Monthly Archives: March 2015

Ritualism

“I just do EMDR.”

 

“Once I found internal family systems, I never had to read another book.”

 

“Anyone who doesn’t do transference analysis is doing lie therapy.”

 

I’ve actually heard people say these things!

 

Can you imagine a carpenter showing up at a conference and saying, “I just work with a hammer.” “Once I found the screwdriver, I never had to use another tool.” “Anyone who doesn’t work with a ball peen hammer is doing lie carpentry.” He would be laughed out of the hall. Yet every day therapists fall into the trap of idealizing one technique.

 

Growing up in my father’s blacksmith shop I learned that every tool works until it doesn’t. Then you better have another tool and another approach. My father didn’t have just one hammer, but dozens. He didn’t have one wrench but many types and sizes of wrenches. We could weld iron in the forge or with a stick welder or a metal inert gas welder. We could weld aluminum, but with a torch. We could weld cast iron, but that took a torch and bronze rods. We could work with copper too, using solder. You get the idea.

 

As a blacksmith working with my dad, I had to be able to work with any kind of situation a customer brought into the shop. Cars, trucks, farm implements, ornamental iron, we fixed them all. But it required flexibility, creativity, and lots of tools.

 

From the forge to the therapist’s office has been quite a journey, but I’m also struck by the similarities. We are asked to fix. We need to recognize the unique problems posed before us. We need to be flexible because no one approach works all the time with every person.

 

If your car mechanic told you he could do everything you wanted done to your car by using his hammer, you would race to the next repair shop. Yet every day therapists offer to help patients by using a single tool, as if it has magical powers.

 

Don’t get me wrong. Interpretation can be fantastic. EMDR can be extremely helpful. And mirroring as in focusing can be exceptionally helpful for some people. But when we offer only one tool and expect everyone to benefit, we set ourselves up for disappointment.

 

Every technique works until it doesn’t. And when it doesn’t, you better have another approach in your hip pocket. Nothing works with everyone all the time.

 

So let’s see how to recognize ritualism.

1)    Oversimplification: “All you need to do is ___.” Some psychoanalysts have said that all you need to do is interpret the transference. Some people say all you need to do is hypnosis. Others say all you need is mindfulness. Some ISTDP clinicians have said all you need to do is pressure and head-on collision. I don’t know which world they live in, but it’s not mine. We work with people who are incredibly complicated. Yet some suggest that a single technique will heal all disorders. Not true. Every technique is useful at what it does, but patients usually need help in multiple areas requiring very different kinds of therapeutic action.

2)    Repetition: “When it doesn’t work, just do it again.” Rather than choose a technique or approach based on the patient’s need, the therapist just keeps repeating the technique, even if it doesn’t work. Then technique becomes a Procrustean bed. We try to stretch or shrink the patient to fit our technique. Instead, we need to stretch ourselves.

3)    Technique is equated with a theory: Mindfulness, EMDR, and interpretation are valuable techniques. But none of them is a therapy. A therapy model requires a theory of development and a theory of assessment, which allows the therapist to choose techniques suited to the patient’s need in the moment. When a technique is mistakenly equated with a therapy, there is no need for a theory of development or assessment. There is no need for multiple technical skills. Ritual (repeating a technique) becomes a substitute for thought (assessment).

4)    Claims of power: “This technique is very powerful.” Every technique is powerful until it isn’t. In fact, every technique is powerless much of the time because it is not suitable. What is powerful is not a technique but the process of assessing the patient’s need, which allows you to offer the right interventions at the right time with the right patient.

5)    A messianic vision: “This technique will change the world.” A well-known therapist made this claim at a recent conference. No technique or therapy will change the world. We help most people some of the time in some parts of the world. And that is no small accomplishment. With each generation, new traumas occur leading to new emotional difficulties.

 

So why do we seek omnipotence and grandiose fantasies through ritual?

 

If we accept mere competence, we face our inevitable limitations and those of our patients. We face the limits of reality and death. The grief and loss over what we can and cannot do is part of growing up. And rather than face the losses and limits inherent in life, we yearn for manic fantasies where we are omnipotent instead of merely competent, omniscient rather than knowledgeable, changing the world rather than helping one person at a time.

 

Doing therapy well is difficult, requiring years of study, practice, supervision, personal therapy, and hard work. It takes time. Ritualism is a form of magic. It happens now! Rather than face the limits of reality, who wouldn’t want a magical solution?

 

We can only do what we can, with the capacities we have, with the people we are with, in the place we are in, with the time we have. Modest perhaps, but realistic, and also loving of our patients.

 

When we try to do magic, we ask our patients to have magical results so we can feel like magicians. Thus, we doom them to fail, sacrifices on the altar of our narcissism.

 

Instead, when we shed ritualism and turn away from the siren song of magic, we can offer genuine help so the patient can achieve what is possible within his limits and capacities. And once we drop our ritualism, we move from formula to genuine encounter with this mystery known as our patient. And once we drop the idealization of any technique as the “final” answer, we can become perpetual learners, open to whatever anyone can teach us.

 

 

She attacks me as a therapist!

“I’ve had a few really good sessions with a severely depressed woman who has hated herself for years. She started to remember her rage toward her father, a cousin who abused her, and a former partner who raped her. When I focused on her rage and her avoidance of it, she became angry with me.

 

The next session she said she had not wanted to come, and she became flat again (I think to avoid her anger.). In addition, she started to attack me as a therapist and became passive aggressive. I addressed this defense and asked about her anger again. She then said she had looked up on the internet ways to commit suicide because she did not want to remain so flat and depressed. We explored the murderous rage behind her suicidal wish and she admitted she was angry with me and said she wanted to kill me. We then recapped our work and I became more supportive, but I thought we should still focus on her feelings rather than have her turn the anger onto herself. I felt we were able to repair a lot of the damage in the alliance, but I’m not sure all is good. What do you think I should do now?” Thanks to one of our community members for offering this question!

 

Triangle of conflict: rage; anxiety (discharge pattern unknown); defenses: self-attack, depression, provoking punishment, and passive aggression.

 

Process: when the therapist explores rage in a current or past relationship, the patient begins to

 

When the therapist addressed the patient’s anger and her defensive avoidance, the patient became angry with the therapist. We often think that is a bad sign. In fact, it is a good sign. It means she is able to feel angry toward the therapist rather than turn it against herself and get depressed. In addition, her ability to avoid and detach is also a good sign. It means she has access to isolation of affect. Thus, she probably has high resistance with repression. By highly resistant we mean that she can put up a wall of avoidance and detaching with the therapist. By repression, we see that she turns anger against herself by going flat, getting depressed, criticizing herself, and becoming suicidal.

 

In the first session mentioned, the therapist correctly asked about feelings toward him. In the next session, the patient tests the therapist, “I didn’t want to come.”

Th: Insofar as you didn’t want to come here today, it suggests there are some feelings coming up here toward me. I wonder what feelings you have here toward me?”

 

Not wanting to come to therapy is a defense to avoid feelings toward the therapist. Take that invitation and ask about feelings toward the therapist.

 

The patient then attacked the therapist verbally. This is a way to provoke the therapist to punish her for being angry. Don’t punish the patient by getting angry. Instead, help her face her feelings without provoking punishment.

Th: You say I am useless to you. What is the feeling here toward me underneath that sentence? [Block the defense and invite the feeling.]

 

She said she had looked up on the internet how to kill herself. Without seeing the video and knowing the exact context, we can’t know for sure what the therapist could say. However, you might try the following.

Th: Insofar as you are thinking of killing yourself, I wonder what feelings are coming up here toward me? If we look underneath this wish to kill yourself, what feelings are coming up here toward me? [Encourage the patient to face her rage toward you so she does not have to turn it onto herself.]

 

The therapist did this and the patient admitted she was angry. Great success on the part of the therapist! In fact, the patient said she wanted, in fantasy, to kill the therapist. That is great progress as well: she can admit her wish to kill the therapist rather than turn that wish upon herself. Her threat to kill herself wards off her rage toward the therapist and, no doubt, others in her life.

 

The therapist thought the patient’s anger was a sign of damage to the alliance. In fact, it revealed the patient’s increased freedom to feel her rage toward the therapist rather than turn it upon herself. This is a sign of a much improved alliance. Now his task is to keep asking the patient about her anger toward the therapist so he can help her see the defenses that cause her symptoms, and then let go of those defenses so she can face her rage as deeply as possible toward the therapist.

 

The resulting unlocking of the unconscious will help the patient see where her rage really belongs so she no longer has to turn it against herself. Once she can face her complex feelings of rage, love, and guilt with the therapist and those who hurt her in the past, she won’t have to punish herself through self-attack and suicidality.

 

When a suicidal patient can describe and experience her anger toward the therapist, this is a positive sign. Her alliance is so good she can admit her anger toward the therapist. If the alliance is poor, she will protect the therapist and then turn the anger back upon herself. In a research study conducted years ago by Maltsberger, he and his associates found that patients who committed suicide often had therapists who had become angry with the patient. If you feel a flash of anger, let that be a signal that the patient may be angry with you. Then encourage her to face her feelings toward you: “What feelings are coming up here toward me?” Then you send her a powerful communication: “You don’t have to kill yourself to protect me from your feelings.”

 

Needless to say, without seeing the video, my comments can only be provisional. Getting good supervision with a case like this is essential if you want to do exploratory dynamic therapy of any kind.