secret and consequently never became clear that her self control was easily strong enough to prevent any murderous act.
Unprocessed Trauma or Grief: A great deal of pathological behavior can be generated in efforts to avoid the terrifying recall of traumatic events. Incessant activity, alcoholism and avoidance of whole areas of functioning can serve primarily as a means of distancing from painful recall. As the patient is able to share these experiences in an empathic context, cathartic healing takes place, and pathological behavior can be relinquished with surprising ease.
Dissociation: More frequently than is usually recognized, some individuals have learned to use dissociation to avoid uncomfortable experiences. Patients may feel "spaced out" or "numb" for months after an emotionally traumatic experience. This is usually not recognized or diagnosed. The treatment is to do the emotional work so that dissociation is no longer necessary for coping.
Family Distortion : Families and individuals have their own ways of experiencing the world, and pass these on. The impression that the world is a dangerous place and that the unknown should be feared and other people mistrusted is an example of such a perspective. It may be very helpful for the patient who has inherited these beliefs to learn that there are other ways to look at the same reality.
Developmental Distortions : Most of character pathology such as narcissism and borderline personality can be understood as distortions in early development as a result of traumatic or adverse conditions. When possible, the first hypothesis should be arrested development, implying that the treatment is to restart the developmental process. (My experience is that age does not prevent this from taking place) On the other hand, it may be necessary to consider maldevelopment that will have to be undone before healthy development can take place.
Internalization of pahtological attitudes, values, prohibitions, ideals, etc.: In order to maintain connectedness, humans identify with attitudes, values, etc. of those they need. They do so most powerfully when they are threatened with aloneness. For this reason, when the central caretakers express negative attitudes, children tend strongly to internalize these. Such internalizations tend to last and actively resist change for a lifetime unless there is a combination of the desire to change and help from outside. Cognitive-behavioral treatment has always centered on the active challenging of such pathological internalizations. They are key to many conditions including complex PTSD, depression and much of what is known as character pathology.
Another group of internalized values are the positive goals that parents were unable to achieve. Children often take these on and spend their lives unconsciously trying to fulfill those needs, presumably in the hope of making the parent happier and more capable of providing the love the child needed in the first place.
Internal Electric Fences: This is a term for internalizations that are similar to the ones above, but even more stringent. Children sometimes internalize values, prohibitions and ideals that do not come from any caretaker. They are the child's own rules for development and survival. For example, as a boy's mother was flirtatious, but not overtly abusive. He did not trust her self-control and felt responsible for preventing anything bad from happening. He developed his own, very repressive rules about sexuality and was far more broadly inhibited than if he had been raised in a puritanical atmosphere.
Deferring Needs : The usual situation is the "parentified child," the child who must forgo age-appropriate needs in order to function at a more mature level than his or her development would warrant. The inevitable result is that the needs that were "abandoned" and that may be subject to internalized prohibitions, continue to exert a powerful pull and to seek satisfaction in indirect ways. The caretaker who was never taken care of is an example.
Archaic Solutions to Life Problems: Many examples of pathology can be seen as coping strategies that were the best a child could do to cope with a pathological situation, but have survived into adulthood, and now are the cause of problems. Trust problems and fear of intimacy are good examples.
Systems Factors : The "systems" point of view brought by the field of family therapy is exceedingly rich in explanatory power, both for the influences of the past and those of the present. Especially when it comes to intervening, it is helpful to think of the patient as embedded in a system including the therapy as well as family and other elements. Interventions can be seen as perturbations to the system, which may have ripples beyond the individual. This point of view makes one more circumspect about moving too quickly when the full complexity of the system is not yet known.
The Five-Year-Old Plan: Many analysts have observed that around age five, there is a major reorganization of emotional life and defenses around the sophisticated fantasies of which the five-year-old is capable. I believe that the five-year-old's ability to look into the distant future is one of the most important developments, because it allows the child to crystalize unfulfilled needs, wishes and fears into a "someday" fantasy. The pursuit of such fantasies can become a highly energized driver for the transference. The patient's hidden belief that the therapist is the key to fulfillment of those wishes forms a layer that becomes apparent further into treatment when the above problems have been identified and are on the way to being cleared out. The remaining conflict and angst may be clues to the presence of such wishes.
Influences Outside the Realm of Psychotherapy
Genetic Influences and Biological Illness: It is clear from twin studies that genetics contributes substantially to the characteristics of individuals, but it is very hard to know exactly where and how. Psychodynamic hypotheses try to explain everything relevant to entrenched dysfunctional patterns of reaction, but in fact they only explain part. Genetics is something we know is there, perhaps background noise in our attempt to understand. It is at least proper to recognize that psychodynamics only explains a portion of what we see.
On the other hand, the nature of the mind is such that even when genetics is a major determinant in some behavior or preference, it still takes on psychodynamic meaning as it is drawn into the organizing framework of the patient's emotional life. Thus, the psychodynamic explanation is still meaningful and valid, even though genetics is an important component.
Some illnesses are currently thought of as "biological" in their origin. They still have developmental impact as they exert whatever their core effects are over time. Often families are affected, causing distortions of early environment. These two influences along with stage-specific emotional impact are complex determinants of what we may see in the adult.
Alcoholism and substance abuse involve major genetic factors (genetics explains 25% of the variance, and "other" things explain 75%). Psychodynamic factors can support the development of the condition, and can develop later as a result of ongoing addiction. These complex relationships make for complex hypotheses.
Biologically based depression: Theories of the psychological causation of physical illness are not currently prominent in the psychiatric community. It is my belief that this may be more the result of a pendulum swing, than lack of validity to the idea that emotional experience can influence biology. One area that seems particularly germane is depression, where much of what is labeled depression and treated as a chemical illness is actually better understood as brain dysregulation set off by emotional triggers in succeptible individuals. In such cases it is necessary to approach treatment from the direction(s) most available for intervention.
Random Circumstance : Many things happen to our patients that they have little or no role in determining. These, too take on dynamic significance. For example a disability due to an accident, let's say a car run into at a stop light, still takes on an emotional significance. The disability will still be drawn into the patient's way of understanding and coping with life and loss.
Sociopathic or Manipulative: Occasionally patients speak of how they participated in psychotherapy but had some other agenda having to do with money, courts, drugs, disability, etc. Therapists are in a very poor position to identify lies or witheld information. What will usually be apparent is that therapy does not progress. Occasionally the persistent identification of resistance and metacommunication will eventually unearth the hidden distortion.