Clinical Workbook for Psychotherapists

Robert Langs

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9781855750043
• eBook ISBN:
  9780429912016
• Topic: Psicologia
• Subtopic: Storia e teoria della psicologia

This clinical workbook stresses the details of sound clinical practice, invites the reader to engage in exercises related to these practices as he or she goes through the volume, and offers practice in techniques that are essential to sound psychotherapy.

PART ONE

UNDERSTANDING UNCONSCIOUS COMMUNICATION

CHAPTER ONE

Unconscious communication and madness

INTRODUCTION

There are many factors contributing to emotional dysfunction, or madness, in human beings, patients and therapists alike. By madness I mean all types of emotional disorders: psychotic, neurotic, narcissistic, characterological, somatic, and otherwise. Of the factors that might be considered—social and cultural, biological and psychobiological, intrapsychic and interpersonal, the influence of fantasy and perception, individual and family history, and so on—psychoanalysis, along with its offspring, psychoanalytic psychotherapy, has concerned itself largely with the intrapsychic and interpersonal dimensions of madness. In this workbook I do not distinguish between these two treatment modalities, because the ideas and tools presented apply to both psychoanalysis and psychoanalytic psychotherapy with comparable pertinence. Psychoanalysis has sought to provide patients relief from emotional suffering primarily by establishing a secure framework for the treatment experience and a sound holding and containing relationship with the therapist; by proposing that the therapist respond to the behaviours and associations of the patient with silences, interpretations, reconstructions, and framework-management responses; and by implicitly fostering in the patient an inevitable unconscious introjective identification with the well-functioning therapist.

Each of these components of cure is dependent on the others. In particular, a sound holding relationship must be supported, when necessary, by interventions that secure the framework and by validated interpretive and reconstructive work. Conversely, the constructive influence of a confirmed interpretation, which leads to intrapsychic-conflict resolution and development of adaptive resources, must be supported by a healthy therapeutic symbiosis—the ideal frame and mode of relatedness for the psychotherapeutic experience.

Fundamental to the psychoanalytic therapeutic endeavour is a recognition of the importance of unconscious factors in all forms of madness. Other contributing causes notwithstanding, an extremely important component of emotional dysfunction exists entirely outside the awareness of the patient, finding expression only in disguised or encoded form. The patient may lack conscious realization not only of the influence of repressed genetic and other experiences, but of the meanings and functions of his or her immediate associations and behaviours. Those who practice psychoanalysis and psychoanalytic psychotherapy contend that, given the ego support provided by a sound holding and containing relationship, the specific insight afforded to a patient, based on the validated interpretation of his or her material, will lead to a variety of constructive consequences—among others, conflict resolution, interpersonal change, intrapsychic structural realignment, self-enhancement, the development of new adaptive resources, and true growth. These will gradually create a highly durable, adaptive resolution to a patient’s emotional disorder. Although there are, indeed, other means by which patients obtain relief from madness, such therapists claim that insight into the meaning of unconscious material is the most proficient and least damaging means by which emotional disturbances may be resolved.

At the heart of the psychoanalytic therapeutic technique, then, is an understanding of the patient’s unconscious communications —his or her encoded, or disguised, messages. It is therefore essential for a therapist to appreciate and to be capable of fully applying the kind of listening process whereby a patient’s unconscious expressions can be properly decoded and understood for their most cogent meanings and functions. For many years now, psychoanalysts have believed that they share in common a listening process of this kind. As documented elsewhere (Langs, 1981a), however, extensive evidence indicates that this is not the case. It therefore behooves us, experienced analyst and novice alike, to study the nature of unconscious communication and to perfect, as far as is possible, the means by which encoded messages can be properly and incisively decoded.

SOME BASIC MODELS

In his greatest work, The Interpretation of Dreams (1900a), Freud proposed, in a moment of singular insight, that human mentation takes two basic forms: what he called primary-process and secondary-process thinking. Secondary-process thinking is conscious thinking; it is attuned to the external world and proceeds by way of individual, discrete thoughts. These thoughts are logical, sequential, and confined to manifest meanings. Primary-process thinking occurs mainly by way of narratives and visual images that have multiple meanings. Such thinking is fluid and unconcerned with objective reality or sequential time. It readily shifts about without linear focus and uses a set of specific and unique mechanisms in its operation. Many of these ideas—especially the contention that unconscious mentation is out of touch with reality and the failure to recognize the profound defensiveness of conscious thinking—have been challenged by communicative studies (Langs, 1988a, 1988b). Still, I will first define Freud’s position, and that of classical psychoanalysis, and then clarify the modifications necessitated by communicative understanding.

Freud’s basis for working out the laws of primary-process mentation was the reported dream. Freud believed that memories and fantasies that are ordinarily repressed from consciousness gain access to consciousness during dreams, when defences are relaxed. In order to experience these threatening images without anxiety, the dreamer unconsciously transforms them, by way of primary-process mentation, into less threatening verbal and visual equivalents. When the dreamer reports the dream, these transformed images are pulled into a secondary-process narrative that gives them an immediate surface meaning; but they also contain evidence of the threatening repressed thoughts from which they are derived. These repressed thoughts are said to be ‘latent’ in the disguised images; they have been permitted conscious expression, but they remain unconscious to the person telling the dream.

Freud was interested in the means by which an anxiety-provoking memory or fantasy is transformed into a manifest dream element and, conversely, how a manifest dream could be decoded into its latent meanings. The discovery of the mechanisms of transformation would indicate those processes that had to be undone or reversed in order to decipher the manifest dream elements.

The depth model

Freud’s original idea about intrapsychic functioning was that repressed mental contents seeking access to consciousness are kept at bay by a repressing force. The model he used to illustrate his hypothesis (the topographic model, presented in The Interpretation of Dreams, 1900a) is now mainly discarded by classical analysts, but its physical imagery continues to shape the ideas of psychotherapists today. The model for intrapsychic functioning is generally that of a surface that in some way reveals but also conceals a configuration lying deeper, on a lower psychic stratus. This is why psychoanalysis has been called a depth psychology. Sometimes the image envisioned is that of an opaque surface lying above contents hidden within the depths, accessible only via some type of fresh opening.

This model is not without value. It has stood the test of time, because it has helped psychotherapists to visualize the idea that unconscious factors contribute to surface madness. Nevertheless, the value of any psychological or dynamic model is limited by the concrete nature of its imagery, which ultimately misleads. The depth model encourages the reification of what is mistakenly called ‘the unconscious,’ in that the model suggests a static state of affairs rather than a continual interplay of dynamic forces. The model leads to notions of fixed elements pressing upward, seeking discharge, and to the sense that these elements involve isolated or concrete thoughts or ideas.

The depth model, accordingly, has had important technical consequences for the practice of psychotherapy. It leads to digging by the psychotherapist, to probing, to ‘penetrating’ questions, to pushing past a surface association by asking the patient to move deeper, to go further or to somehow pull out in direct and manifest form the deeper, hidden contents of the unconscious mind. The endeavour is directed towards reaching in and gaining access to an emergent disguised unconscious element. A great deal of psychoanalytic listening and technique has been designed in this fashion. The model leads to much active probing by the psychotherapist and to a belief that those associations which the patient produces in response to this probing tend to embody the underlying concealed contents.

It is critical in examining this model to recognize the absence of a postulated process of transformation and disguise. Despite Freud’s consideration of these mechanisms in The Interpretation of Dreams (1900a), the model of listening used by many psychotherapists is entirely devoid of reference to a need to undo disguise or to decipher transformed images. The unconscious element is expected to leap whole cloth through the opening provided by the probes of the psychotherapist, and, once stated directly, its supposed unconscious meaning is presumed to have been captured. However, there is considerable evidence to indicate that unconscious material does not reach the surface of the patient’s associations in this manner, so that the depth model of psychoanalysis has ultimately proved as misleading as it has been helpful.

Resolution of these issues lies in the communicative approach, in which the emphasis is placed not on the mind and mentation but, rather, on conscious and unconscious expressions—communication. Such an approach is capable both of dealing with intrapsychic, interpersonal, and interactional factors in emotional dysfunctions and also of generating a revised model of the unconscious dimension of human madness.

The communicative approach to madness

Stimulus and adaptive response

The development of madness may be understood in terms of a simple stimulus–response paradigm. In general, we may propose that traumatic stimuli may lead to the maladaptive responses that we term emotional dysfunctions, or madness. Symptoms and interpersonal dysfunctions are only one kind of response among the many responses to a stimulus that are possible; when these symptoms and dysfunctions do appear, however, their unconscious structure proves to be of great importance. By the word ‘unconscious’ I mean those aspects of a stimulus that lie outside the awareness of the sender (the creator of the stimulus), the receiver, or both, but nonetheless induce in the receiver a tendency to respond. The unconscious aspects of messages sent and received and the responses to these messages are crucial in the development of an emotional disturbance and in the perpetuation of symptoms indicating that disturbance. Because they exist outside the awareness of the individual experiencing the symptoms, such unconscious factors cannot be stated directly by that individual; they can be expressed only indirectly—through messages derived from those unconscious factors, but symbolized by mental contents that are conscious.

Understood from a communicative standpoint, a stimulus may be both a direct message and an encoded message, an expression having both manifest and latent contents and functions. Similarly, the response to such a stimulus often has both manifest and latent meanings, because the receiver has registered, both consciously and also without awareness, the conscious and unconscious meanings of a received message. Thus, a symptomatic or associative response to a stimulus reflects, in part, the unwitting registration of the implications of that stimulus, leading to a responsive encoded message. Quite often, the key factor in sender/receiver exchanges is unconscious communication between the participants—expressions whose implications are registered and have led to response outside the awareness of both the sender and the receiver of the encoded messages.

The question arises as to what evidence exists that the receiver has registered the unconscious aspects of a sender’s encoded message in some form outside the recipient’s awareness. Such evidence is constituted by the receiver’s reactions to the imparted message. Typically, they include behaviours and associations that are in keeping with the unconscious implications of the stimulus; in this way there is clear evidence that the stimulus has registered outside awareness and has led to a responsive communication.

In summary, from a communicative standpoint, a stimulus is an expression that contains both direct and encoded messages. It leads to a response that similarly contains both direct and encoded messages—messages that are shaped by both the nature of the stimulus and the condition of the receiver.

In psychotherapy, this latter factor—the condition of the patient/receiver—is mainly the state of his or her inner madness. In addition, however, a receiver’s condition is influenced by his or her intrapsychic state, constructive capabilities, genetic history, and the like. In substance, encoded messages lead to important encoded responses. Such reactions thereupon become fresh stimuli leading to still further encoded responses. In this way cycles of unconscious interaction are initiated and carried out. It is the goal of the psychotherapist to develop the techniques to decode such messages, whether they are taking place between a patient and figures in his or her outside life, or directly between the patient and therapist within the treatment situation.

From this standpoint, a symptom is a dysfunctional encoded response to a stimulus having both manifest and latent meanings. Symptoms usually involve highly disguised encoded messages and are difficult to decode except in a very general way. In contrast, dreams and other kinds of free associations are often the carriers of thinly disguised encoded responses to a stimulus and are more readily decoded. The communicative valence of responses to conscious and unconscious stimuli varies from patient to patient, as does the vehicle of expression. Some behaviours and material are highly meaningful carriers of unconscious expression, whereas others are not. Nevertheless, in the therapeutic situation, all of a given patient’s associations and behaviours have the potential to function as carriers of encoded reactions to the stimuli with which that person is presently dealing.

Madness itself, then, should be understood as an encoded expression—as unconscious communication, whose underlying meanings and functions, as such, cannot be stated manifestly and directly by the person experiencing that condition. The associations produced in response to the surface forms that madness takes reveal its unconscious basis by way of their derivative aspects. Accordingly, the listening process in psychotherapy must centre on efforts to decode the unconscious meanings and functions of madness in light of the stimuli that helped to create its existence.

It should be noted in this regard that a patient’s encoded expressions will necessarily reflect his or her registration of unconscious aspects of the therapist’s interventions. Patient cure or lack of cure (and even regression) is effected in terms of a therapist’s unconscious as well as conscious messages to the patient. One of the goals of psychotherapy is thus to create an interaction wherein the therapist’s expressions to the patient are primari...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Part One Understanding unconscious communication
• Part Two Listening and formulating
• Part Three Intervening and validating
• Appendix The seven dimensions of the therapeutic interaction
• References
• Index