Category: The Therapeutic Instrument

For Some Psychotherapists, the Work Has Always Been Virtual

Posted on by Melonie Bell

A therapist shares knowledge gained from two decades of teaching online.

  • Familiarity with the experience of online therapy can help ameliorate stress, both on therapists and our patients.
  • Online learning opportunities abound for mental health professionals, particularly in this era.
  • The ongoing stressors of the pandemic will affect individuals, couples, and families differently.

It has been a difficult year for patients and psychotherapists everywhere. As all therapeutic work moved online, my colleagues at the International Psychotherapy Institute and I had one advantage: We have been at a distance-learning institution for 25 years. As a result, we were ready when suddenly everything was forced onto online platforms. In particular, we were prepared to treat couples and families negatively affected by lockdowns, and to help our students do the same.

Even as vaccines offer a light at the end of the tunnel, online therapy and training are not going away. Here’s what I think therapists can learn from our experience:

Online therapy is better than ever. Our initial close partnership with the Tavistock Clinic, the Tavistock Institute for Marital Studies (now called Tavistock Relationships), and Westminster College in Salt Lake City, Utah, used early shaky technology and unreliable internet to establish distance training. At first, all of our students had to be in the same room at one of four locations; that was all the platforms would support. Over time, we adapted to each iteration of improving technology, and eventually we could reach people on their own computers, beginning about 15 years ago. We have now been conducting online trainings and supervision in China and Russia for a decade, even as the technology has continued to improve dramatically.

Opportunities for online training have grown enormously in the pandemic. A real paradox, for us, is that our training programs have grown enormously. Through offering Town Hall meetings and online trainings, we have colleagues and students joining us at IPI from around the world in much larger numbers, and despite the time zone differences. The need to put all our conferences online has meant that people could come to courses and conferences without the expensive need to travel. I do miss seeing my friends and colleagues at in-person conferences, which IPI has always held four or five times a year. But I am reaching and interacting with more people from all over – throughout the U.S. and Canada, India, Pakistan, Europe, the Americas, Australia and New Zealand, China, Romania, and Russia. For some in India, China, and Australia, our programs happen in the middle of the night, but still they come.

Online therapy allows for international insight: you’re not alone, and neither are your patients. Because I work with therapists worldwide, especially in China and Russia, I could see how much the pandemic affected couples and families everywhere, not just in the United States. Some were positively affected when they had more time together, and solved the problems of quarantine and risk reduction together. But as we all know, other couples and families were adversely affected, with more conflict while confined together in marriages that went from contentious to unbearable familiarity, and often then to an urgent need to divorce.

A spike in divorce rates, for example, was reported in Wuhan, China from the outset of the pandemic. Couples that had maintained their marriages by spending very little time at home together, usually with one member of a couple working in another city or traveling for work, were now locked in together. Some were suddenly much happier together. But many found themselves with a new and unbearable closeness, and their therapists had a new problem to deal with.

Some takeaways from our experience. Patients—especially couples—have had increased need this year, which has kept me and my colleagues even busier than usual. For therapists still learning the ropes of online appointments, here are a few ways to support the couples you work with:

  • We are all experiencing “PTSE” – Pandemic Traumatic Stress Experience. It’s not a disease. It is not PTSD. It is a shared experience of stress common to therapists and patients alike.
  • Acknowledge the differences in the way of working online that color the therapy.
  • Look for analogous differences in patients’ and couples’ lives that are highlighted by the experience in online couple therapy.
  • Connect their distress as a couple or family with the wider distress that we are all living with – our shared PTSE.

Thankfully, my colleagues and I are surviving the covid pandemic. Though we miss our freedom, we have been able to use our expertise to benefit both our students and patients in the newly virtual world. We’ll be glad to be able to meet patients in the office again and to meet each other in person at our conferences, but we all know that our ways of conducting therapy and training will never be the same again.

 

David Scharff, M.D., is Clinical Professor of Psychiatry at the Uniformed Services University of the Health Sciences, as well as at Georgetown University. He is also Co-Founder and Former Director of the International Psychotherapy Institute; Chair of the International Psychoanalytic Association’s Committee on Family and Couple Psychoanalysis;  Co-Chair, APsaA Advisory Committee on COVID-19, and editor-in-chief of Psychoanalysis and Psychotherapy in China. He directs training programs in analytic couple and family therapy in Beijing and Moscow.

The Therapeutic Instrument

Posted on by Melonie Bell

By David E. Scharff, M.D.

The psychotherapeutic instrument is, of course, the therapist – in all aspects of her or his personality – who has the unique capability of being honed by experience to create a relationship that helps other people grow, heal, and expand the range of possibilities in their lives. Fashioning your personality to fill a role isn’t unique to psychotherapists. Dancers, ministers, cops, business people all do it. But our field is right up there among those whose training is the most intensive and extensive – and it needs to be. We are unique in our ambitious goals of creating lasting change in our patients.

When I think of the therapeutic instrument, and of tuning that instrument, I consider all the elements that go into our work: The personality of the therapist, her growth and development, her well-being; her theoretical education; her treatment; her knowledge of all sorts of things that her clients and patients encounter. The job we do is complex, pretty much as complex as humanity itself, from the sociological and anthropological differences that now people our country, to the complexity of individual personality, to the more complex patterns of interaction in couples and families.

Because of the ultimate complexity of our work and the demands it can make on us as therapists, a wide variety of topics is relevant to getting us in tune. As we explore the process of therapy, I want to discuss issues having to do with theory and with technique, even though the boundary between these often blurs. I want to draw from diverse theoretical and scientific universes that can be brought to bear on understanding our patients. This is all with an eye to fine-tuning ourselves as therapeutic instruments.

The therapeutic instrument gets tuned by being open to influence from diverse fields that may, at first glance, seem to have nothing to do with our work and to be unrelated to each other: Chaos theory, literary theory, anthropology, large group psychology. And the obvious fields of neuroscience, psychoanalysis in its many forms (object relations, self psychology, relational, contemporary Freudian, Lacanian) systems theory, and strangely (from my point of view) cognitive and behavioral therapy. As John Sutherland, editor of the International Journal of Psycho-Analysis 40 years ago, used to say, “People are so complex that we need all the theories we can get to make sense of them.” We need diverse theories and models to expand our understanding of therapy, to help frame, contain, and to provide narrative to patients’ lives and interactions. So we need to learn, and to continuously relearn, how to draw on our own experience, cognitive and especially emotional, to sharpen our understanding, to catch the faint whiff of transient emotional trends that come and go between us and our patients. The complexities of human experience are always more than our comprehension. That daunting fact is also a lifelong invitation to continue our own growth endlessly towards fuller understanding. Tuning our therapeutic instrument is nothing less than tuning the whole of ourselves.

All of that is what this blog is about. I plan to write from as wide a variety of experiences as I can, and from time to time, will invite colleagues to contribute their experiences and special areas of understanding of diverse aspects of the wonderfully unfolding world of psychotherapy and psychoanalysis. That includes what we learn about the interest in and practice of psychotherapy around the world. I plan to write about psychotherapy in China in a posting soon, drawn from my recent trip there. Beyond that, we want to explore topics that interest us, writers who seem to have something new to say – or even something old restated in an original and fresh way.

I have found central support of my work in the contributions of the original Object Relations theorists, Klein, Winnicott, Bowlby, Bion, and especially Fairbairn. More modern contributions – those that take us beyond the original formulations from, say, 1940 through 1975, and into the dynamically evolving field that has come from the premises Fairbairn first spelled out – are just as pivotal. To the foundation work of what we might call ‘classical’ Object Relations theory, we have to add the rich elaboration by many others such as Sutherland, Guntrip, Kohut, Segal, Kernberg, Bollas, Steiner, Britton, McDougall, Mitchell, Fonagy and Target, Jacobs, Akhtar, on both sides of the Atlantic over the years. And recently there has come an explosion of new research and conceptual material that has enriched our thinking almost beyond our wildest hopes. Here I mean first the contributions of the study of affect, trauma, attachment theory, and neuroscience. Psychoanalytically we have been enriched by self psychology, the study of intersubjectivity, relational theory, self psychology and motivational systems theory, family and couple therapy, sex therapy and many other clinical areas of study. These fields of research overlap greatly and enrich each other, and the cumulative effect is to transform our thinking and our reach beyond object relations. I’ve used object relations as a foundation whose elaboration leads to areas that, while confirming the original insights of Fairbairn, Klein, Bion, Winnicott and Bowlby, offers new insights and newly penetrating and flexible ways of working clinically.

Object relations theory was the first theory that focused on the relationship between therapist and patient as the essential factor in psychological change, the heart of growth and development. But in recent years, I have also based my ideas on the model provided by chaos or complexity theory, also called the theory of dynamical systems. This modern theory began to be developed in the mid 1970s, and was formulated for a popular audience by Gleick in 1987. Since then it has been applied to neuroscience, psychoanalysis, and family systems theory. It has the paradoxical quality of being a set of real operating principles for the physical universe as well as the world of psychology, and at the same time being a useful metaphor that can help achieve a new vision clinically and theoretically.

I’m going to begin with the foundation because if you are unfamiliar with the basics of object relations, the rest won’t make so much sense. I take Fairbairn as the spine of object relations theory. He knew Freud’s work extremely well, from studying it and teaching it to medical and philosophy students, and he adopted Freud’s clinical method in his own practice. But he had questions about some logical inconsistencies in Freud’s theory. For instance, he could not see how the superego could be the agent of repression if it was repressed itself. And he worried about the absence of a clear theory of aggression, having refuted the idea of a death instinct. In place of these theories, Fairbairn said that when people acted clinically as though driven by either the pleasure principle or the death instinct, they were acting in a closed system cut off from dynamic influence of the wider social environment.

Fairbairn’s reformulation of basic theory began with the child’s need for a relationship with a primary caretaker – a mother (although we now see that fathers can fill this role too.) He thought this was central, and that the vicissitudes of that need dominated development and all of life, with the drives having meaning in the context of that need. Although we know now that there are aspects of development that are not centrally relational (learning motor skills, for instance), we can also see that the need for relationship still dominates psychological life and therefore is what is most important in our work.Fairbairn thought that when the mother inevitably disappointed the infant, he or she then introjected (that is psychologically incorporated) this disappointing experience with mother as a “bad internal object” – that is, an image of the mother as painfully disappointing, rejecting, neglectful or even persecuting. Introjection, however, creates the same painful experience inside that the child had outside just before, which then necessitates the next defensive maneuver: the splitting apart of the bad image of mother from the good, and repressing the bad image. Now these split-off bad images are more than just bad internal objects: they are actually parts of the ego organization, because they quickly become part of the self, capable of generating ideas and actions themselves. You can see what this means if you think of times you catch yourself acting like someone you don’t like, or who treated you badly. In such a case, you are acting in the image of your internalized “bad objects.” We all do that frequently, and perhaps most significantly, we do it when we act like our parents did when we resented them the most, when we swore we’d never act that way ourselves. So these aren’t just passive internal images. They are capable of organizing part of our actions. We all have multiple aspects of our selves in our psyche, and these parts are in dynamic relationship with each other. They monitor experience with the outer world, and determine how we understand the meaning of experience with others.

Fairbairn also realized that affect was the link between these internal aspects of self and object (or “other”), and therefore that affect was crucial theoretically and clinically. His ideas were forerunners of modern affect theory. And his realization that the psyche is a dynamic, complex system, always on the move internally, that also interacts with the world of people outside the self, made his work one of the precursors of the way we take advantage of chaos theory to understand the infinitely complex organization of emergent selves in interaction with the complex outer world.

Clinically, Klein and Winnicott wrote compellingly from an object relations perspective, and Bion offered theory that is a direct imaginative precursor to many modern developments, including chaos theory. Bowlby’s attachment theory, the elaborations in infant research, and the ideas of affect regulation and mentalization by Fonagy and Target give us further crucial elaborations on the theory Fairbairn began. But each of these is so rich that they deserve their own focus – which will come in subsequent postings.