Thinking Multiculturally was a
workshop led by Claire Arbour, Amy Basford, Emily
Barrett, Beth Kita and Patsy Wood. It kicked off by
describing the findings of a survey of multicultural
issues in members of SFPRG that will be reported in
more detail in another section of this newsletter. It
also featured a talk by Jane Dulay who highlighted
some of the possible issues that one might keep in
mind in working with Asian American clients. Her talk
provided evidence that, while the dynamics of each
client are unique and case specific, certain cultural
values and norms may be extremely relevant and
important for a therapist to be mindful of in working
with clients of different cultural groups. Finally, Emily
Barrett described a case of a young biracial
adolescent male who is struggling with his sense of
identity and whose struggle was deeply affecting for
his therapist. The presentation stimulated a lively
discussion about how to think about and work with
these issues. All in all the workshop was a successful
first effort that identified many more questions than it
answered. Nevertheless, this provides plenty of
potential topics on multicultural issues to pursue in
our future workshops and presentations.
The workshop led by Beth Kita and Jack Bugas
on "Working with Incarcerated Patients" was also
fascinating and offered a unique and incredibly
compelling view of the immense challenges of trying
to do "pro plan" therapeutic work in prison settings.
The extreme polarization between the guards and the
inmates that is so prominent in the prison system
creates a very capricious environment where
therapists must posture in very particular ways in
order to create safety for themselves and their clients.
Nevertheless in spite of these considerable barriers
to treatment, there is powerful pro plan work being
done by therapists in the prison system where
inmates are hungry for connection and an opportunity
to be authentically heard and understood. Yet the
unfolding of client tests and therapist interventions
because of the lack of safety in these inmate's lives
often looks very different than therapy done in
outpatient settings. Many of us attending the workshop
were deeply moved by the presentations and case
vignettes described by Beth and Jack and came away
with a broader perspective on doing therapeutic work.
The final workshop taught by George Silberschatz
and Suzanne Gassner on the strengths and
limitations of Control Mastery Theory was also very
stimulating and thought provoking. The workshop
began with a presentation by George and Suzanne on
their view of the strengths and limitations of CMT. In
terms of the many strengths of the model, they both
noted the integrative nature of CMT as a significant
strength. George described how CMT integrated a
theory of how the mind works with a theory of
psychopathology along with a theory of doing therapy.
Suzanne also noted the integrative nature of the
model but in particular she noted how CMT served as
a "meta" theory that explains why many therapists
working from very different orientations could be
successful therapists. She pointed out how resilient
clients can be in making use of what their therapists
offer in order to get their needs met in therapy
regardless of their therapist's orientation. A second
strength was the way that Control Mastery is a very
clear, straightforward theory that is easy to teach. The
simplicity of the model lends it to greater empirical
scrutiny and empirical testing. A third strength is that it
HAS been empirically tested which is often rare,
particularly in psychodynamic models of treatment. A
fourth strength of the model is how clinically useful the
model is. Consider the assumption of testing and
how this concept can make certain common client
behavior comprehensible to therapists that might
otherwise appear provocative or "resistant" rather than
as furthering the client's plan. A fifth strength of the
model is that the basic assumptions of CMT are
consistent with modern biological research,
evolutionary theory, developmental research and
attachment research. This provides powerful
evidence for the viability of the model. A sixth strength
of CMT cited by Suzanne is the empirical focus of
CMT. It is empirical because it asks the therapist to
monitor the patient's response in order to determine if
the patient is progressing or not. So the key to
assessing how pro plan our interventions are is to
track how our clients are doing both in and out of the
therapy. In this way, as Suzanne Gassner put it, "the
client is our best supervisor". If our clients are
bringing forth new material, more affect and the client
is bolder in terms of engaging in behavior that is
consonant with desired goals, then we can conclude
that our interventions as therapists are likely pro plan.
Indeed, Suzanne made the point that this empirical
focus should be our guide over any reified model or
input from "experts" that we might rely on. A seventh
strength is that CMT is client specific so each client is
viewed as unique and one's approach as a therapist
is geared to the particular needs of that individual
client. An eighth strength is the notion of passive into
active testing where the client may unconsciously
need to traumatize the therapist in order to work
through his or her trauma. This concept provides an
explanation that allows therapists to contain very
difficult experiences and provides a perspective for the
therapist to not be reactive in a way that could
undermine treatment. Finally CMT often focuses on
early trauma - particularly those disruptive events that
occur in children in the context of their most important
family relationships. This view of the client can be very
orienting in formulating a client's case by providing a
map for the therapist as to what experiences in
therapy might disrupt the therapeutic relationship and
what behaviors, attitudes and affects on the part of the
therapist might strengthen that relationship. It also
provides an understanding of how clients' pathogenic
beliefs emerged as well as explaining why clients
have such conviction relative to their pathogenic
beliefs. In the discussion that ensued, Heather
Folsom also noted the power of CMT in focusing on
the adaptive strengths of clients and an inherently
positive view of human psychological function.
Some of the limitations presented highlight areas
for future research. One area noted by both
presenters as a potential limitation was that certain
key assumptions of CMT such as the concept of the
plan formulation and testing remain somewhat vague
and may be applied in a diffuse way across CMT
therapists. For example, recently Marshall Bush
gathered a list of what different CMT therapists
considered testing. There was tremendous variability
to this list suggesting a possible lack of consensus in
what CMT therapists consider to constitute testing.
Suzanne also made the point that not everything
clients do in or out of therapy is necessarily testing;
sometimes life events occur inadvertently that may
either further or inhibit a client's progress or plan and
these can lead to further active testing on the patient's
part. A second limitation of the CMT model that was
cited involves the assumption that clients always exert
unconscious control over their mental lives. While this
may be the case in many clients, this begs the
question of how CMT explains clients who have poor
self regulation skills and who may appear to have little
or no such control. George reminded us that in order
for clients to test therapists and thus come to
disconfirm pathogenic beliefs they need to be able to
read a therapist's response. Yet if a client is very
impulsive or "disregulated", he or she may not be
able to accurately read and make use of a therapist's
response. So how does CMT think about such
clients? A third area of limitation has to do with the
idea that CMT is a very cognitive model - this is often
a common criticism of CMT. Yet, if cognitive aspects
of the model are important, how do we work with
clients who have suffered from very early trauma,
perhaps even preverbal trauma? These clients may
have much more difficulty disconfirming pathogenic
beliefs because of the absence of narrative
associated with their trauma.
Four other areas of limitation were mentioned.
First, is the issue of guilt. When Joe and Hal
developed the model, a huge advance that they made
in psychoanalytic theory was a focus on guilt as a
source of psychopathology rather than instinctual
needs. As Joe had apparently put it: guilt can emerge
out of love. Both Hal and Joe recognized the relational
aspects of guilt where people are often traumatized
by living with people who have been significantly
traumatized. In particular this guilt often manifests
with clients living in fear of hurting others or clients
who have an exaggerated sense of omnipotent
responsibility toward others. The problem with this
focus in CMT according to Suzanne is that guilt can
be overemphasized and this, in turn, may lead at
times to somewhat "canned" interpretations on the
part of therapists with their clients. Indeed, Suzanne
suggested that CMT therapists may be overly fixated
on guilt to the exclusion of other powerful affects such
as shame and humiliation, both of which are very
common in trauma. She went on to point out that not
all shame (feeling less than) is necessarily the other
side of guilt (feeling too powerful). Indeed shame can
occur in the absence of guilt just as guilt can occur in
the absence of shame and often the two can also
occur together. Suzanne cited the intersubjectivity
model as having a more focused and systematic way
of addressing both shame and humiliation in clients
and suggested that this may be an area that CMT
therapists could give more thought to. A third area of
limitation according to George is the inadequate
attention that those writing about CMT have paid to the
larger empirical and psychological literature. While
Joe focused primarily in his writings on CMT in
juxtaposition to classical psychoanalytic models,
these models have grown tremendously in the last
four decades. What future writing on CMT might do is
work to tie assumptions of CMT to the broader
scientific and psychological literature. Finally Bill
Dickman weighed in on the tendency for CMT to
overemphasize intrapsychic issues and
underestimate the powerful biological and organic
variables that play such a strong role in diagnoses
such as ADHD, OCD or a non verbal learning
disability. For the therapist to attribute pathogenic
beliefs to symptoms in these cases may miss the
weight that biological factors play in these symptoms.
Suzanne agreed and noted in her own work with
clients that she had found it important to consider
hormonal influences and the role of poor nutrition in
her work with clients. The issue of cultural sensitivity
in the CMT model was also raised and Suzanne
framed the issue as one of safety. She asked how
can CMT therapists make it safe for the client to talk
about the differences between therapist and client?
This discussion can then lead to a greater
understanding of the client's world on the part of the
therapist and a stronger therapeutic relationship.
In this way the CMT model is a work in progress
that, like all good models, needs further elaboration
and research. Given this discussion, some of the
areas that future research might address include
further studies to develop a clearer conceptualization
of the plan concept and the concept of testing.
Another area is to more carefully consider how CMT
might view the process of working with clients who
have greater problems with self regulation or clients
with preverbal trauma. Those of us writing about CMT
might also work to tie CMT concepts into the broader
literature on mental processes. Similarly, paying
more attention to the role that shame and humiliation
play in human life and viewing these affects more
centrally might be a source of future research. Finally
the role of biology and culture needs to be further
explored in considering client safety and the
evaluation of client symptoms. In short there is plenty
of work to be done. The idea of "beginner's mind" is
key here according to George. We need to adopt an
attitude where we are always exploring and
questioning and refining our model with ongoing
research. In this process we also need to resist
the "expert's" mind that tends to be closed and sure of
one's model. Only in this way will CMT remain vital
and adaptive.
