How a Psychoanalyst Got "Permission" to Use Cognitive Behavior Therapy, Mindfulness and More

By Joan Glass Morgan, PsyD 

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)

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Monica Carsky, PhD

What makes patients begin to seem overwhelming?  How do we as therapists end up feeling overwhelmed?  At the CPPNJ Faculty Forum on November 4, Monica Carsky presented her recent paper addressing these very questions. She described her work with Frank Yeomans and the Kernberg research group involving many years of consultation with therapists who often feel they have reached the end of their rope.

Carsky's work is grounded in the object relations model of Transference Focused Psychotherapy. TFP was first designed by Kernberg and his group to structure psychoanalytically oriented treatment of borderline personality disorder.  More recently, they have focused on work with severe narcissistic character disorders.  The crux of this treatment approach, grounded in a solid assessment of character structure and ego functioning, is the identification of internalized dyads:   self and object representations in affective relation to each other.  This here-and-now focused treatment aims to track which internal dyad is activated for the patient at any given moment in the transference relationship with the therapist.  Quite often, in more severely disordered character structures, these internal dyadic roles shift back and forth between who is experienced in what role at any point in time.  Although the therapist is experiencing the projections of these roles in the interaction with the patient, she seeks to maintain a reflective stance on these moment-to-moment transitions.  The therapeutic goal is to identify which internal dyad is being activated and use interpretation to help the patient begin to understand how his internal world is determining his experience of relationships in the present moment.

Key to this process - and what can lead it to become overwhelming for both parties - is the presence of powerful, disavowed emotions that are intolerable to the patient, and which come to feel that way for the therapist as well.  At this point, the therapist is overwhelmed in her ability to contain, reflect and interpret the patient's internal object world.  Carsky finds that aggression is most often the central issue.  Many times, the aggression is also being acted out in other areas of the patient's life, and as a result, he is doubly unable to become aware of the disavowed affects and internal dynamics involved.  Anger, hate and devaluing are the kinds of powerful negative affects that become disavowed and projected in various forms.  The resulting projective identifications are often the only way for the patient to communicate his need to defend against intolerable feelings of fear, envy, longings for dependency and/or closeness. This can create a sort of vicious cycle for the therapist in which there are intense and conflicting feelings of responsibility for the patient at the same time as feelings of being exploited.  The tendency is to counter this with providing more flexibility and support to the patient, but with the therapist increasingly feeling trapped, "...like a prisoner of the patient."  As the therapist relaxes the limits of the treatment frame in an attempt to respond supportively to the patient, the patient just seems to become increasingly worse.  

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Elise Snyder, MD, President, CAPA, in Changdu, China

Thank you for joining us.  Look for our next newsletter in January when the featured article will be:

"Exploring Psychoanalysis:" Sally Rudoy reflects on her recent trip to China with CAPA (The China American Psychoanalytic Alliance). 

Unsolicited articles are welcome.  Something you'd like to write?  Send it to us at cppnj@aol.com.  We're happy to hear from you.