Dear Colleagues,

Last week, we wrapped up our excellent Spring Conference entitled "The Role of Exposure and Safety in Two Treatments for Trauma: Control Mastery Theory and Cognitive Behavioral Theory" with Victoria Beckner, Susan Landes and Ginger Rhodes. Susan and Ginger did a beautiful job presenting Control Mastery Theory and trauma, while Susan presented a terrific case in the afternoon. Victoria, a rising star in the Bay Area, presented her work on the neurobiology of trauma. Though her focus was on Cognitive Behavioral Therapy (and being relatively unschooled in CMT), Victoria sounded more like a Control Mastery therapist than many Control Mastery therapists. She spoke clearly about siding with the patient's plan and helping patients disconfirm grim and crippling pathogenic beliefs. Her therapeutic focus was on behavioral change and its relation to exposure therapy. She reminded me of Hal Sampson, who recognized that behavioral change often occurred first before intellectual insight. We look forward to having Victoria come back to collaborate in more conferences in the future.

SFPRG offered our first conference in Portland, Oregon earlier this month. Former SFPRG intern, Susan Evans, did a wonderful job organizing the conference with the Oregon Psychoanalytic Center. We have been planning this Portland conference since last year's International Conference on CMT in San Francisco in March of 2012. We learned that people in Oregon are very hungry to learn about Control Mastery Theory. It was wonderful to see Rachel Chester, a former SFPRG Clinic intern, who drove two hours in each direction from Eugene to Portland to hear the seminar. We gave an overview of the theory and research in the morning and went over three plan formulations of cases presented by attendees in the afternoon. People seemed to really appreciate learning about Control Mastery Theory. We hope to have more teachers go to Portland to present in the next few years and we hope that some of those who attended the conference will join us for future International Conferences on CMT in San Francisco.

We are currently planning similar conferences in New Haven, Los Angeles, and eventually in Seattle and Vancouver. One of our goals as an organization is to develop familiarity with Control Mastery Theory nationally by expanding teaching around the country and by making contacts with interested students and practitioners who may want to join us for our international conference in March. A related goal of our group has been to expand research and encouraging more members to write and publish.

In that regard, Marshall Bush and I have been talking about offering a small seminar for those interested in Control Mastery Theory to come and present their work, their research, and their new ideas in the development of CMT. We would offer continuing education credits for participants.

Several years ago, Norman Sohn made the suggestion that SFPRG offer a seminar to support those who are interested in writing and publishing, but who may have less experience or confidence. The idea for this seminar is to have people share their ideas with colleagues, so that we are not so woefully ignorant of each others' work. We hope to inspire people to develop their ideas further and ultimately to publish them. We also want to clarify and organize the next logical steps in conceiving of research projects based on previous and current research. Our goal is not just to disseminate the work that already exists but to continue to see it grow, as Hal envisioned in his video interview shown at last year's award banquet.

If people are interested in participating in a conference on Further Developments in Control Mastery Theory and Research, either as a presenter or as a participant, please let Marshall or me know. We would like to at least set up a day conference that could possibly expand into a regular monthly meeting.

I hope you all have a wonderful month. See you next month.

Steve Foreman

Hello Community.

Spring is in the air and like many of you I am thinking about a vacation this summer. But before that happens, as promised, I want to fill you in on my recollections of the March Workshop. First of all I would like to thank all the teachers that gave their time and energy to the Workshop including, Steve Foreman, Jessica Broitman, Paul Ransohoff, Denny Zeitlin, Rachel Rivers, Bill Dickman, George Silberschatz, Elayne Lansford, Susan Badger, Jane Jordan, John Gibbins, Marshall Bush, Irwin Gootnick, Carol Drucker, Michaelanne Baker, Harriette Grooh, Peter Schumacher, Heather Clague, Jack Maslow, John Snyder, and Larry Hetrick.

The series we did on CMT and other theoretical approaches was well attended. There was an interesting discussion in the CBT training on the possible limitations of CMT as it relates to the treatment of anxiety disorders. Bill Dickman pointed out that there is a difference in how we view inhibitions. Some inhibitions come out of guilt (CMT approach) and some come out of fear (CBT approach). For certain anxiety disorders like OCD and panic disorder, understanding psychodynamic forces are not always helpful to the client. Sometimes the client needs to be exposed to fear through more structured exposure work.

On the last day of the workshop George Silbershatz and Marshall Bush lead a discussion on the future of CMT. There were many interesting ideas generated out of that discussion including the idea that maybe CMT is not complete as a theory. For example, if clinicians are using other techniques or theories along with CMT, do these other theories call attention to something that CMT is not addressing? Maybe CMT does not pay enough attention to genetic factors. On the topic of testing, how many tests does a client have to pose before it is passed, does the nature of trauma and/or attachment help predict certain tests? How does our current understanding of neurophysiology and neurobiology fit with CMT? How can we answer some of these questions through our research?

The Trauma conference held April 13 took up the topic of exposure work again. Victoria Beckner, Ginger Rhodes and I discussed the importance and prevalence of exposure work in the treatment of trauma. There were many similarities between our two approaches, CMT and CBT/ACT. In CBT/ACT the exposure work is more explicit. In CMT the exposure work is more implicit and planfull based on the case formulation. The role of safety was also thoroughly addressed with comparable between the two approaches.

Steve Foreman gave a talk in Portland earlier this month. We are looking to give talks in other locations this year including New Haven and Los Angeles. Let us know if you know of other locations where we can give an introductory conference and/or if you would like to give one.

Lastly, this fall we are planning a conference on Treating Addiction. Stay turned.

SFPRG will start our annual Membership Drive soon. Please renew your membership with SFPRG promptly - help us save stamps and paper! We depend on our members' support to continue our Mission: To improve the practice of psychotherapy through the further development of Control Mastery Theory by educating mental health professionals, conducting research on psychotherapy, and providing mental health services to the community.

HELP NEEDED FROM CHILD THERAPISTS! Are you a child therapist (MFT, PsyD, PhD, MD)? Do you have a caseload of at least 50% children? Have you been licensed for at least 5 years? Have you treated a child of divorce where you believe the child actually grew or flourished following the immediate negative impact the divorce?

If you answered YES to ALL of these questions, please consider being interviewed for my study about post-traumatic growth in children experiencing family transition (divorce).

Your participation would entail: Having one confidential interview (phone or in person) lasting approximately 1 hour, reflecting on a case you treated where you perceived the child had a growth reaction (more than just a return to baseline functioning) following his/her parents' divorce, and discussing your knowledge of post-traumatic growth in children.

Participation is voluntary and confidential.

If you are interested in helping, please contact SFPRG Intern Jodi Engstrom, M.A. at (415) 609 - 2813 or e-mail Jodi.L.Engstrom@gmail.com

It has been an amazing and busy couple of months at the clinic! We had lots of applicants and conducted many interviews, which involved all of us as the current interns help us as well, to create next year's cohort. We are always sad but proud, to see our interns graduate and move on to the next phase of their professional life. This year we will transition Laura Condylis, Helga Flashing, Amy Freidman and Rick Pomfret into esteemed colleagues. We will be sharing more about their new practices in the coming months.

We welcome five new pre doctoral interns: Joshua Rothenberg, and Beth Mitchner who are from CISS, Denise Lew from the Wright, and Kirsti Skogestad Næs (Naes) and Thomas Kleppestø (Kleppestoe) from Norway will join us for the fall term.

Lindsay Durgan, and David K. Becker, M.D., M.P.H. will complete their MFT hours and Miya Drucker, ASW, M.Ed comes from Smith to complete her social work hours.

With all the current interns who are continuing on we will have our largest cohort ever, consisting of 16 clinicians! Continuing on with us: Joy Phillips will be collecting her last MFT hours, Gena Castro and Valentina Gandini continue on as pre docs and Camerin Ross and Jodi Engstrom will become post doc's, joining Valerie Crawford, Ilysa Goldblatt and Patrick Norton. As you can imagine, we are bursting at the seams! Due to the large group we are looking to add additional supervisors to our crew. We are especially in need of SF based supervisors. Please contact me (drjess@comcast.net) or Carol (bcarmenlo@sbcglobal.net) if you have one hour (at a time of your convenience) a week to contribute to training these wonderful students. We are also in the process of creating next years training schedule and would love to add new teachers. Let us know if you would like to teach. We would love to have you join us and bring each of your perspectives to the clinic!

This is Part Three of an article called "Pathological Identification." Part Two appeared in last month's newsletter

Joseph Weiss

Weiss noted that pathological identification, where patients repeat their parents' negative, problematic behaviors and feelings, occurs both in therapy and in people's lives outside of therapy (3, p. 15). These repetitions in therapy can be adaptive when patients pose passive-into-active tests in order to try to relinquish pathogenic beliefs and get better (3, p. 12, 17). Weiss explained , "In passive-into-active testing, the patient behaves to the therapist in the traumatic ways that a parent behaved toward him. The patient hopes to demonstrate that the therapist will not be upset by him as he was by his parents. He does not want the therapist to be constrained by pathogenic beliefs such as those from which he himself suffers" (3, p. 12).

Whereas passive-into-active testing in therapy can be adaptive, pathological identification in a patient's outside life is almost always maladaptive (1, pp. 123-140). Weiss gave an example of a man who experienced a lot of shame in identification with his parents who also experienced shame. Weiss explained that the motivation of the patient feeling shame, as the parents did, was to maintain "his ties to parents" (3, p. 42). If the patient stopped feeling shame, he may feel guilty that he had lost an important connection to his parents and that would make him sad. Weiss said that this feeling shame in identification with parents was "held in place by survivor guilt" (3, p. 43), the guilt over doing better than or leaving a loved one behind (18-20).

Weiss gave another example of a patient who came from a family tradition where everyone sadistically teased everyone else and could not express love simply and directly. The patient identified with her parents' behavior and had difficulty expressing love and affection to her boyfriend. She worked on this problem in therapy and was finally able to tell her boyfriend, "I love you", after which she immediately felt sadness. She became aware that she felt sorry for her parents for acting so "inappropriately" in their sadistic teasing of her and her siblings. Now that she was able to express affection directly in her relationship with her boyfriend, she felt more disconnected from her parents as if she were "cut off (from them), floating in outer space" (3, p. 43).

Weiss gave another example of a patient whose parents were inadequate in their ability to assert authority. As an adult, the patient, like the parents, was unable to make and carry out plans without being indecisive. Weiss suggested that by identifying with the parents, the patient was protecting his parents' authority by failing to allow himself to be more assertive and effective than they were.

In his many examples of patients repeating their parents' weaknesses, problematic behaviors, or shameful feelings, Weiss explained that these pathological identifications resulted from the patients attempting to protect their parents, to make them look better than they were, and feeling guilty for outdoing them or leaving them behind. He saw children as strongly motivated by loyalty, wishing to protect their parents as well to connect with and maintain attachment to them.

The Role of Loyalty
The concept of the "Identified Patient" (IP) in the family therapy literature reflects a child's strong motivation to loyally protect her parents in a dysfunctional family. According to Satir, an identified patient is a family member, usually a child, who both absorbs the pain of her parent(s) and serves as a red flag so that other family members can get help (21, p. 2). Family members may assign the identified patient her role and scapegoat her, but the IP also actively participates in perpetuating her role as a sick, different, and blamed weak link in the family (21, p. 3). A child, in the role of identified patient, becomes the object of her parents' anxiety and allows her parents' negative expectations to come true. This allows the IP not only to take on the identity but also the blame for whatever problem exists in the family (21, p. 39).

Bateson said that children, in the role of IP, work hard to make their parents seem right. They "sacrifice themselves" to maintain the "sacred illusion" that their dysfunctional parents are making sense (22, p. 237). Searles (23) and Laing (24) both wrote how the schizophrenic sacrifices his own individuality and sense of self in order to protect his pathological parents and family (25).

O'Connor argued that children are inherently empathic, caring and protective of their parents and families based on genetics and natural selection (26). Developmental psychologists show evidence that infants show empathic responses to family members' distress from the age of ten months and perform care-giving functions by eighteen to twenty-four months (27,28). Darwin argued that humans have an evolutionarily derived, genetic basis for altruism and pro-social behavior (29-30). Others have suggested that human altruism is an evolutionarily derived trait that enhanced the ability of the group that had that trait to survive (31-35). Bowlby wrote, "altruistic behavior springs from roots just as deep as egoistic...." (36).

It has been argued that "children worry about parents (and to a large degree, siblings) as much as parents worry about children, using the same instincts" (1, p. 59). Parental instincts that motivate mothers and fathers to sacrifice life, limb, and livelihood to protect and promote their children is actually present from birth and is demonstrated by children toward their parents and siblings (1, p.59).

The biological structural underpinnings of empathy, loyalty, bonding and attachment behaviors are becoming better understood. The role of mirror neurons reveals how empathy is not just a learned experience in humans but is hard wired in the brain (37). Neurotransmitters and hormones such as oxytocin, endogenous opioids, and norepinephrine mediate attachment and bonding behaviors between parents and children as well as between adults in romantic relationships (38-40). Oxytocin has been shown to mediate not just affiliative behaviors between parents and children, spouses, and members of the family or tribe, but it also mediates discriminating and aggressive behaviors towards others outside the clan or tribe (41,42).

Loyalty is biologically based and evolutionarily determined. I hope to show that it is central to the mechanism of pathological identification. As Friedman said, "To a degree not generally recognized, psychopathologies are pathologies of loyalty" (43, p. 530). (To be continued.)

References 1. Foreman, S.A., Breaking the Spell, Understanding why Kids Do the Very Thing That Drives You Crazy, SF Press, 2009.

2. Weiss, J. & Sampson, H., The Psychoanalytic Process, Guilford, New York, 1986.

3. Weiss, J. How Psychotherapy Works, Guilford, New York, 1993.

4. Freud, Sigmund, "Family Romances" (1909) in Collected Papers Volume V, Ed. By James Strachey, Basic Books, New York, 1959, pp. 74-78.

5. Freud, S., "Humour" (1928) in Collected Papers Volume V, , Ed. By James Strachey, Basic Books, New York, 1959, pp. 215-221.

6. Freud, S., "Distinction Between the Sexes" (1925) in Collected Papers Volume V, , Ed. By James Strachey, Basic Books, New York, 1959, pp. 186-197.

7. Freud, S., "The Ego and the Id" (1927), Standard Edition, 19.

8. Freud, S., "Dostoevsky and Parricide" (1928) in Collected Papers Volume V, , Ed. By James Strachey, Basic Books, New York, 1959, pp. 229-231.

9. Freud, S., "Mourning and Melancholia" (1917) in Collected Papers Volume IV, , Ed. By James Strachey, Basic Books, New York, 1959, pp. 152-170.

10. Niederland, W.G., "The Survivor syndrome: Further observations and dimensions," Journal of American Psychoanalytic Association, 29, 1981, pp. 413-426.

11. Freud, A, "Identification With the Aggressor," The Writings of Anna Freud Vol. 2, The Ego and the Mechanisms of Defense, International Universities Press, Inc., New York, 1936, pp. 109-121.

12. Klein, M., "Notes on Some Schizoid Mechanisms" (1946), The Writings of Melanie Klein Vol III, Envy and Gratitude and Other Works 1946-1963, Macmillan, Inc. New York, 1984, pp. 1-24.

13. Klein, M., "On Identification' (1955), ibid., pp. 141-175.

14. Fairbairn, W.R.D., "The Repression and the Return of Bad Objects" (1943), Psychoanalytic Studies of the Personality, Routledge, New York, 2002.

15. Summit, R., "The Child Abuse Accommodation Syndrome", Child Abuse & Neglect, 7, 1983, pp. 177-193.

16. Foreman, S.A., "Survivor Guilt in Sexually Abused Children," presented at the California State Psychological Association Annual Convention, San Francisco, CA February, 1986.

17. Foreman, S. A., "The significance of turning passive into active in Control Mastery Theory," The Journal of Psychotherapy Practice and Research, 5, 1996, 106-121.

18. Modell, A., "Self-preservation and the preservation of the self: Overview of the more recent knowledge of the Narcissistic Personality," The Psychotherapy Research Group Department of Psychiatry, Mount Zion Hospital and Medical Center, Bulletin #6, June, 1983, 1-11.

19. -----"On having the right to a life: An aspect of the superego's development.," International Journal of Psycho-Analysis, 46, 1965, 323-331.

20. ----- "The origin of certain forms of pre-Oedipal guilt and the implications for a psychoanalytic theory of affects, International Journal of Psycho-Analysis, 52, 1971,337-346.

21. Satir, V, Conjoint Family Therapy, Science and Behavior Books, Palo Alto, 1967.

22. Bateson, G., Steps to an Ecology of Mind: Collected Essays in Anthropology, Psychiatry, Evolution, and Epistemology, University of Chicago Press, Chicago, 1972.

23. Searles, H.F., Collected Papers on Schizophrenia and Related Subjects, International Universities Press, New York, 1965.

24. Laing, R.D., The Divided Self, An Existential Study in Sanity and Madness, Penguin, Harmondsworth, 1972.

25. Feiner, A. & Levenson, E.A., "The compassionate sacrifice, An explanation of a metaphor, Psychoanalytic Review, 55, 1968-69, 552-573.

26. O'Connor, L.E., "Pathogenic beliefs and guilt in human evolution," in Genes on the Couch: Explorations in Evolutionary Psychology, Ed. By P. Gilbert & K. G. Bailey, Routledge, New York, 2002.

27. Zahn-Waxler, C. & Radke-Yarrow, M., "The development of altruism: Alternative research strategies," in The Development of Prosocial Behavior, ed. By N. Einsenberg, Academic Press, New York, 1982.

28. Gopnik, A., Meltzoff, A., & Kuhl, P. The Scientist In the Crib, What Early Learning Tells Us about the Mind, Perennial, New York, 2001.

29. Darwin, C. On the Origin of Species by Means of Natural Selection or the Preservation of Favoured Races in the Struggle for Life, London, John Murray, 1967 (1859).

30. ----------, The Descent of Man and Selection in Relation to Sex, Princeton University Press, Princeton, 1981 (1871).

31. Hoffman, M.L., "Is altruism part of human nature?" Journal of Personality and Social Psychology, 40, 1981, 121-137.

32. Wynne-Edwards, V.C., Animal Dispersion in Relation to Social Behavior, Oliver and Boyd, Edinburgh, 1962.

33. Hamilton, W.D., "The genetic evolution of social behavior," Journal of Theoretical Biology, 7, 1964, 1-52.

34. Trivers, R.L., The evolution of reciprocal altruism,", Quarterly Review of Biology, 46, 1971, 135-137.

35. ----------, Social Evolution, Addison-Wesley, Boston, 1985.

36. Bowlby, J., Attachment, Basic Books, New York, 1982, 133.

37. Iacoboni, M., Mirroring People, The Science of Empathy and How We Connect With Others, Picador, New York, 2008.

38. Nelson, F. & Panksepp, J., Brain substrates of infant-mother attachment: Contributions of opioids, oxytocin, and norepinephrine, Neuroscience and Biobehavioral Reviews, 22:3, 1998, 437-452.

39. Newton, N., The role of oxytocin in three interpersonal acts: coitus, birth, and breastfeeding, In Clinical Psychoneurendocrinology in Reproduction, Ed. By L. Carenza, P. Pancheri, and L. Zichella, Academic Press, New York, 1978, 411-418.

40. Swanson, H., Peptides, in Brain Mechanisms and Psychotropic Drugs, Ed. By A. Baskys & G. Remington, CRC Press, Boca Raton, 131-152, 1996.

41. De Dreu, C.K.W., et. al., "The neuropeptide oxytocin regulates parochial altruism in intergroup conflict among humans", Science, 11:328, 2010,1408-1411.

42. -------, et. al., "Oxytocin promotes human ethnocentrism", Proceedings of the National Academy of Sciences, 108:4, 2011, 1262-1266.

43. Friedman, M., "Toward a reconceptualization of guilt, Contemporary Psychoanalysis, 21, 1985, 501-547.