Saturday, May 24, 2008

Fiumes Vecchios e Pontes Nuovos: Old Rivers, New Bridges

Entry for 18 May 2008:

Based on my roundtable presentation at the conference La Relazione che Cura: Due Scuole, Due Paradigmi a Confronto [The Relationship that Heals: Two Schools, Two Paradigms in Dialogue], Florence, Italy, May, 2008.

Throughout human history, people have chosen to establish towns along rivers. Florence is one of these. These rivers have then created divisions between the people who live on either bank of these rivers. Often, these divisions have led to envy, prejudice and conflict.

These rivers that divide us are old, familiar ones. In these remarks, I describe some of these rivers. As psychodynamic and person-centred therapists, we have often found ourselves in such a conflicted situation, in which we seem to remain stuck in old, entrenched views of one another, views that over time have become caricatures. However, my main goal is to describe a set of new bridges that can cross these rivers, creating dialogue.

1. Interpretation. The first old dividing river is Intepretation: Is it desirable or not to interpret our clients? On the one hand, those of us who are psychodynamic say yes, this is an important change process, perhaps the most important change process. On the other hand, those of us who are person-centred argue that it is wrong to interpret our clients, because we can’t know the client’s truth and because it disempowers them.

However, it turns out that over time people on both sides of this river have been building toward one anothe. Psychodynamic therapists have described how it is important to offer experience-near interpretations, that move just a little bit into the client’s preconscious, what the client is almost but not quite aware of. And person-centred therapists such as Gendlin and Greenberg and myself have described the most important kind of reflection as one which is at the edge of what the client is aware of, in what Gendlin calls the “unclear felt sense”, using a type of response that Greenberg and Emotion-Focused Therapists call “empathic conjecture”, that is, a guess about what the client may be experiencing, but which they have not yet expressed. Actually, this is not a truly new bridge; it goes back at least to Speisman’s (1959) research and an early paper by Gendlin (I forget the exact reference). This is more a bridge that has fallen into disuse and now needs to be rebuilt and renovated. Let us call this first bridge, the Bridge of Responding at the Edge of the Client’s Awareness. (Or as Carmen [whose last name I’ve forgotten] from the University of Pisa noted afterwards, this corresponds to Vygotsky’s idea of a “zone of proximal development”, which is the idea behind the developmental strategy of “scaffolding”.)

2. Motivation Theory. The second river is Motivation Theory: Drive vs. Actualization. Freud postulated primitive drives toward pleasure as the fundamental motives, while Rogers hypothesized the existence of a basic tendency for people to develop themselves. This division has often been couched in terms such as determinism vs. freedom, or pessimism vs. optimism.

However, as Shlomo Mendelovich so clearly described in his presentation, psychodynamic theory long ago went beyond Freudian Drive Theory to develop first object relations theory and more recently intersubjectivity theory. Meanwhile, on the person-centred side, Gendlin developed the idea of Experiencing as the fundamental human process that organizes perception of the environment and motivates action; subsequently, Greenberg, I, and others have attributed this same function to emotion and emotion schemes. But much of it comes down to what is called object relations or mentalization in contemporary psychodynamic approaches, to the same degree to which psychodynamic intersubjectivity overlaps with classic person-centred concepts like frame of reference, empathy and presence. Together, these two concepts make a kind of neo-Lewinian interpersonal field theory. So the second bridge, having to with motivation theory, can be referred to as the Bridge of Intersubjective Representations.

3. Expertness. The third river that divides us is the vexed issue of Expertness. Historically, psychodynamic therapists have tended to embrace their position as experts on clients’ inner experience, valuing diagnosis, prizing models of psychopathology, and setting out rich case formulations. On the other hand, person-centred therapists have classically prided themselves as “experts in being nonexperts”, endorsing the wisdom of “not-knowing”.

Whereas, in fact, good psychodynamic practice has long involved negotiated meaning, in which therapist and client collaborate to come up with a satisfactory explanation for the client’s problems, while person-centred therapy, in its process-oriented forms, has moved increasingly toward process expertise and the development of specific theories for specific client presenting problems (e.g., PTSD, depression, borderline processes), even coining the term “process diagnosis” (Greenberg). At the very least, as Gianni Sulprizio of the Italian Person-Centred Association noted, person-centred therapists are “expert explorers.” And of course, this process expert – whether psychodynamic or person-centred – encounters a client who is now widely recognized to be an “active self-healer” (as Bohart has proposed). Thus, the third bridge is constructed out of this dialectic: the Bridge Where the Active Self-Healer Meets the Process Expert.

4. Client Population. The fourth river is client population focused upon: more vs. less severe disturbance. Although psychoanalysis initially focused on treating neurotic patients, it soon began extending itself into work on more severe problems, such as psychosis and severe personality problems (e.g., borderline, narcissistic). Also, many psychoanalysts, because of their medical background, worked in hospital settings, and so saw more disturbed people. Person-centred therapy was first developed in college-based counselling clinics in the USA, and for a long time emphasized work with clients in the less disturbed range. While Rogers and his team did undertake a major research study on delivering person-centred therapy to hospitalized patients (the Wisconsin Study), at the time and for several decades afterward, this was regarded as an aberration and a mistake.

In the past 15 years, however, as part of the renaissance of person-centred/experiential psychotherapies, Gary Prouty (Pre-therapy, also known as contact work) and Margaret Warner (fragile process) in particular have pioneered work with more severely disturbed clients, with Prouty’s work now recognized internationally by psychodynamic and other therapists for its relevance to psychotherapeutic work with severely disturbed populations. And of course psychodynamic therapists, like their person-centred brothers and sisters, have always treated large numbers of clients with anxiety and depression. (Note also that it would be a mistake to refer to such neurotic difficulties as “mild”; because these problems often carry a severe illness burden for the person and their significant others.) Thus, I would like to christen the fourth crossing as the Bridge of Human Pain: We are all committed to helping our clients reduce, or manage their pain.

Presumed Biological Foundation. The fifth river dividing the psychodynamic and person-centred approaches can be called their presumed biological foundations: On the one hand, psychodynamic theory, as originally put forward by Freud, used a nineteenth century quasi-biological hydraulic model based on sexual energy; the nature of this psychic energy was broadened over time, but remains an abstract concept not clearly based in contemporary neuroscience. Similarly, person-centred theory postulated a growth or actualization tendency, also highly abstract and not clearly related brain structure or function; and even Gendlin’s concepts of experiencing and the unclear felt sense have not really been adequately integrated into what we have come to learn about the human brain.

Rapidly expanding knowledge from neuroscience is, however, giving us increasingly clearer, more powerful understandings of how our brains develop and change in response to our environments, and in particular how central emotion processes are in our brains. For example, we now know that successful psychotherapy, like other kinds of new experience, is associated with changes in brain structure and function, ranging from increases in the size and efficiency of particular neurons to the creation of new neurons (“neurogenesis”). Furthermore, we have now learned quite a bit about how people use their limbic systems (in the midbrain) to rapidly process sensory information via emotion processes. These brain-based emotion processes involve a level of specificity an order of magnitude greater than the old libido and actualization theories, including separate but overlapping systems dealing with separation/loss-fear/sadness-attachment; novelty-curiosity-exploration; noxiousness-disgust-rejection; danger-fear-avoidance; threat-anger-territoriality; etc. All of these emotion processes integrate brain systems that process perceptual information, memory, emotion, autonomic arousal (body), higher cortical processing (cognition), into effective action. I don’t think that we, as either psychodynamic or person-centred therapists, have yet fully embraced this new knowledge to help us understand how therapy works and how to help our clients more effectively. Thus, I propose a fifth bridge, the Bridge of the Emotional Brain, as a path to further exchange and dialogue.

At the present state of development of our two approaches, I think that the most productive stance is not competition or critique but curiosity, questioning, and dialogue. I don’t think that we are ready to come together into a single integrated position, nor do I even think that this would be useful. Instead, for now, I suspect that the most useful meta-position is going to have to be pluralism, by which I mean the acceptance and appreciation of our differences. We are two peoples, living on either side of a river (or several rivers) than run through human experience; from our respective banks, our positions give us sometimes quite different perspectives, and certainly we have cultivated different perception and resources for helping people. But to be connected by a useful set of bridges that bring us into commerce and dialogue with each other, this seems to be the best place for us to locate ourselves for now.

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