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Entrenched Resistance
The structure of all therapies
The "Grow Graph"
Part 2
Chapter 11: Beyond the Classic Session, Part 1, Basic Concepts
Entrenched Resistances Take Hold
The three step dance (nudge, metacommunication, tactical retreat) described earlier actually turns out to be a bit idealistic. It would be wonderful if all you had to do to resolve every resistance was to make a sharp observation. The truth is that as therapy progresses, resistances typically become more entrenched. The mind develops strategies to thwart your best metacommunications. Wilhelm Reich, the first to apply psychoanalysis to characterological problems realized that this kind of work needed something more powerful than open ended free association. He described the therapy as a kind of battle requiring significant structuring for success.
If we think of the therapy as a way of activating emotions so that neural networks can join in new ways, then we could describe entrenched resistances as the mind's successful effort to reduce affective arousal below the threshold where change can take place. Characterological rigidities, behavior patterns and defenses serve to keep stress low, and prevent change. At those times, the therapy must destabilize the system so as to allow new growth. Sometimes, the unstructured interview is just not strong enough to dislodge entrenched defenses, especially in a once-a-week format. Considering all therapies as tools for raising the level of emotional activation, we can begin to evaluate a variety of techniques that can be mixed and matched according to the patient's needs and the therapist's abilities.
All Therapies Have the Same Structure
All psychotherapies have the following structure: The patient, with the therapist as helper, makes an effort, against internal resistance, to perform a task or reach an objective. This is the familiar A----®------>B. The key component that makes therapies different is the nature of the task or objective. In this way, as pointed out earlier, they utilize different means for the common goal of heating up emotions. Regardless of the task, the change processes are the same, catharsis and internalization. Some existing therapy paradigms are more suited as platforms for mixed practice, bringing in techniques form other places. Let us review several therapies from this standpoint.
Psychoanalysis: In a context of three or more sessions per week (very supportive), the patient tries to achieve free association. That is the task. Resistance comes first in the form of psychological defenses. Help from the therapist (more on this below) includes witnessing, expectancy, and metacommunication (interpretation) to help resolve defenses.
As the analysis progresses, a transformation occurs. A new structure begins to appear that alters the analysis in a very interesting way. The patient's secret healing plan begins to compete with the therapist's. The therapist wants the free association to lead to understanding and allow the patient to go through the processes of catharsis and internalization that will allow a new peace with reality. The patient's transference plan consists in inducing the therapist to change in ways that will free the patient from problems unresolved in childhood. In short, the patient wants the therapist to change and the therapist wants the patient to change.
The patient's plan becomes an impediment to free association (transference resistance) and to progress in general. Moreover, the patient is unconsciously ashamed of his or her alternative plan and uneasily aware that once it comes to light it will probably fail. The analyst's greatest skill is in leading the patient to see, acknowledge, and ultimately give up the plan that has, for almost a lifetime, been the secret road to happiness.
Suitability for mixed use: Psychoanalysis is a pure breed. The emphasis is on maximizing the transference and fantasy material. This powerful incubator has spawned a great deal of subtle knowledge of the human psyche. It does not seem wise to suggest altering or diluting this technique. On the other hand, analysts often introduce exceptions or "parameters" into the treatment. The concept that is offered here is that a more active stance is not inhibitory to the transference, and may actually energize the transference further.
Psychodynamic Psychotherapy: The frequency is lower and, as a result, material has more to do with the patient's outside life than with the therapeutic relationship. Transference happens, but tends to be less obvious or intense. Nevertheless, the issues are largely the same as in psychoanalysis. Now the task is to succeed in making the changes agreed upon as part of the treatment contract.
Suitability for mixed use: This therapy forms an excellent base for an integrated therapy. Elements borrowed from behavioral treatment, cognitive therapy, family therapy and other modalities can easily be added when helpful as long as the basic principles and protections are respected. We will explore on the next page how behavioral prescriptions and other non-analytic techniques can be incorporated in the therapy to enhance progress without diminishing effectiveness.
Cognitive-Behavioral Therapy: First developed for treatment of depression, Aaron Beck recognized correctly that pathological internalized attitudes and values were at the core of the illenss. The task was defined as elucidating these dysfunctional "core beliefs" and working at adopting healthier ones. Persistent identification of irrational ideas was very suited to the task of modifying internalizations. The therapist could help with education, probing questions and an attitude of expectancy. These techniques, as we will see, are not incompatible with psychodynamic therapy, nor is psychodynamic exploration really in conflict with cognitive therapy.
Suitability for mixed use: Already incorporating mixed techniques, cognitive therapy is well suited as a starting point for integrated practice. Current technique discourages but does not prohibit exploration of possible origins of entrenched dysfunctional patterns of reaction. This is not felt to be therapeutic, but may be desired by the patient. Those who are invested in the traditional theory of cognitive therapy may take issue in the following ways:
1. Cognitive therapy uses a learning model to explain the acquisition of new core beliefs. This is slightly different from internalization and more like change in behavior patterns. Further scientific exploration may yield a better understanding, but either way, both cognitive therapy and the psychodynamic therapies seek to change those change-resistant mental contents that I have identified as superego contents or internalized values, attitudes, ideals, etc.
2. Cognitive therapy has a tradition of rejecting the unconscious, free association, and introspection as valid sources of information. Science is generally not well served by a-priori rejection of potential soruces of data. Recent work has already demonstrated clearly that a great deal of cognitive processing goes on outside of any consciousness. All that is proposed here is the addition of some possible sources of data on the same entrenched, dysfunctional values, attitudes, ideals and prohibitions that heal by internalization.
3. Having adopted Exposure therapy and EMDR (Eye Movement Desensitization and Reprocessing) for the treatment of the emotional wounds of trauma, cognitive therapy considers the mechanism of healing of painful emotions to be "desensitization." The approach described in these pages deals with the same phenomenon, but describes it as "catharsis." In fact, the EMDR has been the clearest of all therapies in distinguishing between the two healing processes. Slight variations of the therapeutic technique are suggested for the two tasks of healing painful emotions and modifying negative beliefs about the self. It is hoped that the present way of looking at healing will provide a positive challenge to look more in depth at the precise mechanisms of catharsis / desensitization and internalization / modification of core beliefs.
Conclusion:
Either of the two most common forms of psychotherapy, psychodynamic or cognitive-behavioral therapy are reasonable platforms from which to begin to add in techniques from other areas. The principles described so far and in subsequent sections are intended to coherent basis for managing such a mix of techniques.
In the following section, consideration will be given to specific ways of integrating techniques in an office setting.
Beyond the Classic Session, Part 2