How a psychoanalyst got “permission” to use cognitive behavior therapy, mindfulness and moreBy Joan Glass Morgan, Psy.D.
Some of you may have had the opportunity to attend the CPPNJ sponsored conference with Paul Wachtel in 2009. One of the first psychoanalysts to become knowledgeable in the theories and techniques of behavior therapy, Wachtel took up the challenge of integrating active behavioral techniques into his psychoanalytic approach in the book, Psychoanalysis and Behavior Therapy in 1977. But this was not his original intent. As he notes in his preface, he had set out to “slay the philistines” but instead embraced them after studying their work.
Wachtel’s book brought up several controversies at the time. There were many “us” versus “them” challenges. The analysts wondered what the impact of active techniques might be. How would the transference be affected? Is psychotherapy integration possible given that the underlying world views are so different? Behavioral researchers and therapists challenged analysts with questions like: “Where is your evidence? Don’t you want to cure people? Who cares what happened in childhood?” Replies from the analysts included, “We have indeed proven that there is an unconscious dimension to life and its conflicts, and suffering has complicated origins which must be understood.” It was a passionate and occasionally contentious debate that could get particularly heated during that time, when I was a graduate student at Rutgers.
Many students identified with one singular model but a few of us stuck to the mission we had when we chose this unusually diverse program. We took advantage of the privilege of studying with senior analysts, the founder of multimodal behavior therapy, and the major researchers and clinicians associated with behavior therapy. We learned hypnosis and family therapy and constructed protocols for exposure therapy and desensitization. We knew we could not do it all at once, but after a period of percolation, some of us began the project of synthesizing what we learned.
In order to assimilate new ideas and make use of new ways of thinking about helping people, it is important to have a foundation within one model. Stan Messer wrote an article in the Journal of Psychotherapy Integration in which he developed the concept of “assimilative integration.” He suggested that one must have a “home base theory” in order to sensibly bring in new approaches so that one does not end up with a random mix of “techniques,” sometimes referred to as an “eclectic” approach, which cannot be woven together into a sensible whole. From Messer’s perspective of assimilative integration, once a technique is imported into one’s model, both are changed. (For more about this, see also the Society for Psychotherapy Integration, founded by Paul Wachtel and others in 1983.)
It is important to note that Wachtel did not endorse every behavioral approach. For example, he could not accept the early work of Beck, Ellis and others who suggested we could talk people out of their irrational beliefs. He integrates only those theories that focus on the acceptance of experience and affect. And this is the underlying premise of one of the newer branches of CBT, Acceptance and Commitment Therapy (ACT). Rather than teaching the obsessional patient thought–stopping, or the compulsive patient response prevention, she may be taught mindfulness, watching thoughts unfold, accepting, noticing small changes, comings and goings in mind, emotion and body. (It’s noteworthy that the empirical evidence supporting ACT for OCD reflects a higher success rate than when traditional behavioral approaches are used)
My first opportunity to integrate active techniques came when I was working dynamically with a phobic woman who had marital problems. All was going well but circumstances in her life made it important to get her past her elevator phobia quickly. We created the usual protocol and I did go along with her to do in vivo work. Success in her external life brought us to new opportunities for changes in her internal life. We returned to her relationship problems with greater clarity. We came to understand how her fears developed only after she had gained some behavioral freedom. Now that she could travel with her husband on the very important business trip to Europe how would she manage her anger and the many ways she felt subjugated by him. A quick release of the elevator phobia brought us deeply into the work. In order to maintain that newfound freedom she had to address the feelings and relationship problems that led to the phobia.
The issue of integration permeates my work daily. As a student of Buddhism and teacher of Mindfulness-based stress reduction (MBSR) I see that mindfulness can be placed at the center of what has been called a “unified” approach to theory and technique. Buddhist psychology is uniquely concerned with the nonjudgmental acceptance of “what is,” and the cultivation of positive mind states in which we attempt to loosen the grip of the toxic self states which come from rigid identifications with stories we tell about ourselves to ourselves. (See Mindfulness and Psychotherapy by Germer et al, 2005) Perhaps this sounds like an analyst who works to integrate dissociated aspects of the self. Perhaps this also sounds like a CBT approach using positive psychology. Yes and more. What mindfulness and Buddhist informed approaches offer is a way to invite all parts of ourselves into the room, and teach the needed skills to bring acceptance to all parts. Our suffering is seen as the result of clinging to what is comfortable, familiar, pleasant; recoiling from what is painful or scary. Within this system we learn to cultivate an attitude of nonjudgmental awareness as stories, feelings, and symptoms come and go and we learn to identify less with each of these and as we learn that all is transitory.
Of course there are also radically different views about theory, technique, and how people tick even within the smaller analytic community. Can I draw on the theory of self psychology one day, provide selfobject functions and stay very experience near -and the next day draw on interpersonal theories which would allow me to introduce more of my subjective experience? How would Joyce Slochower, a contemporary interpreter of Winnicott, who makes the case for the importance of “bracketing” subjective experience (so as not to impinge upon the patient) integrate the theories of Darlene Ehrenberg, a contemporary interpersonalist, who argues for the importance of meeting patients at the “intimate edge,” sometimes confronting them with their immediate impact on her? We intuitively know we cannot bounce around this way, yet we must also figure out what the options are, and we must have studied enough to know why we are rejecting what we reject! As Wachtel stated years ago in relation to the controversy at the time, not introducing active techniques has just as great an impact as introducing them. And I would add that a choice to not do something is very different than a choice to not know something.
There are few analysts now who would not encourage the use of exposure in real life while also exploring underlying dynamics. But Wachtel was amongst the first in our field to articulate how and why. Back in the year 1969 he wrote, “To the extent that the theory truly becomes a general psychology it will cease to be a psychoanalytic theory and will tend to simply be a psychological theory…” I suspect CPPNJ is a bit unique in this way: Our community is not threatened by such a possibility.