March 26, 2014

Dear Colleagues,

Happy beginning of Spring. We have just finished the 27th Annual International Conference on Control Mastery Theory, a thoroughly enjoyable experience. We had slightly fewer attendees than usual but the group of new participants and returnees were enthusiastic and wonderful contributors. The new attendees included one from Russia, one from the Ukraine, one from England, and two from Norway. We also had new people from Bozeman, Montana, Austen, Texas, Portland, Oregon, and even Sacramento. The new participants were so excited by the conference that they created an email network with each other and several have promised to come back next year. We welcome you all.

Many of the interns at SFPRG participated in the workshops this year. They said they learned a lot and I think they made the conference richer for everyone. We tried some new ideas for the conference this year. A few of the Core Seminars were offered both in a beginner and advanced format. We offered some new topics including a workshop on poetry and psychotherapy presented by John Gualtieri.

The Education Committee has been debating the idea of changing the schedule next year from a weeklong conference to a Wednesday through Sunday event, hoping to attract people who may not be able to take a full week off from work. This is a conference format that is fairly standard and we are considering trying this next year to see if we might appeal to more attendees. The attendees' feedback about the quality of the conference was very positive this year as it is most years. We are hoping to increase the number of attendees to 30 or 40. The Education Committee will be working on this idea.

Next month, the Course on New Directions in CMT Research and Theory will meet on the third Saturday, April 19, 2014 from 9 to 12 noon at the Conference Room at 9 Funston. The topic will be Emotion Focused Therapy and CMT. The discussion will be led by Valerie Crawford and Jay Seiff-Haron, both of whom have extensive interest and experience with EFT. Jay just taught a workshop on EFT at the International Conference in March and Valerie has offered workshops on EFT inspired therapy to couples through the SFPRG Clinic over the past month. We will have readings available beforehand by email. Please let Rob know at Rob@sfprg.org if you plan to attend on April 19 so we can arrange to forward the readings.

Mark your calendars for two important spring conferences. Denny Zeitlin is presenting Control Mastery Theory Couple Therapy on May 24. Denny gives a beautiful overview of Control Mastery Theory and masterful presentation of Couples Therapy. He is a gifted clinician and a terrific teacher. I have heard his presentation on Couples Therapy and it should not be missed.

On June 7, Victoria Beckner and I will present a day-long conference on The Treatment of Anxiety, A Collaboration Between Control Mastery Theory and Cognitive Behavioral Therapy (Subtitled: How much to push the patient). This is a very important topic and a contribution to both CMT and CBT. It has been argued that the CMT approach of waiting for the patient to feel safe before venturing forward therapeutically may not adequately meet the needs of severely anxious patients. According to CBT, severely anxious patients often seek "safety" by Avoidance including the avoidance of getting better. This population of anxious patients may pose a particular challenge to CMT practitioners if the therapist takes a passive stance by waiting for patients to feel safe before they change. This is an issue that Bill Dickman and I have been discussing and exploring for some time. We have both presented workshops about this topic in recent Annual Conferences. CMT and CBT both emphasize the importance of the patient feeling safe, but their technical uses of safety may look different. This workshop will look at the strengths and weaknesses of both CMT and CBT in dealing with anxiety disorders and try to forge an approach that marries the virtues of these different models. Victoria Beckner presented last year on the treatment of Post-Traumatic Stress Disorder at an SFPRG conference in collaboration with Ginger Rhodes and Susan Landes. She is a wonderful, clear lecturer. She is an expert in CBT but has a passion for psychodynamic psychotherapy and is becoming a great friend and ally of Control Mastery Theory. I hope you can all attend.

We are kicking off our spring fundraising campaign to raise money for the clinic, the education program, and research. Please be generous so we can expand and promote our programs.

See you next month.

Steve Foreman

Hello Community,

This year I was able to attend most of the week of the International Conference on Control Mastery Theory. I thoroughly enjoyed all the classes. Attending the returning students case conference was a highlight for me. I was so impressed with the level of clinical discussion. I was particularly impressed with our interns' knowledge and participation. I would like to thank all the people who helped put the conference together, especially Rob Petitpas who is the behind the scenes backbone of our organization. In addition, some of you may have met Barnabus at the Thursday night party. He is the newest addition to our administrative staff.

We have several course offerings this spring including Denny Zeitlin's class on Couple Therapy on May 24th and June 7th Steve Foreman and Victoria Beckner's upcoming class on The Treatment of Anxiety, A Collaboration Between Control Mastery Theory and Cognitive Behavioral Therapy. There are so many ways to increase one's clinical knowledge through membership in our group.

Stay tuned for the upcoming events in the fall. Happy Spring!

Dr.Susan Landes

Over the next few newsletters, we will present a talk given by Dr. Joseph Weiss on his work. We think this will be of interest to people curious about the development of Control Mastery Theory. This is the second installment continued from the previous newsletter. - Editor

The Study of Process Notes

I was introduced to the careful, sequential study of process notes as a research method in a research group organized by Emanuel Windholz in the late 1950's. Finding this method highly instructive, I continued to study process notes on my own until 1962 when I began frequently to discuss the ideas I was developing with Harold Sampson whose perspective I found invaluable. We formed a collaboration that has lasted until the present.

In my process note studies I made use of the concepts I had relied on to explain the phenomenon of crying at the happy ending. Indeed, the first analysis I studied from process notes provided evidence that the patient is highly motivated to make progress and may make it with only minimal help from the analyst (Sampson & Weiss, 1972)

The patient, Randall, was a graduate student in physics who suffered from an obsessive compulsive character disorder. At the beginning of his analysis, Randall was paralyzed. He was unable to work on his Ph.D. and he had not dated since a bad experience with a woman ten years before. Indeed, he spent most of his time in his apartment sometimes masturbating and watching TV. However, after a hundred sessions of analysis in which I made only a few interpretations, Randall had obtained his Ph.D., found a good job, and acquired a girlfriend who later became his wife.

The study of the first hundred sessions of Randall's analysis can be told in terms of his becoming conscious of and then of gaining control of his obsessing. At the beginning of his analysis, Randall did not acknowledge his obsessing. He was not conscious of it. However, he seemed to be making an effort to avoid confusion by speaking very slowly and deliberately. Around session twenty Randall began occasionally to acknowledge that he felt confused. Then, over a period of time he began to realize that he was confused by his obsessing. He would undo one thought with another and so had trouble maintaining a train of thought. He had difficulty making plans and decisions. Around session fifty he began to obsess openly. For example, on one occasion he reported that he had avoided tackling a project at work because he feared he did not know how to do it. Then a few minutes later he stated that he had avoided the project, not because he felt unable to do it, but because he was stubborn. Later still, he explained that he didn't really understand the project. Then, that he had been stubborn. He went back and forth in this way for at least fifteen minutes.

After Randall's obsessing became completely conscious, he was helped by my pointing out to him how after deciding on a plan or idea he quickly undid it by another, different plan or idea. He immediately understood this interpretation and over the next twenty sessions used it to gain some control over his undoing defense and hence over his behavior. He became able to hold a thought or plan without shifting away from it and he also became able to shift away from a thought or plan at will. As a consequence of this achievement, he became more able to make decisions and carry them out.

Hal Sampson and I studied the process notes of the first hundred sessions of Randall's analysis in a research study using quantitative methods. Our research was supported by NIMH and reported in a journal article (1972). We demonstrated that Randall did change as described above. We also showed that as Randall acquired control over his undoing defense he became more able to express a variety of affects. He could safely express an affect knowing that he could shift away from it at will.

Our study of Randall's analysis gave Hal and me the following intuition: Randall had unconsciously wanted to make his obsessing as obvious as possible and had succeeded in doing this so that he could obtain help from the therapist in his effort to understand and master his obsessing. At the beginning, Randall had been afraid to experience this symptom. He was afraid that he would become unpleasantly confused. He was afraid, too, that the therapist would deride him for having a symptom that Randall considered absurd. As he became more secure with the therapist, he did expose the symptom in such a way as to enable the therapist to help him with it.

Our impression derived from the study of Randall's analysis, that the patient unconsciously sets the agenda, was supported by my next process notes study (Weiss, 1993). From this study I concluded that the patient unconsciously devised and carried out a test of the analyst in order to assure herself of his reliability so that she could safely reveal to him and subsequently master her unconscious feelings of sadness and humiliation.

The patient, Roberta, a thirty three year old lawyer, came to me for analysis because she was depressed. She was an only child of parents who were themselves depressed and whom Roberta experienced as extremely rejecting. According to Roberta, her parents scarcely talked to her.

When Roberta began therapy she was working at a low paying job in a law firm and had no close friends. Roberta's problems centered around her profound fear of rejection. Because of this fear she was afraid to make friends or to take any initiative. During the first three years of her analysis Roberta made modest progress in overcoming this fear. She made a few friends and took more responsibility at work. Then, during the 4th year of her analysis, Roberta surprised me by announcing that she had obtained what she wanted from the treatment and that she planned to stop in three months.

Since Roberta was still quite handicapped by her problems, I implicitly opposed her stopping. I offered her a number of interpretations that linked her planning to stop to her fear of rejection. I told her that she was afraid she was a burden on me. By stopping, she would be rejecting me before I rejected her. Also she assumed that she did not deserve help. Roberta showed mild interest in these interpretations, but was not swayed by them. However, she acknowledged that she did not know why she was stopping. I urged her to continue until her motives became clear. Then, just before the deadline she grudgingly agreed to continue.

Shortly after she agreed to continue Roberta brought forth a number of painful memories of maternal rejection. She reported that on one occasion when she was six years old a riot broke out in her neighborhood and her mother, unlike the mothers of her schoolmates, gave Roberta some money and sent her out to buy groceries. Roberta assumed that her mother wanted her to be killed. As Roberta reported this memory she wept uncontrollably.

After that, Roberta decided to stay in therapy. A few sessions later she became aware that she had wanted me to urge her to continue and that she would have felt quite devastated if I had not. About a year after that Roberta described how she had consciously tested her one girlfriend in grammar school. Roberta had become worried that her friend no longer liked her. Roberta tested this friend by telling her that she didn't want to go to the movie matinee with her as they had planned. Roberta was greatly relieved when her friend insisted that she keep the date.

I concluded from the above that Roberta had threatened to stop treatment partly in order to test me and that her testing was unconscious.

Roberta had tested me in order to assure herself of my commitment to her and her test was well designed to enable her to assess this. By telling me that she had obtained all that she wanted from therapy she made it easy for me to reject her with a clear conscience. She assumed that if I was burdened by seeing her I would take the opportunity she gave me to stop seeing her.

Roberta was rewarded for the effort she put into testing me. When I passed her test by urging her to continue she felt great relief. She could then safely remember how rejected she had felt by her mother. Apparently, Roberta could not face the overwhelming sadness connected with her mother's rejection of her until she had replaced her mother with another, more reliable person.

Roberta's experience may be compared to Louise's as follows: Roberta's sense of being accepted by me provided her with a kind of happy ending. However, unlike Louise, Roberta's happy ending did not overcome her sense of sadness. Her sadness was so profound that her sense of acceptance by me merely enabled her to begin to experience it. Thus, unlike the moviegoer, and unlike Louise, Roberta was not tempted to experience her weeping as weeping for joy. She knew that she was weeping for sadness.

Roberta's behavior made clear the curative power of the patient's forming a good relationship with the therapist. Her sense of being accepted by me was more helpful to her than the numerous interpretations that I had offered her about her fear of rejection. It was not until she experienced my commitment to her that she felt safe enough to bring forth the traumatic memories of maternal rejection.

Roberta's sadness provided evidence against the traditional idea that the therapist should maintain neutrality. If I had been neutral about Roberta's plan to stop treatment she would have been deeply hurt. Nor did Roberta's behavior support the traditional idea that the frustration by the analyst of an unconscious wish, in this case the wish to be accepted by the analyst, intensifies the thrust to consciousness of that wish and so facilitates the patient's becoming aware of it. The opposite proved to be the case. It was when I satisfied Roberta's wish to be accepted by me that Roberta could face her deep seated feelings of rejection.


Pathogenic Beliefs

The hypotheses that I developed from my process note studies while throwing light on the patient's efforts to solve her problems left unanswered certain important questions about the nature of her problems. How does the patient develop problems? Why in therapy does she become afraid to make certain mental contents conscious? And what makes her feel unsafe with the therapist?

Once I asked myself these questions I realized that I had already begun to answer them though I had not made my answers explicit (Weiss & Sampson, 1986). I reasoned that if the patient feels unsafe with the therapist and therefore afraid to experience certain memories, ideas or affects in the therapy for fear of the therapist's reactions, this is because the patient unconsciously believes that the therapist's reactions may endanger her. She must have acquired this belief in childhood experiences with persons whose support and protection and help were important to her. In other words, patients' problems stem from certain unconscious beliefs about themselves in relation to others that make them vulnerable to others. These beliefs, which we call pathogenic, give rise to guilt, shame and low self esteem and they prevent the pursuit of important desirable goals. For example, Roberta suffered from the pathogenic belief that she was unattractive, boring and a burden on others, and so would and should be rejected by anyone from whom she sought support. Roberta reported that she had experienced her parents as extremely rejecting. Therefore, I assumed that she had acquired the belief in her rejectability from traumatic experiences of rejection by her parents.

Roberta's belief in her rejectability made her fear rejection by the therapist. She had been afraid to tell the therapist about her mother's severe rejection of her not only because she was afraid of being overwhelmed by sadness, but because she feared that the therapist would agree with her mother that she should be rejected. She feared that the therapist was finding her burdensome and boring and unattractive just as she assumed her mother had. She unconsciously knew that if the therapist rejected her she would be extremely upset because she would experience his rejection as confirming her deeply upsetting pathogenic belief.

The idea that Roberta suffered from a pathogenic belief permitted a reformulation of the test that Roberta had given the analyst. Roberta was not only testing the analyst, she was testing her pathogenic belief in her rejectability as part of her effort to disprove it. When the analyst did not react as the belief predicts, Roberta took a step toward disproving it.

As evident from the above, the concept of pathogenic belief gave us a new way of following the therapeutic process. This process became much more vivid and compelling. As we read the process notes and transcripts of therapies we could observe the patient working throughout her therapy, often by testing the therapist as part of her effort to disprove a few major pathogenic beliefs. We observed that as long as a patient experienced the therapist as helping her in her efforts to disprove her pathogenic beliefs, she would become more insightful and move toward her goals. However, if she experienced the therapist as opposing her efforts, she would stop progressing and retreat. Then, if sufficiently flexible, she might approach the therapist in a new way, continuing to pursue her basic goals but by a new route. When we observed a therapy in these terms it became easy to follow, clear and predictable.

At this point I end my history and present my theory in its current form:

The patients' problems stem from pathogenic beliefs. These are grim and frightening. They may adversely affect the patients' self-esteem and prevent him from pursuing adaptive, desirable goals.

The patient wants very much to solve his problems, and so is highly motivated to disprove his pathogenic beliefs. He works to disprove them by testing them with the therapist, hoping that the therapist will pass his tests.

The therapist's task follows from above. It is to help the patient in his efforts to disprove his pathogenic beliefs and to pursue the goals forbidden by these beliefs.

to be continued next month

Our next conferences are:

Control Mastery Theory Couple Therapy
with
Dennis J. Zeitlin, M.D.
Saturday, May 24, 2014
9 am - 1:15 pm. 4 CEs at the JCCSF


register now online

The Treatment of Anxiety, A Collaboration between Control Mastery Theory and Cognitive Behavioral Therapy: How Much to Push Your Patient

Victoria Beckner, Ph.D. and Steven Foreman, M.D.

Saturday, June 7, 2014 details on website soon!

If you live outside of the Bay Area, SFPRG needs your help!

We want to present conferences on CMT outside of the Bay Area. Do you have connections with an organization that could either sponsor us or allow us use of a mailing list? We are APA approved so we can give CE hours anywhere in the U.S. If you know of an organization that would sponsor us, we can provide a lecturer; if you can get us a mailing list and leads on venues, we can do the rest.

Please contact Rob in our office (rob@sfprg.org) if you can help!

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