Gaining a Second Impression in Psychotherapy

Pivoting Toward a More Accurate Understanding of the Patient

James Gustafson

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000765335
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Integrating psychotherapy with psychoanalysis and philosophy, this text offers therapists a way to reframe a client's understanding of their mental health issues through a holistic, dynamic lens.

Drawing from theory, research and over fifty years of clinical practice, Dr. Gustafson analyzes a unique range of case stories from diverse clients with varying problems including trauma, anxiety, depression, stress and relationship conflict. This book pictures five different domains that make huge differences in the quality of psychotherapy. Part I offers a snapshot of what is possible for the patient during the initial patient study. Part II shows how the patient's expectations can be subverted. Part III draws upon subconscious elements, mainly dreams, that can provide the patient with unique perspectives that the conscious mind is not capable of. In Part IV, the author looks at how the evolution of human emotions and relationships can have a negative impact on the individual patient. Part V examines the impact that large-scale issues such as religion and faith can have upon our daily lives.

The author weaves together philosophical theory, psychoanalytic techniques and psychodynamic psychotherapeutic strategies, to provide clinicians and therapists with an innovative approach to healing their clients.?

Part
IFocus

Chapter 1 What Is Possible And What Is Not Possible

Chapter 2 Forces In Shadow

Chapter 3 Dilemmas

1What Is Possible And
What Is Not Possible

Your advantage in reading this chapter could be your readiness to hear the tone of amazement in your own voice. You may remember I told you that it signifies the following sentence: “I cannot believe this is happening again.” Well, it is happening again, so you might as well be ready for it.

Many patients look to find the ideal. For example, a graduate student went to Mexico to study Spanish intensively, being sure it would be great. It was actually terrible. The lessons were poor. The students were rich kids looking to take trips every weekend. Her roommate talked about our patient to the rich kids. Tension built slowly by weeks until she awoke at 3 AM with the sensation that her heart had stopped and then just jumped out of her chest.

It turned out that her conviction that her moves should have great results had a long history of great hopes turning into unbearable pain. She needed my help to comprehend the entire series of being thwarted, set in motion by great expectations. She had been living a myth of her omnipotence.

In other words, some patients need depth of understanding in order to see how their idealizing that things will be great will keep getting them in trouble. On the other hand, some patients see too much of what is painful. They need comforting details to go on at all.

Couples therapy is another such place to be clear about what is possible and what is not. I had a patient whose husband seemed to have to control everything. She could not bear it. He seemed to feel that she never gave him a chance to be helpful.

I said to her that maybe she was not giving him a chance? She thought and thought and could come up with nothing she could do. We were about to finish our session. Somehow she got talking about how small their house was. She felt she could never be alone with her thoughts and feelings in her own house. When she took to her kitchen to clear it up and make supper, her husband always came in to help her.

I said to her that she could give her husband a chance. She could tell him she wanted the kitchen to herself. “Can I?” She said. I replied: “Is it possible to have a room of one’s own?” That seemed right to her. That detail made a big difference to her.

It is time to go back to Freud and Breuer in Studies on Hysteria (1895) to see what they saw. Then we can see successively what their successors saw.

Freud and Breuer told of what they saw in five patients, all women. They saw women subjugated to men holding all the power in Victorian Vienna. For example, Lucy came to Freud complaining of the smell of burnt pudding that would not go away. Freud’s instinct was to follow the trail of this smell to where it happened. Lucy was a governess for two children of a man whose wife had died. Lucy’s hopes were to be the next wife since the two children were devoted to her. He would be grateful. Alas, he would not. Just as she was making pudding for the children, the father let her know that she would not be the next wife. That is how Lucy forgot the pudding she was making. It was burned. The stench was in her nose.

Lucy could not say on her own, without Freud, what had befallen her. As Freud and Breuer wrote in the conclusion of their book, these five women were self-strangulated. Freud helped Lucy remove the noose from her neck.

Wilhelm Reich was Freud’s favorite in the 1920s. He was the training analyst in the Vienna Psychoanalytic Institute and published his findings in his book called Character Analysis (1933). He saw something that was not seen by Freud. He saw the character armor that assembled all the lesser defenses under a constant attitude, such as having to be nice. This limitation would make things like rage impossible. Of course, being subordinated and subjugated as women would tend to smolder more and more and not find a voice.

Sullivan in his Clinical Studies in Psychiatry (1956) saw things differently with his women patients as in the case of the housewife economist. She had a PhD in economics like her husband, but just stayed miserable and apathetic as a housewife.

Sullivan saw her as vastly underemployed. He said in his lecture that he was determined to help raise her sights about her potential. Why not economics? Sullivan saw her husband not as oppressing her. He was not a bad guy. It was a matter of the wife seeing her potential and gradually giving herself more interesting things to do using her intelligence. She would gradually see that she did not have to remain miserable and apathetic.

Sullivan was a master at seeing what was possible and what was not possible. He would not suggest a wild goose chase. After all, there are husbands that are bastards. To encourage a wife to challenge him would be dangerous. Sullivan could look at the world beside his patient and judge its potential and lack of potential accurately with her.

Now I am quite aware that there were many more masters of seeing what the patient has not been able to see. I am thinking of Jung and Alexander and French and Balint much later.

I would like next to consider how D.W. Winnicott saw his patients as portrayed in Therapeutic Consultations in Child Psychiatry (1971) and The Piggle (1977). Winnicott saw his consultations with children as a sacred event. He would see the child when the parents had spoken of him enough times. The children who came to visit him would often have had a dream of his being the doctor that he or she needed.

His interviews were generally what Winnicott called the squiggle game. He would make a mark with a crayon and ask the child to complete it. After the child did complete it, Winnicott would ask her to say what she saw. At the start, the child saw conventional objects like dolls and houses. The child then made a mark first and Winnicott completed it. He would ask what the child saw in their shared drawing. Again the child would see something conventional. So they went on taking turns making the first mark.

At some point in the game, Winnicott would feel the interview was hanging fire at he put it. He called this the moment of the dream drop. He would say casually to the child something like this: “I bet you have dreamed about this.” Often the child would nod and tell it.

In other words, Winnicott had found a way to get the help from the unconscious as a 2nd impression. The dream would be uncanny in going to the situation in which the child had lost faith and thus lost her lifeline. Often this happened when a younger child was born and the mother would be preoccupied with him. The unspoken disaster was that the child patient had lost her mother. Winnicott and the child would see it together for what it was, a disaster, yes, but now a shared disaster that was not so overwhelming.

So the focus had another possibility with Winnicott that was not seen with Freud, Reich or Sullivan. All four of these doctors gave their company to the patients with the pain that made it less overwhelming. This was the common thread to enter the labyrinth of the past gone wrong, to enter it together and then to come back out together with new potential. Freud gave his company to the smell of burnt pudding as a neurological symptom, Reich to the smolder of rage under the nice constant attitude, Sullivan to the potential of an interesting life as an economist and now Winnicott to the dream drop where the disaster happened.

As for me, I love having these four ways to be company for the hurt patient. I find it moving and even thrilling.

Seeing differently from amazed patients can make a big difference. When they are amazed they are actually saying: “I cannot believe this is happening.” It is happening. It can be spelled out. I often see one such patient after another. Each plays a sequence that is harmful for him or her. The first I saw was bored with too little work. When he took on more he was suddenly swamped by far too much. The second compared himself to illustrious people and of course felt inadequate. The third was about being bulldozed by his big brother he really could get away from.

Each could see that he could refrain from the sequence that was bad for him. Sullivan (1956) taught me this. Sullivan called it selective inattention. The remedy is careful precise attention.

Unselfishness as a virtue sees selfishness as evil. Of course it could be evil. But unselfishness by itself gets run over. I like to say to unselfish patients they are poorly defended. I like to ask them what they are going to do for themselves? It often turns out that they have already begun.

One such patient liked to be in my office for all the pictures of animals. She liked the wolves the most, especially the one staring right at her. She commented to me that that wolf could be her totem animal. She told me why. “He looks right at you straight out and asks nothing of you.” This is what she wished people were like. This is not what people are like. They asked way too much of her. She had better be prepared to say no. She needed a lot of practice with the word no. Once again we come across what is possible with people and what is mostly not possible. Wolves are different.

I had a patient who noticed that she did many things like her mother and she did not like what she saw. She noticed that she mostly acted entitled to be taken care of without lifting a finger. She felt it was high time to take care of the household herself.

This 2nd impression was an opportunity, a picture of a pivot, to begin going in another direction. I asked her how she was going to do it? She replied that a friend told her she might make a list every day in the priority or order she would work. She liked that idea and she liked herself much more. She respected herself more.

She saw in one glance that it was possible to go on being entitled like her mother that she did not respect, but it was also possible to pivot to go in this different direction to begin taking care of her household quite unlike her mother. This is what I meant in my Preface about a picture that poses a problem and brings it to an absolute clarity of focus.

References

Freud, S. and Breuer, J.: Studies on Hysteria (1895). London: Hogarth Press, 1955.

Reich, W.: Character Analysis (1933). New York: Farrar, Straus and Giroux, 1949.

Sullivan, H.: Clinical Studies in Psychiatry (1956). New York: W.W. Norton, 1992.

Winnicott, D.W.: Therapeutic Consultations in Child Psychiatry. New York: Basic Books, 1971.

Winnicott, D.W.: The Piggle. London: Penguin Books, 1977.

2Forces In Shadow

Your advantage in reading this chapter could be your readiness to look for forces that are in shadow.

Patients often ask us to reduce or eliminate their anxiety and/or depression. A drug can often do that. The drug can also obscure anxiety as a signal of threat and depression as a signal of defeat. These common symptoms may be reduced, but the dynamics remain ready to come back (Malan, 1976, Gustafson, 1986).

For example, a woman had her depression reduced by sertraline (anti-depressant) and her suicidal ideation seemed to disappear. This was misleading, because the bitter fights she had been having with her husband seemed to go away when he was traveling for his business. She was not really out of danger, except for the time being before the husband returned.

George Engel’s famous essay on “The clinical application of the biopsychosocial model” (1980) told the revealing opposite story of a man in the cardiac care unit for a heart attack. The longer he stayed there the worse his panic. Perhaps part of his panic was about having had a heart attack. This was the biological aspect of the panic. Engel’s contributions were to the aspect of his psychology and to the social aspect. His character as a business owner was to seek always to be in charge. His social context was that he had been fully in charge as the owner. That was where he belonged. Being on the cardiac care unit was the opposite place. He entered the unit regretfully and became more and more tense the longer he stayed and more and more vulnerable to another heart attack or an extension of the heart attack he had already had and thus in more and more panic.

Janus was the Roman god of the gates between a household and the public world (and he was god of many other things as well). Positioned in the gates, the two faced god looked inward to the house and outward to the public realm. From there, he could see the buildup of dangers inward and outward. In bot...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Acknowledgements
• Part I: Focus
• Part II: Reversals
• Part III: Dreams and Myths As Second Impression
• Part IV: The Evolution Of The Species In Everyday Life
• Part V: The Great World In Everyday Life
• Afterword
• Index