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Lucid psychotherapy contd ...


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.

As I worked therapeutically to change these negative attitudes, it seemed likely that the process was analogous to that by which the negative attitudes were internalized in the first place. The difference was that in therapy, the internalization was gradual and slow, while in the context of trauma it was often rapid, even sudden. Perhaps therapeutic internalizations came in small increments, where traumatic ones tended to happen at times of extreme stress.

Observation suggested a model of the superego where, once contents were internalized, they were essentially permanent. The tendency to regress under stress strongly suggested that negative attitudes and values could be suppressed, but not eliminated. The superego, or whatever one might wish to call this collection of attitudinal contents, was capable of containing contradictory elements, with some more active than others. Part of healing was helping patients reactivate the positive feelings they had had before their trauma. Superego contents could be described as layered. Positive ones could become active as they were layered over negative ones, but the negative ones could be re-awakened at any time by adverse circumstances. Thus, I was led to conclude that internalized attitudes, values, etc. were permanent, layered, and subject to a reawakening phenomenon triggered by circumstances that resembled the original trauma.

The mechanism of internalization

The next area to clarify was the precise mechanism of internalization. Hoping that a single explanation would cover both the fast and the slow versions of internalization, I looked for examples across a wide swath of life, both inside and outside therapy. In the end, I became convinced that internalization takes place in quantum steps that can be small so as to make the process appear gradual, or large, making for sudden change. In each case, the mechanism appeared to be the same. In the end I came to believe that internalizing the values and attitudes of others constituted a basic mechanism for reinforcing human connection at times of real or threatened aloneness.

Freud noted two kinds of internalization. First, (1921) in the mechanism of "identification with the lost object," he observed that individuals suffering from separation would internalize characteristic mannerisms of the other. "Identification is the original form of emotional tie with an object." Second, after developing the structural theory, he described the resolution of the oedipus complex as the boy's internalization into the superego, of what he perceived to be his father's prohibition of sexual involvement with his mother under threat of castration. In both cases, the child's need to remain connected with his parents was the driving force for internalization.

In a book called Snapping (1978), Conway and Siegelman describe instances of "sudden personality change." In phenomena such as cult induction, religious conversion and trauma, the combined elements of heightened emotion, mental turmoil, the presence of a strong authority and a need for belonging or connection result in a sudden, massive internalization of new values and beliefs. Again the need for connection seemed to be the one common thread. Prospective cult members needed an identity and a sense of belonging. Trauma survivors, in their extreme aloneness, needed someone to hold onto, even a perpetrator. Children needed the security of feeling connected to their parents. Internalization becomes a way of securing an otherwise tenuous bond, and is triggered by anxiety over that bond.

This thinking about the characteristic elements involved in internalization shed new light on clinical practice. The goal of therapeutic internalization was to help patients improve self-esteem and in general, internalize healthier values and attitudes. What I learned was that slight anxiety about the therapeutic bond was positive. This meant a stance of slight aloofness. I came to call this attitude "expectancy." By this, I mean a subtle communication that my patience is not unlimited and that our being on the same wavelength depends on the patient's commitment to change. On the other hand, when therapy is stagnated, a stance of unlimited acceptance would constitute "enabling" and would be anti-therapeutic.

Suddenly I could make sense of the apparent contradiction between the closeness that worked best for catharsis and the "neutrality" that I had been taught. Catharsis calls for close connection and internalization requires expectancy. Perhaps the wars within psychoanalysis over empathy and interpretation (Josephs, 1995), were really a reflection of an instinctive appreciation of the two mechanisms of healing. In practice, I began to adopt the stance that corresponded to the work currently being done.

As I was formulating these ideas about catharsis and internalization, I attended a conference on Therapeutic Change hosted by the Boston Change Process Study Group. The presenters echoed the key observation that change takes place in the moment. Their views, coming not from trauma, but from everyday psychotherapy and child observation reinforced my thinking. Recently, Daniel Stern, one of the presenters that day, published The Present Moment in Psychotherapy and Everyday Life (2004), arguing for a vision of therapy similar to mine in its emphasis on moments of change.

A dual-mechanism view of therapeutic action

At this point in my journey, I had come to believe that catharsis and internalization were the fundamental and only mechanisms of structural change. I was determined to push this idea till it led to the goal of lucid psychotherapy or produced the kind of jagged cleavage that would signal failure to find the true internal structure. Could this dual-mechanism view, originally derived from trauma work, apply to therapy in general?

As my thinking had strayed from established dogma, what I had learned had subtly changed the way I did therapy with all patients. It felt as if I were looking through a magnifying lens. The healing processes that formerly looked unitary, were now resolved into two separate tracks, each with a phenomenology of its own. Having separated the two, I found myself focusing on specific changes that needed to take place and how best to make them happen.

One group of therapeutic tasks was the resolution of painful affects. The moments during which listening led to the softening of a wide variety of painful feelings were no different from moments of catharsis. Certainly a major part of treatment consisted in destabilizing the defenses that warded off painful feelings, but the resolution of feelings was what made for permanent change. Next the goal was to detoxify the feelings. The same three elements of telling, feeling and empathic connection resulted in the same lasting resolution of each level of affect.

Again, as with my trauma patients, catharsis was not enough. Depression, for example, involved painful affects, but catharsis did not produce resolution. Again, the problem was internalized attitudes and values. Depressed patients measure themselves against internalized values and attitudes, and find themselves lacking. Therapy has to attack the values before there is a chance to heal the angry feelings behind them. Just as with the loss of self-esteem that goes with trauma, the impossible standards of the depressed person are hard to change and require a focused, prolonged effort to replace rigid values or to reactivate more reasonable ones.

I now believe that catharsis and internalization are indeed sufficient to explain the structural changes that are the overall goal of psychotherapy. The entrenched dysfunctional patterns of reaction that are the target of psychotherapy involve combinations of warded off feelings and pathological internalized values. Together, catharsis for painful feelings and internalization for healthier values and attitudes are the final steps in structural change. Looking more closely at emotional development and at transference work will help flesh out this view.

First, emotional development does not stop in childhood. Adult patients exhibit arrested development in various ways. In furthering the developmental processes, catharsis and internalization are so closely tied that they are hard to distinguish. For example, a patient who has never developed adequate impulse control goes through the process of practicing waiting before acting. The patient feels anxious, uncomfortable, even strange, waiting instead of acting. Going through this exercise involves almost simultaneous painful affects, which heal through catharsis, and the laborious establishment of new values favouring acceptance of reality on its terms and self-control over impulses. The actions of catharsis and internalization take place together and cannot be observed separately.


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