Embracing Therapeutic Complexity

A Guidebook to Integrating the Essentials of Psychodynamic Principles Across Therapeutic Disciplines

Patricia Gianotti

• Publisher: Routledge
• Year: 2022
• Print ISBN: 9780367636869
• eBook ISBN: 9781000585841
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In an era where instant gratification has filtered into training programs geared toward technique-driven solutions, Embracing Therapeutic Complexity takes a step back and re-introduces fundamental touchstones that enable clinicians to apply an integrative treatment model in the service of in-depth healing and growth.

Using attachment theory as a bridge, this text connects key principles and practices that cut across various therapeutic disciplines and combines them into a unified framework where readers do not have to "put aside" their expertise in order to benefit from the skill sets provided in this book. In addition, this text addresses the impact that power and privilege have had on shaping our psychological constructs, and it challenges cultural assumptions and blind spots that have shaped our treatment approaches in the past.

Furthermore, this book illustrates how the application of psychodynamic principles can be combined with advances in trauma treatment, thus offering a practical guide for both beginning and seasoned therapists to amplify and expand their current clinical expertise.

1 Creating a Three-Dimensional Matrix of the Psyche: Contrasting Two Roadmaps of Relational Development

DOI: 10.4324/9781003120278-2

Introduction

Imagine, if you will, a healthy, intact human being. Does such a person exist, and if so, can we agree upon what he or she looks like? What are the dimensions of self and self-in-relationship that we would use to assess the quality of health, spontaneity, authenticity, whole-heartedness, ambition, resilience, and personal growth throughout the life span? As therapists we are in the business of healing and transformation, of repairing psychic injuries that accumulate as a result of insecure attachment bonds, trauma, cultural inequity, isolation, and racism. Yet, our approach to treating psychological injuries vary according to one's theoretical orientation and training in combination with the needs, goals, and resources of our clients. This creates a complicated picture of precisely how to proceed with treatment, one in which therapists have argued over for more than a century.

In an attempt to create unifying principles around factors that contribute to health and psychic disease, this chapter presents two visual graphics of psychic development. One graphic describes individuals who were afforded the opportunity to thrive in a safe, secure, and loving environment, and the other describes individuals who suffered from varying degrees of trauma, deprivation, and/or insecurity in childhood. The outcome of a healthy upbringing allows for the unique qualities of the self to be supported in the context of providing fair and consistent rules of relational engagement that foster a sense of mutuality, where respect for self and other are treated equally. The outcome of an upbringing where the unique qualities of one's self had to be sacrificed in order to preserve a precarious attachment with fragile, disorganized, or narcissistic care-givers results in varying degrees of insecurity, affect dysregulation, traumatically induced neurological and physiologically embedded injury, and acquired defense structures that attempt to compensate for these losses and limitations.

What do these two pictures of psychic development look like as individuals evolve throughout the life span? This chapter presents two models that can be used as assessment tools when evaluating the spectrum of health and illness. Regardless of one's theoretical training and expertise, these models provide therapists with a template that illuminates factors that comprise defense structures, psychic stability, degrees of self-care, and the dimensions and quality of interpersonal relationships.

Measures that Depict Health, Fragility, and Psychic Stability

Identifying qualities that contribute to mental/emotional health is not a new concept to the field of psychology. There are numerous theories as well as lists of attributes that determine psychological health (Fredrickson & Losada, 2005; Markstrom & Marshall, 2006; Metz, 1961; Peterson, Park, & Seligman, 2004; Seligman, 2004; Vallerand et al., 2003.) A list of quality that measure aspects of psychological health, taken from the Psychodynamic Diagnostic Manual include a number of specific capacities such as:

• self-regulation, attention and learning,
• intimacy and mutuality in relationships,
• differentiation & integration,
• self-reflection,
• constructing and applying internal standards of morality,
• assimilating new learning,
• creativity and curiosity.

Adler (1930); Allport (1943, 1950); Bellak and Sheehy (1976); Erickson (1950); and Fairbairn (1952) all speak of ego strengths that contribute to stability and well-being. These include measures of a person's temperament, motivation, and psychological mindedness, that increase an individual's personal and social competence as well as contributing to psychic stability in times of stress. In addition, ego strengths such as self-efficacy, intelligence, and cognitive flexibility are closely related to openness and creativity, and successfully adapting to external stimuli. Psychological flexibility, which is measured by the capacity to tolerate certain degrees of distress while maintaining psychic equilibrium is a critical measure of psychic resilience (Hayes et al., 1996; Kashdan & Rottenberg, 2010). In general ego capacities reflect the quality of one's internal experience as measured by level of confidence and self-regard, one's affective experience, and the quality of expression, and communication. Deficiencies in any of these areas result in greater difficulty managing life's challenges (Gfellner & Cordoba, 2017; Hartmann, 1958; Kagle & Levay, 1977).

In my first two books, written with co-author, Jack Danielian, we provided a visual matrix of patients who present with varying degrees of psychic injury. We entitled this graphic the Four Quadrant Model, a model that simultaneously captures a picture of intrapsychic, relational, systemic, and socio-cultural aspects of an individual. Regardless of symptom presentation or diagnosis, this model enabled therapists to better understand the interaction between shame, self-stability, fears, expectations, and longings for interpersonal connection. It measured how individuals respond to disappointment, and it provided therapists a means to assess degrees of defensive over-compensation that individuals use in an attempt to keep feelings of shame and inadequacy from breaking into conscious awareness.

Since the development of the Four Quadrant Model and the publication of our first two books, we began using this model as a teaching tool in our advanced training programs, public lectures, and continuing education seminars. We soon discovered that clinicians were often confused about the sometimes-fine-line between healthy self-esteem and pathological over-compensation that masqueraded as success in the outside world. This confusion meant that therapists often misjudged the toll that defensive over-compensations took on their patients over time.

Defensive solutions that attempt to mask feelings of inadequacy are ultimately unsustainable because the drive to continually prove self-worth will deplete a person's energy over time. Defensively based behavioral patterns create a vicious cycle in that they never permanently ameliorate one's core sense of underlying shame. These never-ending cyclic patterns of overcompensation eventually lead to symptomatic break-through, or in cases of severe trauma or deprivation, they can lead to psychic fragmentation. The toll on the psyche may be subtle at first, and therefore difficult to recognize, but over time these patterns drain vitality, resulting in increased rigidity, resignation, and/or resentment.

The Healthy Self-Actualizing Model presented for the first time in this book was created to illustrate specific attributes and measures of healthy development throughout the life span. This model is meant to serve as a companion piece to the Four Quadrant Model to help practitioners more easily recognize how healthy behaviors fuel and invigorate psychic vitality rather than drain psychic energy. The Healthy Self-Actualizing Model, with a similar graphic design as the Four Quadrant Model, presents a matrix that highlights degrees of evolving resilience and growth. The identified qualities in each quadrant can be used as a means of placing the various aspects of a patient's presentation in a context, where defense structures are weighed along-side a patient's strengths and resilience. Using the two models together can also help therapists recognize when defensive patterns begin to give way to emerging signs of growth throughout the treatment process.

Therapists can draw upon these models as a diagnostic tool, in assessing levels of symptom severity, setting treatment goals, as well as increasing proficiency around treatment interventions throughout the course of therapy. We have found that by providing a comparison of the two models, therapists can better assess the degree of fragility and shame sensitivity as well as discover pockets of resilience and strength that exist along-side of the defensively driven patterns. In that regard the two models can be used throughout the treatment process as a means of reviewing and tracking therapeutic progress.

Personal clinical styles often become more routinized over time. The longer we work with a patient and hear repeated stories, there is a drift toward assuming we know what the patient is saying, which may result in missing nuances of communication or other important parts of the client's narrative. Those parts of the relational dynamic that remain under-attended or minimized are often aspects of the patient's psyche that are either consciously hidden, or they are unconsciously enacted within the therapeutic relationship. Clinical blind spots, left unattended, often reveal a shared, intersubjective dynamic that has developed between client and therapist. More often than not, these blind spots eventually create a stalemate in the treatment and result in some degree of frustration on the part of both parties.

What the Four Quadrant Model and Healthy Self-Actualization Model can provide is a type of a safety net, a reference point where clinicians can check-in with themselves or confer with colleagues when moments of therapeutic impasse occur. Using the Four Quadrant Model as a reference point, clinicians often discover areas of the psyche that may have received little attention in terms of therapeutic inquiry. For example, some clinicians may focus more on relational dynamics while under attending to intrapsychic conflicts. Others attend exclusively to symptom reduction, where others work to change negative cognitions. Using the Healthy Self-Actualizing model allows us to more easily recognize the areas of strength that the patient has used to master challenges and attain a sense of authentic accomplishment. Using these two models as a dual reference point during the course of treatment can assist in keeping the complexity of therapeutic attention in the forefront, attending to both areas of defensive constraint as well as areas of health and resilience.

The Structural Design of the Two Models

Some of the content presented in the next section of this chapter has been drawn for our first two publications. The Four Quadrant Model will be reviewed and explained in this chapter. However, for a more detailed description, please refer to Chapter Two, pages 32–61 of Listening with Purpose: Entry Points into Shame and Narcissistic Vulnerability, and Chapter Four, pages 57–94 of Uncovering the Resilient Core: A Workbook on the Treatment of Narcissistic Defenses, Shame, and Emerging Authenticity.

The structural design of the two models is broken up into four different quadrants (Figure 1.1), each representing its own psychic function. Although both graphic models separate these components of the self into four different quadrants, when viewed as a whole, the model is meant to capture a dynamic composite of interconnected parts that are either integrated or split off from one another. Each of the four quadrants in both models maintain varying degrees of conscious awareness/attention at any given time, depending on both external and internal triggers.

Figure 1.1 Two Model Comparison.

The Four Quadrant Model, which is on the top, offers a picture that captures the defensively based character organization of individuals who suffered from early attachment failures. When trauma or neglect impact the degree of safety and security in childhood, conditions that are necessary for the developing self to thrive, the formation of a secure attachment fails to occur. As a result, feelings of confusion, fear, and a core sense of unworthiness become internalized, producing defensively based behaviors and beliefs that then become used in an attempt to over-compensate for feelings of inadequacy through repeatedly trying to prove self-worth. This diagram presents a structural map or organizing schema, that represents a person's core beliefs about self as well as relational expectations of others.

Insecure attachments produce personality structures that are best understood on a continuum of defensively based rigidity or flexibility. In the Four Quadrant Model the thoughts, values, behaviors, beliefs, and expectation of self and others illustrate some degree of over-determination and compulsivity. These personality styles often display varying degrees of reactivity, impulsivity, under or over-attention to self-care, and acts of retaliation that surface when longings, wishes, and personal ambitions are thwarted. Because the Four Quadrant Model illustrates a character structure that is defensively driven, there is an overall lack of integration between each of the quadrants as well. Thus, capacities such as self-reflection, lifestyle balance, and to learn from one's mistakes are inhibited.

Although the individual's over-determined efforts are aimed at maintaining hope, a positive sense of self, and affective stability, the cost of this type of character organization is that the capacity to change and grow throughout the lifespan is compromised. Thus, we see a personality that is fraught with repeating dysfunctional patterns. These patterns attempt to serve the function of maintaining the over-idealized belief in perfectionism, both in the self as well as the wish for a perfectly attuned partner. Unfortunately, these efforts are in opposition to the emergence of authentic self-expression. They also present a challenge to the real work of psychotherapy, where feelings of shame and the grieving past attachment failures must be confronted and metaboliz...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• List of Figures
• Foreword
• Acknowledgements
• Introduction: Designing a Framework That Connects Attachment Theory, Neuropsychology, and Trauma Treatment into a Psychodynamic Theoretical Orientation
• 1 Creating a Three-Dimensional Matrix of the Psyche: Contrasting Two Roadmaps of Relational Development
• 2 Understanding the Power of Loyalty Contracts: How to Recognize, Articulate, and Interrupt Repeated Patterns of Early Relational Failures
• 3 Recasting the Art of Case Conceptualization: Holding the Macro and the Micro Perspective Within a Cultural Context
• 4 Getting Beneath the Tip of the Iceberg: How to Use Entry Points in Language to Uncover Hidden Material
• 5 Mastering the Technique of Moment-to-Moment Tracking: Mirroring, Sequential Reflection, and Reframing
• 6 Speaking to the Splits: Understanding the Continuum of Dissociative Process
• 7 Working with Transferential Enactments as a Leverage for Change
• Index