Formation of Self as a Clinical Instrument in Psychodynamic Psychotherapy
(On March 12, 2016, I participated in a presentation on “Formation of Self as a Clinical Instrument in Clinical Pastoral Education and Psychodynamic Psychotherapy Education,” sponsored by the Chicago Association for Psychoanalytic Psychology, and presented at the Chicago Institute for Psychoanalysis. I was one of four co-presenters, and this is the handout I prepared for this presentation.)
There are many methods and techniques in psychotherapy, and new therapists usually learn by focusing on some of them, but this is at best only a step toward the development of a “therapeutic self.” Especially in psychodynamic psychotherapy, it is the self of the therapist which is the therapist’s clinical instrument, a therapeutic self which is formed through experience in doing therapy and receiving consultation and supervision in doing therapy. This is an experiential process, not a scholarly one. It can’t be learned by rote, and imitation of the behavior of role model therapists is at best an early stage that should be superseded as soon as possible. The dynamic therapist must be authentically present, and there is no script and no methods for that.
Psychodynamic psychotherapist Jonathan Shedler, in a recent conversation, described psychotherapy as essentially a partnership between the therapist and patient, emphasizing the collaborative, and what I call the reciprocal, nature of psychotherapy. The therapist facilitates that dynamic reciprocity through the instrumental use of self.
Psychodynamic psychotherapy is something a therapist does with someone else, not to someone else. Or we might say, to the extent that therapy is done to someone else, it is done to them by being with them, by becoming a facilitative companion on a certain kind of journey. Shedler referred to Mary Jo Peebles’ description of the message from therapist to patient in her book, “Beginnings, The Art and Science of Beginning Psychotherapy,” as follows: “You’re suffering for reasons neither of us fully understands, and I’m just starting to get to know you. Neither of us is going to be able to understand it by ourselves, and the two of us together are going to be able to develop a shared understanding.” So good treatment begins from a place of mutual not-knowing, and a mutual agreement that we are here to enter into the unknown together. It is both an investigation and a relational healing process, and although Peebles describes this as the beginning of therapy, and it can be said in words at the beginning, it takes time to cultivate a working therapeutic relationship.
The dynamic psychotherapist develops a clinical self largely based in the interpersonal and intrapersonal executive functions of the brain. The executive functions, largely the activity of the prefrontal parts of the frontal lobes of the left and right cerebral hemispheres, include selecting what to focus on, sustaining that focus for as long as necessary, inhibiting distractions while sustaining that focus, monitoring the environment for cues that the focus might need to change, deciding when to change focus and managing the transition from one focus to the next. Neuropsychologist Elkhonon Goldberg, author of The New Executive Brain, compares the executive functions of the prefrontal lobes to the role of the conductor of an orchestra, calling in and out and regulating the various musicians and sections in order to perform the composition. Goldberg emphasizes that our tests of executive functions don’t reflect what those functions mainly do, because life doesn’t usually present us with situations in which there is only one correct answer. Rather, we are agents responding to situations on the basis of preference. When we apply this perspective to psychotherapy, we see that the client in dynamic therapy is not a multiple choice question with one right answer, or even an algorithm to resolve the problem(s) that led to therapy. The therapist, responding to the field of issues that the client presents, acts as an agent, selecting issues to respond to, and how to respond to them, as a therapeutic self-in-action.
The psychodynamic psychotherapist forms a professional self which facilitates a collaborative investigation, together with the patient, of the patient’s way of making sense of the world and responding to it. Questions, responses, support, challenge, metaphors, storytelling, playfulness, laughter, and developing models of how the client experiences and makes sense of self and others, are all part of it. How the therapist facilitates the investigation in the context of the relationship is part of the healing of therapy.
In order to accomplish that, the therapist needs to have a great deal of attention focused on the patient, and simultaneously, or intermittently, also have a great deal of attention focused on his or her internal processes. The therapist must monitor her reactions to the patient and the relationship, and evaluate which reactions are the therapists’ own and which might reflect how the patient might be thinking or feeling, or how the patient might be provoking and evoking reactions in the therapist. No matter how good the therapist is, the relationship will have discontinuities, ruptures and repairs, and eventually therapist and patient will wind up in a therapeutic cul-de-sac, brought there together by an enactment of some kind, a counter-therapeutic process in which they were implicitly joined, and which the therapist must discover and facilitate their working their way out of. All this contributes to the development and successive refinement of models of client self and life, which client and therapist co-create.
In my supervision of new therapists, certain kinds of issues come up again and again. Avoidance of areas of vulnerability in the client, either out of a misplaced protectiveness of the client or because the therapist has similar areas of vulnerability and is colluding in avoidance, is one. Another is the use of apparent kindness and compassion to distance the therapist from the client rather than to approach the client with empathy and genuine empathic reciprocity. Another is to want to do something to fix the client rather than to establish a relationship within which the client’s nascent capacities for self-observation, self-regulation and self-development can emerge.
Formation of self as a clinical instrument in psychodynamic psychotherapy supervision and consultation means that the therapist is learning to operate herself or himself in the reciprocal space of the therapeutic relationship in such a way as to facilitate the client’s integration of previously dis-integrated parts or networks of self, including the maturation of some of them, into a revised, reorganized self with which the client can more effectively address the issues that brought her or him into therapy.
We are all works in progress.