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Finding the “Subversive” in the Persona of the Therapist

James Tobin, Ph.D.March 20, 2014

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Today’s Talk

Part I. Recording of the Beginning of a Session“Typical Social Reality”Socialization of Therapists-in-Training

Part II. “Therapeutic Reality”Part III. Attachment/Splits of the Self

Fear of Crossing the Bridge Part IV: “Therapeutic Persona” and

“Subversion” Challenges for Trainees

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Part I

Recording of the Beginning of a Session

Typical Social Reality

The Socialization of Therapists-in-Training

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Recording: Beginning of a Session

Christine French, M.A.

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Comments/Observations?

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Discussion in Supervision

“The client had anxiety about not knowing what to say ...”

“I gave her an out ... I saved her from sitting with her emotions and discomfort.”

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The audio is invaluable in pointing out a major issue involved in

learning to be a clinician:

Shifting from typical social realityto therapeutic reality (therapeutic

space)

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What is Typical Social Reality?

In typical social reality, a transaction between person A and person B occurs guided by certain expectations/conventions.

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Expectations of Typical Social Reality

Kindness Comfort Reduction of anxiety Avoidance of conflict or difficulty Appeasement Compliance/Don’t annoy or aggravate Being liked Achievement/progress Back and forth/Q and A quality (a

conversation – a transaction)

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The Therapist-in-Training: Typical Social Reality + Notions of What a Therapist Should Do

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Common Assumptions Among Trainees

I want the patient to like me I must be kind to the patient and build the

therapeutic alliance I must alleviate the patient’s distress, make the

patient feel better, solve the patient’s problems If I am too confrontational, challenging, or

merely direct, the patient will be hurt or injured, or get angry, and won’t come back and I will fail as a therapist

I must be very careful about what I say to a patient; I can’t say what I really think or feel

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The Socialization of Graduate Students: Positive Outcomes & Change

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The Socialization of Graduate Students: Empathy = (+)Therapeutic Alliance

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Are Graduate Students in Clinical Psychology (or Early-Career Clinicians) Socialized to Believe They Should Be and Act Like a Restaurant Hostess?

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If Your Answer is “Of Course Not!,” Consider This Very Common Interaction...

Patient: Hi! It’s good to see you today? How was your weekend?

Therapist: My weekend was great, thanks. It is nice to see you too. How was your week?

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Part II

Therapeutic Reality

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Therapy is the Bridge to Another Reality

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The Therapeutic Space: 3 Main Components

#1: The patient begins with a blank canvas.

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The Therapeutic Space: 3 Main Components

#2: The therapist establishes a culture NOT based on typical social reality (SUBVERSION), but on the patient’s capacity to paint his- or herself: to creatively self-express, self-relate and experience oneself.

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The Therapeutic Space: 3 Main Components

#3: Gradually over time, based on the therapist’s capacity to subvert the patient’s dependence on typical social reality, the patient tolerates what he/she begins to paint and ultimately arrives at a creative depiction of his/her inner life.

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THE OTHER SIDE OF THE BRIDGE We as therapists are to

stand next to our patients and as the patient illustrates/portrays his or her life experience, we are to consider its parts and seek to understand how all the parts work together.

When we can do this, the patient actually learns who he or she is (for the first time in life).

This is an extraordinary opportunity!

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What the Patient is Able to Produce in this Process is Significant and

Powerful ...

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In this Model of the Therapeutic Process, the Potential Outcomes Are:

The patient has a deeper appreciation of his/her own life, problems, conflicts, feelings, and limitations.

What patients ultimately paint is often quite different from what they thought they would paint or would have preferred to paint (they see themselves more realistically)

The patient finally has had a new relational experience: one un-encumbered by typical social reality.

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Part III

Attachment/Splits of the Self

Fear of Crossing the Bridge

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The Patient Has Been “Brainwashed” into One Reality (Typical Social Reality)

Given the validity of attachment theory, we can assume that every patient – despite diverse presenting concerns -- has had to accommodate to his or her primary caregiver (and to the world).

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The Drive to Survive

The evolutionary drive to survive is so hardwired in our genetic makeup that we are literally programmed to adapt.

Compromises and accommodations to social demands occur over and over again, inevitably resulting in splits in our identity as typical social reality takes over our experience of ourselves and others.

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Compromises & Accommodations

By so doing, each patient’s “self” has been compromised, to a greater or lesser degree.

Over time, the patient developed a characteristic repertoire of being in the world that systematically accommodated to that which was needed to survive in the social realm.

Winnicott’s notion of the “false self.”

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Splits of the Self

The False Self

The True Self

The Lost Self

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Our Personality as Adults: Social Reality-Based

At the core of our personality as adults is a highly adaptive child (if the adaptation worked early on, we repeated it again and again – it became habituated across the lifespan).

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When the Patient Enters Therapy ...

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The Therapeutic Situation When patients enter the therapeutic

situation, they have and know only one (typical social) reality and

resort to it immediately ...

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The Danger ...

The danger, of course, is that NOT only the patient, BUT ALSO THE THERAPIST, has one (social) reality as well ....

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Typical Social Reality of the Therapist

Kindness Comfort Reduction of anxiety Avoidance of conflict or difficulty Appeasement Compliance/not annoying or aggravating Being liked Progress/Change/Positive Outcomes Conversation/ transactions

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Adaptive Aspects of the Therapist’s Character

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Adaptive Aspects of the Therapist’s Character

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Both Patient and Therapist Cannot Travel Across the Bridge: Collusion

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TH

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Patient starts to paint the picture of their pain, sorrow, sadness, anger, etc. Therapist engages in typical social reality efforts: Reduce the client’s affective or cognitive states by:--comforting the patient--avoiding the

affective/cognitive states of the patient

--helping/problem-solving/advice-giving

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PATIE

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When this happens: 1. Patient will

usually return to the typical social reality where they will conform and comply with what they perceive the therapist wants.

2. Or the patient will try to paint some other experience.

Either way:1. The therapeutic

relationship becomes no different than any other relationship in the patient’s life.

2. The patient has been impinged upon and can no longer engage in the process of self-expression and self-experience.

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Part IV

“Therapeutic Persona” and “Subversion”

Challenges for Trainees

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Therapeutic Persona

“Persona” suggests that therapists cannot just be themselves and act as they always do, i.e., with an adherence to typical social reality.

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Therapeutic Persona Instead, you must adopt a therapeutic

persona that is partially you and partially alien to you, i.e., one that cultivates and lives in an alternate reality oriented toward therapeutic presence and therapeutic reality, not social reality.

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Therapeutic Persona: Not Responsible for ...

Kindness Comfort Reduction of anxiety Avoidance of conflict or difficulty Appeasement Compliance/not annoying or aggravating Being liked Progress/Change/Transformation Conversation/transactions

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Therapeutic Persona

Embodying this therapeutic persona, the therapist consistently works toward:

(1) resisting patients’ preference for typical social reality, and (2) helping patients evolve out of

their characterological repertoire of adaptation which has compromised their identities and their own self-recognition and self-understanding.

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Subversion

In this way, the therapist works to “subvert” attachment patterns and self-relational tendencies that have become habituated over time.

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Getting to the other side of the bridge!

Patient AND therapist both transition out of a typical way of being with self and others (typical social reality) into a new way of being that no longer depends on accommodating to the needs of others or compromising one’s self in order to play a role with others.

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• Therapists must do the exact opposite of what they are socialized to do or do what they “fear” the most.• Therapists must recognize that “being liked” or “client progress or change” are not a part of the client’s self-experience. • The therapist’s goal is to help the patient see and acknowledge what they have been doing (adaptively) all their lives.

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The Hard Truth about Empathy

“Empathy” in a typical social reality sense (as it is often taught and conceptualized) sets up the therapist to perpetuate yet again the instruction the patient has received from all others: we each must exist for the other and not for ourselves – we must stay in the familiar/nothing new can happen that has not happened before.

Rather than finally relieving the patient of a social/transactional burden, the therapist merely affirms its necessity once more.

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The Hard Truth about Empathy

Empathy has more to do with drawing patients’ attention to what they have had to do to accommodate to significant others in their lives -- it is promoting the patient’s awareness of what he/she had to be (a clown or XYZ).

This is shameful, embarrassing, and profound when patients finally see their repertoire and realizes that you see it.

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The Therapeutic Reality

Notice that this is not transactional (typical social reality) and not replete with accommodation, but instead is self-oriented/self-observant/self-transactional.

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In Conclusion ...

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If We Are Able to Adopt a Therapeutic Person and Be Subversive as Clinicians ...

(1) We provide patients with another reality, i.e., another way of being;

(2) They become exposed to a self-relational experience that is more realistic, tender, and curious;

(3) The therapist is able to promote the patient’s growth, decision-making, and adherence to one’s self.

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A Final Word on the Therapeutic Alliance

Ultimately, with this perspective, the therapeutic alliance will be enhanced by the patient’s gradual recognition that the therapist is different from all prior caretakers and people in general.

The patient will realize he or she has finally found someone who promoted growth and tolerated the true nature of the patient – which no one else had been able to do previously in the patient’s life (this may be one way to perceive love).

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James Tobin, Ph.D.Licensed Psychologist PSY 22074220 Newport Center Drive, Suite 1Newport Beach, CA 92660Assistant Professor of Clinical PsychologyThe American School of Professional Psychology at Argosy University

Email: jt@jamestobinphd.com Website: www.jamestobinphd.com 949-338-4388