The Silent Language of Psychotherapy

Social Reinforcement of Unconscious Processes

William Zimmerman

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351474122
• Edition: 3
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Therapeutic changes occur in many places, and among animals as well as humans. A theory that attempts to explain therapeutic changes should be based on principles that apply not only to those changes occurring during the hour, but also to those observed in the educational process, in interpersonal relations, and in the social milieu, as well as with animals. It would be desirable to discover principles broad enough to provide a deeper understanding of therapeutic change in this wide variety of situations.

Experienced therapists appear to be similar in what they are doing, although they may disagree as to why they do it. In spite of the arguments about theoretical formulations, it can be observed that during an hour with a patient many psychotherapists may not follow their own theories too well. There probably is some relevance in a comparison of psychotherapy with a concept formation test: the subject gives the correct answers but is unable to state why he did so or what principles he followed in making his choices. The therapist, too, may help a patient but he is often uncertain as to "why" and "how." It is very likely that the effective principles in therapeutic work rest on processes that are more general than the specific principles advanced by different schools.

This volume combines the elements of psychodynamic and cognitive behavioral therapy in a theoretical system that focuses on the importance of patient-therapist interaction, especially in terms of the exchange of subtle or covert communication cues. In this significantly updated and expanded edition of their classic text, Beier and Young analyze recent developments in new areas of practice facing today's therapist: managed care and the clinical impact of the control of healthcare delivery; and biological intervention and other issues related to psychotropic medication.

CHAPTER
1
Introduction and Overview

The Therapeutic Model

In psychotherapy, two or more individuals affect each other through a mutual exchange of information. The contact should allow the patient to replace old behavior patterns with more appropriate ones, leading to greater satisfaction and more effective functioning.

Many theorists have attempted to explain how therapeutic changes occur. Often these investigators talk about “therapeutic gains” or “therapeutic changes” as if these occurred only in the unique setting of the therapeutic hour. But there is evidence that such changes occur in many places, and among animals as well as humans. A theory that attempts to explain therapeutic changes should be based on principles that apply not only to those changes occurring during formal treatment, but also to those observed in the educational process, in interpersonal relations, and in the social milieu, as well as in nonhuman species. It would be desirable to discover principles broad enough to provide a deeper understanding of therapeutic change in a wide variety of situations.

Reaching this goal is not extraordinarily difficult, once we search empirically. For though the theories and principles of various therapies vary enormously, the actions of most psychotherapists are remarkably similar. During an hour with a patient they do pretty much the same things and they may not follow their own theories too closely. There probably is some relevance in a comparison of psychotherapy with a concept-formation test: subjects give the correct answers but are unable to state or agree on what principles they followed in making their choices. The therapist, too, may help a patient or offer an intervention spontaneously in a session, but is often uncertain as to why and how. The effective principles in therapeutic work probably rest on processes that are much more general than those principles advanced by different schools.

Much additional confusion has resulted from the fact that change and improvement have been considered together. It is probable that more accurate explanations of psychotherapy can be advanced when the processes of behavioral change and behavioral improvement are separated. In the following, an attempt will be made to do just that. First, we shall analyze what sort of information effects change in a patient. Then we shall discuss the conditions under which changes are directed toward improvement.

The information exchanged during the therapeutic hour has both verbal and nonverbal content. Many therapeutic models stress vocal and non-vocal communication, from “primal screams” (Janov, 1991) to staring at video wallpaper. Yet most psychotherapists probably think of verbal communication as the essential element of the therapeutic hour, and most therapeutic models elaborate on the nature of verbal interaction. A general theory, especially if it is ambitious enough to include unconscious processes, needs to concern itself with information from both verbal and nonverbal sources.

We do know that humans can countermand conditioning efforts at will (at least sufficiently to give conflicting results) if they are aware of such efforts and if they desire to do so. Models that try to explain psychotherapeutic efforts in terms of simple operant conditioning are likely to encounter problems; they disregard subtle and covert behaviors of which a person may not be aware but that may allow a psychotherapist to identify unconscious motivations. Our model of communication analytic therapy is interested in conscious as well as unconsciously coded communication. Unconscious cues help the therapist know where the patient hurts and what experiences have to be provided to help to decrease suffering.

In the communication model, each message is of great importance. Some messages convey manifest meanings designed by the sender to be fully recognized by the receiver. But a message can also convey information that is not designed to be understood as easily or at all. The purpose of these components is to elicit a desired emotional reaction from the respondent. The remarkable fact is that in any given message the manifest and the covert components can represent different motivational states of the person, sometimes even mutually exclusive states. The nature of the message and how it specifically affects a given respondent is at the base of the communication analytic therapy model.

The initial psychotherapeutic goal, then, is to analyze the communication processes, look at the conscious and the unconscious expectations conveyed by each message, and discover how a given response affects the sender. The foundation of this theory requires a marriage of Skinner and Freud; an attempt to facilitate changes of unconscious motivational states. Communication analysis tells us how people maintain continuity in their conduct as well as how changes can be brought about.

Toward a More Sophisticated Model of Human Communication

Skinner’s model of scheduled learning has been widely used, both in rigorous research efforts as well as in somewhat hasty applications to clinical practice, which a historic review demonstrates: a schizophrenic patient who talked very little was trained to talk more by being rewarded with chewing gum for talking (Isaacs, Thomas, & Goldiamond, 1960); a decerebrate individual was trained to raise his arm when hungry (Fuller, 1949); very young children have been trained to type and to master languages (Haas, 1964); a whole industry (teaching machines) (Schramm, 1964) was developed that used programmed instruction based on Skinnerian scheduled reinforcement; and many families apply scheduled reinforcement methods for raising their children.

Reinforcement schedules have been introduced into school systems, state hospitals, and even the courts. Public criticisms of these programs claimed that they were too mechanical, that human beings should not be “conditioned” or manipulated. The criticism of many clinicians was that these direct applications of reinforcement methods indeed oversimplify human behavior and do not take into account the complexity of mediating stimuli to which humans respond. If parents reinforce a child’s getting up on time with a monetary reward, the child may learn that “it pays” to get up early, that this behavior is significant to the parents, that failure to comply is likely to make the parents anxious or raise the ante, and that violating the contract gives the child the delicious feeling of being a person in his or her own right!

Operant conditioning probably works well with fairly simple behaviors. If a child is knocking his^* head against a wall until it is bloody, aversive conditioning such as administering light shock might be indicated. In more complex behavior, there are always surprises. A poor reader was given M&M candies for each line read correctly, and the reading improved rapidly. After a few hours, the child threw the accumulated M&Ms into the wastepaper basket. She said she hated them. She said that she was always called stupid when she was helped with her reading, and that she liked the idea that her therapist didn’t!

People attach personal meaning to certain acts or objects that they perceive as either reward or punishment. These “attachments” are not necessarily conscious. Human needs are complex, and we must respect the fact that there is much we do not know about another person.

When we think of reinforcement systems that are a reasonably good analog for a therapeutic model, we think beyond the elements of simple Skinnerian conditioning. It is true that classic work on nonverbal operant conditioning shows that individuals properly reinforced with “Mm, hmm” (Greenspoon, 1976) will produce more of the reinforced words (such as nouns); and that the length of time of the therapist’s comments predicts the average length of time of the patient’s response (Matarazzo, Wiens, Saslow, Bernadene, & Weitman, 1965). But the operant aspects are at best limited: “Mm, hmms” as reinforcers of nouns do not merely increase their frequency. When we look into the substantive meaning of these “Mm, hmms,” or head nodding, we realize that probably these responses say, “Keep talking,” and are also likely to tell the patient that the therapist is attentive, is listening and caring, and respects the patient for “working through” the problem.

These latter meanings are not overtly communicated. They are directed at an unconscious system of the patient and are thought to create an emotional climate of uncertainty that is a challenge but not a threat to the patient. The motivation to change is likely enhanced by these communications.

Unconscious Motivation in the Communication Process

Theorists who believe that people go into therapy to get away from their displeasure have an easy task of accounting for the patient’s motivation for seeking help. But the “displeasures” about which patients so often complain seem to be as rewarding as they are punishing to the patients, though the rewarding function may be unconscious. (To the person who has a problem, the thought that it is rewarding is, in fact, unthinkable.) If the patient’s problem occurs with high frequency, and if the patient has not learned to avoid the problem, even though he has had a chance to do so, and if the behavior fits clearly into the psychological economy of the patient, then in many ways it can be understood as the patient’s unconscious search for meaning and an expression of individuality. This explanation is similar to Freud’s formulation of the “pleasure in the symptom.”

A brief example may clarify this confusion of rewards and punishments. A suicidal man who has learned that threatening others with his own suffering is a useful behavior said in his second interview, “I was not happy here last week. You didn’t talk enough. You didn’t talk about my deeper problems. I felt quite without hope when I left here.” The therapist responded, “Why don’t you tell me about your mother? Why don’t you tell me about your dreams?”

What are the subtle meanings in this exchange? One hypothesis about the patient would be that with his message he wants to have an impact on the therapist. He is setting him up to feel guilty for having failed him. This is a form of emotional blackmail. In the past, this man has probably been successful in this subtle blackmail behavior—setting up others to do his bidding by threatening hopelessness. Note that the therapist responds by talking about “deep things” (dreams or mother), and with this response, subtle as it is, the therapist actually helps train this man to use his eminently successful blackmail behavior again. Had the therapist responded here with a simple “Mm, hmm,” notifying the patient that he was listening, he would not have reinforced the response expectation of the patient. We observe that the therapist gave a reinforcing response without awareness of its meaning, and we assume that most people in whom the patient wants to create a guilt trip would do likewise. The therapist failed to help the patient to experience uncertainty about his blackmail behavior because he was caught in the social role that the patient had imposed upon him.

The patient, too, does not know what he is trying to achieve with this message. If asked, he would say that he was complaining about the therapist’s effectiveness. He would hardly be aware that he was trying to black-mail the respondent, using his own unhappiness as a lever. In fact, he would probably deny that he tried to imbue the therapist with guilt, even though he had repeated this type of message again and again.

Once we assume that our interpretation is correct, we can make some statement about the unconscious motivation of this man. He has mastered a very special skill, namely, setting up an emotional climate in the other person that significantly limits the responses this person is likely to give. Every message has an expected response from the respondent, and some messages give more freedom to the respondent than other messages would. Whenever the patient is able to send messages in such a way that he will obtain the expected responses, he is, in fact, reinforcing his present adjustment. Reinforcement principles and unconscious motivation are closely related in the maintenance of problem behavior, and the understanding of both qualities is necessary to help the patient change.

A large number of unconscious systems probably operate within us. While driving a car, a person also may eat a sandwich, look at a map, and drum the fingers of one hand on the steering wheel. All these systems operate without much thought—unless a pedestrian suddenly runs across the street. At this time, the driver may drop his sandwich, forget the map, stop drumming his fingers, and give full attention to avoiding the hazard. The various systems are operating reasonably independently; the driver does not have to think how to lift his free hand, to eat his sandwich, or to figure out how to bring his map into his visual field. Yet at the critical moment, the conduct of the driver changes rapidly. He now overrules the various systems and tries to avoid the accident. Hilgard (1986) thought that this sudden change in the motivational state is due to the predominance of the “executive ego.” He demonstrated that under hypnosis a person can in fact simultaneously do two diverse, separate, intelligent tasks, such as writing one story with the left hand and another story with the right hand. He also studied persons with dissociative identity disorder. He found that Personality A of a given person may be accessible to Personality B of the same person, but this may not be true in the reverse, or both may be accessible to each other. In other words, the multiple motivational states may be independent of each other or they may be partially independent. In all such cases, one can assume that the “executive ego” determines which motivational state is dominant.

While such extreme cases as dissociative identity disorder are the exception, the principle of various motivational states operating within an individual is probably true for all of us. The conduct of a person is determined by many factors, such as physiological and genetic makeup, early learning, traumatic experiences, stress-avoidance mechanisms, and the rules learned to cope with the environment. Unconscious motivations resulting from these inputs may not share the same goal, and there will surely be some that result in discordant actions. Each motivation will seek its own satisfaction, even though the person may not understand what is happening. Based on the above-mentioned input, an infant establishes manifest as well as hidden rules, and the latter ones in particular get embedded in the various unconscious systems that determine behavior and communication patterns. “Silent rules” directly affect conduct, often to the bewilderment of the person who is not aware of the hidden motivating forces that are originating the behavior. Such rules can make persons flirt with great and dangerous events, even though consciously they are trying desperately to avoid them. They can serve to isolate a person who feels lonely and who longs for company, or make persons unfit for love relationships when they perceive themselves as seeking love.

To help a person therapeutically, one has to understand the silent rules with which the person operates. Very often these silent rules can be decoded from the discordance found within a single message. A mother says, “I just hate my boy. I know he is only ten and he can’t help it, but he is so much like his father. I sometimes think of putting my cigarettes out on his body, thought I hope nobody will ever do that to me.” For better or worse, these are the feelings the therapist has to decode by asking, “What is the mother expecting from me with her message?” Analyzing his own feelings of pity, fear, and disgust, the therapist notes that this mother’s threat that she may lose control of her aggressive impulses restricted his responses. This analysis gives the therapist some information about the mother’s silent rules. A plausible one is, “People pay attention to me when I threaten harm. They may think ill of me, but it’s better than not thinking of me at all.”

With most patients, the procedures and communications that obey the silent rules are often repeated endlessly. The possible unconscious motivation to seek disdain and punishment from the respondent in order to achieve some “sense of being a person” is one that may illustrate that apparent displeasure is not always to be avoided. We should especially note that the messages are designed to have a significant and specific impact on others, and analyzing this impact can be most informative. That people can seek out punishment or even death can be understood if one assumes people prefer suffering to total uncertainty, indifference, or randomness.

Such an assumption is necessary to avoid simplistic theoretical formulations by which the patients are reinforced with conventional rewards. Human processes are too complex for such simple solutions. For example, a young man who attempts suicide may suggest as his reason that his parents overloaded him with demands, but we would not be amiss to assume that he probably got some gratification from thinking about his parent’s guilt. Suicidal behavior is also a complex communication—a cry for help—that is the basic assumption around which suicide-prevention centers have been organized.

After examining what his social response to the mother who threatens to put her cigarettes out on her son might be, the therapist can formulate a response that is likely to create uncertainty rather than to reinforce her behavior. This response is apt to be other than a social response, and we have labeled it an “asocial” response. Whether the paradigm the therapist analyzed is accurate or correct is really not the question. What matters is his not reinforcing her behavior with an expected, social response.

Therapeutic Gains

Here we shall present a statement about how communication analytic psychotherapy differs from other schools with respect to providing change in patients. Historically oriented schools claim that therapeutic gain comes from reexperiencing one’s traumatic history with a happy ending. The in-sight school attempts to produce an awareness of inner dynamics, and the relationship schools attempt to recreate a sense of human closeness through love, warmth, and understanding. Most of these schools posit that insight is needed for change, that true acceptance by the therapist is the working ingredient, or that lifting of unwholesome repression and working through of resistance by way of transference are critical elements. Behavioral therapies posit that reward and/or punishment will provide for change. All these theories assume that the experiment from the therapeutic hour will carry over into patients’ lives, and that they have contributed a clearer understanding of the therapeutic process even though it is probably the therapist’s temperament that largely determines his or her conduct rather than any theoretical framework.

A communications model of psychotherapy is probably the only model that provides us with a general understanding of the therapeutic process. All models are based on information exchange and the question of impact and change. Our most general formulation is that therapeutic intervention provides the patient with a new experience that d...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Preface to the Third Edition
• Acknowledgments
• 1 INTRODUCTION AND OVERVIEW
• 2 THE ANATOMY OF A MESSAGE Structure and Motivation
• 3 DEVELOPING PATTERNS Choosing Responses to the Environment
• 4 INFORMATION-GATHERING PROCESS IN PSYCHOTHERAPY
• 5 THE USE OF CONVENTIONS
• 6 INTERVENTIONS IN PSYCHOTHERAPY
• 7 LABELING THE THERAPIST’S ACTIVITY
• 8 CONTENT CHOICES IN THE PSYCHOTHERAPEUTIC HOUR
• 9 EXTRATHERAPEUTIC INCIDENTS
• 10 TECHNICAL PROBLEMS IN THE THERAPEUTIC PROCESS
• 11 COMMUNICATION ANALYSIS IN FAMILY GROUP AND GROUP THERAPY
• 12 THE CHILD’S COMMUNICATION IN THERAPY
• 13 THE CHANGING LANDSCAPE OF PSYCHOTHERAPY PRACTICE Managed Care
• 14 THE THERAPIST AS A CONSULTANT
• 15 SUPERVISION IN COMMUNICATION ANALYTIC THERAPY
• 16 NONVERBAL COMMUNICATION IN PSYCHOTHERAPY
• 17 THE ETHICAL PROBLEMS OF CONTROL OF BEHAVIOR
• 18 PILLS AND CARING TALK
• 19 SUMMARY AND CONCLUSIONS: Being Asocial in Social Places; Giving the Patient a New Experience
• References
• Author Index
• Subject Index