An Outline of the Basic Therapeutic Model

Presented in Stockholm on Friday, 15th, and Saturday, 16th April, 1994

by Dr Robert Gordon


"It is an uneasy lot, at best, to be what we call highly taught and yet not to enjoy; to be present at this great spectacle of life, and never to be liberated from a small, hungry, shivering self." George Eliot, Middlemarch, 1871 - 1872.


First of all, as an introduction to our frame of reference, Craigie Macfie and I will outline the principal elements of our theoretical model, which is self-psychological. I shall lay down some of the important elements of the model, and Craigie will elaborate on them.

We, of course, shall not be able to give you more than a basic outline of the model, but I hope it will be enough to clarify our position and the direction, that is our frame in supervision, which follows from it.

elements of the self psychological model

The self-psychological model has a number of basic elements:

  1. The centrality of the concept of the self

  2. The concept of the primacy of subjective experience

  3. The centrality of the concept of empathy

  4. The selfobject concept and selfobject transferences

  5. The recognition of disjunctions, or therapeutic errors, and the bilateral work between patient and therapist, of reparation, to reconstitute the self

  6. The transference-like states of idealising selfobject experience, mirroring selfobject experience and twinship selfobject experience - and the relevance of function pertaining to each

real relationship

First, let me say a little about the relationship between therapist and patient, and what I call the form and shape of psychotherapy. Craigie Macfie will expand on it further.

In my opinion, there is always a real relationship in psychotherapy. There is humanity, sensitivity, patience and the continuing concern of the therapist, and there is the growing commitment, curiosity and trust of the patient.

the frame

There is also the frame in psychotherapy; consisting of the contract, the consistency, in terms of time and space, the continuity, in terms of the repeating of number of sessions per week and year, and the concept of care or, what Winnicott termed, the 'holding environment'.

These elements are the bedrock of psychotherapy and they sustain the process - often when all else is failing.

Paul Ornstein suggests, and I would support his view, that the important element in the process of psychotherapy is the development of a curiosity about the self by the patient. To do so requires a process which, to my mind, must centre the concept of subjective experience and subjective, reflective style, as the focus of attention through an empathic mode of listening. This subjective experience has been shaped and coloured by early childhood experience with a relevant other, and the vicissitudes of early developmental life, and perhaps even later developmental processes.

immerse and validate

The importance of the therapist's ability to validate subjective experience and to immerse himself within it, to maintain this immersion as much as possible, and to recognise the disjunctions when this immersion has failed, are also key elements of the model.

the concept of empathy

Empathy, as defined by Basch, is an affective communication going beyond the self referential.

Heinz Kohut has defined the concept of empathy as 'vicarious introspection' and defines it as 'a data gathering tool', thus lifting it out of the realm of sympathy and morbid curiosity.

One allows the patient to play on one's internal 'musical instrument'. The therapist picks up the reverberations and attempts to recognise the 'melody', particularly the 'emotional melody', and makes a suggestion as to the 'words and music' heard. The therapist's sensitive resonance to the subjective experience of the patient, and his attempts to recognise and understand 'the music' made, bring about 'a sense of feeling understood'. To Kohut, feeling understood is the symbol for 'being held' in a psycho-physiological sense.

The work of empathic immersion in the patient's state brings about an expansion of self experience; 'instruments' of the personal self begin to play and resonate to, or harmonise with, the basic melody. With growing strength and harmony 'the symphony' of the functioning and organised self begins to emerge and a personal 'piece of music' is created.

But first the primary musical instrument, that of the therapist, must be available and appropriately tuned to the hushed notes and tentative tunes of the patient.

To my mind, empathy is central to all therapies that work, but the centrality of empathy as a data gathering tool, and the significance of this, can be attributed to the genius of Kohut.

disjunctions

His genius was also the one to recognise the concept of a 'therapeutic error', or disjunction, when the therapist's empathy fails, when the musical instrument of the therapist will not resonate to the subjective experience being played by the patient, the music ceases and some other activity commences. The therapist must be sensitive to this failure or disjunction, recognise its symptoms of disharmony in the patient, and take the necessary steps to replace 'the patient's fingers on the keyboard', and 'to tune the therapist's instrument'.

The signals of a disjunction are:

  1. Shift of affect, usually of a negative kind

  2. Disorganisation of thought, through confusion, or a breakdown of speech - such as stammer or broken sentences

  3. Linearity of thought

  4. Development of a cognitive style of communication

  5. Perseveration or rumeration

  6. Fragmentation of the self

These fragmentations, according to Kohut, can take the shape of panic, rage reactions, empty depression, hypochondriasis, perversions and addictions, somatasation disorders, and suicide.

Behavioural patterns driven by intense affect states than dominate, and there is 'a cacophony of sound'. The behaviour does not appear to make sense, and can in fact be 'mad'.

repair

The importance of repairing this error cannot be overemphasised.

The therapist must recognise the disjunction or error and bring it to the notice of the patient. Asking the patient to return to the point where the disjunction appears to have occurred, for either the patient primarily or the therapist.

By the therapist recognising the part he has played in the disjunction, and the therapist and patient reappraising the 'moment of experience' where the disjunction is likely to have occurred (both from the point of view of the content of the material and the affective experience that was probably not recognised by the therapist), and then reorientating to the material, and its background music, in the light of the patient's elaboration of the experience of the disjunction, through this replay of the misunderstanding by the therapist's experience, brings about a reconnection of empathy to the patient's subjective experience.

It is through this process that Kohut's concept of 'transmuting internalisation', is brought about in microscopic shifts in the self's capacity to function. A new form of functioning is slowly internalised by the self to allow for more competence in dealing with the environment and personal experience.

The model of self psychology differs from other models because of this therapeutic process. The microscopic repair to self structure, cohesion and functioning through this process, places it apart from other theoretical models, and defines the shape and direction of self psychology.

the concept of the selfobject

Kohut, Wolf and Ornstein have conceptualised the concept of selfobject as 'objects' which are experienced as a part of, or support, the functioning of the self. Expected control of them is closer to the concept of the control which an adult expects to have over his own body and mind.

Such an object is related to only in terms of the specific phase-appropriate needs of the developing self, without recognition of the separateness of the object and its own control and initiative.

My definition would be: the experience generated by relevant others in a self 'in need'. This experience is that of providing a capacity to function in the 'area of need' of that self. These needs may be those necessary for:

  1. self cohesion

  2. self elaboration

  3. affective self-experience

  4. making sense of previously fragmented experience or behaviour or combinations of the above

In my opinion, to learn to function using affective resonance, self reflection and environmental responsiveness brings about an efficacy, confidence, and competency of the self, which builds self-esteem and permits further elaboration of the innate creative self.

competence

The concept of competence is central here. The self searches for competence and competence builds the self. Brandshaft proposes that borderline personality disorder is brought about by the experience of a fragile self in a failing selfobject environment, and suggests therefore that the borderline experience may, in fact, be iatrogenic when an unempathic therapist is in the presence of a precarious self. An interesting proposition.

This concept of selfobject is another of Kohut's contributions, and highlights the relevant capacity of the primary care giver, both in her ability to tune to, recognise and resonate with the child's early affective 'statements' and experience.

This early empathic resonance by the primary care giver allows for what I call 'embedding' of the emerging self in the matrix of the self and primary selfobject, experience. It is here that the self becomes 'rooted' or embedded in the experiencing state of the relevant other, and determines whether the individual can go forward to elaborate the core self or begin the long torturous and painful task of the 'false self' system of Winnicott's. Or what I have termed the reverse mirroring self.

The reverse mirroring self proceeds to elaborate in response to the failing primary selfobject function of the mother, her own vulnerable self, and the need for the child to be the selfobject of the mother, rather than the mother functioning as a selfobject for the child.

Most commonly, there is a slow, progressive, and selective deterioration of certain affective states and their relevance, a shrinking of self state and a lowering of self-esteem, with a progressive vulnerability to self fragmentation. In essence: there is a failure of the child to 'emotionally' thrive.

selfobject functions

What then, you say, are these functions that the primary selfobject provides for the child? I shall use the concepts of Daniel Stern to organise my ideas.

These concepts are:

  1. The emerging self which occurs between zero and two months of age

  2. The core self which progresses from two to six months of age

  3. The subjective self which emerges at seven to fifteen months of age

  4. The verbal self that becomes apparent from sixteen months or so onwards

  5. The narrative self which develops around the third or fourth year of life

During the phase of the emergent self, the primary function of the maternal selfobject is nurturing, soothing. All in the process of allowing this emerging self to embed in what Kohut has termed the 'self-selfobject matrix'.

During the core self period the primary maternal function is the progressive naming and validation of affective expression - it is so-called 'affective attunement'.

During the subjective self phase, when the earliest signs of the representational self (with its capacity to recall and then to compare a memory with present experience) arise, the primary maternal function is the naming, the validation and the assimilation of affect and affective experience.

In the later phase of this subjective self, the concepts of Furer's 'emotional refuelling' and the 'practicing subphase' component of self elaboration (described by Margaret Mahler) become evident - as well as the concept of intersubjectivity: the experiencing of 'two minds in harmony or disharmony'. These affects colour and, further, shade experience. They elaborate the 'social style' of the individual.

During this period, the maternal selfobject function is to name, to validate and to help organise the assimilation of social and personal experience.

The progressive role of cognition complicates the picture. What was once obvious self experience exhibited on the face and in body movements now becomes elaborately reorganised in response to the primary care giver, the family and the developing social environment.

The interplay of the instruments of the self slowly evolves into a personal symphony where each instrument becomes less and less evident yet continues to play its part in the final expression and experience of the personal self.

During the period of the narrative self somewhere around the third or fourth year of life, the concept of time begins to become more and more part of the self state, and the relevance of past, present, and future makes its presence felt.

Stories have become more and more relevant, and the recognition of a history of self and its future further expand the self state.

selfobject transferences

In therapy, the 'self in need' responds to the empathic immersion of the therapist by forming transference-like interactions, and by calling upon functions from the therapist, to respond to previously wilted affective self experience or what I would call 'overmodulated' affective self experience, or on the other hand, to 'undermodulated' affective intensity.

As well, the yearning for competence, self-esteem, and goal directed behaviour also calls upon functions of the therapist to redress past 'failed' self-primary selfobject experiences.

The therapeutic self-selfobject experience brings about these transference-like states of, the needs for idealising selfobject or mirroring selfobject or the twinship selfobject experience.

The important contribution of the therapeutic selfobject is to provide a capacity to function in such a way that the self reverberates to, not fragments with, the 'containing' environment.

These 'self-therapeutic selfobject' transference like states require a response from the therapist:

(a) In the mirroring self-selfobject experience, the need of the self is for a mirroring response which works towards the building of self esteem, self assertion, goal directed behaviour, and personal fulfilment.

(b) the idealising selfobject requirement, is that of internalising a soothing function which leads to a stability of the self and a move towards ethical standards, cultural activities, morality, and perhaps creativity.

(c) In the twinship of self and selfobject need, the therapist is required to provide a sense of belongingness in a familiar and cultural matrix, a sense of oneness with one's cultural, traditions, and societal values, 'a being part of the human race and of the human experience'.

Failure of the primary care giver to provide these responses brings about a lack of cohesion of self, a low self esteem, a diminished sense of vitality, and a functional disharmony deteriorating from a sense of order to that of a chaos. There is a lack of self validity, a disavowal of certain affective self experiences, a limitation of the participation in certain environmental experiences, a diminution in initiative, a lack of goal directed behaviour, which involves initiative, purpose, ambition, and assertion, the inability to be alone, the lack of a cultural self, and the creative self, the lack of ability to organise productive 'organisation' behaviour, the failure to be empathic, a failure to organise time, space, money, and purpose, a failure in appreciation of one's emotional states and their affects, a failure in oedipal maturation, a failure of adolescent separation behaviour, a failure to grow and mature with time, and more pathologically, if there is more pathological than all the above, the fragmented states either acute or chronic of the narcissistic state and borderline personality and behavioural structures.

emotional development

A few words on the emotional development of the self.

I have referred to Daniel Stern's work about the phases of self development, but I would like here to return to the work of Charles Darwin and Silvan Tomkins to suggest that there is clear evidence of genetically programmed neuro-physiological substrates of affective experience, and that these genetically endowed signals permit the individual to recognise and respond to external and internal experience.

Silvan Tomkins proposed that there were nine primary emotions: interest, pleasure, surprise, distress, anger, fear, disgust, contempt, guilt and shame. Subsequent researches have further elaborated this concept, such that the emergence of these affects along a temporal continuum can be appreciated.

Michael Lewis proposed that to the primary emotions of joy, fear, anger, sadness, disgust, and surprise one may, with the passage of time and the developing presence of a self-reflective self, progressively add those of embarrassment, empathy, envy, pride, shame and guilt.

These primary affects require maternal responsiveness to each one and require help in modulating their expression, so that they remain within the realm of personal experience and do not produce fragmentation.

Perhaps at this point, it is important to state what my use of the word affect implies: a pre-programmed, genetically endowed, neurophysiological and psychological state which is beyond control or recognition by the individual, and that only after recognition and appreciation of the affect, does the concept of 'feeling something' become evident.

I would, therefore, use the term feeling at the point where there is recognition of the affective state by the individual and an appreciation of what that feeling reflects.

the importance of empathic understanding and explaining

The Ornsteins, in a paper titled "Understanding and Explaining, the Therapeutic Dialogue", make a shift from the concept of interpretation to that of understanding the subjective experience of the patient through an empathic mode of listening, and subsequently explaining, that is elaborating, this empathic shared experience.

By elaboration, I mean when a therapist empathically resonates with the patient's material, and the experience is shared with the associated affect and feelings underpinning the shared experience, and is responded to, by the therapist's empathy, it generates a progressive deepening of shared experience as the therapy progresses, and the emotional resonance more and more deeply understood generates reverberations into the other realms of personal experience that the patient has probably not shared in the past or not recognised.

The fact that the state of experiencing is in the present, the therapist anchors the experience as alive and valid. This elaboration of self experience, this progressive branching of experience embedded in the affective colouration, forms what I called 'tree of the self'. It is firmly planted in the time and space provided by the therapeutic hour and the therapist's activities, and it is this elaboration of personal experience that gives shape, colour and form to a new world of reflective self experience.

Mirroring responsiveness and empathic resonance by the therapist is the 'facilitating environment' for growth, the 'oxygen and warmth' of the therapeutic atmosphere.

With the passage of therapeutic time, creativity blossoms; first, is the original imaginative experience, and then, progressively, there is a flowering of personal self components into original, totally unexpected forms of self-expression, which is the personal 'art' of the self.

supervisory process and self psychology

"Follow the 'Lieder' "

The issue of supervision is not an easy one. Many minds have tried to find the most conducive way of helping a trainee to learn, and I am immediately reminded of the excellent work of Imre Szecsody, his very clear demarcation of areas in which a therapist must contain his involvement in enquiry. His idea of the clear frame in supervision, of the maintenance of the boundaries around the primary task of supervision, and the use of the P (P-T) T paradigm, where the emphasis is on the supervisor continuously connects how the P (patient's) personality, conflicts and transference enactments are expressed in the interaction with the therapist (P-T), and how the therapist (T) experiences this, reacts to it, and interacts with the patient. His idea of the 'mutative learning situation', the capacity to step out of his system, and appreciate the unexpected is a very significant contribution to clarifying our thinking about supervision.

What we ask of our trainees in Sydney is to develop skills in:

  1. Maintaining the setting and contract of the therapeutic relationship.

  2. Acknowledging and respecting the patient's subjective experience.

  3. Clarity about the therapeutic task at any particular point in the therapy.

  4. Attempting to follow the patient's experience and blocks of the full expression of that experience. This involves:
    a) The capacity to attend to disruptions in the empathic connection between patient and therapist, and to manage this by accepting that both play a part in disjunction;
    b) The capacity to listen and tolerate uncertainty, and to appreciate the role of anxiety in blocking the patient's experience;
    c) The capacity to detect when the patient is becoming disorganised by anxiety;
    d) The ability to appreciate the relevance of the transferences, as defined.

  5. Putting into words the main experiences the patient has been relating.

  6. Responding to the various layers of feeling in the therapeutic conversation without the use of jargon.

  7. Developing an awareness of the therapist's changing own states during the therapy, and in particular, appreciating the universal tendency to intellectualise, and to understand its links to the level of anxiety in a therapist.

  8. Making links between otherwise disconnected areas of the patient's experience, and to utilise metaphor to expand the experience.

Because we are attempting to train the trainee to hear 'the song' of the patient, we do not feel that process notes can possibly provide this information. We have, therefore, for some years now, used audiotaped sessions as a method by which to conduct supervision. This allows both the supervisor and, particularly, the trainee to stand back from the patient-therapist interaction and to listen to the moment to moment interchanges between the emotional expression of the patient and the resonance of the therapist's instruments. The trainee therapist, being given the opportunity to stop the tape and to elaborate upon his experience of the patient, gains a deeper understanding of his resonances; his appreciation of those moment to moment interchanges with the patient is enriched and expanded.

The task of empathic immersion can be studied and understood more clearly with tape recordings and the signal of the therapeutic error or disjunction can only be heard by this audio-taped method. Of course, video tapes would add even further dimension.

This replay of the therapist-patient interchange gives the trainee a chance to review his empathic style and therapeutic techniques, and it opens up the field of discussion and elaboration much more than other methods of supervision I have been involved in.

The fact that the trainee can hear himself speak, can respond to, and we hope resonate with, the patient's material, enriches his understanding of the therapeutic interchange. Empathic responsiveness by the supervisor usually permits the therapist to explore his therapeutic responsiveness in the presence of the supervisor.

As I said previously, the use of audio tapes is not as effective as video taped interviews, but it does allow for the consideration of much more empirical data than just subjective reporting of the interviews. Audio taping allows supervisors and trainees to study the same material together and to formulate relatively consistent responses.

It is our opinion that, throughout supervision, the supervisor should follow the trainee's 'lieder' - should allow the trainee to lead with the expression of his own experience of the psychotherapeutic experience, should let him move in the direction he needs to go and to make the elaborations he needs to make. The trainee may then begin to understand himself better - his abilities and disabilities - in the psychotherapeutic learning experience.


bibliography

BASCH, Michael. 1985. Interpretation: Toward a developmental model. Progress in Self Psychology, Vol. 1, ed. A. Goldberg. New York: Guilford Press, pp. 33-42.

DARWIN, Charles. 1872. The Expression of Emotions in Man and Animals. London: Murray. Reprinted Chicago: University of Chicago Press, 1965.

ELIOT, George. 1871 -72. Middlemarch, Book 3, Chapter 29, New York and Boston. H. M. Caldwell Company.

KOHUT, Heinz. 1971. The Analysis of the Self. N. York: International Universities Press

KOHUT, H., WOLF, E.S. 1978. The disorders of the self and their treatment: an outline., Int. J. Psychoanal., 59:413-426.

LEWIS, Michael and BROOKS-GUNN, Jeanne. 1982. Self, Other, and Fear: The Reaction of Infants to People. In Belsky, ed. (1982), pp. 167-77.

MAHLER, Margaret, PINE, Fred and BERGMAN, Annie. 1975. The Psychological Birth of the Human Infant: Symbiosis and Individuation. New York: Basic Books.

ORNSTEIN, Paul and Anna. 1985. Clinical understanding and explaining: The empathic vantage point. Progress in Self Psychology. Vol. 1, ed. A. Goldberg. New York: Guildford Press, pp. 43-61.

STERN, Daniel. 1977. The First Relationship: Mother and Infant. The Developing Child Series. Cambridge: Harvard Univ. Press.

SZECSODY, Imre and MATTHIS, Irene (Editors). 1998. On Freudís Couch: Seven New Interpretations of Freudís Case Histories. Northvale: Jason Aronson.

TOMKINS, Silvan. 1962. Affect, imagery, consciousness. Volume 1: The positive affects. New York: Springer. (1962-92)

WINNICOTT, Donald. 1958. Through Paediatrics to Psychoanalysis. London: The Hogarth Press and the Institute of Psychoanalysis, 1975. First published as Collected Papers: Through Paediatrics to Psycho-Analysis. London: Tavistock, 1958. Also published as Through Paediatrics to Psycho-Analysis: The Collected Papers of D. W. Winnicott. New York: Basic Books, 1975.

WOLF, Ernest S. 1988. Treating the Self - Elements of Clinical Self Psychology. NY: Guildford.



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"An Outline of the Basic Therapeutic Model"  © 1994-2004. Dr Robert Gordon.