By Duncan Cartwright
I am sitting listening to Arieh, a patient. He tells me about the conflict he gets into at work and complains about how people always seem to think he can’t do his work adequately. In reaction to these conflicts, he ends up becoming passive-aggressive with his colleagues and withdraws. We have discussed some of this before, specifically related to his experience of feeling constantly shamed and put down by his father. At this point, he leans forward and asks me if I understand what he’s been on about. Somewhat mindlessly and taken off guard I say, ‘I think so’! In reaction he starts to get lost in his thoughts and appears to become increasingly unsettled and irritated with himself. He falls into silence and then moves on to talk more about how absentminded his father was.
At this point I am aware that some affective shift, some change in feeling, is taking place between us and I draw his attention to this. Our attention is now focused on the proverbial ‘here-and-now’. Arieh and I explore the possibility that my malattuned ‘I think so’ triggered a sense of inadequacy and a feeling of not being able to do his ‘work’ here with me. I add that I wonder if his irritability with himself was an expression of anger meant for me. He replies in a rather sheepish way, saying it wasn’t my fault that I had difficulty concentrating as I had many other patients to listen to. What follows appeared to productively explore Arieh’s defensive use of aggression ‘turned inward’ as a means of protecting me. Towards the end of the session he expresses a sense of relief about being able to directly address these issues. “Something has changed’, he says, “I could really feel some of my anger instead of going on about memories of my father all the time”.
What is it about the here-and-now that fosters change in psychotherapy? Why is it often privileged for its therapeutic power when compared to interventions aimed at the past (then-and-there) or the future (when-and-where)? Despite its intuitive importance there has been remarkably little written about the therapeutics of the here-and-now. Why might an intervention that focuses on the present moment be more effective? Is it more effective than focusing on integrating memories, recalling, focusing on the past? How should we focus on the here-and-now? When is it necessary to bring awareness to the here-and-now? Finally, are there therapeutic factors inherent in working with immediate experience that cut across all therapies?
Psychoanalytic, humanistic and experiential approaches all emphasize the mutative impact of immediate emotional experience. Group Psychotherapy has also emphasized the importance of using the here-and-now as a means of reworking current interaction as observed by group members. Although there has been a growing focus on the subject since the 1960’s, we still have a lot to understand about its lasting impact on the therapeutic process.
Perhaps this is partly due to difficulties in conceptualizing what we mean by ‘working in the here-and-now’. After all, is it not the case that we do everything in the present, it cannot be otherwise? Everything occurs to us in the here-and-now and the therapeutic process could be seen as a series of ‘now’ moments, one leading to another (Stern, 2004). When I am listening to Arieh, thinking, talking, interpreting, recalling, attending to my own somatic states, I am doing it in the present moment. When Arieh remembers his father’s absentmindedness, he is also remembering it in the here-and-now. Even when we ‘live in the past’ we do so in the here-and-now. This, of course, does not mean that we are always aware, or need to be aware, of everything that goes on in the present and that nothing else counts. In fact this is an impossible feat and persistent focus on the present can be experienced as intolerable and paralyzing. It does suggest, however, that unfolding experience and ongoing therapeutic interaction is always full of potential to be used in the clinical encounter.
In a seminal paper on therapeutic action, Stachey (1934) highlighted the importance of using the immediacy of the therapeutic situation to generate mutative interventions, interventions that create lasting change. Today few would disagree with the idea that it is the immediacy of drawing the patient’s attention to a dynamic as it is playing out in the room that grants the therapeutic couple powerful insights and ‘evidence’ that the intangibles of psychic life are there to be observed. However, it also seems that there is something about the experience itself, experiencing the ‘lived present’, that also generates therapeutic effects. These two observations appear to characterize two different therapeutic approaches to the here-and-now that are not necessarily mutually exclusive. I shall refer to these as the ‘insightful present’ and the ‘experiencing present’. Both emphasize Wilfred Bion’s (1961) adage that ‘learning from experience’ generates more impact than ‘learning about experience’.
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