Copyright © New Therapist
In search of lucid psychotherapy
By Jeffery Smith
Many years ago I was struck by the fact that the microscopic structure of crystals determines their regular shape and smooth surfaces. Salt, for example naturally forms in cubes. If you try to break a crystal at an unnatural angle, a jagged surface will result. But, by respecting the natural planes, the crystal cleaves neatly, leaving a fine, smooth surface.
Over my 30 years of practice I have been drawn by the ideal of understanding the structure and cleavage planes of psychotherapy. Training had taught me to listen to the unconscious and interpret defenses, but exactly when and how did the therapeutic action take place? Traditional explanations did not seem adequate to capture what instinct and experience nevertheless produced. Still, there must be structure and cleavage planes.
This paper is the story of a search for "lucid psychotherapy," an approach to psychotherapy focused on understanding and fostering specific moments of healing and change. Lucid therapy would mean having clarity about change processes, about where you are, where you are going and how to get there. This understanding would be expressed in terms that would transcend the vocabulary of traditional schools and would help integrate the diverse wealth of wisdom about psychotherapy as well as much new information about neurophysiology.
In recounting the journey, I will follow several threads that ultimately converged in a framework that crosses the lines between schools of therapy and allows for coherent use of tools from many toolboxes.
I had just finished my residency at Albert Einstein College of Medicine. The training was wonderful. My teachers and supervisors were sophisticated and human at the same time. However, in the mid-seventies, trauma was not considered part of the curriculum. So, when shortly after graduation, I found myself working with a patient who had suffered extreme childhood abuse, I had little to go on. The psychoanalytic concepts I had learned were not very relevant, but in going back to Freud's early description of cathartic treatment, e.g. Studies on Hysteria (1895), I found someone who had traveled the same road and observed the same phenomena.
It took my patient four years to be ready to face the emotions that surrounded the worst of several major traumatic events. At age six, she had been forced to kill and then to burn the body of her favourite pet and only friend. When this atrocity began to come to light, her feelings had all the intensity of the original experience. Just as Freud had described, sharing her horror, grief, rage and disgust, led, surprisingly rapidly, to permanent healing for that part of her experience. After each extended session, my patient felt like she had been "run over by a truck," but was emotionally more at peace. Over a period of three to four weeks the acute pain was transformed into a dull ache. Each session focused on a new aspect or new level of pain. It seemed that each experience of catharsis started the clock on healing for that segment. When there was no more, it was clear to both of us that that part of the work was done. For each "chunk" of emotion, one time was enough. We did not have to return to that material again.
I began to wonder if the mechanism of catharsis might be a core element in the structure of psychotherapy in general. It seemed so clear and definitive, at least in the extreme case of trauma. I sought to analyze the experience. What were the necessary elements in the catharsis that my patient and others experienced? Freud had identified just two elements. First, there had to be conscious memory of the events and second, the recall had to be with feeling. These requirements were certainly in line with my experience. Freud stopped at these two elements, but there was a third one that intuitively seemed essential, that of a listener. More specifically, it seemed clear to myself and to my patients that an empathic connection with the listener or witness had to be part of the experience.
I could understand Freud's desire to omit this element. He was, after all, a nineteenth century scientist. Like his contemporaries, he believed that being "objective," meant mistrusting anything as fuzzy and subjective as empathy. By the middle of the second half of the 20th century, this mistrust was no longer required to be "scientific." Empathy can now be measured and even visualized in real-time brain scans.
By empathy, I do not mean being solicitous. Empathy happens when facts are communicated with feeling. If the telling is abstract or intellectual, the communication of feeling does not happen. I could still "understand" feelings, even when the events were beyond my experience, but not with the full vividness of someone who had actually been there. Even this limited empathy appeared to be sufficient for healing. On the other hand, when the empathic understanding was missing, I came to expect that healing would not occur.
This new understanding began to influence my practice. As I listened, I was no longer focused on the formulation of what was happening, but on giving the occasional nudge that would help the flow of detail so that my empathic understanding continued to grow. When empathy stopped, it was time to look for resistance, or perhaps countertransference, and work with that.
Still, there was a nagging doubt. Was the need for empathic connection more perceived than real? Did it simply feel good to make a connection? The answer would have to wait.
In the work with trauma survivors, it soon became clear that catharsis alone was not enough to repair all parts of the damage. Traumatized patients typically had low self-esteem and inappropriate guilt when things began to improve. At first, I tried to use the same cathartic method. I explored the origins of my patients' low self-esteem and inappropriate guilt. I assumed that uncovering and understanding would work the same way to bring about an improvement in self-esteem as it had for painful feelings. My attempts did not work.
Catharsis was not enough, and there was not a clear answer as to how to repair the damage that catharsis could not. Perhaps this was the reason why the concept of catharsis had largely been abandoned. Yet, the clinical experience was clear. Catharsis worked well for traumatic memories and not for damaged self-esteem.
I now tried educating my patients about the cause and inappropriateness of their self-loathing. This worked better, but change was still very slow. I pushed further. When I was successful in encouraging patients to act as if they were worth more than they felt, there was a backlash. They would self-sabotage, or feel anxious or guilty about treating themselves better. It was as if change was going against their conscience. Still this unnatural exercise seemed to further their growth. What was needed for healing was a change in their fundamental value system. I began to call this "superego healing," because the mental contents that needed to be modified seemed similar to the contents of the superego.
This mechanism, in contrast to catharsis, was gradual and laborious. It would sometimes continue after the formal therapy was ended. Even more interesting, while catharsis was permanent, this kind of healing was not definitive. It was subject to regression. When the patient would find him or herself in a situation that resembled the abusive one, the old attitudes would return with strength and power. It might be easier to push them aside a second time, but these back-slidings were still daunting to patient and therapist.
It was clear that my trauma patients were exhibiting pathological attitudes, values, prohibitions and even ideals. Could it be that the superego was pathologically changed by the experience of traumatic abuse? A hallmark of the superego is a similar resistance to change in the face of pressure from ego and id. Perhaps the superego should be seen not as static, but as a collection of values, attitudes, ideals and prohibitions internalized at various times.
The existence of a mental organ that could contain these contents and keep them independent from the wishes of the self would clearly serve an important purpose. This would constitute a source of governance that could not be swayed by the desire of the moment. In addition, it would serve to protect the individual from pain, individual or even social. Like traumatized people who seemed to have adjusted to the values of their perpetrators, people who grew up as slaves or other devalued groups would be better able to tolerate their disadvantaged status by internalizing a sense of low self-worth in line with the way they were treated.
The clinical facts of my cases made it clear that they had not gotten their negative superegos in early childhood. My first patient and, later, others, had started life relatively well adjusted and happy before they encountered severe abuse. It seemed increasingly clear that they had absorbed the negative attitudes directly from their traumatic experiences. Under duress, they had internalized negative attitudes towards the self. In fact, examining the specific content of these internalizations, it was clear that the attitudes, values, prohibitions and ideals were taken directly from the child's perception of the attitudes of the abusers.