January 20, 2014

Dear Colleagues,

Happy Martin Luther King's Birthday. Marshall Bush and I led a class on January 18 on "New Directions in CMT Research & Theory." For the last 2 months, the class has been brainstorming about research questions, some of which involved pathogenic beliefs: How do therapists undermine pathogenic beliefs? How do pathogenic beliefs vary in particular diagnostic categories such as in bipolar disorder, narcissistic disorders, anxiety disorders, or post-traumatic stress disorder? Other questions to be studied include: How do CMT assumptions vary in different cultural contexts? Can we compare the CMT concept of testing with the analytic concept of resistance in a research design? Other topics of interests: the role of safety, the role of the therapist's use of Authority, how the patient protects the therapist, how to help patient's recognize and relinquish pathological identifications in therapy.

We have gone back and forth, initially focusing on new theoretical concepts and then looking at research questions and design. We think we would like to revisit theoretical issues in the next few classes, particularly about comparative theories. We might invite people with a particular interest, for example, in Narrative Therapy, Cognitive Behavioral Therapy, or Emotion Focused Therapy to present, hand out readings, and spend a session or two looking what we can learn from each other. We will try to plan topics in advance and announce them in this column. The New Directions class will not have a meeting in February but will reconvene again on the third Saturday in March (March 15) from 9-12.

Speaking of March, the Workshops of March are upon us. The 27th Annual International Conference on CMT is convening from March 3 to March 7, preceded by an all day Introduction to CMT on Saturday, March 1, 2014. During the week-long conference, new participants will attend a two hour morning seminar studying an audio-taped therapy of a case conducted by a skilled senior member of SFPRG. For those of you who have never had an opportunity to experience a careful line-by-line analysis of a case, there is no more impressive way to see how Joe Weiss' theory captures the powerful interplay between patient and therapist.

As the patient tells her story, you can see how she presents pathogenic beliefs or tests the therapist in other subtle ways. You can see how the therapist responds. You be the judge whether the therapist's intervention was pro-plan or anti-plan. Then you get to see how the patient responds. Did the patient relax or get more anxious? Did the patient get more in touch with affect or did she retreat? Did the patient bring unconscious material to consciousness? Did she make progress in her outside life?

By starting with historical material and observing how the patient responds to the therapist's interventions, participants will be able to develop a plan formulation for the case. This careful study of the process of psychotherapy is something you can't get from process notes because process notes only reflect what the therapist is aware of. This intensive case study format allows the student to see what the therapist is not aware of. It is one of the most powerful learning experiences about how psychotherapy works and it will enhance your ability to pay attention to your own patients in therapy. Participants will also have an opportunity to meet and interview the therapist on the case on Wednesday morning.

Afternoon seminars include core seminars about plan formulation, testing, pathogenic beliefs, and dreams. Other afternoon seminars focus on important topics of technique, special patient populations, and new applications of the theory. Monday night is research night. We will have pizza and beer while participants present research that is planned, completed, or in progress. Wednesday night is movie night. Thursday afternoon offers participants the opportunity to get one-on-one supervision with experienced clinicians. Thursday night is a party for guests and faculty.

People come from all over the world and the United States. People come year after year, and feel they get more every time. On more than one occasion, I have heard different students say they learned more in one week at the March Workshops than they learned in four years of graduate school.

This week in March is a particular pleasure for me -- an opportunity to see old friends - an opportunity to teach more students and get different questions and different challenges. I hope to see you all at the Presidio, either as teachers or as students.

I am announcing a last call for a February 1 Introductory Conference in Irvine. If you know anyone in Southern California who might be interested in CMT, please let them know to sign up for the intro course at Concordia University on the SFPRG.org website.

Have a wonderful month. See you in February.
Steve Foreman

Hello Community,

The 27th Annual International Conference on Control Mastery Theory is almost here and I am very excited about this year's course offerings. As has been our tradition, we are offering the morning case conferences for new and returning students. For the last few years I have participated in the new students class. This year I will be participating in the returning students class. I'm eager to hear how therapists from all over the country, and a few from other countries, are using CMT and/or integrating CMT into their thinking about and working with clients.

This year we are offering an opportunity to go deeper with two of our core courses. On Monday afternoon John Curtis will be teaching a beginning and advanced class on identifying and understanding the role of pathogenic beliefs and their impact on a person's life and in treatment. Figuring out what a client's pathogenic beliefs are is one of the most challenging yet fundamental aspects of CMT. On Tuesday afternoon George Silberschatz will be teaching a beginning and an advanced Plan Formulation class. Like pathogenic beliefs, plan formulation is one of the central organizing principles of the theory. Joe Weiss' idea that people have an unconscious plan to move towards health was one of the concepts that drew me to CMT. George's class will help give you to tools to develop a provisional plan that can then be revised as you get to know the person better.

There are a total of 19 courses being taught at this year's conference. I don't know how I will choose between such great presenters and topics. For a description of each course visit our website and open the Full Schedule.

The Education Committee has also been busy planning other events including a half-day conference on Control Mastery Theory Couple Therapy with Denny Zeitlin, Saturday May 24th, another daylong conference with Victoria Beckner and Steven Foreman on Safety and a daylong Couples conference with Dan Wile. Lastly, every year as a way to kick off the March conference we offer a daylong introductory class on CMT. I'd strongly recommend this course to new and returning conference participants as a refresher. This class is taught by several of our senior clinicians. This year the teachers will be Jan Schrieber and Steven Foreman.
Take Care,
Susan Landes

The clinic is thriving right now. We are beginning the second half of our training schedule where the trainees get to listen to real recorded sessions of therapy with Alan Rappoport; work with Jay Seiff-Heron on couples, spend time with Ginger Rhodes on working with trauma- and these sessions are just the beginning.

Thomas and Kriste the two Norwegian students who came in August have just left to go back to Norway. They were a wonderful addition to our community. They loved the training they received at the clinic, told us they learned a great deal and were so excited they wrote all their colleagues in Norway and we had several Norwegians who wanted to come in the spring. We chose two. Elida and Ingrid started in the first week of January and are trying to figure out all the ways we do things at the clinic. They seem to be settling in quite nicely. The relationship we are developing with the University in Bergen is quite good and we have a growing number of CMT therapist practicing in Norway. We think it is very exciting to have CMT a world wide community.

The intern group has reached its largest numbers ever which makes being in the room challenging. In order to give everyone a chance to be seen and heard, Jessica and I have created mentor groups. These are smaller groups that meet periodically and talk about issues that are interesting to the group. This year we have the trainees divided into the new trainees and all the rest. It also means that Jessica and I have chief responsibility for the people in our groups. Everyone seems to like the whole system. It means each intern has a place to go with a problem as well as a group with which they go through their training.

Keep thinking about us for referrals. Many of the interns have space for new clients.

If you have not filled out a profile on our website, please consider doing so. It is a way for our members to find others to refer to as well as a resource for the general public.

You can print out the membership roster from our website.
Step 1: Login under Membership - remember your Login name is your email. Contact Rob in the office (sfprg@sfprg.org) if you do not remember your password.
Step 2: Click Member Directory from the menu
Step 3: Click Printable Directory in the upper right
Step 4: Print

Part 8 appeared in the November Newsletter

Summary

Pathological Identifications are common sources of patient suffering that interfere with healthy relationships in every setting. Sometimes patients who are most recalcitrant to change are locked in an intense repetition of other people's (parents') problems and are not aware of it. These pathological behaviors and attitudes are most clearly seen in couples' or family therapies, but often in individual work as well. Pathological Identifications are maladaptive to the couple, to the child, and to the patient. Their origins can often be clearly seen in earlier relationships between the patient and parent(s), or between the patient's parents, but only if the therapist bothers to ask.

There is an incorrect maxim often quoted by therapists that patients must be getting something out of their behavior or else they would not be doing it. This idea that there is always primary or secondary gain was challenged by Weiss (3) who noted that patients often hold themselves back or punish themselves out of guilt towards loved ones who have suffered. The idea that patients slavishly repeat miserable patterns of behavior out of guilt and loyalty is a different explanation of behavior and is a significant contribution of Weiss' model of psychology.

Weiss said that patients repeat these behaviors to "maintain a tie" with pathological parents. This paper goes further to suggest that the patient's unconscious motive is to protect the parent(s) by repeating behaviors and repressing memories and feelings that would be potentially threatening to them.

If, in fact, the patient's pathological behaviors represent pathological repetitions, the treatment implications are that the therapist and the patient should eventually become aware of that. Helping the patient see that her behavior is a repetition is often enough to help the patient step out of it. Sometimes, the therapist has to help the patient pay attention to her scary and inconvenient feelings toward the loved parent, remember what actually happened and how she feels, while facing fears about how her feelings might hurt her vulnerable parent(s). As the patient explores and tolerates her unacceptable feelings to her parent, she often becomes less compelled to repeat pathological identifications.

Talking about change and relinquishing pathological identifications indirectly gives the patient permission to step out of these behavior patterns. Patients often feel obligated to repeat pathological behaviors. They expect punishment and judgment and they often see themselves hopelessly trapped, doomed, and fated to repeat them. When the therapist talks about the patient's misguided loyalties and protecting parents by repeating their mistakes, it gives patients a sense of power and agency they did not believe they had. Sometimes change is slow and the patient's negative behavior may continue. Patients may be afraid to face memories and feelings they have long repressed. They may feel guilty getting better too quickly even though they are motivated to do so. They may feel guilty solving their problematic behavior and looking good while their parents never changed. The therapy may need to progress in a gradual, step-by-step fashion.

Therapists may need to be patient in the face of the patient's intransigence. Patients may turn passive-into-active and do to the therapist what their parents did to them (17). Patients may fail to change in the face of their therapists' best efforts in the same way their parents failed to change in the face of their own best efforts as children to help them. In many dysfunctional families, children poured alcohol down the drain while their parents went out to buy more. Kids begged their mothers to leave abusive husbands and the mother could not leave. These children may grow up to be our patients, drinking hopelessly in front of us or suffering in abusive relationships they will not leave. It is useful to remember Marsha Linehan's concept of the dialectic, that therapists must want the patient to get better without needing the patient to get better. Otherwise we will be tortured and defeated by the same guilt and frustration that tortured our patients when they were children.

Despite the patient's guilt about progressing, Weiss argued that patients are highly motivated to get better (3). If the therapist stays attuned to the patient and supportive of the patient's drive toward health, even very disturbed narcissistic and borderline patients can show dramatic improvement over time. Understanding the role of pathological identifications can help therapists read their patients better and allow a compassionate treatment approach that will facilitate disturbed patients to step out of pathological repetitions.

References

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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.

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48. Miller, A., Banished Knowledge, Facing Childhood Injuries, Doubleday, New York, 1985.

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SFPRG has an office for rent. Now is your chance if you ever wanted to have an office in a beautiful national park! We signed a 5 year lease renewal with The Presidio. Contact Rob in the office if you are interested. 415-561-6771 or sfprg@sfprg.org